ALBERT

Description: Background: Geriatric deficits in patients with malignancy are predictive of morbidity and mortality. Measuring geriatric deficits provides additional prognostic information not otherwise captured in routine oncology care. Currently, the gap in geriatric-care delivery is the paucity of data demonstrating effective interventions once geriatric deficits are identified. Older adults with hematologic malignancy are understudied and evaluating both the impact of geriatric factors and interventions to improve upon geriatric deficits are warranted. Here we demonstrate the impact of identifying functional impairment and an exercise program among older adults with hematologic malignancy. Methods: This was a single center prospective study of older patients (≥60 years) with hematologic malignancy. Patients actively receiving any therapeutic treatment (chemotherapy, immunotherapy, targeted agents) were enrolled in a six-month exercise program to attenuate functional decline. The Otago Exercise Program (OEP) has been found to be an effective exercise regimen to improve functional balance, muscle strength, and prevent fall-related injury and mortality.1 The OEP is a structured combination of physical therapist prescribed individualized exercise plans with home-based exercise targeted to improve balance and functional decline. Patients enrolled had mild or moderate impairments in physical function, as defined by a score ≤9 on the Short Physical Performance Battery (SPPB). Patients were evaluated at baseline for geriatric deficits (Visit 1), after four months of OEP training (Visit 2), and following two months of self-directed exercise (Visit 3 - end of study) using a standardized Geriatric Assessmpent (GA) tool (CARG GA). The relationship between geriatric deficits and mortality and hospital utilization were analyzed. The change in GA factors over 3 visits were evaluated through a linear mixed model. The proportional hazards model was built to assess the association between Visit 1 GA and overall survival (OS), where OS was defined as time from date of V1 to death, censoring patients who were still alive at time of last follow-up. The generalized linear models were used to link Visit 1 GA with other clinical outcomes such as hospital length of stay (LOS) and the probability of emergency room (ER) visit. Results: Older adults (median age: 75.5; range 62-83) actively receiving chemotherapy for hematologic malignancy were enrolled (n=30). Physical health scores as measured by the MOS-PFS increased significantly at the second visit. [Median MOS-PFS: V1=55 (0-100); V2=70 (30-100), p

Description: Introduction: Multiple myeloma (MM) is associated with profound and widespread disarray of both the adaptive and innate arms of the immune system including loss of effector T cell function, humoral immune deficiency, and natural killer (NK) cell immunity. This immunosuppressive milieu is crucial to promoting disease progression. Standard treatment options (immunomodulators (IMIDs) and proteosome inhibitors, radiation, and high-dose corticosteroids) offer modest benefit, but also contribute to further immune suppression. Little is known regarding the mechanisms by which immune dysfunction and immunoevasion occur. Our group has characterized an important role for the programmed death receptor-1 (PD-1) / PD-L1 signaling axis in these processes. MDV9300 (formerly CT-011 / Pidilizumab) is a novel IgG1 humanized monoclonal antibody (mAb) that modulates the immune response through interaction with PD-1. Lenalidomide (Len) an IMID exerts efficacy in MM in part through enhancement of NK cell versus MM effect - an effect likely mediated through T cell production of interleukin (IL)-2. In our in-vitro study, pretreatment of NK cells with MDV9300 with or without Len enhanced immune complex formation between NK cells and MM tumor targets and also augmented NK cell activation and cytotoxicity against MM. We sought to determine the safety, tolerability and any early signs of efficacy in relapsed or refractory MM patients using MDV9300 in combination with Len. Methods: In the phase I portion, the primary endpoint is to determine the maximum tolerated dose (MTD) of the combination. Key eligibility criteria are relapsed or refractory disease but not progressed on Len 25 mg; ≥2 prior lines of therapy, absolute neutrophil count ≥ 1000/µL; Platelets ≥60,000/µL; and creatinine clearance of ≥ 40ml/min. Patients are treated with escalating doses of MDV9300 and Len utilizing a 3x3 escalation design (Table 1). If stable disease is the best response after 4 cycles, patients have the option of adding dexamethasone (20-40mg weekly). Len dose may be modified independently of MDV9300. Patients can receive a maximum of 12 cycles of therapy. Results: Twelve patients are evaluable to date. The median age was 68.5 (range 49-82) and the median time from diagnosis 4.98 years (range 1.54-12.62). At study entry, 67% had high risk cytogenetics (del 17p, complex karyotype, gain 1q) and the median number of prior treatment lines was 2 (range 2-11). 