ALBERT

Description: Introduction: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired clonal abnormality of hematopoietic stem cell leading to lack of phosphatidylinositol glycoproteins, sensitizing cells to complement-mediated lysis. Despite the efficient symptomatic treatment of hemolytic PNH with eculizumab, allo-HCT is the only curative treatment for the disease, although outcomes presented in the past were controversial. Material and methods: We report 41 allo-HCTs: 37 from MUD and 4 from MRD performed for PNH in 2004-2016. Median age of recipients was 29(20-62) years and donors 30(19-53), median time from diagnosis to allo-HCT was 16(2-307) months. Median size of PNH clone was 80% granulocytes (0.5%-100%). Indication for allo-HCT was PNH with aplastic/hypoplastic bone marrow (19 pts), MDS (2 pts), overlapping MDS/aplasia (3 pts), severe course of PNH with hemolytic crises and transfusion-dependency without access to eculizumab (17 pts). Additional risk factors were Budd-Chiari syndrome and hepatosplenomegaly (1 pt), history of renal insufficiency requiring hemodialyses (2 pts), chronic hepatitis B (1 pt) and C (1 pt). The preparative regimen consisted of treosulfan 3x14 g/m2 plus fludarabine 5x30 mg/m2 (31 pts) or treosulfan 2x10 g/m2 plus cyclophosphamide 4x40 mg/kg (10 pts). Standard GVHD prophylaxis consisted of cyclosporine-A, methotrexate and pre-transplant ATG in MUD-HCT. 2 pts instead of cyclosporine-A received mycophenolate mofetil and tacrolimus. Source of cells was bone marrow (13 pts) or peripheral blood (28 pts) with median 6.3x108NC/kg, 5.7x106CD34+cells/kg, 24.7x107CD3+cells/kg. Myeloablation was complete in all pts with median 9(1-20) days of absolute agranulocytosis

Description: Abstract 3498 Introduction: Oral mucositis is a complication of conditioning treatment that produces pain and morbidity in allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients. The rationale of this study was to evaluate the efficacy of a calcium phosphate mouth rinse (Caphosol) vs standard regimen in 40 adult patients undergoing allo-HSCT. Patients and Methods: 40 patients treated with allo-HSCT (31 from unrelated donors, 9 from siblings) performed in Hematology and BMT center in Katowice in 2009 were randomized and stratified by the conditioning regimen (busulfan-, treosulfan- or TBI- based), type of transplant (unrelated or related) and age into two equal groups. Treatment group received Caphosol washes 4 times daily from first day of conditioning until reaching ANC 0.2 G/l. Control group received standard topical mouth care with salvia, antibacterial and antifungal solutions. During the trial patients subjectively assessed level of pain in mouth and in pharynx using 0–10 scale and swallowing problems using 0–5 scale. Mucositis was judged by experienced physician. Nonparametric Mann-Whitney U-tests were used for statistical analysis. Results: Average oral toxicity in WHO scale in Caphosol vs control group was 0.9 vs 1.8 (p=0.02), duration of mucositis was 3.2 vs 7.1 days (p=0.02). Total parenteral nutrition (TPN) due to mucosits was required in Caphosol vs control group in 0 vs 6 pts, average duration of TPN was 0 vs 1.9 days (p=0.009). Analgetics were required, respectively, in 3 vs 9 pts and analgesy lasted for 1.1 vs 3.4 days (p=0.047). Average subjective peak pain in mouth was 0.85 vs 1.75 (p=0.005) and in pharynx 1.95 vs 2.2 (NS) in Caphosol vs control group, average pain intensity was lower in Caphosol group throughout the whole period of mucositis. Intensity of swallowing problems tended to be lower in Caphosol group (NS). Acute GVHD was observed in 7 vs 9 pts in Caphosol vs control group and its average degree was 0.5 vs 0.9 (NS). Conclusions: Caphosol mouth rinse in the allo-HSCT recipients is associated with decrease of oral toxicity, lower peak pain due to mucositis and its shorter duration. In consequence, comfort of life is improved and the incidence of acute GVHD is reduced, as well as the requirement of TPN and analgetics. Disclosures: No relevant conflicts of interest to declare.

