ALBERT

Description: We have studied the impact of cell dose on short- and long-term graft function and outcome in 905 patients undergoing an unmanipulated allogeneic bone marrow transplantation (BMT) from an HLA-identical sibling (n = 735), a one-antigen mismatched related donor (n = 35), or a matched unrelated donor (n = 135). Median number of nucleated cells infused was 3.4 × 108/kg (25th percentile 2.4 × 108/kg, 75th percentile 5 × 108/kg). Patients were stratified according to cells infused in 3 groups: ≤ 2.4 × 108/kg (n = 247; low dose); 〉2.4 × 108/kg and ≤ 5 × 108/kg (n = 452; intermediate dose); and 〉5 × 108/kg (n = 206; high dose). Patients receiving high cell dose had significantly higher platelet counts on days +20, +50, +100, +180, and +365 after BMT (P〈 .01) and higher white blood cell counts on days +50, +100, and +180 after BMT (P 

Description: Abstract 3050 Background. Allogeneic hematopoietic stem cell transplantation (HSCT) is the treatment of choice for the majority of hematological malignancies. Early and successful immunologic reconstitution after HSCT reduces morbidity and mortality due to infection complications and improves survival. Aim of the study. We analyzed immune recovery after HSCT in 444 patients according to donor source. Patients and Methods. From January 2005 to June 2011 176 patients were grafted from HLA identical siblings (MSD), 125 from alternative donors (1 antigen mismatched family or unrelated donors) (ALT), 103 from unrelated cord blood grafted intra bone (CBIB) and 40 from haplo-identical mismatched family donors (HAPLO). All patients received unmanipulated bone marrow: 283 after a myeloablative (MA) conditioning regimen (CY-TBI or BU-CY) and 161 after a fludarabine based reduced intensity regimen (RIC). Graft versus host disease (GvHD) prophylaxis was cyclosporin methotrexate (CyA+MTX) for all patients except for CBIB (CyA and mycophenolate, MMF) and for HAPLO transplants which consisted of CyA+MMF and post-transplant high dose cyclophosphamide (HDCY) according to the Baltimore protocol (Lutznik et al BBMT 2008). Anti-thymocyte globulin (ATG) was used only for ALT transplants. Results. We compared immune reconstitution in MA and RIC transplants according to donor type at different time points post BMT. CD3+ absolute median counts/μl in MA conditioning on day+30, +90, +180 were respectively in MSD 477, 565, 700; in ALT donors were 146, 404, 470; in CBIB were 30, 57, 196; for HAPLO transplants they were 195, 182, 499. CD3+ absolute median counts/μl in RIC conditioning on day+30, +90, +180 were respectively in MSD 301, 660, 700; in ALT donors were 506, 186, 721; in CBIB 234, 399, 522; in HAPLO were 178, 276, 1300. CD4+ absolute median counts/μl in MA conditioning on day+30, +90, +180 were respectively in MSD 166, 170, 198; in ALT donors were 36, 86, 111; in CBIB 7, 36, 106; for HAPLO transplants they were 45, 127, 211. CD4+ absolute median counts/μl in RIC conditioning on day+30, +90, +180 were respectively in MSD 89, 189, 274; in ALT donors were 131, 210, 220; in CBIB 52, 110, 130; for HAPLO transplants they were 41, 205, 385. CD8+ absolute median counts/μl in MA conditioning on day+30, +90, +180 were respectively in MSD 280, 389, 500; in ALT donors were 102, 278, 413; in CBIB 42, 16, 51; in HAPLO transplants were 73, 424, 408. CD8+ absolute median counts/μl in RIC conditioning on day+30, +90, +180 were respectively in MSD 196, 432, 300; in ALT donors were 366, 65, 494; in CBIB 71, 167, 199; for HAPLO transplants they were 137, 129, 900. CD3, CD8, and CD4 counts in HAPLO transplants were not statistically different from MSD with the only exception of day +30, both for MA and RIC conditioning. Platelet median counts/μl on day+30, +90, +180 in MA conditioning were in MSD 142, 129, 180, in ALT 75, 101, 147, in CBIB were 19, 77, 128 and for HAPLO transplants were 67, 126, 128; in RIC conditioning platelets counts were in MSD 137, 156, 168, in ALT 33, 134, 142, in HAPLO were 77, 95, 188. Acute GvHD II-IV developed in 29% (MSD) 38% (ALT) 16% (CBIB) and 12% (HAPLO) (p=0.004) in MA conditioning and 40% (MSD) 18% (ALT) 25% (CBIB) and 10% (HAPLO) (p=0.07). Overall Cumulative Incidence of Non-Relapse Mortality (CI-NRM) was respectively 18% (MSD), 35% (ALT), 34% (CBIB), 22% (HAPLO) (p=0.02) in MA conditioning (p=0.02) and was 30% (MSD), 33% (ALT), 45% (CBIB), 0% (HAPLO) (p=0.02) in RIC conditioning (p=0.02). Day+100 CI-NRM was respectively 10% (MSD), 21% (ALT), 19% (CBIB), 12% (HAPLO) in MA conditioning (p=0.01) and 11% (MSD), 19% (ALT), 26% (CBIB), 0% (HAPLO) in RIC conditioning (p=0.02). Death due to infections were respectively 6% (MSD), 26% (ALT), 30% (IBCB), 17% (HAPLO) in MA conditioning and for RIC were 15 (MSD), 36% (ALT), 32% (IBCB), 0% (HAPLO). Conclusions. HAPLO transplant with HDCY post transplant as proposed by the Baltimore group, is associated with (1) rapid immunologic (CD3, CD4, CD8) recovery (2) low infectious death rate, (3) low overall and Day+100 CI-NRM, (4) rapid hematologic recovery. These results are comparable with those achieved with MSD and warrant further studies with HDCY post transplant as a GvHD prophylaxis. Figure: absolute CD4+ counts/μl on day+30, +90, +180, according to donor type in MA conditioning regimen. Disclosures: No relevant conflicts of interest to declare.