100% of patients had received prior Len, bortezomib and Dex, 50% alkylating agents (cyclophosphamide, oral melphalan, bendamustine), 75% autologous stem cell transplant, 25% pomalidomide and 33% carfilzomib. MDV9300 infusion has been well tolerated with only one grade 2 infusion related toxicity with sore throat. The patient received hydrocortisone with no further reaction observed. Grade 3/4 Anemia, neutropenia, and thrombocytopenia attributable to therapy have been seen in 25%, 23%, and 34% of patients, respectively. Other common grade 2-3 therapy related adverse events are fatigue (50%), anorexia (17%), and hypophosphatemia (17%). There has been no grade 3 or higher infection and no worsening of neuropathy from baseline. Len dose was reduced in 3 patients (25%) and increased in one. There has been no dose reduction in MDV9300. Dex 20 mg or less was added in 2 patients for muscle cramps and 〈 PR after 3 cycles. To date 7 patients are off therapy; 1 due to grade 3 fatigue and 6 due to disease progression. Five patients continue on therapy at respective 12, 11, 9, 5 and 3 months. Responses to date have been 3 Very good partial response,1 partial response, 2 minimal response and 2 stable disease. Conclusion: The combination of steroid sparing MDV9300 and Len regimen has demonstrated an acceptable toxicity profile to date with evidence of anti-myeloma activity. This is the first reported combination anti-PD-1 based immune therapy for MM. Updated results will be presented at the meeting including the MTD dose for phase II. Table 1. MDV9300- mg/kg Intravenously given on day 3 every 28 days Lenalidomide- mg orally days 1-21 every 28 days DLT Evaluable DLTs Cohort 1 1.5 15 6 Grade 3 fatigue. Cohort extended to 6 Cohort 2 3 15 3 none Cohort 3 3 25 3 none Cohort 4 6 25 0 Acknowledgments: Drug has been provided by Medivation; The study is sponsored by the American Cancer Society Disclosures No relevant conflicts of interest to declare.

Description: Background: Donor grafts with more naive T cells and plasmacytoid dendritic cells were associated with improved overall survival after unrelated donor bone marrow, but not peripheral blood stem cell (PBSC) transplants (Waller, E JCO 2014). Here we present results on influence of innate and adaptive immune subsets in G-CSF mobilized allografts on incidence of acute GVHD (aGVHD) and chronic GVHD (cGVHD) in 238 patients (pts). Methods: We analyzed the absolute numbers and percentages of T, NK, NKT and B cells along with an extensive immunophenotypic characterization of their activation status in consecutive PBSC allografts obtained from sibling and unrelated donors between 2010 - 2014 and studied their association with the incidence of aGVHD and cGVHD. Wilcoxon rank sum tests were used to screen differential marker expression between those who did vs. did not develop aGVHD and similarly for cGVHD. Significant markers were evaluated in the multivariable (m.v.) setting along with known prognostic factors, including: recipient age, related vs. unrelated donor, female donor vs. not, Anti-thymocyte globulin (ATG) use (yes vs. no), and Reduced-intensity conditioning (RIC) vs. not. Cutpoints for markers were generated using recursive partitioning algorithms and evaluated in m.v. models. Results: Of the 238 alloSCT pts evaluated, most (71%) had unrelated donors, 64% received ATG, where most pts with unrelated donors received ATG (83%), and 78% received RIC. The incidence of aGVHD and cGVHD was 58% and 38% respectively. A total of 107 pts had grade II-IV aGVHD reported (71 II, 28 III, 8 IV), and 92 of 192 evaluable for cGVHD (at least 100 days of f/u) had reported cGVHD. Median follow-up in living pts was 21 months (range: 1.4 to 41.1 months). Table 1 shows dichotomized markers most influential on aGVHD. Higher absolute numbers of T cells, activated T cells, CD8+ cells, CD8+ cells expressing IL-7 receptor and CD27 were associated with higher incidence of aGVHD. Higher number of Stage 4 NK cells expressing stem cell factor receptor, and T-regs were associated with a lower incidence of aGVHD. Similar analyses were done for cGVHD (Table 2). Higher absolute numbers of activated T lymphocytes, activated B lymphocytes, KIR expressing CD3+ cells, CD8+ lymphocytes and activated NK cells were associated with higher incidence of cGVHD. When the percent of these makers in relation to total lymphocytes was evaluated regarding association with aGVHD, higher percent of T-regs (OR: 0.204, p=0.0018), effector memory T cells (OR: 0.45, p=0.024) and NKG2D positive NK cells (OR: 0.38, p=0.0008) conferred protection from aGVHD . Similar analysis