Description: Background. The best donor source for adult patients with acute leukemia lacking an HLA-identical donor still remains to be established. The objective of this study was to compare the outcome after T-cell-replete hematopoietic stem cell transplantation from haploidentical donor (HAPLO) and transplant from Matched Unrelated Donor (MUD) or Mismatched Unrelated Donor at a single HLA-locus (MMUD) for patients with acute leukemia in remission. Methods. From January 2007 to December 2012, 313 consecutive HAPLOs were performed as first allogeneic transplants in adult patients with de novo acute leukemia in CR1 or CR2 and reported to the EBMT Registry. We were able to pair match 273 of these 313 patients with another 273 patients who received a MUD and 273 who received a MMUD transplant. The matching factors were as follow: age (+/-5y), diagnosis (myeloid or lymphoblastic leukemia), disease status at transplant (CR1 or CR2) and interval from diagnosis to transplant (+/-1mo). Results. The median follow-up was 22 months. The two-year non-relapse mortality (NRM) and relapse (RI) cumulative incidences were 28% and 30% for HAPLO, 21% and 19% for MUD, and 28% and 27% for MMUD. The two-year KM estimates of leukemia-free survival (LFS) and overall survival (OS) were 42% and 49% for HAPLO, 59% and 65% for MUD, 45% and 51% for MMUD. In multivariate analysis both NRM and RI were significantly reduced in MUD compared to HAPLO (NRM, hazard ratio (HR): 0.61, p=0.02, 95%CI: 0.40-0.91; RI, HR: 0.59, p=0.01, 95%CI: 0.39-0.89) but there was no statistical difference between HAPLO and MMUD (NRM, p=0.59; RI, p=0.52). LFS and OS were significantly higher in MUD compared to HAPLO (LFS HR: 0.61, p=0.001, 95%CI: 0.45-0.81.OS HR: 0.63, p=0.004, 95%CI: 0.46-0.86) but not statistically different between MMUD and HAPLO (LFS, p=0.45. OS, p=0.84). Of note, type of donor was neither associated with day-100 grade II-IV acute graft-versus-host disease, nor to chronic graft-versus-host disease. Conclusion. These findings suggest that LFS and OS were significantly higher in patients with acute leukemia in remission receiving a MUD compared to patients with similar characteristics receiving a HAPLO. We didn’t find significant differences between MMUD and HAPLO. In the absence of a MUD, host/donor features and urgency of transplant should drive us towards the best choice between these alternative donor sources. Disclosures No relevant conflicts of interest to declare.

Description: The goal of this study is to compare the efficacy and safety of an original DAF regimen: daunorubicine (DNR) 60 mg/m2/d iv, days 1–3; cytarabine (AraC) 200 mg/m2/d ci, d 1–7, and fludarabine 25 mg/m2 2h inf. iv d 1–5 versus previously studied DAC regimen* (DNR, AraC, Cladribine), and versus standard DA in de novo acute myeloid leukemia (AML) patients below 60. Primary objective is complete remission (CR) rate after single course of induction and overall survival, secondary objectives - overall CR rate, toxicity, leukemia-free survival rate, assessment of lymphocyte subpopulations levels and survival in patients submitted to bone marrow allotransplantation (alloBMT) immediately after CR assessment. Patients achieving CR and did not submit to alloBMT received two courses of subsequent intensive consolidation: 1) HAM (HD AraC, mitoxantrone) 2) HD AraC. In case of partial remission (PR) after the first induction course the same regimen was repeated, Patients with no remission (NR) or PR/NR after 2 induction courses were withdrawn with the study. We are planning to enrol to the study 600 patients in 3 years. Between 09.2004 and 07.2005, 147 adult AML patients, aged 48 (19–60)y, sex: male 57, female 90, treated in 16 co-operating Polish Adult leukemia Group (PALG) centres were randomised to either DAF (n=44), DAC (n=49) or DA (n=54) arm. PML/RAR alfa positive - FAB M3 cases were excluded. Both study groups were well balanced in respect of age, sex, FAB subtype, and WBC. The final CR rate and CR rate after the first induction course equalled: for DAF 65% and 60%, for DAC 70% and 60%, and for DA 55% and 47%, respectively (p=NS). The median times to ANC recovery 〉 0.5 G/L, and PLT 〉50 G/L in each arms were similar (22–26 d.) (p=NS). All patients developed WHO grade IV thrombocytopenia and agranulocytosis. The frequency and severity of infections, mucositis, vomiting, diarrhea, alopecia, polyneuropathy as well as of cardiac, liver or kidney failure were comparable in each treatment arms. Early death was noted in 6% (n=2) in DAF, in 9% (n=3) in DAC, and in 13% (n=5) in DA group, because of bacterial sepsis in every cases. In conclusion, this original study proves that the addition of fludarabine to the standard DNR+AraC regimen (DAF) comparing to DAC and DA regimen is a potent antileukemic treatment without increased toxicity.

