ALBERT

Description: Introduction The International Myeloma Working Group (IMWG)-frailty index (IMWG-FI) and revised myeloma comorbidity index (R-MCI) are multiple myeloma (MM)-specific frailty scoring systems, which the European Myeloma Network advocates to assess patient frailty, and to select goals and treatments including autologous stem cell therapy (ASCT). In Japan, patients

Description: Abstract 2007 Background: High-dose cyclophosphamide (HD-CY) + granulocyte-colony stimulating factor (G-CSF) and G-CSF alone have been used to mobilize hematopoietic stem cells (HSCs) for autologous SC transplantation (ASCT) in multiple myeloma (MM). However, which regimen is better is unknown; anti-myeloma effects of HD-CY + G-CSF have not been established. From January 1999 to June 2009, we administered HD-CY+G-CSF but changed to G-CSF alone during July 2009–December 2010. We retrospectively assessed HSC collection efficacy, complications, and anti-myeloma effects of these regimens. Patients and methods: We analyzed 147 MM patients from whom HSCs were to be collected at our institute. For mobilization, 115 patients were administered HD-CY (4 g/m2)+G-CSF (600 mg/body filgrastim or 500 mg/body lenograstim) and 32 were administered G-CSF alone (same dose as HD-CY). Here, 17 patients received therapeutic intervention between mobilization and transplantation without disease progression (PD). To avoid the patient outcome effect, we defined event- and progression-free survivals (EFS and PFS). EFS was defined as PD, death, or therapeutic intervention without PD. PFS was defined as PD or death, where therapeutic intervention without PD was used as a censor. Both were calculated from the start of mobilization. For analyzing response by mobilization, patients receiving therapeutic intervention without PD were excluded. Response was evaluated in those not receiving therapeutic intervention without PD or in whom response could not be evaluated before ASCT. Thalidomide was administered as maintenance therapy to 14 and 6 patients in the HD-CY+G-CSF and G-CSF groups after ASCT. Thalidomide administration was used as a censor. Results: Vincristine, doxorubicin, and dexamethasone (VAD) and HD dexamethasone (HDD) therapies were administered as induction therapy (VAD for 117, HDD for 2, and both for 11). New (bortezomib or thalidomide) and alkylating agents were administered to 7 and 13 patients, respectively. Before mobilization, 26 patients received radiotherapy; none were administered lenalidomide. No statistical difference was seen in baseline characteristics (Durie-Salmon stage, International staging system, interval from diagnosis to mobilization, disease control, and previous therapies) between both groups. However, patients mobilized by G-CSF alone were significantly older. Among 147 patients, 121 underwent planned ASCT. Of the 17 receiving therapeutic intervention without PD, 13 and 4 belonged to the HD-CY+G-CSF and G-CSF groups, respectively. More than 2 × 106 CD34-positive cells/kg were collected from 93% and 75% patients in the HD-CY+G-CSF and G-CSF (p = 0.0079) groups, respectively. More than 4 × 106 CD34-positive cells/kg were collected from 84% and 69% in the HD-CY+G-CSF and G-CSF (p = 0.07). Mean HSC count was 11.4 × 106/kg in the HD-CY+G-CSF group and 4.5 × 106/kg in the G-CSF group (p = 0.0007). Among patients receiving HD-CY+G-CSF, 66% were treated with intravenous antibiotics; 3 suffered cardiac shock and 2 septic shock. However, among those receiving G-CSF alone, no severe complications were seen. Median hospitalization days were 21 and 8 for the HD-CY+G-CSF and G-CSF groups, respectively (p 〈 0.0001). In the HD-CY+G-CSF group, 16% improved in disease control before ASCT, 71% showed no change, and 13% progressed. However, no patient improved, 63% showed no change, and 27% progressed in the G-CSF group (p = 0.015). Median EFS was 25 months in the HD-CY+G-CSF group and 13 in the G-CSF group (fig 1, p value of log-rank test = 0.012). Median PFS was 28 months in the HD-CY+G-CSF group and 15 in the G-CSF group (fig 2, p value of log-rank test = 0.011). Median overall survival did not differ significantly. Conclusion: Regarding the safety and duration of hospitalization, G-CSF alone may be safer and beneficial. However, HD-CY+G-CSF was more effective as a mobilization regimen and showed higher anti-myeloma effects than G-CSF alone. Disclosures: No relevant conflicts of interest to declare.