for cGVHD showed higher percent of naïve CD4+ T cells conferred protection from cGVHD (OR: 0.44; p=0.0062) while higher percent of CD8+ cells (OR: 3.93; p=0.0032) and activated NK cells (OR: 2.08; p=0.024) was associated with cGVHD. Conclusions: These results show a protective role of donor T-regs, CD4+ T cells and Stage 4 NK cells from aGVHD. Additionally, higher content of activated T cells, CD8+ cells and B lymphocytes are associated with higher incidence of cGVHD. Higher content of activated NK cells seems to protect from aGVHD, but not from cGVHD. Updated results including multivariable analyses will be presented. These findings showing the influence of specific subsets in the allograft on aGVHD and cGVHD may provide opportunities for therapeutic interventions for graft engineering or pharmacologic methods for targeting specific immune subsets to decrease incidence of aGVHD and cGVHD. Table 1 Univariate model results for aGVHD with dichotomized markers using cutpoints: Marker Absolute OR p-value CD3+/CD5616- (T lymphocytes) 3.07 0.0013 CD3+/HLA DR+ (Activated T lymphocytes) 3.26 0.012 CD8+/CD45RA- (CD 8+ lymphocytes) 2.56 0.012 CD8+/CD27+ (Effector Memory CD8 cells) 3.25 0.0082 CD8+/CD127+ ( CD8 cells expressing IL-7 receptor) 2.92 0.073 CD4+/CD25+/CD127-(T regs) 0.43 0.057 CD3-/CD16-/CD56+/CD117+ (Stage 4 NK cells expressing Stem cell factor receptor) 0.12 0.0007 Table 2 Univariate model results for cGVHD with dichotomized markers using cutpoints: Marker Absolute OR p-value CD3+/HLA DR+ (Activated T lymphocytes) 4.41

Description: Introduction: Post autologous transplant maintenance therapy with lenalidomide for patients with multiple myeloma (MM) is standard of care (McCarthy et al, NEJM, 2012). Vorinostat (SAHA, Zolinza) is a HDAC inhibitor and preclinical data suggested that HDAC-I's increase MHC class I and class II expression, rendering tumor cells more susceptible to host innate immune killing. Lenalidomide activates NK cells via PP2A inhibition and induces CD56 expression in CD16+CD56- cells thereby enhancing NK cell-mediated ADCC. Initiating lenalidomide to enhance NK cell activity against tumor cells in the early post autologous transplant period may be particularly effective when the NK:myeloma cell ratios favor NK killing, especially if administered after increased MHC class I expression induced by HDAC-I pretreatment. We hypothesized that the combination of vorinostat and lenalidomide would be both tolerable and effective in the post-transplant setting. We have published the initial report of this combination (Sborov, BJH, 2015). We now present the long term follow up. Methods: This was a non-randomized, open-label phase I trial for patients with myeloma who have received high dose IV melphalan followed by autologous peripheral blood stem cell transplant (ASCT) following the three-and-three up-and-down phase I design. Vorinostat was administered beginning at 200 mg starting day +90 after HSCT for days 1-7 and 15-21 of a 28-day cycle combined with lenalidomide 10 mg days 1-21 of a 28-day cycle until progression or clinically significant toxicity. The initial dose of lenalidomide could be increased from 10 mg after cycle 1 and escalated as tolerated up to 25 mg. Results: Sixteen patients were enrolled after autologous transplant with a median age 58 y.o. (range 41-67), with a median number of prior therapies at enrollment of 2 (range 1-8) and mean ISS stage 1.5 (range 1-3). Twelve patients had trisomies on CD138-selected FISH, one patient had normal cytogenetics, and three patients had high risk features [complicated karyotype, t(4;14), or abnormal chromosome 1]. All patients started with 10 mg of lenalidomide and 14 patients received more than one cycle of therapy. 11/14 (78%) were able to escalate the lenalidomide dose. 4/11 (36%) were able to escalate to 25 mg of lenalidomide. The tolerability, toxicities and adverse events have been previously reported (Sborov, BJH, 2015). With a median follow up of 84 months (range 17 - 88), 9 patients (56%) have progressed and 5(31%) have died due to disease progression. Seven patients (44%) remain in complete remission with 5 currently on continued maintenance more than 72 months from ASCT. The median progression-free survival (PFS) is 46.5 months (range 2 - 88) and the median overall survival (OS) has not been reached (17 to NR) (Figure 1). Conclusions: The combination of lenalidomide and vorinostat is well tolerated, with prolonged PFS and OS. Details on the current seven patients still in remission and on continued maintenance will be presented at the meeting. Disclosures Hofmeister: Adaptive biotechnologies: Membership on an entity's Board of Directors or advisory committees; Oncopeptides: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Bristol-Myers Squibb: Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees.