Description: Abstract 4537 Most of lymphoma patients are chemo- and radiosensitive. Using a conventional therapy we can cure about 50% of patients (pts). Unfortunately the rests achieved only partial remission or have a rapid relapse after treatment. These pts are a real challenge for nowadays hematology. Till now there is not a recommended scheme of therapy. Using high dose chemotherapy with autologous hematopoietic cell transplantation (AHCT) is the most popular one. During the last year in our Department we have been started using BeEAM as the conditioning treatment, and the results of a single centre observation are presented now. Material and Methods Actually: between April, 2011 and February, 2012 we conducted AHCT using BeEAM as conditioning treatment in 23 pts with lymphoma (18 pts with Hodgkin Lymphoma (HLy), 2pts with diffuse large B cell lymphoma (DLBCL), 2 pts with T cell lymphoma (TCL), 1 with follicular lymphoma (FL). There were 14 male and 9 female, with a median age of 37,6 (range 21–62 yrs). Ann Arbor staging at diagnosis was as follows: II-33%, III-50%, IV-17%; 83% of patients manifested B-symptoms. Clinical manifestation at diagnosis included: enlargement of the lymph nodes (n=18), bone marrow infiltration (n=2), lung infiltrates (n=3). Initially, all patients received at least 2 cycles of chemotherapy; in HLy all pts received ABVD, in non HLy- RCHOP. None of them achieved complete remission (CR). Partial response (PR), defined as the reduction of measurable disease by ≥50% without the appearance of any new lesions, achieved 11pts. The rests underwent high dose chemotherapy (HDT) followed by AHCT without remission (NR). Stem cells were collected from peripheral blood after IVE chemotherapy (Ifosfamide 3g/m2 iv in 1–3d, Etoposide200mg/m2 iv in 1–3d, Epirubicine 50mg iv in1d) and subsequent administration of G-CSF at a dose of 10ug/kg/d, starting from +5 day after chemotherapy till the last day of collection. Collections were performed using Optia Spectra. All pts collected the sufficient number of CD34+ cells for AHCT procedure. Conditioning regimens before AHCT consisted of BeEAM (Bendamustine 200mg/m2 in -8-7d, Etoposide 200mg/m2 in -6-3d, Ara-C 400mg/m2 in -6-3d, Melphalan 140mg/m2 in -2d). A median number of transplanted CD34+ cells was 5,58 (2,05–17,8×10∧6/kg). All except one pt successfully engrafted. 1 pt with Hly died within 8 day after transplantation due to infection. Hematopoietic recovery was as following: WBC count 〉 1,0×10∧9/L after median of 12 days (range 9–15 days),ANC〉 0,5×10∧9/L after median of 13 days (range 9–16 days) and platelet count 〉20×10∧9/L after median of 13days (range 7–20 days). Results 3 pts died after AHCT. Two of them due to progression of the disease within 5 and 16 months after AHCT. Both were without remission before AHSCT. 1 pt died due to heart insufficient after 3 months after AHCT. The complications after transplantation procedure were rare and included mainly: bacterial infection in the upper respiratory tract (n=3), viral skin infection (n=1), oral mucositis (n=2). At the last contact, 19 pts are alive and 9 of them achieved CR, and 3 – stable disease. One pt underwent sibling alloHCT and 2 others will undergo alloHCT within 2 months. 4 pts with Hly were treated with anty CD 30+. Conclusion Autologous hematopoietic cell transplantation using IVE for mobilization and BeEAM as conditioning is effective treatment for lymphoma patients with refractory disease. Disclosures: No relevant conflicts of interest to declare.

