ALBERT

Description: Myeloablative transplant has been investigated in poor prognosis indolent lymphoma; although recurrence rate is low it is associated with high mortality; the use of non-myeloablative conditioning regimens could reduce TRM maintaining the GVH effect. Up to May 2006, 35 patients with follicular NHL received a Non Myeloablative related allogeneic according to two prospective multicenter trials; conditioning regimen consisted of Fludarabine 150 mg and Melphalan 70–140 mg. GVHD prophylaxis consisted of CSA plus short-course MTX. All patients received filgrastim-stimulated peripheral blood stem cells from a HLA related identical donor. Median age at transplant was 50 years (34–62) and 16 (46%) had received a previous autologous transplant. At transplant, 5 patients (14%) were in CR1 (after several lines of chemotherapy), 9 (25%) in 〉CR1, 12 (34%) in PR, 1 (3%) had stable disease (after 3 chemotherapy lines) and 8 (23%) progressive disease. All patients engrafted. Acute GVHD developed in patients 19 (54%) (17patients (48%) grade II-IV). Chronic GVHD developed in 18 out of 27 patients at risk (67%), being extensive in 11 (41%). Disease was evaluated at day +100 and at that moment 23 patients were in CR, (85%) 1 (4%) in PR, two (7%) had stable disease and 9 patients ( 26%) have died. With a median follow up of 60 months (range: 32–80 months), 20 patients (57%) are alive disease free, and 14 (43%) have died, 12 of them (37%) due to transplant toxicity and 2 patients (6%) due to progression. Overall Survival (OS) and Event Free Survival (EFS) are 57 and 54 % respectively. Analysing variables which influence on OS and EFS, patients 55 years have a OS significantly shorter than those

Description: Background Allogeneic stem-cell transplantation with myeloablative conditioning (MAC) in multiple myeloma (MM) is associated with a high transplant-related mortality (TRM) with a 15% of long-term survivors. Allogeneic transplantation with reduced-intensity conditioning (alloRIC) results in a lower TRM with a higher relapse rate. When used in first line in a tandem transplant approach (auto/alloRIC), the incidence of acute graft-versus host disease (aGvHD) grade II-IV reported ranges between 20-43%, chronic GvHD between 50-75% and the TRM between 10-15%. The reported PFS was 25% beyond 7 years. Because of this high morbimortality and the higher rate of relapse, the role of allogeneic transplantation in MM remains controversial, especially as part of the front-lline therapy. Aim to analyze the results of allogeneic transplantation in patients with MM outside clinical trials at our institution over a period of 27 years. Patients and Methods Between Feb 1986 and April 2009, 23 patients (17 M, 6 F, median age 41 –range 21-52 -) received a MAC from an HLA identical sibling donor. Disease status at the time of transplant was first response in 12 patients (53%) (3 CR, 9 PR), sensitive relapse in 3 (13%) (all PR) and refractory disease in 8 (35%). Conditioning regimen was heterogeneous (6 Cyclo/TBI, 2 Bu/Cyclo, 3 BCNU/Mel/Cyclo/TBI, 4 Cyclo/Mel/TBI, 5 Mel/TBI, 2 Bu/Mel). GvHD prophylaxis consisted on cyclosporine/MTX (10), cyclosporine/PDN (8), cyclosporine (2) or other (3). Between April 2001 and Aug 2012, 31 patients (18 M, 13F, median age 48 –range 25-64) received an alloRIC: 25 of them (80%) from an identical sibling donor and 6 (20%) from an unrelated donor. Seven patients (13%) who did not achieve a CR after front-line autologous transplant received an alloRIC in a tandem strategy. 17 (31%) were in sensitive relapse (first relapse 14, second relapse 3). Seven patients (13%) had refractory disease at the time of alloRIC. Conditioning regimen consisted on Fluda/Mel (26 patients), Flu/TBI (3) and Fluda/Mel/bortezomib (2). GVHD prophylaxis consisted on cyclosporine/MTX (6) or cyclosporine/MMF (25). All patients in the alloRIC group had received a prior single autologous transplant. Results On an intention-to-treat analysis, the CR rate after MAC was 35%. The incidence of aGvHD grade II-IV and III-IV were 48% and 39%, respectively. The TRM at any time was 56%. The causes of death were GvHD in 7 patients, infection not related to GvHD in 5 patients and VOD in 1 patient. The relapse rate was 30%.There are 3 patients who remain in continued CR at 13, 23 and 27 years beyond transplantation. With alloRIC the CR rate was 45%. The incidence of aGvHD grade II-IV and III-IV were 55% and 22%, respectively. Nine patients develop chronic GvHD. The TRM at any time was 29% and the causes of death were GVHD in 7 patients and pulmonary hemorrhage and postransplant lymphoma one patient each. Nine patients remain alive in continued CR from 5 months to 9 years of follow-up. After a median follow-up of 36.4 months, the median PFS was not significantly different between MAC and alloRIC and there was a trend towards a longer overall survival in the alloRIC group (4.6 vs 35 months, p=0.05). Conclusions Although a small fraction of patients with MM can be cured with MAC allogeneic transplantation, this procedure is associated with an extremely high TRM. Unfortunately, alloRIC was also associated with a high incidence of severe aGVHD resulting in a high TRM leading to a short PFS. New approaches aimed at decreasing the incidence of aGVHD are crucial. Disclosures: Jiménez: Janssen: Honoraria. Rosiñol:Janssen: Honoraria; Celgene: Honoraria. Blade:Janssen: Honoraria; Celgene: Honoraria.