Description: Introduction Multiple myeloma (MM) remains an essentially incurable plasma cell malignancy. MM utilizes specific immunoevasive strategies to avoid natural killer (NK) cell immune surveillance and cytotoxicity. Immunomodulatory agents such as lenalidomide (LEN) may exert indirect anti-MM efficacy via expansion and activation of NK cells. However, these favorable effects may be diminished when LEN is co-administered with high doses of dexamethasone (DEX). IPH2101 is a monoclonal anti-inhibitory KIR antibody which prevents negative signaling in NK cells and enhances NK cell recognition and killing of MM cells. A single-agent, phase I study of IPH2101 demonstrated full KIR blockade with encouraging safety and tolerability, and 34% of heavily pre-treated patients achieved disease stabilization (Blood 2012;120:4324-33). Preclinical data demonstrate that LEN and IPH2101 exert anti-MM effects via complementary NK-cell immunomodulatory mechanisms (Blood 2011;118:6397-91). Herein, data are presented from the first clinical experience with IPH2101 and LEN in combination in patients with MM. Methods A 3+3 phase I dose-escalation trial was conducted. Patients (age 18-80) with measurable, progressive MM were enrolled having received one or two prior lines of therapy. Prior LEN exposure was permitted unless resistance or intolerance was observed. Patients must have had ECOG performance status ≤ 2, creatinine clearance ≥ 60 ml/min, platelets ≥ 75,000/uL (or ≥ 30,000/uL if 〉 50% bone marrow plasma cells), absolute neutrophil count ≥ 1,000/uL, bilirubin 〈 1.5 ULN, and ALT / AST 〈 3 ULN. Patients must have adhered to standard prescribing guidelines for LEN. Three dose levels included: IPH2101 0.2mg/kg IV q 28 days + LEN 10 mg PO days 1-21; IPH2101 0.2 mg/kg + LEN 25 mg, and IPH2101 1mg/kg + LEN 25 mg for 4 cycles. Responding patients were allowed to receive 4 additional cycles. Patients completing all 8 cycles were maintained on LEN thereafter. No administration of DEX or other systemic corticosteroids was permitted. Dose reductions of LEN were permitted per prescribing information. The primary objective was to determine the safety and tolerability of IPH2101 + LEN, the secondary objectives included pharmacokinetics (PK) and pharmacodynamics (PD) of IPH2101 and biologic correlates with LEN as well as to determine clinical activity by standard IMWG uniform response criteria. Results 15 patients (10 M, 5 F, median age 60) were enrolled, 8 in first relapse and 9 in second relapse. 9 had prior LEN exposure. Cohorts 1 and 3 were expanded to n=6 patients respectively due to occurrence of possible dose-limiting toxicity. In both cases, a patient experienced a similar, apparent infusion reaction on cycle 1, day 1, characterized by fever, chills, cytokine release, and leucopenia. Events resolved with supportive care and both patients continued on trial without recurrence. The protocol was amended to include premedication with anti-histamine and acetaminophen,and no further infusion reactions were observed. Most other observed adverse events were of low grade and generally investigator-attributed as possibly or probably related to LEN. IPH2101 PD were not affected by co-administration of LEN. Full KIR occupancy was achieved in cohort 3 across the dosing interval. Five patients achieved a response (2 VGPR, 3 PR) with a median duration of 15+ months (3-26+). Conclusion The combination of IPH2101 + LEN appears to be a safe and well tolerated, and steroid-free combination in MM patients. Infusion reactions have not been observed since the addition of premedication prior to IPH2101 dosing. IPH2101 PD do not appear to be altered by co-administration of LEN, and full KIR blockade over the dosing interval has been achieved. Although the study is small, response rate and response duration are encouraging. These findings support further investigation of antiKIR therapy with LEN as the first, steroid-sparing, dual immunotherapy for MM. Disclosures: Benson: Innate Pharma: Research Funding. Off Label Use: Lenalidomide without concomitant dexamethasone. Zerbib:Innate Pharma: Employment. Andre:Innate Pharma: Employment. Caligiuri:Innate Pharma: Membership on an entity’s Board of Directors or advisory committees.