Description: We evaluated the impact of World Health Organization (WHO) classification and WHO classification–based Prognostic Scoring System (WPSS) on the outcome of patients with myelodysplastic syndrome (MDS) who underwent allogeneic stem cell transplantation (allo-SCT) between 1990 and 2006. Five-year overall survival (OS) was 80% in refractory anemias, 57% in refractory cytopenias, 51% in refractory anemia with excess blasts 1 (RAEB-1), 28% in RAEB-2, and 25% in acute leukemia from MDS (P = .001). Five-year probability of relapse was 9%, 22%, 24%, 56%, and 53%, respectively (P 〈 .001). Five-year transplant-related mortality (TRM) was 14%, 39%, 38%, 34%, and 44%, respectively (P = .24). In multivariate analysis, WHO classification showed a significant effect on OS (P = .017) and probability of relapse (P = .01); transfusion dependency was associated with a reduced OS (P = .01) and increased TRM (P = .037), whereas WPSS showed a prognostic significance on both OS (P = .001) and probability of relapse (P 〈 .001). In patients without excess blasts, multilineage dysplasia and transfusion dependency affected OS (P = .001 and P = .009, respectively), and were associated with an increased TRM (P = .013 and P = .031, respectively). In these patients, WPSS identified 2 groups with different OS and TRM. These data suggest that WHO classification and WPSS have a relevant prognostic value in posttransplantation outcome of MDS patients.

Description: Background. Molecular monitoring of the BCR-ABL transcripts in patients with chronic myeloid leukemia (CML) using quantitative real-time polymerase chain reaction (QRT-PCR) provides important information about the leukemia cell mass and the response to therapy. After allogeneic hematopoietic stem cell transplants (HSCT) patients with persistently positive levels of BCR-ABL transcript have a molecular relapse and some of these patients progress to develop a cytogenetic or hematologic relapse. Objectives. To test whether molecular detection of BCR-ABL transcripts is comparable using peripheral blood (PB) and bone marrow (BM) aspirate samples after allogeneic HSCT. Patients and Methods. BCR-ABL transcripts were monitored the interval of time 2003 – 2005 in 118 patients who received an allogeneic HSCT in chronic or advanced disease phase. BCR-ABL transcripts were evaluated concomitantly in 200 blood samples and 200 marrow samples (total 400 determinations) using real time PCR (QRT-PCR) assay to analyze BCR-ABL gene rearrangement (p210 b2a2 and b3a2). A complete molecular response (CMR) both for PB and BM we defined has undetectable levels of p210 and Major molecular response (MMR) was defined when p210/ABL ratios where