Description: Abstract 4575 Introduction: Anti-HLA antibodies constitute potentially important factor that may influence outcomes of HLA-mismatched allogeneic hematopoietic stem cell transplantation (allo-HSCT). The rationale of this study was to detect presence of anti-HLA antibodies in recipients of allo-HSCT from HLA-mismatched unrelated donors. Patients and Methods: Anti-HLA-A,B,C,DR,DQ,DP antibodies were identified in sera collected from 46 recipients of allo-HSCT from HLA-mismatched unrelated donors. Sera were collected between 1 month and 5.5 years after allo-HSCT, and additionally before allo-HSCT in 17 pts. We have used microchips spotted with purified HLA class I and HLA class II antigens to allow binding of anti-HLA antibodies present in tested sera to the surface of the microchip, pre-optimised reagents and DynaChip Processor (Dynal Invitrogen Corporation) for assay processing, data acquisition and analysis. Results: Antibodies against HLA class I, II or I and II were detected in 15%, 11% and 35% of pts whereas no antibodies were detected in 39% of patients. Antibodies were directed against HLA-A, B, C, DR and DQ in 37%, 46%, 35%, 48% and 35% of pts, respectively. Pre-transplant anti-HLA antibodies have been detected in 7 pts (41%) out of 17 tested before allo-HSCT. In this group percent of Panel Reactive Antibodies (% PRA) increased following allo-HSCT in 3 pts and decreased in 4. In 5 out of 10 remaining pts without pre-transplant antibodies, %PRA increased post-transplant. DynaChip software allowed to define specificities of HLA-A,B,C,DR and DQ antibodies on low and high resolution levels. The specificity of antigens that masked results of antibody identification has been also defined in 2 pts. At this stage we did not define exactly whether detected anti-HLA antibodies were donor-specific. Cross-reactive groups (CREG's) analysis has been also used to compare antibodies’ reactivity. Anti-HLA-DP antibodies were not detected in the examined group of transplanted patients. Conclusions: Presented preliminary study results indicate, that anti-HLA antibodies can appear post-transplant in mismatched allo-HSCT recipients. Further analysis aiming to evaluate their influence on transplant outcomes is ongoing. We intend to extend the search for anti-HLA antibodies with use of Luminex LabScreen method. Disclosures: No relevant conflicts of interest to declare.

Description: Introduction Although anti-HLA Antibodies (Abs) are considered an important factor of graft failure in solid organ transplants, their role in allogeneic hematopoietic stem cell transplantation (allo-HSCT) is still undiscovered. Large polymorphism and immunogenicity of HLA-antigens and heterogeneity of anti-HLA Abs warrant the need of such investigation. The purpose of this study was to define the presence of anti-HLA Abs before allo-HSCT from HLA-mismatched unrelated donors and their impact on engraftment and post-transplant full donor’s chimerism. Material and Methods 70 HLA-mismatched donor/recipient pairs entered the study. Indication for allo-HSCT was: ALL, AML, CML, SAA, PNH, MDS and CLL. Preparative regimen was myeloablative in 68pts (97%) and reduced in 2pts (2.3%). Standard GVHD prophylaxis consisted of cyclosporine, methotrexate and pre-transplant anti-thymocyte globulin (69pts) or Alemtuzumab (1pt). HLA A,B,C,DR,DQ alleles were PCR-typed. Single HLA-antigen was mismatched in 46pts, single HLA-allele in 16pts, double antigens or alleles in 2 pts and another 2 pts had combined antigenic/allelic HLA mismatch. Anti-HLA A,B,C,DR,DQ,DP Abs were identified in sera collected prior to the conditioning treatment with use of automated DynaChip assay utilizing microchips bearing purified class I and class II HLA antigens. Post-transplant chimerism was analyzed using STR-PCR method at 30, 100-days and 1-year after allo-HSCT. Results Anti-HLA Abs pre-formed before allo-HSCT were detected in 32pts: against class I, II or both in 13(18.6%), 7(10%) and 12(17.1%) pts. Anti-HLA Abs were