Description: Background: Multiple Myeloma (MM) is associated with T-cell dysfunction. MM-related T-cell deficiencies are reported as both quantitative and qualitative defects with variable functional abnormalities. The clinical significance of these T-cell abnormalities in MM is not fully characterized. Furthermore, the impact of Autologous Stem Cell Transplant (ASCT) on T-cell subsets and immune checkpoint molecules, including PD-L1, PD-1, BLIMP-1, CTLA-4/CD28, TIM-3, and LAG-3, is being explored. Here we examined these features along with other mRNA markers of cellular senescence, immunosenescence, and exhaustion in MM patients pre- and post-ASCT. These studies aimed to improve understanding of the immunologic changes in MM and relationship to disease progression. Evaluating T-cell immune reconstitution post-transplant is invaluable for future therapies to identify targets or stimulate T-cell response to mitigate relapse. Methods: 100 MM patients were prospectively enrolled in a longitudinal study prior to ASCT for analysis of clinical and biologic factors related to clinical outcomes and event free survival (EFS) post-transplant. Paired peripheral blood T-cells (PBTL) were analyzed (n=31) before ASCT and 90 days post-ASCT. PBTL mRNA targets were anayzed using a custom Nanostring platform (OSU_Senescence) evaluating markers of cellular senescence, immunosenescence, and exhaustion. T-cell populations and subsets were further characterized by flow cytometry pre- and post-ASCT in 20 representative trial patients and 10 age- and sex-matched controls. Serum samples were analyzed for soluble ligands using Luminix MAGPIX multiplex analysis. Results: Increased PBTL LAG-3 mRNA expression at 90 days post-ASCT was significantly associated with EFS, HR 5.44 (95%CI 1.92-15.46, p=0.001, adjusted p* controlling for false discovery rate=0.038). When adjusted for age, a similar relationship of increased PBTL LAG-3 mRNA expression and EFS was found, HR 5.66 (95%CI 1.83-17.47, p=0.003, p*=0.056). No relationship was observed between other mRNA markers of immunosenesence or exhaustion and EFS. Flow cytometric analysis of post-transplant PBTLs revealed an inverted CD4:CD8 ratio, reduced CD28 expression on CD8+ T-cells, and increased levels of CD4+ T-regulatory cells. LAG-3 expression was significantly increased in CD4+ T-cells post-ASCT, predominately in the CD4 naïve and central memory subsets. Soluble LAG-3 (sLAG3) serum concentrations were similar pre- and post-ASCT, and in comparison to controls. Conclusions: We found increased expression of Lymphocyte-Activation Gene, LAG-3 (CD223), on CD4+T-cells post-ASCT. PBTL LAG-3 mRNA expression 90 days post-ASCT was associated with EFS and may serve as an early indicator of adverse outcomes. LAG-3 is expressed on activated T-cells and modulates T-cell expansion and function. Future studies targeting the LAG-3 pathway are warranted to restore T-cell dysfunction and augment immunity in MM. Figure. Figure. Disclosures No relevant conflicts of interest to declare.

Description: Abstract 3807 Intro: Multiple myeloma (MM) is an incurable clonal plasma cell cancer characterized by a microenvironment of inflammatory cytokines, specifically IL-6, VEGF, TNF-α, and marrow stromal cells that all support the growth of myeloma cells. Given the connection between depression with pro-inflammatory cytokines (Kiecolt-Glaser, et al. 2003) and a postulated connection with cancer relapse (Marx 2004), we hypothesized that these inflammatory cytokines not only promote disease progression, but also are associated with the patient's quality of life (Maes, et al. 1997) and that traditional definitions of high-risk disease will correlate with measures of depression and fatigue via circulating inflammatory cytokines. In fact, fatigue and depression might influence disease progression rather than being an obvious consequence. Methods: For this pilot cohort study, we developed web-based versions of the Brief Fatigue Inventory (BFI), Brief Pain Inventory short form (BPI-SF), Functional Assessment of Cancer Therapy – General (FACT-G), and Center for Epidemiologic Studies Depression Scale-short form (CES-D) and administered the survey by tablet computer connected to our Wi-Fi in the myeloma clinic. This was a cohort study of five different patient groups – untreated patients, patients receiving lenalidomide-based therapy, patients 0–2 months post-treatment, patients 6–12 months after completion of treatment, and patients without treatment for more than 12 months. The first 10 patients were filled out feasibility questionnaires to provide data on patients' experience using a tablet computer. Plasma during the visit was cryopreserved and evaluated by RayBioTech's Quantibody Human Inflammation Array platform, a multiplexed sandwich ELISA-based technique of 40 different inflammatory cytokines. Results: We recruited 65 consecutive myeloma patients with complete quality of life data available in 42 patients. The majority of patients found the tablet-based method easy to use and understand, but more than a third did not find the experience enjoyable. On all scales, there was a non-significant worsening in fatigue, pain, and depression with decreased functional well-being in patients from diagnosis through initial treatment compared to patients 〉6 months from the most recent treatment. The FACT-G functional well-being yielded a mean summed score of 18.2+/−6 in this group compared to 21+/−6 in 652 lymphoma patients that were 〉2 years from diagnosis (Crespi CM et al, 2010). The brief fatigue inventory global fatigue score was 2.8+/−2.4. The brief pain inventory short-form mean severity score (the mean of the “worst,” “least,” “average,” and pain “now”) was 2.34. And the weighted sum from the CES-D was 7.19+/− 5.1, similar to breast cancer at least one year from diagnosis (van Wilgen et al, 2006). Quantitative data of the tested inflammatory cytokines will be presented. Conclusion: There have been few efforts to explore the neuropsychoimmunologic axis in myeloma patients. Information generated from this work will allow us to further explore the connection between quality of life measures, myeloma cytogenetics, and circulating inflammatory cytokines, and ultimately devise interventions to improve quality of life of myeloma patients. Disclosures: No relevant conflicts of interest to declare.