Description: Background:Uncontrolled complement activation plays a pivotal role in a variety of disorders such as paroxysmal nocturnal hemoglobinuria (PNH). Challenges to be addressed with eculizumab therapy include inter-individual variation in clearance of eculizumab, economic burden, and improvements in the current biweekly intravenous infusion maintenance schedule. ALN-CC5 is a subcutaneous (SC) investigational RNA interference (RNAi) therapeutic targeting hepatic complement C5 (C5) synthesis. Previously presented data from our ongoing Phase 1/2 study showed that ALN-CC5 was generally well tolerated and exhibited a clamped C5 knockdown and complement activity inhibition in healthy volunteers (Hill et al. Haematologica 2016; 101, Suppl 1). The aim of this abstract is to report updated tolerability and clinical activity of ALN-CC5 in patients with PNH. Methods: A phase 1/2 single-ascending dose (Part A) and multiple-ascending dose study (Part B) of ALN-CC5 was conducted in healthy adult volunteers and in patients with PNH (Part C). In Part C, patients with PNH received weekly doses of 200 mg or 400 mg of ALN-CC5 for 2 to 16 weeks; ALN-CC5 is administered subcutaneously at a concentration of 200 mg/mL. The primary endpoints are safety and tolerability and secondary endpoints include: pharmacokinetics (PK), reduction of circulating C5 and complement activity, as measured by CAP/CCP Wieslab ELISA assays and sheep erythrocyte hemolysis assay, as well as reduction in LDH. Results: Part C included 6 patients with PNH (treatment naïve n=3; patients receiving eculizumab n=3), including 1 patient who was experiencing breakthrough hemolysis despite receiving 1200mg eculizumab q2wk. ALN-CC5 was generally well tolerated in patients with PNH after multiple doses with the majority of adverse events (AEs) being mild or moderate in severity. There were no serious AEs or discontinuations due to AEs. One patient, who was also taking eculizumab, cyclosporine and anabolic steroids as concomitant medications, experienced a transient asymptomatic grade 3 elevation of liver transaminases that was deemed possibly related to study drug. In eculizumab naïve patients (n=3), ALN-CC5 monotherapy achieved a mean maximum C5 knockdown of 98.2% ± 0.3%, residual C5 levels of 0.9 mcg/mL and a mean maximum CCP inhibition of 94.2 ± 1.7%. During treatment with ALN-CC5, maximum reduction in LDH was 37% and 50% in 2 patients who received 17 doses of ALN-CC5 but remained above the goal of less than 1.5 times the ULN. In the remaining eculizumab naïve patient, LDH lowering was not observed following 8 doses of ALN-CC5. After completion of ALN-CC5 dosing and in the setting of ongoing 〉95% ALN-CC5-mediated KD of serum C5, treatment naïve patients received a single 600 mg dose of eculizumab (labeled induction dose is 600 mg weekly x 4) for the treatment of residual hemolysis followed by close clinical monitoring. An exploratory analysis was conducted to understand the potential for ALN-CC5 to reduce eculizumab dose and frequency. All 3 patients achieved sustained lowering of LDH