detected after allo-HSCT in 49pts: against class I, II or both in 22(32.4%), 7(10.3%) and 20(29.4%) pts, respectively. Anti-HLA Abs directed against the mismatched HLA antigens were observed in 4 pts before allo-HSCT. Although no Abs specific to mismatched HLA alleles were detected, Abs belonging to the same Cross-Reactive Groups (CREGs) were present in 5pts. No graft failure has been observed (graft failure was defined as absence of neutrophil recovery by day 30 after allo-HSCT or loss of donor’s chimerism). The detection of anti-HLA Abs before allo-HSCT was associated with decrease of post-transplant donor’s chimerism (18/31 vs 11/35, p=0.03). Anti-HLA Abs had no significant impact on engraftment of platelets and neutrophils. The median time to neutrophils engraftment was 16.9 days (range 7-31 days) in pts with and 18.9 days (range 13-30 days) in pts without anti-HLA Abs (p=0.188). The median time to platelets engraftment was 16.9 days (range 9-31 days) in patients with and 18.3 days (range 10-32 days) in pts without anti-HLA Abs (p=0.274). Conclusions Our preliminary results indicate, that anti-HLA Abs are present before transplantation in mismatched allo-HSCT recipients. They influence the post-transplant full donor’s chimerism, but they did not influence engraftment and graft failure. Disclosures: No relevant conflicts of interest to declare.

Description: The aim of this study was to evaluate long-term outcome of acute myeloid leukemia (AML) patients treated within the PALG 1999 DAC vs. DA Study. [b][Within 3 years (1999–2002) 445 patients, aged 18–60, were randomized 1:1 to the induction treatment DAC-7: daunorubicin 60 mg/m2/d iv 1–3; cytarabine 200 mg/m2/d ci d 1–7; cladribine (2-CdA) 5 mg/m2 2h inf. iv d 1–5 and standard DA-7 regimen (the same therapy excluding cladribine). Patients achieving CR received two courses of subsequent intensive consolidation: HAM (HD AraC, mitoxantrone) HD AraC with or without cladribine in the DAC-7 or DA-7 arm, respectively. In case of PR after the first induction course the same regimen was repeated, Post-consolidation therapy was comparable in both arms with following proportions of autoHCT, alloHCT and maintenance: DAC-7 17%, 14%, 69%; DA-7 21%, 14%, 65%, respectively. As previously reported, a single course of DAC-7 induction resulted in 17% higher CR rate compared to the DA-7 treatment (p=0,0008). The difference was particularly pronounced in patients: aged 〉40 years and with initial WBC 〉100x109/L. In the latter subgroup also the overall CR rate (achieved after entire induction program) was higher in the DAC-7 arm (71% vs. 43%). [Leukemia.2004;18:989–97] In the present report we analyzed seven-year long-term outcome (median follow-up 5 yrs) in the whole study population and in subgroups stratified according to age, initial WBC, cytogenetics, sex, FAB subtype, and preceding myelodysplasia. In the whole group the overall survival (OS) rate equaled 29,5% for DAC-7 and 24% for DA-7 arm (p=NS) and leukemia free survivall (LFS) 30% vs. 28% (p=NS), respectively. Of note, in patients aged 〉40 years, the therapy containing cladribine was associated with improved OS (26% vs. 14,5%, p=0.03), and LFS (28% for DAC-7 vs. 18,5% for DA-7, p=0.02). Other subgroup analyses revealed higher probability of the OS in patients with initial WBC ≥ 50 G/l assigned to DAC-7 compared to DA-7 arm (32% vs. 20,5%, p=0.04). The LFS rate equaled 35% and 27% (p=NS), respectively. In women receiving DAC-7 induction therapy in comparison with those treated in arm without 2-CdA reached higher OS: 29% vs. 19,5%, p=0,03, respectively. LFS in these subgroups was comparable: 25% vs. 22%, p=NS, respectively. We conclude that addition of cladribine to induction and consolidation therapy of AML improves long-term outcome in patients: older than 40 y, as well as in those with high tumour burden. The better outcome in older patients results mainly from reduced risk of relapse, whether that in cases with high WBC seems to be linked to a higher CR rate.