Description: Abstract 3564 Background: Autologous stem cell transplant (ASCT) with high-dose therapy (HDT) is an effective treatment modality for multiple myeloma (MM). MM is the leading indication for ASCT in North America. It was shown in a recent meta-analysis that a strategy of using ASCT early in the course of myeloma improves progression free survival (PFS) and quality of life. However, this study addressed only patients who had received conventional chemotherapy. Over the last decade, novel agents (thalidomide, bortezomib, and lenalidomide) have replaced conventional chemotherapy for induction in myeloma. These agents have demonstrated superior response rates when compared to conventional chemotherapy, and there is some indication that using novel therapies for induction before ASCT improves the duration of response and overall survival (OS). However, the question of whether early ASCT is the best strategy in the era of novel agents remains unanswered. We performed a retrospective analysis in order to compare the outcomes of patients with newly diagnosed MM treated with novel agents who received an early versus late ASCT. Methods: 179 newly diagnosed MM patients were treated or referred to The Ohio State University for ASCT between October 2006 and December 2009. All patients in the analysis received either thalidomide, bortezomib, or lenalidomide as part of their induction regimen and went on to receive HDT and ASCT. We compared the outcomes of patients who received ASCT within 12 months of diagnosis (early group, N=134) to those who received ASCT at a later date (late group, N=45). All patients received melphalan 140mg/m2 or 200mg/m2 as preparative regimen. Kaplan-Meier estimates were used to compare PFS and OS. Result: In our sample of 179 subjects there were no statistically significant differences in age, sex, race, performance status, comorbidity index score, disease stage at diagnosis, genetic risk and preparative regimen dose between the two groups. The median time from diagnosis to transplant was 7.2 months in the early group (N=134) and 17.7 months in the late group (N=45). In the early group, 81% of patients had received one line of treatment before transplant vs. 49% in the late group (p 〈 0.001). The overall response rate (ORR) prior to transplant was 90% (9% complete (CR), 31% very good (VGPR), 45% partial (PR)) in the early group, and 83% (9% CR, 22% VGPR, 47% PR) in the late group (p = 0.277). The ORR post transplant was 92% in the early group and 82% in the late group (p = 0.082), with a statistically significant proportion of patients in the early group obtaining CR (52% vs. 27%, p = 0.003). One year non-relapse mortality was 2% for both groups. At a median follow up of 22 months, 36% vs. 47% of patients had progressed (p = 0.29) and 7.5% vs. 24% had died due to disease progression (p = 0.005) in the early vs. late group. Median PFS was 30 months vs. 27 months with 1 year and 3 years PFS of 83% vs. 75% and 64% vs. 55% in the early vs. late group respectively (p = 0.851, Fig. 1). Of patients who had only one therapy pre transplant, results trended toward equivalent PFS in the two groups (p = 0.090), however more than 1 line of therapy and late transplant resulted in a progression hazard ratio of 2.43 (p = 0.050). OS was significantly better in the early group vs. the late group (p = 0.005, Fig. 2). On Cox regression analysis, a late ASCT resulted in a mortality hazard ratio of 3.30. Conclusion: An early ASCT in newly diagnosed MM patients receiving novel agents for induction resulted in an improved OS but not PFS. Patients who are responding well to their first line treatment may have equivalent PFS regardless of time to ASCT. Patients who have had ≥ 2 lines of treatment and underwent ASCT within 12 months had significantly improved PFS compared to those who received ≥ 2 lines of treatment but were transplanted later. Therefore, patients who have not responded to their first line regimen and are within 12 months of diagnosis may have the greatest benefit from ASCT. An extended analysis will be presented at the meeting. A multicenter randomized study comparing early vs. late transplant is underway. Disclosures: Phillips: NCI/NIH: Research Funding; NCCM Grant: Research Funding; ARRA RC2 Grant: Research Funding. Byrd:Genzyme Corporation: Research Funding.

