ALBERT

Description: Background: In 1994 Severe Chronic Neutropenia International Registry (SCNIR) opened for enrollment of patients with at least 3 absolute neutrophil counts (ANC) less than 0.5 x 109/L during a three month period. At that time severe chronic neutropenia (SCN) was categorized as cyclic, congenital, autoimmune or idiopathic based largely on clinical criteria. A randomized trial had established effectiveness of treatment with granulocyte colony-stimulating factor (G-CSF), but long-term consequences of such treatment were unknown. Hypothesis: We began the SCNIR based on the hypothesis that underlying pathophysiology, natural history of patients with chronic neutropenia and benefits and risk of G-CSF therapy could only be accurately established through an international registry with long term follow-up of patients with these rare hematological disorders. Methods: SCNIR enrollment requires informed consent, ANC90%) of severe outcomes (e.g. MDS/AML, failure to respond to G-CSF, death from infections, need for stem cell transplant) often many years after SCNIR enrollment and beginning G-CSF therapy. GSD1 patients improve with G-CSF treatment, but experience splenomegaly and continued problems with infections or complications. The SCNIR through a SDS sub-registry is redefining Shwachman-Diamond syndrome; only about one-half of enrollees have “classic” presentation and a substantial number with “classic presentation” lack mutations in SBDS. The SCNIR is participating in an NIH trial of a CXCR4 antagonist for treatment of WHIM syndrome, as an example of molecularly targeted treatment for this rare disease. The SCNIR is also the key resource for discovery of genetic causes for congenital neutropenia, e.g., G6PC3, HAX1, and TCIRG1 and others, recognition of differences in frequency of autosomal dominant and recessive SCN in populations of Europe and North America and identifying congenital neutropenia cases of unknown cause. Genetic testing has also broadened the clinical spectrum of these disorders. Conclusions: Through the efforts of patients, families, physicians, nurses and investigators, and with support from the NIH, industry, and private philanthropy, chronic neutropenia is now far better understood at the genetic, molecular and cellular level than 20 years ago. Treatment responses to G-CSF are well characterized; novel therapies are emerging; and the prognosis for patients with SCN appears to be improving. The knowledge gained through the SCNIR and availability of G-CSF has redefined clinicians’ approach to chronic neutropenia. The SCNIR is a model of international research collaboration to understand rare diseases in hematology and other areas of medicine. Broad enrollment criteria, physician, patient and family participation, a dedicated staff, and continuing cooperation underlie success of the SCNIR and this model to understanding rare diseases. Disclosures Dale: Amgen: Consultancy, Honoraria, Research Funding. Boxer:Amgen: Equity Ownership. Morrow:Amgen: Employment.

Description: Abstract 1362 G-CSF is a very effective treatment for idiopathic, congenital and cyclic neutropenia (SCN). G-CSF also expands myeloid tissues that give rise to osteoclasts that resorb bone. For this reason, the Severe Chronic Neutropenia International Registry (SCNIR) has collected data on fractures in this population for over 15 years. These data indicate that fractures are uncommon events. To expand information on bone health for patients on long-term G-CSF, we collected additional information from a patient survey and reviewed reports of bone mineral density measurements (BMD) in US children and adults in the SCNIR. Letters were sent to 680 patients; 367 responded. 17 of 367 patients reported fractures; 15 were related to accidents (11 extremities, 4 spine) and 2 were categorized as spontaneous (both spine). The frequency of fractures was 0.005 per patient year on G-CSF. 222 patients indicated that they had not had a BMD study. We received 266 BMDs on 145 subjects (45 children {

Description: Immune neutropenia is the most common referral to pediatric hematologists. Controversy exists as to whether anti-neutrophil antibody testing is necessary or helpful in establishing a diagnosis, predicting outcomes or establishing the necessity of treatment with G-CSF. It is also unclear if clinicians can separate immune neutropenia and hereditary/congenital neutropenia based on patients' clinical presentations, blood counts and anti-neutrophil antibody testing. We reviewed the records of 60 patients with the clinical diagnosis of autoimmune or idiopathic neutropenia, enrolled in the Severe Chronic Neutropenia International Registry (SCNIR) who had the onset of neutropenia before age 2 and who were tested for anti-neutrophil antibodies (positive or negative) to see if they resolved neutropenia by age 7 years. We identified 36 antibody positive and 24 antibody negative patients. Neutropenia resolved by age 7 in 27/36 (75%) antibody positive and in 15/24 (62.5%) antibody negative patients (p = 0.3910, Fisher's exact test). The median age at recovery for those with resolving neutropenia was 3.10 years for the antibody positive and 3.60 years for antibody negative patients (mean ages 3.39 and 3.52 years, respectively; p = 0.7614, unpaired t-test). All 60 patients had severe neutropenia (mean ANC 0.376 x 109/L ± 0.620, median 0.193 x 109/L) and history of recurrent fevers and infections, and were treated with G-CSF (mean dose antibody positive 3.12 ± 7.22 mcg/kg/day, mean dose antibody negative 2.57 ± 3.21 mcg/kg/day, p = 0.7311, unpaired t-test; median doses 1.42 and 1.53 mcg/kg/day, respectively). The ANC responses were quite similar, with antibody positive patients' mean ANC on treatment 3.36 x 109/L ± 1.48; antibody negative mean ANC on treatment 4.10 x 109/L ± 2.06 (p = 0.107, unpaired t-test; median ANCs 1.83 and 2.42 x 109/L, respectively). There were no apparent differences in demographic or hematological characteristics of the patients that resolved or failed to resolve. We also identified 8 children with ELANE mutations who had a positive test for anti-neutrophil antibodies. A positive anti-neutrophil antibody result is generally thought to predict a benign course and favor withholding treatment with G-CSF. Six of eight of these children did not receive G-CSF until after the development of severe infections, which included pneumonia, liver abscess, and cellulitis, including one who developed severe cellulitis with the loss of a lower extremity. Importantly, neutropenia did not resolve in any of the ELANE mutated patients. This retrospective review demonstrates that anti-neutrophil antibody testing in young children is of very limited or perhaps no value in predicting prognosis or response to G-CSF treatment. Furthermore, the results of the antibody testing may lead to withholding G-CSF therapy from children who are at risk of severe infectious complications. We believe it is prudent to treat young children with severe neutropenia who have recurrent fevers and infections independent of the anti-neutrophil antibody test results. We also advocate genetic testing to detect congenital neutropenia and predict outcomes in these patients. Disclosures Boxer: Amgen: Equity Ownership. Dale:Amgen: Consultancy, Honoraria, Research Funding.

Description: Abstract 4791 Neutropenia and recurrent infections are common manifestations of glycogen storage disease 1b (GSD1b), a disease caused by mutations in G6PT1, the glucose 6 phosphate transporter 1 gene. Patients with GSD1b have complex defects in neutrophil deployment and function. GSD1b causes recurrent infections – gingivitis, mouth ulcers, respiratory infections, abscesses and enterocolitis. Granulocyte colony-stimulating factor (G-CSF) has been used to treat these patients for more than 2 decades. We reviewed the presentations, manifestations, complications and G-CSF treatment for 54 GSD1b patients (31 adults and 23 children) at Duke University, the University of Florida and through the Severe Chronic Neutropenia International Registry at the University of Washington. Observational data were available on most patients for at least 3 years (mean = 12 years, median = 13 years, range = 1 to 23 years). Available data showed that before treatment with G-CSF, all of these patients had mild to moderate neutropenia; the mean of the median absolute neutrophil count (ANC) was 0.839 × 109/L ± 0.165 SEM (median = 0.503 × 109/L, range = 0.038 to 7.665 × 109/L). All of the patients also had recurrent infections; the most common events were mouth ulcers, otitis and skin abscesses. There were 7 patients who had enterocolitis prior to G-CSF treatment. G-CSF therapy was initiated at various ages ranging from birth to age 30 (mean = 6 years, median = 4 years). Initial daily doses of G-CSF ranged from 0.50 to 63.28 mcg/kg/day (mean = 5.86, median = 3.65) and were generally titrated upward to achieve a normal neutrophil count. The mean ANC on treatment was 2.598 × 109/L ± 0.136 SEM (median = 1.856 × 109/L, range = 0.0 to 12.645 × 109/L). G-CSF treatment was uniformly associated with an increase in blood neutrophils and reduced patterns of infection. In most patients the symptoms of enterocolitis improved within a few days to a few weeks after starting G-CSF therapy. An increase in spleen size also commonly occurred. In 630 patient-years of observation, there have been 3 deaths attributable to the following causes: 1 subject died of sepsis, 1 subject died of complications from hepatomegaly and neutropenia, and 1 subject died 6 years after a liver transplant. The subject developed AML 5 years after the liver transplant while receiving a combination of immunosuppressant drugs. Patients with GSD1b associated neutropenia respond well to G-CSF with reduced infections and symptoms of enterocolitis. Long-term complications are infrequent and G-CSF is well tolerated in most patients. Disclosures: Dale: Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Boxer:Amgen: Equity Ownership.