Description: Introduction. Allogeneic stem cell transplantation remains the only curative therapy for patients with myelofibrosis, but is associated with relevant morbidity and mortality, possiby due to the specific nature of the disease. The outcome is significantly worse when alternative donor transplants are compared to matched siblings (MSD): in a recent cooperative study, TRM was 22% in MSD vs 59% in patients receiving unrelated donor grafts (UD) (Blood 2014 124:1183). Aim of the study. This is a retrospective analysis of 95 patients with myelofibrosis (MF) allografted in our Unit between 2001 and 2014. The aim of the study was to assess whether (a) the outcome of alternative donor grafts has improved with time and (b) how this compares with the outcome of identical sibling grafts. Patients were studied in two time intervals-2000-2010 (n=58) and 2011-2014 (n=37). The DIPSS score was comparable in the two time periods, but differences in the most recent group included older age (58 vs 53 years, p=0.004), more family haploidentical donors (54% vs 5%, p

Description: Anemia is one of the most prevalent clinic condition leading to a specialist medical consult. In 2014 our Internal Medicine unit started a Multidisciplinary Anemia Ambulatory (Internist, Immune-Hematologist, Hematologist) with the purpose to rapidly manage, diagnosis and treatment of anemic patients, giving a direct connection between general practitioners and hospital services. We treated and collected data on patients come to our attention in a tertiary care hospital in Genoa (Liguria), an area characterized by elderly population, which often carries more than one comorbidity with the purpose of better define the epidemiology of such a prevalent but underestimated issue. From January 1st 2014 a total of 212 patients came to our attention for internist consult due to anemia: 165 female and 47 male, medium age 63,23 years (F 58,86, M 78,57, range 19-100). A precise classification of anemia was determined for 187 patients: 130 had iron deficiency anemia (IDA, 61,32%), 17 multifactorial anemia (inflammatory disorders, chronic kidney disease and combined deficiency, 8,02%), 16 combined deficiency anemia (iron and vitamins, 7,55%), 9 chronic kidney disease related anemia (4,25%), 7 anemia secondary to inflammatory chronic disorder (3,30%), 5 B12 deficiency (2,36%), 2 both folate and B12 deficiency (0,94%), 1 folate deficiency (0,47%). Twenty-five patients were not classified due to lack of data. Severity of anemia was defined according to WHO criteria: 53 patients (25%) presented mild anemia (Hb 129 - 110 g/L), 123 (58%) moderate anemia (Hb 109 - 80 g/L), 33 (15,6%) severe anemia (Hb 〈 80 g/L). Three patients were not anemic at the baseline evaluation. We considered comorbidities of internistic relevance, which could be worsened by anemia: cardiovascular (coronary heart disease, arrhythmias, heart failure), 30 patients; neurologic (ischemic and degenerative diseases), 19 patients; respiratory disease (COPD and asthma), 11 patients. Eleven patients had 2 comorbidities (cardiovascular and respiratory or neurological) and 3 patients had all three comorbidities. Patients were treated according to clinical practice in relation to type, severity and clinical manifestation of anemia. One hundred and thirty patients needed more than one access to ambulatory to correct anemia; data from the second access were: patient responders (normalization of Hb levels or improvement of at least 20 g/L): 78 patients; partial responders (improvement of Hb levels from 5 to 20 g/L): 34 patients; non responders: 18 patients. Fourteen patients needed at least 1 blood red cells transfusion, 12 with severe anemia and 2 with moderate anemia. A total of 93 patients needed deep diagnostic insight through specialist pathways, such as hematologic (4 patients), gastroenterologic (39 patients), gynecologic (37 patients), both gastroenterologic and gynecologic (13 patients). All patients were managed as outpatients, except for 8 patients which required hospitalization due to severity of clinical findings: 4 patients were hospitalized in Internal Medicine ward, 1 patients in Gynecology and 3 patients needed access through Emergency Care Unit. Among IDA patients, 92 were treated with intravenous iron supplement: 32 with sodium ferric gluconate (SFG) (medium 16,68 vials, range 8-43) and 50 with ferric carboxymaltose (FC) (medium 1,04 vials). Nine patients treated with SFG experienced allergic reaction, so they were switched to FC. Patients treated with SFG were successfully treated for 69,56% and 26,08% responded partially. One patient treated with FC experienced allergic reaction, so he was switched to oral therapy. FC patients fully responded in 76% and 22% were partial responders. These preliminary data shows that Multidisciplinary Anemia Ambulatory and its diagnostic-therapeutic path, with the involvement of different Specialists and Operative Unit, resulted in an improvement of the coordination and continuity of care, reducing sanitary cost in terms of hospitalization, drugs rationalization and quality of life for patients. More data will derive from the newborn Anemia Regional Register, which will lead to a better comprehension of the real size of anemia in our local epidemiology, in which health derived costs are rising together with ageing of the comorbid population which often needs longitudinal assistance, coordination and continuity of care. Disclosures No relevant conflicts of interest to declare.