Description: [Background] FLT3 is a class III receptor tyrosine kinase which is widely expressed on hematopoietic stem/progenitor cells. Two types of constitutively active FLT3 mutations have been reported to be expressed on a subset of leukemic cells; internal tandem duplications (ITD) and kinase domain mutations. The former are associated with poor prognosis in acute myeloid leukemia (AML) patients. Although several inhibitors targeting FLT3-ITD are tested in clinical trials, their cytotoxic effects are still unsatisfactory. Innate and acquired resistance is also a problem to be solved. [Purpose] To screen a novel potent FLT3 inhibitor and characterize its in vitro activity. [Materials and Methods] MOLM13 and MV4-11 cells, human leukemia cell lines expressing FLT3-ITD, were exposed to candidate compounds for 48 hours, and cytotoxic effect was assessed by colorimetric assay. Inhibitory effect on autophosphorylation was evaluated by immunoprecipitation and Western blotting. These effects were also tested in 32D cells engineered to express wild type FLT3 (FLT3-WT) or FLT3-ITD. FLT3-WT was activated with 50 ng/ml FLT3 ligand for 15 min. Proapoptotic effect was confirmed by flow cytometry with Annexin V staining. In vitro kinase assay was performed to demonstrate direct inhibition of tyrosine kinase activity of FLT3-ITD. Inhibitory effects on downstream signaling molecules, ERK and STAT5, were assessed by Western blotting. [Results] Among candidates for VEGFR inhibitors from a library, a quinoline-urea derivative Ki23819 (KRN383•HCl) was identified to specifically inhibit proliferation and induce apoptosis to MOLM13 and MV4-11 cells. Ki23819 inhibited proliferation of MV4-11 cells more effectively than SU11248, a precedent FLT3 inhibitor (IC50

Description: Abstract 5001 Background: Renal insufficiency is one of the main complications in myeloma patients. Various causes were reported to be responsible for renal damage. Through analysis of an autopsied cases we would show the diversity of the renal diseases in myeloma. Methods: We studied 41 autopsied myeloma cases from 1979 to 2008 at the National Center for Global Health and Medicine. The kidneys were evaluated by light microscopy using hematoxilin-eosin-stained sections, as well as Congo-red stain when amyloidosis was suspected. Results: There were 21 men and 20 women. Mean age at autopsy was 64.5 years old. The most common lesion was cast nephropathy (41.5%). The giant cell invasion was found in 35.3% of patients with cast nephropathy. Plasma cell tumor involvement was detected in 29.3% of all 41 autopsied cases. Fourteen per cent of cases had both cast nephropathy and plasma cell tumor involvement. In 75.6% of the patients, arteriosclerosis was found. In addition, 32% of the patients had the glomerular sclerosis which involved more than 20% of the glomerulus. Other findings include acute tubular necrosis (31.7%), AL-amyloidosis (19.5%), renal calcification (17.1%), bacterial and fungal infection (7.7%), micro thrombo-embolism (7.7%), mesangial proliferation (4.9%). At least one of above findings were detected in all cases and combined findings were detected in 65.9% cases. Conclusion: We evaluated the renal manifestations in 41 autopsied cases in detail. In all cases, at least one pathological finding was detected. Cast nephropathy was the most common renal manifestation. However, direct myeloma cell invasion was found in 29.3% and combined pathologic findings were common. Disclosures: No relevant conflicts of interest to declare.

Description: Abstract 5004 Background: Despite recent progress in treatment, multiple myeloma is still uncurable disease. The impact of modern therapy on the causes of death and pathological feature of end-stage myeloma is not fully understood. Methods: We studied autopsied cases with multiple myeloma between 1979 and 2009 at National Medical Center of Global Health and Medicine, Tokyo, Japan. We compared the clinicopathological feature of the autopsied cases in recent 10 years with the cases before 2000. Statistical analysis was performed using student's t-test and chi-square test. Results: There were 81 autopsied cases between 1979 and 2009. 31 cases were autopsied in recent 10 years and the older 50 cases were before 2000. Mean age at death was 59.2 and 65.1 years old, and the mean duration of illness was 46.1 and 31.9 months, respectively. Stem cell transplantation was performed in 13 (12 autologous, 1 allogeneic) of recent cases and 3 (2 autologous and 1 allogeneic) of older cases. In recent cases, five patients were treated with bortezomib, 2 were with thalidomide and 2 were with both. Extramedullary infiltration of myeloma cells were observed in both groups. The frequent sites of involvement were spleen, liver, kidney, lymph nodes, lung, pancreas, adrenal gland and perioneum. The infiltration in liver and lung was significantly frequent in the recent cases than in the older cases (58.1% vs. 28.0%, p=0.007, and 38.7% vs. 18%, p=0.039). Infection as a cause of death was noted more frequently in the recent cases than in the older cases (41.9% vs. 18.0%, p=0.019). Amyloid deposition was detected in 16.1% and 22.0% (ns.), and myeloma kidney was noted in 48.4% and 60% (ns.). Conclusion: High dose chemotherapy with stem cell support and novel agents have been contributed to improving the survival. However, the increase in resistant bacterial and fungal infection is serious problem. Also, extramedullary relapse after autologous and allogeneic stem cell transplantation is not rare, and extramedullary progression under thalidomide has been reported. In our recent autopsied cases, the incidence of fatal infection and extramedullary involvement of myeloma cells was significantly higher than in the older cases. Disclosures: No relevant conflicts of interest to declare.