Description: Introduction. The viral oncolytic agent, Reolysin (RV), is a promising novel therapeutic that selectively proliferates in myeloma cells. Our group conducted a phase 1 clinical trial of single agent RV in patients with relapsed and refractory multiple myeloma (MM), and reported that treatment was well tolerated and associated with prolonged disease stability in 25% of patients. Objective responses were not evident, likely because the viral RNA present in the myeloma cells was not producing infectious viral particles. Proteasome inhibitors can lead to myeloma cell death due to increased endoplasmic reticulum (ER) stress and induction of ER-stress related apoptosis (Kelly, Oncogene, 2012). We confirmed this effect preclinically with Carfilzomib (CFZ), and hypothesized that the addition of CFZ to RV would increase viral proliferation and MM cell death sufficiently to obtain objective response in patients with relapsed MM. Methods. For this pilot trial, patients were required to have relapsed myeloma with IMWG-defined measurable disease, ANC ≥ 1,000/uL, platelet count ≥ 50,000/uL, with no creatinine requirements. Cohorts of 6 patients each were planned. Cohort 1 included patients who were CFZ na•ve or had not progressed on a CFZ containing regimen. Intravenous CFZ (20 mg/m2 days 1 and 2 of cycle 1 and 27 mg/m2 thereafter), Reolysin (3 x 1010 TCID50/day), and dexamethasone (20 mg) were administered on days 1, 2, 8, 9, 15, and 16 of a 28-day cycle (Table 1). In situ based methodologies were used to examine the distribution of CD138, CD8, NK cells (CD117 and IL-22), CD 68, PD L1, reoviral capsid protein, and reoviral RNA in bone marrow biopsies performed prior to treatment on days 1 and 9 of cycle 1. Results. Seven patients have been enrolled, four are male, and all are Caucasian. Patients have a median age of 64, and have received on average 2.4 prior lines of therapy and 4.4 prior treatments. All patients were previously exposed to Revlimid and Velcade, and 4 patients were Velcade refractory. One patient was previously treated with CFZ but was deemed to be CFZ sensitive, one patient has dialysis-dependent CKD, and all but one patient had evidence of high-risk cytogenetics on CD138-selected FISH at the time of enrollment. 6/7 patients suffered myalgias and fever after the first two doses of Reolysin, but these symptoms did not recur in any subsequent doses. Treatment has been well tolerated in 5 patients, but 2 patients were removed from study after 2 doses of combination therapy, one for congestive heart failure, and the other for gastrointestinal bleed in the setting of grade 4 thrombocytopenia and an arteriovenous malformation. Due to these 2 DLTs, patient 7 was enrolled at dose level -1 (Carfilzomib 20 mg/m2 and Reolysin 3 x 109 TCID50/day on days 1, 2, 8, 9, 15, and 16 of a 28 day cycle). Within the first 14 days following the initiation of treatment, the mean decrease in platelets for the 7 evaluable patients was 79 (50 - 139), and this included grade 4 (N = 1), and asymptomatic grade 2 (N = 3), and grade 1 (N = 3) events. All patients have had a reduction of the monoclonal protein, 5 patients remain on study, and the longest duration of response is currently 8 cycles. Responses are VGPR (N = 2), PR (N = 3), MR (N = 1), and SD (N = 1) (Figure 1). Intracellular viral replication will be reported at the meeting. Conclusion. This 3-drug regimen is relatively well tolerated in heavily treated patients with relapsed MM. Most patients experience low grade fever and myalgias after the first two doses, and patients have evidence of thrombocytopenia in cycle 1. Combination treatment is associated with reduction of the monoclonal protein in all patients, and 86% (6/7) CFZ-sensitive patients have evidence of objective response. Table 1. Combination treatment dose levels Dose level Dexamethasone (IVP) Carfilzomib (IVPB) Reolysin (IVPB) -1 20 mg/day 20 mg/m2 /day 3 x 109 TCID50/day 1 (starting dose) 20 mg/day C1 Day 1 & 2 - 20 mg/m2 /dayC1 Day 8 & onward - 27 mg/m2 /day 3 x 1010 TCID50/day Figure 1. Waterfall plot representing response of 7 patients with relapsed MM Figure 1. Waterfall plot representing response of 7 patients with relapsed MM Disclosures Off Label Use: Reolysin - oncolytic viral, anti-cancer agent.