Description: Background. Hematologic relapse after an allogeneic HSCT for acute leukaemia is associated with poor outcome: in our Unit, 5 year survival for acute lymphoblastic leukaemia (ALL) relapsing after an allograft is 10% and for acute myeloid leukaemia (AML) this figure is 15%. Most relapses (79%) occur within the first year after transplant. Aim of the study. Prospectively assess minimal residual disease (MRD) after allogeneic HSCT to test (a) incidence of MRD positivity, (b) predictive value on hematologic relapse and (c) whether MRD positivity can be used to initiate treatment with donor lymphocyte infusions (DLI). Patients and methods. Seventy three patients with ALL (n=29) or AML (n=44) received an allogeneic HSCT, most of them after a conventional (CY-TBI) conditioning regimen. Re-arrangement for JH regions and fusion genes (bcr/abl) (RQ-PCR) were used to monitor MRD in ALL, whereas Wilms Tumour 1 (WT1) expression (RQ-PCR) was used in AML. Monitoring was done on bone marrow samples taken pre-transplant, and on day+30, +60, +90, +120, +150, +180. At the time of a positive MRD patients would be eligible for DLI in escalating doses, starting at 10^6/kg CD3+ cells for matched related donors, increasing by ½ log every 30 days up to a maximum dose of 5x10^7/kg CD3+ cells. For unrelated and 1 antigen family mismatched transplants the dose of DLI was reduced by 1 log. Number of MRD+ patients post-transplant. Overall 30 patients of 73 patients (41%) were MRD positive after transplant, 66% for ALL and 25% for AML. Predictive value of MRD positivity on relapse. Hematologic relapse occurred in 15 of 30 MRD+ patients and in 2 of 43 MRD negative patients (p=0.0001). For ALL patients these figures were 10/19 vs 2/10 (p=0.09) and for AML it was 5/11 vs 0/33 (p=0.0004). Preventing relapse with DLI in MRD+ patients. Of the 30 MRD positive patients 16 were given no DLI because the donor was not available or unsuitable for second donation at the time of MRD positivity: 14 patients relapsed (87%) and 3 (19%) survive. Fourteen patients were given DLI, one relapsed (7%) and 12 survive (86%). The difference of hematologic relapse in MRD positive patients receiving DLI (8%) or not receiving DLI (57%) is highly significant (p=0.0001). This particularly true for ALL patients receiving DLI (n=10) (1 relapse and 8 survivors) as compared to ALL patients not receiving DLI (n=9) (9 relapses and 1 survivor). Conclusions. This study shows that (a) MRD positivity is frequent after allogeneic HSCT, (b) MRD positivity predicts hematologic relapse and (c) treatment of MRD with DLI protects against hematologic relapse, and improves survival. This study also confirms our previous data on the efficacy of DLI in acute lymphoblastic leukemia, when the tumour burden is low.

Description: Abstract 1725 Patients with myelofibrosis undergoing an allogeneic stem cell transplant (SCT), can be classified as low or high risk based on spleen size, transfusion history, and donor type (BMT 2010;45:458). In the present study we wished to validate this scoring system, based on a larger number of patients and longer follow up. We have now analyzed 70 patients with myelofibrosis and a median age of 51, who underwent an allogeneic SCT in our Unit. The median follow up for surviving patients is 4.4 years (range 0.4–17 years). 33 patients had 0–1 unfavourable predictors (low risk) and 37 patients had 2 or more negative predictors (high risk). Results. The overall actuarial 10 year survival is 41%. In multivariate COX analysis independent unfavourable factors for survival were red blood cell (RBC) transfusions 〉 20 (RR 3,9; p=0,007), a spleen size 〉22 cm (RR 2,8; p=0.01) and an alternative donor (RR 3,4;p=0.001). Donor and patient age and gender, splenectomy and interval diagnosis transplant were not predictive. The actuarial 10 year survival of patients with no risk factors (n=14), is 100%, with 1 risk factor (n=19) 47%, with 2 factors (n=27), 30%, and with 3 negative predictors (n=10) 0%.The actuarial 10 year survival of low risk (0–1 risk factors) and high risk patients (2–3 risk factors) is respectively 66% and 20%(p=0.0001): the difference is due both to a higher transplant related mortality for high risk patients (38% vs 9%, p=0.005) and a higher relapse related death (35% vs 21%; p=0.1). Peripheral blood CD34+ cell counts, pre-transplant, was a strong predictor of survival in univariate, but not in multivariate analysis. Conclusions. Patients with myelofibrosis undergoing an allogeneic SCT, can be classified as low or high risk based on spleen size, transfusion history, and donor type. This scoring system may be useful to identify patients who would most benefit of the transplant procedure. Disclosures: No relevant conflicts of interest to declare.