Description: background. High dose therapy and autogenic or allogeneic stem cell transplantation plays an important role in the treatment course of hematological malignancies. In some countries, major method of unrelated stem cell donation programs had shifted from bone marrow harvest (BM) to peripheral blood stem cell harvest (PBSCH). PBSCH is a heavy duty not only for donor or patient, also for medical staffs. In some cases, poor mobilization may cause poor collection of stem cells. Hemogram needs time for May-Giemsa stain, and CD34 count needs complicated technique and running cost. New simple tool to predict the count of mobilized stem cell is needed to optimize PBSCH. methods. Since 2009, we started measuring peripheral blood hematopoietic progenitor cell (HPC) with Sysmex XE-5000(R) blood cell counter. With IMI channel method, we could rapidly know the count of circulating stem cells. Daily HPC count and yielded CD 34 positive cell count were analyzed. results. 189 samples were collected from 122 donors/patients. Diagnosis of patients: malignant lymphoma (n=29), leukemia (3), multiple myeloma (74), amyloidosis (5), cryoglobulinemia (1). 10 healthy donors were also included. Age: 18-66, Sex: male 82/female 40. Mobilization regimen: G-CSF 57, chemo+G-CSF 74, G-CSF+plerixafor 1 HPC count (cells/ul) and collected CD34 positive cells (106cells/kg) had positive correlation. When HPC count was above 25/ul, collected CD34 positive cells were above 1x106/kg (positive predictive value: 80.9%). Number of PBSCH operation was 1.59 in average. We also show three cases in which HPC count was useful to make clinical decision of initiating PBSCH. discussion. HPC and CD34 had positive correlation, and HPC 〉25/ul seems to be appropriate cut-off to start PBSCH. With our former threshold of PBSCH (G-CSF day〉4, WBC 〉3000/ul), 241 operations were to be planned. Including HPC count, we could reduce PBSCH operation to 204. Hematopoietic progenitor cell count is rapid and inexpensive method. Within 5 minutes, mobilized stem cells can be measured, and it may be also useful in outpatient-based harvest settings. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Description: Abstract 3639 Background: The combination therapy of RCHOP [rituximab (R), cyclophosphamide (CY), doxorubicin (DOX), vincristine (VCR), and prednisone (PSL)] is a standardized treatment for diffuse large B-cell lymphoma (DLBCL). However, its clinical outcome is worse in elderly patients because of comorbidities, age-related decrease in organ function, and impaired drug metabolism. If possible, the dose of RCHOP in elderly patients and patients with comorbidities should be adjusted appropriately. Since 2005, we have used a unified dose attenuation system for RCHOP according to the age and comorbidities of patients. This study retrospectively verified this system. Patients/Methods: We analyzed 115 consecutive DLBCL patients treated at our institute from September 2001, when rituximab was approved in Japan, to December 2010. From September 2001 to August 2005, 33 patients received dose adjustment of RCHOP according to the physician's discretion (PHY group). From September 2005, 82 patients received RCHOP according to the unified dose attenuation system (UNI group). In the UNI group, patients younger than 60 years received the standard RCHOP dose [R, 375 mg/m2; CY, 750 mg/m2; DOX, 50 mg/m2; VCR, 1.4 mg/m2 (max 2.0 mg/body); PSL, 100 mg/m2]. In patients older than 60 years, the doses of CY, DOX, VCR, PSL, and R were attenuated as shown in Table 1. In addition to age, the doses of CY, DOX, and VCR were adjusted according to organ functions (Table 2). The two groups were compared statistically. Results: The median age of patients was 70 years (range, 38–91), with 70.4% of patients classified as stage III or IV DLBCL, 40.4% with an international prognostic index (IPI) score of 0–2, and 70.2% with a ECOG performance status (PS) of 0 or 1. Low serum albumin levels (under normal range) were observed in 50.5% patients, and a high Charlson comorbidity index (CCI) score of 〉1 was found in 58.3%. The characteristics of the patients in the two groups were almost similar. The UNI system was completed in 94% of patients. The complete response (CR) rate was 63% in all patients (UNI group, 73%; PHY group, 39%; P = 0.0006). Univariate analysis revealed that better prognostic factors for CR were a low IPI score, better PS, and the UNI group. In the multivariate analysis, only the UNI group was a significantly better prognostic factor for CR. With a median follow-up of 26 months, the 5-year event-free survival (EFS) and overall survival (OS) were 39.3% and 68% in all patients, 43% and 72% in the UNI group, and 27% and 59% (5-year EFS; P = 0.0083, 5-year OS; P = 0.16) in the PHY group, respectively. Multivariate analysis showed that better prognostic factors for EFS were a low IPI score, a low CCI score, and the UNI group, and that for OS were low IPI and low CCI scores. In elderly patients aged 〉70 years (N = 59), the CR rates were 81% and 13% in the UNI and PHY groups, respectively (P = 0.0004), with OS in the UNI group being longer than that in the PHY group (72% vs. 59%; P = 0.02; Fig.1). In the UNI group, patient age did not affect the CR rate (79, 79%; P = 0.56) or 5-year OS (79, 66%; P = 0.58). The actual dose of CY, DOX, and VCR compared with the standard RCHOP dose was 64% and 26%, 63% and 16%, and 63% and 21% in the UNI and PHY groups, respectively. Disease progression during treatment, discontinuation of therapy, and death during treatment were observed in 10% and 15%, 5% and 24%, and 5% and 3% in the UNI and PHY groups, respectively. Nineteen patients (23%) from the UNI group died over a median follow-up of 15 months, while 15 patients (45%) of the PHY group died over a median follow-up period of 29 months. Lymphoma-related deaths were 12 (14%) in the UNI group and 8 (24%) in the PHY group. Five secondary primary malignancies (SPM) were observed (1 colon cancer and 1 breast cancer in the PHY group, and 1 lung cancer and 2 myelodysplastic syndrome in the UNI group). Four deaths were related to SPM. Conclusion: The unified dose attenuation system determined by the patients' age and comorbidities may achieve an effective dose level and better prognosis in elderly DLBCL patients. Disclosures: No relevant conflicts of interest to declare.