Description: Introduction: We reported that microRNA-155 (miR-155) expression is upregulated in donor T cells during aGVHD and mice receiving miR-155 knock-out (KO) donor splenocytes do not exhibit lethal GVHD and have improved survival as compared to mice receiving wild type (WT) splenocytes.1 While we showed that miR-155 does not affect the allo-reactive proliferative potential of T cells, a significant decrease in the expression of the homing receptors CCR5, CXCR4, and S1P1 was found on miR-155-KO T cells, suggesting that the loss of miR-155 could impair the migration of donor T cells to aGVHD target organs resulting in less lethality. Here, we further investigate the impact of miR-155 expression in T cell migration. Materials and Methods: Lethally irradiated BALB/c or B6D2F1 recipients were infused with T cell depleted WT bone marrow (BM) cells (5x10^6) and GFP expressing miR-155 KO or GFP-B6 WT T cells (1x10^6). Recipients were sacrificed at day 7, 14 and 21 post-transplant, organs harvested and donor T cell infiltration evaluated via confocal microscopy. Transwell migration assays towards CCR5 ligands macrophage inflammatory protein-1a (MIP-1a) (100ng/mL) and RANTES (100ng/mL) was performed utilizing WT or miR-155-KO T cells activated using irradiated BALB/c splenocytes as allogeneic stimulators at a stimulator: responder ratio of 1:5. Lower chambers with medium only served as a control for spontaneous migration. CCR5 ligand-dependent migration was calculated according to the formula: Migration Index (MI) = number of cells CCR5 ligands / number of cells medium only. Results: On days 7, 14 and 21 post transplant, recipient mice were sacrificed, and tissues harvested in order to study the kinetics of miR-155 KO T cell migration following allogeneic hematopoietic stem cell transplant. There was a dramatic decrease in T cell infiltration of peripheral organs (PeyerÕs patches, liver, lung and skin) in recipients of miR-155-KO T cells as compared to WT T cells as evidenced by confocal microscopy of GFP labeled donor cells, Figure 1. We reasoned that these effects could be due to the modulation of CCR5 and other chemokine receptors by miR-155. There was a significant decrease in CCR5 mRNA and protein expression in miR-155-KO versus WT donor T cells obtained from recipient mice at the time of aGVHD. To demonstrate the functional significance of decreased CCR5 expression in miR-155 KO donor T cells, we performed in vitro transwell migration assays to CCR5 ligands RANTES and MIP-1a. To our knowledge, we are the first to show that allo-activated miR-155 KO T cells show significantly reduced migration towards CCR5 ligands, as demonstrated by the average MI of 1.08, when compared to the average MI of WT T cells of 4.79, p=0.004, Figure 2. There were lower percentages of CCR5 positive T cells and decreased mean fluorescent intensity in the miR-155 KO T cells after allogeneic stimulation when compared to WT T cells, both in the CD4+ and CD8+ populations, confirming lower CCR5 expression in miR-155 KO T cells after in vitro allogeneic stimulation. To further elucidate the mechanism of miR-155 mediated modulation of CCR5 expression, we focused on long non-coding RNA (lncRNA) LincR-Ccr2-5′AS located in the vicinity of several chemokine receptor encoding genes including CCR1, CCR2 and CCR5, known to be important for migration of Th2 cells. We found that LincR-Ccr2-5′AS has 3 potential miR-155 binding sites and so set out to determine if miR-155 negatively regulates the expression of this lncRNA, thereby influencing chemokine receptor expression as well as T cell migration. We isolated T cells from B6D2F1 recipients 21 days post-transplant, and showed a significant decrease in CCR5 mRNA expression in miR-155 KO versus WT donor T cells but no significant difference in the levels of LincR-Ccr2-5′AS. However, this result does not exclude the possibility that miR-155 might influence the activity rather than the levels of LincR-Ccr2-5′AS, which we hope to determine in future experiments. Conclusion: Our data suggest that miR-155 may exert its modulating effects in aGVHD by affecting T cell migration. Experiments are currently underway to determine the role of miR-155 in modulating T cell migration through other chemokine receptors such as CXCR4, as well as S1P1 and ATP receptor P2X7R. Reference 1. Ranganathan P, Heaphy CE, Costinean S, et al. Regulation of acute graft-versus-host disease by microRNA-155. Blood. 2012 May 17;119(20):4786-97. Disclosures No relevant conflicts of interest to declare.