Description: Leukemia relapse remains a significant problem in patients with AML undergoing an allogeneic stem cell transplant(HSCT). Wilms Tumour 1 (WT1) expression has been shown to be a sensitive marker of minimal residual disease (MRD), both in patients after induction chemotherapy, as well as in patients undergoing an allogeneic HSCT. Hypotheses. The present study had 2 hypotheses: (1) WT1 expression in marrow cells of AML patients post-HSCT, will predict leukemia relapse and (2) WT1 based pre-emptive immunotherapy (IT) such as abrupt cyclosporin discontinuation and/or donor lymphocyte infusion (DLI), will prevent leukemia relapse. Patients. Bone marrow WT1 expression, was monitored in 207 patients with acute myeloid leukemia (AML) before and monthly after an allogeneic HSCT, until day +150, and then at every other outpatient access. Eligible for IT were patients without acute or chronic GvHD, with increased WT1 expression and a a marrow in hematologic remission. The trigger for IT was 180 WT1 copies in a first group of 122 patients (group A): this was based on the fact that WT1 expression in normal bone marrow is up to 180 copies . In a subsequent group of 85 patients (group B) the cut off for IT, was 100 copies, due to the fact that a first analysis of group A had shown 100 copies to be an earlier predictor of relapse (BJH 2013; 160: 503). DLI were given in escalating doses, starting at 1x105 CD3+ cells/kg in alternative donor grafts and at 1x106/kg in HLA identical grafts. DLI were escalated ½ log every month, in the absence of GvHD, to a maximum dose of 1x107/kg. Sixtyfour patients were eligible for IT, but only 35 received IT: reasons for non intervention were ongoing GHD, unavailable donor and delay in WT1 results. Results-Hypothesis N.1. Following transplantation, WT1 expression, was highly predictive of leukemia relapse: 12 relapses in 99 patients with WT1 〈 100 copies /104 abl (12%); 19 relapses in 55 patients with WT1 between 101 and 180 copies (35%) and 37 relapses in 53 patients with WT1 〉180 copies (70%) (p

Description: Background. Reduced intensity conditioning (RIC) regimens have been widely used over the past years with the aim of reducing transplant related mortality (TRM) of allogeneic hemopoietic stem cells transplants (HSCT). The preferred source is peripheral blood (PB) cells, although this source has not been prospectively compared with bone marrow (BM) iun the setting of RIC transplants. Aim of the study. To compare BM and PB allogeneic transplants following a RIC regimen in patients with acute myeloid leukemia (AML), chronic myeloid leukemia (CML) or idiopathic myelofibrosis (IM). Methods and patients. This is a prospective multicenter randomized trial: eligible were patients with AML, CML and IM, aged 45–60, with an HLA identical sibling, Conditioning regimen was thiotepa 5 mg/kgx2 and cyclophopshamide 50 mg/kgx2. Graft versus host disease (GvHD) prophylaxis was low dose cyclosporin and low dose methotrexate. Patients were randomized to receive unmanipulated BM (n=36) or unmanipulated PB (n=35), after stratification for disease phase (1st remission, n=47) or advanced disease (n=24). Median age was 51 in both groups and follow up of surviving patients 760 and 756 days respectively. Results. Engraftment was achieved in all but one patient who has autologous reconstitution. Acute GvHD grade III–IV accurred in 0% vs 12% of BM vs PB patients (p=0.03) and extensive chronic GvHD in 13% vs 37% respectively (p=0.03). Cumulative incidence (CI) of TRM at 5 years is 6% for BM and 9% for PB (p=0.6). Relapse of the original disease occurred in 61% vs 29% of BM and PB patients (p=0.007) and the CI of relapse related death (RRD) is 39% vs 19% respectively (p=0.07). Actuarial 5 year survival is 47% in BM vs 68% in PB paitents (p=0.3). A COX proportional step down analysis shows chronic GvHD to be a significant favourable factor for RRD and survival. Conclusions. In patients receiving a RIC allogeneic graftTRM is low and comparable in BM and PB transplanst;acute and chronic GvHD is more frequent in PB transplants,relapse is significantly decreased in PB transplants and RRD is also lower,there is a non significant survival advantage for PB patients andthe occurrence of chronic GvHD protects against relapse and favourably influences long term survival.