Description: Transcription factor AML1/RUNX1, initially isolated from the t(8;21) chromosomal translocation in human leukemia, is essential for the development of multilineage hematopoiesis in mouse embryos. AML1 negatively regulates the number of immature hematopoietic cells in adult hematopoiesis, while it is required for megakaryocytic maturation and lymphocytic development. However, it remains yet to be determined how AML1 contributes to homeostasis of hematopoietic stem cells (HSCs). To address this issue, we analyzed in detail HSC function in the absence of AML1. Notably, cells in the Hoechst 33342 side population fraction and c-Kit-positive cells in the G0 cell cycle status were increased in number in AML1-deficient bone marrow, which suggests enrichment of quiescent HSCs. We also found an increase in HSC number within the AML1-deficient bone marrow using limiting dilution bone marrow transplantation assays. Thus, the number of quiescent HSCs is negatively regulated by AML1, loss of which may result in accumulation of leukemic stem cell pool in AML1-related leukemia. To identify mechanisms through which functional loss of AML1 exerts leukemogenic potential, we focused on the AML1-Evi-1 chimeric protein, which is generated by the t(3;21) chromosomal translocation and disturbs the normal function of AML1. We introduced AML1-Evi-1 and its mutants into murine bone marrow cells, and evaluated hematopoietic cell transformation by colony replating assays. The transforming activity of AML1-Evi-1 was impaired when any of the major functional domains of AML1-Evi-1 was lost. Moreover, overexpression of Evi-1 could not transform AML1-deleted bone marrow cells, suggesting that fusion of AML1 and Evi-1, rather than AML1 suppression and Evi-1 overexpression, is essential for AML1-Evi-1 leukemogenesis. Intriguingly, among the hematopoietic progenitor cell fractions, AML1-Evi-1 could transform only the uncommitted, immature hematopoietic cells, which contrasts with MLL-ENL, a chimeric protein generated in t(11;19) leukemia. AML1-Evi-1 transformed cells show a surface marker profile different from that of the cells transformed by AML1-MTG8/ETO, another leukemic gene product that also perturbs AML1 function. These results provide a valuable clue to a distinct mechanism determined by the Evi-1 moiety in the AML1-Evi-1 leukemogenesis and to a role of AML1 loss in the self-renewal of leukemic stem cells.