Description: Background Paroxysmal nocturnal hemoglobinuria (PNH) is a chronic, life threatening hematopoietic stem cell disorder with chronic hemolytic anemia, peripheral blood cytopenias and thrombosis Aims To observe the PNH clone and LDH evolution of the Spanish patients enrolled in the International PNH Registry, the thrombotic events and the role of eculizumab Methods We analyzed the 117 patients enrolled in the Registry until Dec. 31st 2012, classified in 3 groups: Classic/ hemolytic (group I, n 59), PNH with another bone marrow disorder (group II, n 42) and Subclinical (group III, n 14). The variables analyzed were PNH clone size, LDH levels, and incidence of thrombosis. Medians and percentages should be taken with caution due to the relatively small sample size. In addition to data collected in the Registry, additional patient information was obtained from local physicians. Results The median (range) age at presentation was 36.6 yrs. (16-83); 48 patients (41.0%) were women. Median (range) time from disease start to enrollment was 11.3 years in group I (0.1-41.2), 3.5 in II (0.1-33.8) and 3.4 (0.3-20.8) in III. A total of 49 patients (39 in group I) were started on eculizumab, 38 prior to enrollment (31 in group I) and 11 on or after enrollment; 3 were treated prior to enrollment but discontinued for different reasons (pregnancy, ending trial, access problems). Clone evolution (Table 1). In group I the median clone size remained stable during the follow-up period in the Registry; however, 4 patients in group II evolved to group I, with granulocyte clones 〉 50% and LDH levels 〉2000 U/L, while 3 initially in group I evolved to group II at 6, 12 and 18 months respectively. At enrollment 64 patients had a clone ≥30% and 31

Description: Abstract 898 Chronic graft-versus-host disease (cGvHD) remains a major barrier to allogeneic (allo) hematopoietic cell transplant (HCT). Previous studies have identified several variables associated with high mortality in persons with cGvHD. The most consistent risk-factors for mortality are thrombocytopenia and the progressive type of cGvHD onset. We evaluated subject-, disease-, and transplant related variables at diagnosis of cGvHD to develop a risk score in 5343 patients with cGvHD. All patients received first allo-transplant for acute myeloid leukemia (AML), acute lymphoid leukemia (ALL), chronic myeloid leukemia (CML) and myelodysplastic syndrome (MDS) between 1995 and 2004 and reported to CIBMTR. 10 variables were significantly correlated with cGvHD in multivariate analysis of overall survival and non-relapse mortality (NRM) and were used to build the risk score (Table 1). Variable-specific risk scores (VSRC) were constructed for each factor based on the relative risk (RR) of overall or NRM associated with each factor category. Scores were summed for each subject to assign an overall risk score (ORS). Risk groups (RG) of 1–6 were assigned based on the overall risk score. RG1: ORS 0–2, RG2: ORS 3–6, RG3: ORS 7–8, RG4: ORS 9–10, RG5: ORS: 11, RG6: ORS ≥ 12. Survival and NRM were significantly different between RGs (Figure 1 and Figure 2). Although this cGvHD risk score requires independent validation, knowledge of the above HCT factors and cGvHD-specific factors at the time of initial diagnosis provides important prognostic information for clinical care and clinical trial planning. Future analysis will validate this risk score in a more recent allo-transplant cohort assembled after 2005. Table 1: Variable Overall Survival NRM VSRC RR P RR P Recipient age (baseline:

Description: Abstract 1389 Although chronic lymphocytic leukemia (CLL) is considered incurable, a proportion of patients treated with modern therapy achieve complete remission (CR) with minimal residual disease (MRD) negative status, which translates into a better outcome. In addition, survival curves for allogeneic stem cell transplant (alloSCT) appear to plateau, suggesting possible cure. Profound immune disturbances are a major cause of morbidity and mortality in CLL and can be exacerbated by therapy. We studied the immune status of 26 patients with CLL with a sustained (median 8 years, range 2.2 to 17) CR following treatment (4 patients received fludarabine, cyclophosphamide and mitoxantrone [FCM], 6 autologous SCT [autoSCT]) and 16 allogeneic stem cell transplantation [alloSCT]. Lymphocyte subsets were studied using multiparameter flow cytometry and compared to healthy controls. CD8+ T cell response to cytomegalovirus (CMV) was assessed using a pentameric HLA-A2 binding CMV pp65-derived peptide and functionality was confirmed by interferon gamma (IFNγ) ELISPOT. Immunoglobulin subtypes, complement proteins, and β2-microglobulin (B2M) were quantified by standard techniques, interleukin 10 (IL-10) and vascular endothelial growth factor (VEGF) by flow-based cytometric bead array technology, and B cell activating factor (BAFF) and a proliferation-inducing ligand (APRIL) serum levels by commercial ELISA. Median age at the time of study was 57 years (55 for the alloSCT, 54 for the autoSCT and 63 for the FCM patients). Two alloSCT patients had chronic graft-versus host disease (cGVHD) at sample collection and were receiving immunosuppression. In addition, three patients experienced autoimmune cytopenia after alloSCT, but had responded to therapy at the time of the study. Detectable residual CLL cells (〉 10-4) in peripheral blood were found in six patients (3 alloSCT, 3 FCM). The 20 patients in MRD negative CR had a significantly higher absolute B cell count compared to normal controls comprised of both CD19+CD5- cells (154 cells/mm3vs. 76 cells/mm3, p=0.005) and CD19+CD5+ cells (22 cells/mm3vs. 1 cell/mm3, p=0.002). Normal serum levels of immunoglobulin were present in 17 patients whereas 9 had persistent hypogammaglobulinemia (4 were MRD positive, 2 were on immunosuppression for cGVHD and 1 patient had received rituximab). Thus only 2 patients had unexplained hypogammaglobulinemia despite being in MRD negative-CR. T cell abnormalities were also common in these patients. An abnormal CD4:CD8 ratio was present in 9 patients, and CD4+ cells had failed to recover to 〉400 cells/mm3 in an additional 5 patients. An increase in CD8+ cells (620 cells/mm3vs. 379 cells/mm3 in normal controls) was mostly comprised of cells with a chronically activated phenotype, CD8+DR+ (220 cells/mm3vs. 78 cells/mm3 in normal controls, p=0.062). Furthermore, in CMV+/HLA-A2 patients, an elevated cytotoxic CD3+CD8+CD45RA population was seen (200 cells/mm3vs. 51 cells/mm3, p=0.037). In all cases, cytotoxic T cells expansions secrete IFNγ in response to pp65. As regards T regulatory cells, CD4+CD25+FOXP3+ cells were significantly increased in patients after alloSCT compared to normal controls (4.1% of CD4+ cells vs. 2.05% in normal, p=0.023). In contrast, patients who received either FCM or autoSCT had Treg levels equivalent to our normal samples (2.45% of CD4+ cells), including the three patients who were MRD positive after FCM. B2M was elevated in 7 patients. No differences were found in levels of complement proteins C3 and C4, direct Coombs test, IL-10 and VEGF. Nevertheless, patients showed median BAFF serum levels significantly higher than healthy controls, even when those patients with conditions considered likely to elevate BAFF and APRIL were excluded (cGVHD, autoimmune cytopenia) (p

Description: Abstract 4646 Background Myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) are clonal disorders characterized by clinical and prognostic heterogeneity, mainly explained by different genetic abnormalities among other factors. The role of some key genes involved in disease pathogenesis in both entities remain unclear. Methods and patients Study objective was to analyse differences in gene expression related to angiogenesis, metabolism and cell proliferation, self-renewal and pluripotency in patients (pts) with MDS and AML. Thirty-three bone marrow (BM) samples at diagnosis were analysed and distributed in 4 different groups: control group (n=8), low-risk MDS (LR-MDS:10% BM blasts; n=4) and AML (n=6). Total RNA was isolated from BM samples. Genes analysed were: vascular endothelial growth factor (VEGF) for angiogenesis, MYC, macrophage migration inhibitory factor (MIF) and glycogen synthase (GYS) for metabolism and cell-proliferation and Oct4 as transcription factor required to maintain an undifferentiated state for self-renewal and pluripotency. Gene expression was quantified by qRT-PCR in triplicate using ß-actin gene as control. SPSS software (v.16) and Mann-Whitney U-test were applied for statistical analysis (P value ≤.05 was considered significant in all cases). Results After analysis, only mRNA levels of VEGF and MYC showed significant difference between LR-MDS and the control group. However, higher expression of all genes were observed in HR-MDS vs LR-MDS (p≤.05) as shown in table 1. When compared HR-MDS to AML, no difference was observed in VEGF, MYC, MIF and GYS, but significant difference was noticed in mRNA expression of Oct4 in AML samples (p=.032) vs HR-MDS. Globally, gene expression in MDS (pts with LR and HR-MDS) was significant lower than in AML pts in all genes studied as expected. Conclusions Increased expression of VEGF, cMYC, MIF, GYS and OCT4 in HR-MDS vs LR-MDS and in AML vs MDS (global) suggests that these factors may play a relevant role in pathogenesis of both entities. These results point towards a different biological behaviour in less proliferative disease respect advanced stages and AML in different cellular pathways involved in disease progression. They might also justify clinical heterogeneity among patients with MDS and in patients with AML vs MDS as a sole group, and also being responsible for different response to treatment options. Analysis of protein expression is ongoing. Disclosures: No relevant conflicts of interest to declare.