Description: Our previous PALG study in 445 de novo AML patients has demonstrated that addition of cladribine to the standard daunorubicine-cytarabine (DA) remission induction regimen - DAC has a beneficial influence on both the CR rate after one induction cycle (p=0,0008) and on survival in patients older than 40 y (Leukemia2004,18:989–97, updated at 7 y: ASH 2006, Abstr.N#2003). The goal of this study was to evaluate the efficacy of original combination including another purine analogue fludarabine – DAF (daunorubicine 60 mg/m2/d iv, d 1–3; cytarabine (AraC) 200 mg/m2/d ci, d 1–7, and fludarabine 25 mg/m2 iv d 1–5) in untreated patients with AML, aged up to 60 y, based on head to head comparison with DAC - (DNR, AraC, Cladribine), and standard DA regimens. We evaluated earlier the DAF protocol in relapsed or refractory AML (PALG pilot study; Ann Hematol.2008, 87:361–7. Epub 2007 Dec 12); the tolerance was good, CR 44%, LFS 38%. Primary objectives of the presented trial were: complete remission rate (CR) and overall survival (OS); secondary objectives were: toxicity and leukemia-free survival (LFS). Additional analysis was planned for patients submitted to an early bone marrow allotransplantation (alloBMT) after CR. Patients achieving CR received two courses of subsequent intensive consolidation: HAM (HD AraC, mitoxantrone) HD AraC. Reduction of consolidation was accepted in patients treated with early alloBMT. In case of partial remission (PR) after the first induction course the same regimen was repeated. Patients with no remission (NR) or with PR after 2 induction courses were withdrawn from the study. Between 09.2004 and 05.2008, 673 adult untreated AML patients aged 18–60 y, median 47 y, sex: male 49,5%, female 50,5%, treated in 18 co-operating Polish Adult leukemia Group (PALG) centres were centrally randomised to either DAF (n=225), DAC (n=224) or DA (n=224) arm (1:1:1). PML/RAR alfa positive - FAB M3 cases were excluded. The study groups were well balanced in respect of age, sex, FAB subtype, and WBC. After a single induction course the CR rate for patients receiving DAC equalling 63% was significantly higher if compared with DA - 51% (p=0,01), whereas no significant differences were noted between DAC vs. DAF - 55% and DAF vs. DA subgroups. Also the entire CR rate of 68% in the DAC arm was higher in comparison with DA one - 57% (p=0,02). No significant differences were found between DAC vs. DAF - 60%, and DAF vs. DA. At median time of 24 months (longest observation time 3,5y) the OS rate equalled 51% for the DAC treated subgroup and was higher in comparison to the standard DA arm - 39% and the DAF arm - 36% (p=0,03). The leukemia free survival rates (LFS) in DAC, DA and DAF treated cohorts equalled 51%, 32% and 41% respectively (p=NS). The early death rates of 8–10%. were similar in the studied treatment subgroups. All patients developed WHO grade IV thrombocytopenia and agranulocytosis. The frequency and severity of infections, mucositis, vomiting, diarrhoea, alopecia, polyneuropathy as well as of cardiac, liver or kidney dysfunctions were comparable in particular arms. In conclusion, this randomised study proves that the addition of cladribine to the standard DA induction regimen (DAC) improves CR rate and the overall survival in adults with AML aged up to 60 y, without additional toxicity. This beneficial effect was not observed in patients treated using the DAF protocol with fludarabine added to the standard “DA 3+7” schedule