Description: Background: Peg-filgrastim (peg-G) is widely used in oncology to accelerate hematopoietic recovery after cancer chemotherapy. It is used occasionally for the treatment of severe chronic neutropenia (SCN). Because of frequent questions from clinicians, we reviewed the use of peg-G, its effectiveness and associated adverse effects for SCN patients followed prospectively through the Seattle office of the Severe Chronic Neutropenia International Registry (SCNIR). Methods: The SCNIR is a long-term observational study of children and adults with congenital, cyclic, idiopathic and autoimmune neutropenia. They are enrolled according to a protocol requiring a minimum of 3 absolute neutrophil counts (ANCs) 10 mcg/kg/day. In the congenital subgroup, adverse events included splenomegaly (8), hepatomegaly (4) and AML (2). Following are brief descriptions of the cases of MDS/AML: Patient #1: A 38 year old female initially diagnosed with SCN in 1989 at age 11 (ELANE mutation C223ter) and started G-CSF at 11.5 mcg/kilograms per day. Because of a poor response, G-CSF was increased to 24 mcg/kg/day. After 15 years she was switched to peg-G (3mg/injection) approximately every 10 days for the next 11 years. At age 37 she had increased blasts in the blood and marrow, leading to the diagnosis of AML and HSCT. Patient #2: A 25 year old female (unrelated to patient #1) was initially diagnosed with SCN at 4.5 months of age (also ELANE mutation C223ter). At age 5 months she started G-CSF (5 mcg/kg/day increased soon to 20 mcg/kg/day). After 12 years, she was switched to peg-G (6 mg/injection) because of poor neutrophil response, and she received peg-G every 14 days for the next 12 years. She became pregnant (previously 3 pregnancies: 2 terminations and one live birth). Early in the pregnancy she appeared to be losing her response to peg-G. Her gums were infiltrated by immature myeloid cells and there were excess blasts in her bone marrow leading to the diagnosis of AML. With intensive care, she delivered a male infant at 30 weeks via C-section and then underwent an HSCT five weeks thereafter. Conclusions: Patients with severe chronic neutropenia respond to treatment with peg-G but it is not easy to determine the proper dose and dosing interval. Bone pain is a common early adverse effect and Sweet syndrome may occur. In patients with congenital neutropenia who are refractory to G-CSF prolonged responses have been achieved lasting for many years with regular injections of peg-G at approximately 14 day intervals. However, 2/9 refractory congenital neutropenia patients developed AML after 11 and 12 years, respectively. Based on this experience, we recommend that peg-G should only be used in congenital neutropenia patients who are refractory to G-CSF (〉20 mcg/kg/day) while searching for a donor for HSCT. Disclosures Boxer: Amgen: Equity Ownership. Dale:Amgen: Consultancy, Honoraria, Research Funding.