Description: Background Kidney injury and/or renal failure are common complication in multiple myeloma. Well known mechanism is deposition of free immunoglobulin light chains in renal tubules leading to cast nephropathy and renal failure. In addition, not only cast nephropathy, but also invasion of myeloma cells is frequently found in autopsied cases of multiple myeloma. Recent development of treatment improved the remission rate and survival of multiple myeloma. Few data exist about pathological findings of kidney injury and it is not well known about kidney findings in autopsy cases at era of novel agent. We investigated the pathological findings and the factors associated with kidney injury in the consecutively autopsy cases. Methods We reviewed the autopsy reports and medical records of 93 consecutively autopsied multiple myeloma cases between 1979 and 2012 at the National Medical Center for Global Health and Medicine in Tokyo, Japan. Patient profile, the clinical records including treatment and the duration of illness, the type of monoclonal gammopathy, clinical stage and history of treatment were studied. Durie & Salmon's criteria was used for diagnosis and staging. The pathological findings like cast nephropathy, invasion of myeloma cell at kidney and the other findings of whole samples were studied gross and microscopically. Immunohistochemistry and Congo-red stain were performed. The pathological findings and the factors were statistically analyzed using Student's t-test and the chi-square test. Results In 93 autopsy cases, 58% was male. Mean age and the duration of illness were 64.3(38-85) years old and 41 months (24.4-37.5). Thirteen patients and 14 were treated with SCT and hemodialysis (Table. 1). Cast nephropathy and direct invasion about kidney were observed in 51.2% and 29.3%, respectively. Other frequent finding associated with myeloma was renal amyloidosis (29%). Frequent non-specific findings were arteriosclerosis (76 %), glomerulosclerosis (61%). Combination of findings were found in 66% cases (Fig.1). The tumor volume in bone marrow (percentage of myeloma cells in cellular component) had correlation to incidence of direct invasion (Pearson's correlation factor is 0.55, p

Description: Background Autologous stem cell transplantation (ASCT) has been a part of the standard therapy for newly diagnosed multiple myeloma and several studies showed double ASCT improved the outcome in comparison with single ASCT, especially the patients who failed to achieve very good partial remission (VGPR). Recently, the introduction of novel agents significantly improved the response rate of the treatment for the multiple myeloma. Although ASCT is still crucial for newly diagnosed myeloma patients, the role of the double ASCT is unclear in the era of novel agents. We performed a single institution-based retrospective study. Methods We reviewed the medical records of patients who treated with ASCT for multiple myeloma between January 2001 and April 2013 in National Center for Global Health and Medicine, Tokyo, Japan. The regimen of the remission induction therapy, number of stem cell transplantations, survival after the first ASCT, progression free survival, the response after the induction therapy and the first ASCT were analyzed. Results Since 2001, we performed ASCT for 167 patients. Ninety-three patients were treated with double ASCT, and 2 patients were treated with tandem ASCT–allogeneic SCT. In 127 patients were treated with vincristine, adriamycin, and dexamethasone (VAD) as an induction therapy, and 40 patients were treated with bortezomib and dexamethasone (BD). Very-good-partial-remission (VGPR) or complete remission (CR) was obtained in 25.2%, 34.6% of the patients treated with VAD, and in 45.7%, 54.3% with BD regimen before and after the transplantation respectively. Overall survival (OS) and progression free survival (PFS) did not differ significantly between VAD and BD induction, the estimated 2 year-OS was 89.8% vs. 79.5%, and the 2 year-PFS was 43.2% vs. 63.5% respectively. Double transplantation improved PFS and OS in VAD induction than single transplantation (p=0.000, p=0.002). In BD induction, patients who failed to achieve VGPR or better after the first ASCT, double transplantation improved OS (p=0.010) but not PFS. In both VAD induction and BD, there was no significant survival benefit in double transplantation in patients who achieved VGPR or better. Conclusion The achievement of VGPR or better after the ASCT resulted in significantly better PFS. The role of double transplantation is still crucial for patients with inadequate response after the first ASCT even in the era of novel agents. Disclosures: No relevant conflicts of interest to declare.