Description: Abstract 211 The adverse impact of chronic GVHD (cGvHD) on health and quality of life is especially critical in children because of their longer life expectancy and problems impacting growth and development. Although risk-factors for developing cGvHD in children are reported, little is known about risk factors for non-relapse mortality (NRM) in children with cGvHD. Identification of predictors for mortality in children with cGvHD could permit risk-adapted therapy, help plan for clinical trials and assist in counseling. We performed a multivariate analysis using data from CIBMTR to identify transplant- and cGvHD-related risk factors for NRM and survival in a cohort of 1117 subjects aged 0–20 years, transplanted from related donors, unrelated donors (URD), or unrelated cord blood (UCB) in 1995–2004 for acute myelogenous leukemia (AML), acute lymphoid leukemia (ALL), chronic myelogenous leukemia (CML) or myelodysplastic syndrome (MDS). Median age was 12 years. Characteristics of cGvHD at diagnosis were: progressive onset (49%), total bilirubin 〉2 mg/dL (16%), thrombocytopenia (platelets

Description: Although increasing numbers of allogeneic stem cell transplants are being performed worldwide using reduced intensity conditionings (allo-RIC), most of the current experience and knowledge on the characteristics of graft-versus-host disease (GVHD), especially chronic GVHD (cGVHD), comes from the use of myeloablative conditioning regimens (MCR). We have analyzed the incidence and characteristics of GVHD among 150 consecutive patients undergoing allo-RIC as compared to 88 concomitant patients undergoing MCR. All patients analized received peripheral blood stem cells (PBSC) from an HLA identical sibling and the same GVHD prophylaxis (cyclosporine and methotrexate). Incidences of acute GVHD (aGVHD) were 69% and 47% among MCR and allo-RIC, respectively (p

Description: Abstract 897 Recent changes in allogeneic hematopoietic cell transplantation (HCT) including increased use of reduced-intensity conditioning, peripheral blood cells as the graft source (PB) and unrelated donors (URD) warrant re-evaluation of risk factors for acute graft-versus-host disease (aGVHD) and its impact on overall survival (OS). Risk factors for these outcomes were analyzed using more recent data from CIBMTR observational database. Methods: The cohort included adult patients ≥ 20 y transplanted from an HLA-identical sibling (SD) (n=3191) or URD (N=2370) for acute myelogenous leukemia (AML), acute lymphoid leukemia (ALL), chronic myeloid leukemia (CML), or myelodsyplastic syndrome (MDS) using a T-cell replete graft from 1999–2005. Six groups were created to evaluate the impact of conditioning [(myeloablative (MA) and reduced-intensity or non-myeloablative (RIC)], total-body irradiation (TBI) and graft source [(bone marrow (BM) or PB] as follows: MA+TBI+PB (group 1), MA+TBI+BM (group 2) MA+ no TBI+PB (group 3), MA+ no-TBI+BM (group 4), RIC+PB (group 5) and RIC+BM (group 6). Separate analyses were performed for SD and URD. IBMTR grade was used to classify aGVHD. A p-value of ≤ 0.01 was considered significant. Results: Among the SD cohort, the probability of aGVHD grade B-D and grade C-D at 100 days was 39% (95% CI, 37–41%) and 16% (95% CI, 14–17%). In multivariate analyses, non-TBI based MA regimens with a BM graft (group 4), RIC conditioning with PB (group 5) and tacrolimus plus methotrexate aGVHD prophylaxis were associated with lower odds ratio of grade B-D aGVHD (Table 1). The probability of OS was 51% (95% CI: 49–53%) at 3 y and 46% (95% CI: 44–49%) at 5 y. In multivariate analyses, grade B-D aGVHD was associated with a higher risk of death. Other independent risk factors for OS are shown in Table 2. Among the URD cohort, the probability of aGVHD grade B-D and C-D at 100 days was 59% (95%, CI 57–61%) and 32% (30-34%). In multivariate analysis, BM with MA (TBI and no TBI) or RIC conditioning (groups 2, 4 and 6) were significantly associated with lower odds ratio of grade B-D aGVHD (Table 1). Other independent risk factors included a diagnosis of CML. HCT from a 7/8 HLA-mismatched URD showed a trend for higher incidence of aGVHD (p=0.02). The probability of OS was 38% (95% CI: 35–40%) at 3 y and 33% (95% CI: 31–35%) at 5 y. In multivariate analysis, grade B-D aGVHD was associated with a higher mortality. Table 2 shows other independent risk factors for OS. Conclusion: Intensity of the conditioning regimen, TBI and the graft source has a combined effect on the risk of aGVHD. In both SD and URD cohorts, BM with MA, non-TBI regimens were associated with lower risk of aGVHD. In URD cohort, BM after a RIC also was associated with a reduced risk of aGVHD. Modulation of these risk factors is needed to reduce acute GVHD incidence and death after allogeneic transplantation. Disclosures: No relevant conflicts of interest to declare.