Description: Abstract 1490 There are currently no established guidelines for granulocyte colony stimulating factor (G-CSF) therapy during pregnancy for women with severe chronic neutropenia. To establish treatment recommendations, we reviewed records of women with the diagnoses of congenital, cyclic, idiopathic or autoimmune neutropenia and blood neutrophil counts chronically or recurrently

Description: Abstract 4786 Pregnancy in patients with severe chronic neutropenia is associated with high risk of spontaneous abortions. Patients and physicians often ask about benefits and safety of G-CSF administration during pregnancy. We therefore conducted a telephone survey of women of child-bearing potential with the diagnoses of congenital, cyclic, idiopathic or autoimmune neutropenia who are enrolled in the North American branch of the Severe Chronic Neutropenia International Registry (SCNIR). We identified 99 women who had 214 pregnancies before and on G-CSF for this cross sectional study, expanding our previous preliminary investigation, (Boxer et al, ASH abstract 2010). In this population, 31 women had pregnancies before availability of G-CSF, 35 were on long term G-CSF at the time of their pregnancies and 33 were taking G-CSF for some, but not all, of their pregnancies. For those on G-CSF during their pregnancies, the median G-CSF dose was 1.30 mcg/kg/day (mean dose 2.2 ± 0.4 [SEM] mcg/kg/day, dose range 0.1 to 28 mcg/kg/day). Treatment was administered throughout the pregnancy in 74% (49/65) of the pregnancies. Five percent (3/65) were treated only in the 1st trimester, 11% (7/65) were treated only in the last 2 trimesters, 5% (3/65) treated for the last trimester only, and 5% (3/65) treated in 2 of 3 trimesters (2 treated in 1st and 3rd trimesters, 1 treated in the 1st and 2nd trimesters). Sixty-two women with 137 pregnancies while not on G-CSF [congenital neutropenia (CN) N=3, cyclic neutropenia (CyN) N=15, idiopathic neutropenia (IN) N=43, autoimmune neutropenia (AN) N=1] were compared with 47 women having 77 pregnancies while on G-CSF therapy [CN=9, CyN=14, IN=21, AN=3]. Pregnancies occurring in neutropenic women without G-CSF therapy had the following complications: premature labors (8), premature rupture of membranes (1), life-threatening infections (2), and minor infections (5). Patients on G-CSF during pregnancy reported no premature labors (0), no life threatening infections (0), minor infections (5), thrombocytopenia (1), placenta previa (1), abruptio placenta (1), and death following incomplete elective termination (1). By diagnostic category complications in the no G-CSF mothers occurred in 16 patients (CN=1, CyN=5, IN=9, AN=1), compared with nine in the G-CSF treated group (CN=1, CyN=4, IN=4). There were 31 spontaneous miscarriages in the women not on G-CSF (CyN=8, and IN=23) compared with 5 in the women (CyN=4, IN=1) on G-CSF. There were 93 live births from 137 pregnancies in the non G-CSF group. Thirteen of these infants had neonatal neutropenia. Other major neonatal complications in the no G-CSF group included significant infections (3) [meningitis 1, septicemias 2], minor infection (1), cerebral palsy associated with prematurity (1), respiratory distress syndrome (1), and collapsed lung (1). In the G-CSF treated group there were 65 live births from 77 pregnancies. Fifteen of these infants were neutropenic. Other complications in the G-CSF treated group included minor infections (2), abruptio placenta associated with neonatal apnea (1), and premature infants with associated complications (2). There were 2 congenital abnormalities: tracheal esophageal fistula (1) and hydronephrosis (1) in 65 live births, a frequency similar to the general population. This study showed that women with chronic neutropenia who were on G-CSF during pregnancy had a higher percentage of live births, 84% (65/77) than those not on G-CSF, 68% (93/137) (p=0.011, two tailed Fisher exact test). G-CSF therapy was associated with a lower number of spontaneous abortions, with a 6% (5/77) spontaneous abortion rate in the G-CSF treated group versus 23% (31/137) in the non G-CSF group (p=0.003, two tailed Fisher exact test). G-CSF therapy was also associated with a lower rate of serious maternal complications. Two common congenital anomalies (2/65) were observed in the offspring of the G-CSF treated mothers and no anomalies were observed in the offspring of the mothers not receiving G-CSF. Overall the newborns from the G-CSF treated mothers appeared to have fewer neonatal complications. Based on this analysis, we recommend that G-CSF therapy should be offered and continued during pregnancy in women with severe chronic neutropenia. The available data indicates that administration throughout pregnancy is well tolerated and protective of maternal health, including reducing the risk of infections and spontaneous abortions. Disclosures: Boxer: Amgen: Equity Ownership. Dale:Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Description: Abstract 3398 Mutations in ELANE are the most common cause of cyclic and congenital neutropenia. We have detected 65 distinctive and presumably causal mutations in 212 patients with cyclic (91) and congenital neutropenia (121), including 28 families with a total of 101 affected members, followed longitudinally through the Severe Chronic Neutropenia International Registry and Repository. The diagnosis of cyclic neutropenia was associated with 13 different mutations. Congenital neutropenia occurred with 61 different mutations and 9 mutations were found in both cyclic and congenital neutropenia patients. ELANE mutations causing cyclic neutropenia cluster at the junction of exons 4 and 5 and include mutations in intron 4 (83/91). In a majority of the patients (64/91), the mutations are predicated to alter the binding pocket for the enzyme with its substrates based on application of the tertiary structure of neutrophil elastase using ICM-Browser-Pro software (Molsoft, San Diego, CA). However, the proportion of specific mutations affecting the binding pocket was similar for cyclic neutropenia 6/13 versus congenital neutropenia 29/61 (P=1, Fisher exact test). For the unique mutations associated with cyclic neutropenia, 2/4 mutations were predicted to affect the binding pocket. ELANE mutations causing autosomal dominant severe congenital neutropenia have been detected in exons 1, 2,3,4,5, and introns 3 and 4, with a wide diversity of predicted effects on the structure of mutant neutrophil elastase. An equivalent proportion of cyclic and congenital neutropenia patients affect the two glycosylation sites (congenital 55/121 versus cyclic 49/91, p=0.26, Fisher exact test). There was also an equivalent proportion of specific mutations in the two groups (cyclic 7/13, congenital 29/61, p=0.77, Fisher exact test). Seven of 7 mutations predicted to affect the structure of the active site of the enzyme caused congenital neutropenia in 10 patients (mutations exon 2: C26S, C42F, C42S; exon 4: Del 145–152, Del 161–170 2fs; exon 5: Del G172 fs182ter, C194ter). A significantly higher proportion of patients with active site mutations evolved to develop leukemia or myelodysplasia (AML/MDS) (4/10 active site mutations vs. other ELANE mutations 16/111, p

Description: Abstract 1363 Shwachman-Diamond syndrome (SDS) is characterized by neutropenia, bone marrow failure, pancreatic dysfunction, and skeletal abnormalities. Its clinical manifestations are variable and there are no reliable clinical or molecular predictors for patient outcomes. In collaboration with the Severe Chronic Neutropenia International Registry (SCNIR), we have established a North American Shwachman-Diamond Registry (NASDSR) to understand the molecular basis, phenotype, natural history and treatment responses of patients with SDS. In this report, we summarize findings related to severe neutropenia and the risk of severe infections or leukemia in 26 patients [12 adults (6 female, 6 male) and 14 children (5 female and 9 male, less than 18 years of age)] observed for up to 12 years (median 3, range 1 to 12), initially enrolled through the SCNIR. 21 of 26 patients were neutropenic prior to enrollment, median absolute neutrophil count (ANC) 0.476 × 109/L, range 0.070 × 109/L to 0.935 × 109/L. Five patients have never received G-CSF. Of the twenty-one patients (ages 4 to 47) who received G-CSF continuously or intermittently, (median dose 1.88 mcg/kg/day, range 0.00 mcg/kg/day to 17.50 mcg/kg/day), 18 are doing well with stable neutrophil responses while on treatment, after a median treatment period of 3 years. Three deaths and outcomes for two other patients are of particular interest. Patient #1 (8 months, female) was hospitalized for infections for most of her life and died at the age of 8 months due to sepsis with multi-organ system failure. This patient received G-CSF only during the final month of life. Patient #2 (age 21, female) developed AML with del(3p)(7)(21)[7] and died in relapse 25 days after starting G-CSF at a dose of 6.0 mcg/kg/day for treatment of severe neutropenia. Patient #3 (age 8, female) received G-CSF (median dose of 8.25 mcg/kg/day) for nearly 6 years, i.e., from age 16 months until developing a cytogenetic abnormality 45,XX,t(6;13)(q21;q32), -7 [3]/46,XX[47] at age 7 years. She underwent a bone marrow transplant 7 months later and died of sepsis after failing to engraft. Patient #4 (age 14, male) received a transplant after developing a cytogenetic abnormality 46,XY[15];46,Xydel(7)(q22q34)[5], 5 years after starting G-CSF at a median dose of 5 mcg/kg/day. Patient #4 is currently 28 years old. Patient #5 (age 7, male) received a matched sibling transplant because of mild marrow dysplastic changes without cytogenetic abnormalities after receiving G-CSF (1.3 mcg/kg/day) with good neutrophil response for 8 years. He is doing well at 3 years after transplantation. All of the enrolled patients have other manifestations of SDS including steatorrhea due to pancreatic insufficiency, hepatomegaly, splenomegaly, and osteopenia. None has developed non-hematological malignancies. The SCNIR-NASDSR seeks to enroll additional patients in North America to build an accurate database for molecular studies and clinical recommendations for this important disease. Disclosures Dale: Amgen: Consultancy, Research Funding, Speaker; Merck: Research Funding.

Description: Abstract 3787 Barth syndrome is an X-linked recessive genetic condition characterized by neutropenia, cardiomyopathy, growth delay, muscle weakness, and 3-methylglutaconic aciduria (an increase in organic acid caused by abnormal mitochondria). Its clinical manifestations are variable and can include fatigue, hypotonia, and dilated cardiomyopathy. Symptoms usually appear at birth or within the first few months of life. Mutations in the tafazzin (TAZ) gene cause Barth syndrome. The Severe Chronic Neutropenia International Registry (SCNIR) is building a base of information about the natural history and response to granulocyte colony stimulating factor (G-CSF) treatment for patients with Barth syndrome and other causes of chronic neutropenia. Through the SCNIR, we follow the clinical course and treatment of seven male subjects (median age 17 years, range: 6–28 years) with Barth syndrome observed for up to 11 years (median 9, range 3–11). Six of these seven subjects were neutropenic prior to G-CSF treatment, the median absolute neutrophil count (ANC) was 0.293 × 109/L (range 0 – 1.260). The seventh subject was not consistently neutropenic, median ANC 2.107 × 109/L (range 0.779 – 3.520). Sixteen bone marrow evaluations were performed on four of the seven subjects. Four of 16 bone marrows were prior to G-CSF exposure (3 subjects). Two of three subjects manifest eosinophilia in the marrow but not in the blood. Marrow exams for two of the three subjects' evaluations were read as normocellular marrow, and one of the three was read as hypocellular with a decrease in cells of the myeloid series. Twelve of the 16 bone marrow evaluations were performed in two subjects who were receiving G-CSF. One of the four subjects had bone marrow evaluations both before and after G-CSF exposure. His pre G-CSF evaluations displayed hypocellular bone marrow, and his post G-CSF evaluations showed normocellular bone marrow and eosinophilia. None of the marrow evaluations before or on G-CSF suggested myelodysplasia or showed evidence of acute myeloid leukemia. The six neutropenic subjects have all received G-CSF for a median of 96 months (range 28 – 137) at a median dose of 1.57 mcg/kg/day (range 0.43 to 2.18). The total G-CSF exposure for all six subjects is 507 months. The median ANC of the six subjects prior to G-CSF treatment was 0.293 × 109/L (range 0–1.260). The median ANC on G-CSF was 2.056 × 109/L (range 1.640–3.403). Prior to receiving G-CSF, three of the seven subjects reported mouth ulcers. Two of seven subjects reported skin infections, including one subject who reported infections around the G-tube used to maintain his nutritional status. One of seven subjects reported an episode of bacteremia. Of the six subjects who received G-CSF, three reported a reduced number of mouth ulcers and two of six reported reduced skin infections (G-tube, port-a-cath). None of the subjects experienced unusual side effects or clinically significant complications associated with G-CSF therapy. These data indicate that patients with Barth syndrome and neutropenia have ulcers and patterns of infections similar to other patients with chronic neutropenia. They are responsive to G-CSF treatment and it appears to be safe and effective to reduce their predisposition to bacterial infections. Disclosures: Dale: Amgen: Consultancy, Research Funding.