ALBERT

Beschreibung: Purpose Vincristine (VCR) is frequently used for the treatment of pediatric cancer. However, it can lead to dose-limiting vincristine-induced peripheral neuropathy (VIPN). This study aimed to investigate if prolonging the duration of VCR administration (1-hour infusions instead of push injections) reduces VIPN in children with cancer during the first year of treatment. Methods The VINCA trial is an international multicenter randomized controlled trial. Participants were randomized to receive all VCR administrations through push injections or 1-hour infusions. Dose of VCR was 1.5-2 mg/m2 with a maximum of 2 mg. VIPN measurements were performed at baseline and 1-3 times during treatment, depending on the number of VCR administrations and the total treatment time, using 4 items of the common toxicity criteria of adverse events (CTCAE version 4.03): constipation, peripheral sensory neuropathy, peripheral motor neuropathy and neuralgia. Individual item scores range from zero (no complaints) to five (death). The primary outcome of this trial was total sum CTCAE score during first year of treatment. For the current analysis, patients treated for acute lymphoblastic leukemia (ALL) or Hodgkin's lymphoma were included. All included patients were analyzed according to the intention-to-treat principle. Besides VIPN measurements, data on all relevant co-medication during treatment were collected, including data of concurrent azole therapy (as azole treatment is known to interact with VCR treatment). Descriptive data were analyzed using either chi-square tests or t-tests. Longitudinal data were analyzed using repeated measures mixed model analysis for continuous outcomes (total CTCAE sum score) and generalized estimating equations for dichotomous outcomes (having VIPN yes or no, with VIPN defined as a CTCAE score of ≥ 2 on any of the 4 CTCAE items). Patients were considered to have been treated with concurrent azole therapy when azoles were used during the week before or following VCR administration and if ≥ 50% of VCR administrations between two succeeding measurements were given with concurrent azole therapy. Results were corrected for concurrent azole therapy, cumulative VCR dose, disease, age, gender, ethnicity and time since diagnosis. Results In total 90 children (n=45 one hour infusions group, n=45 push injections group) participated in the study, 58 (64%) with ALL and 18 (20%) with HL. Participants in the two randomization groups did not significantly differ regarding gender, age, ethnicity, diagnosis, or cumulative VCR dose. Overall results showed no effect of randomization on total CTCAE score (β=0.07, 95% confidence interval (CI) -0.42-0.56, p=0.78). However, concurrent azole treatment appeared to be an effect modifier in this analysis and therefore results are reported separately for measurements with (n=24) and without concurrent azole therapy (n=226). Among patients who received concurrent azole therapy, total CTCAE sum score was significantly higher in the push group compared to the 1-hour group (β=1.95, 95% CI 0.49-3.41, p=0.01), while among those without concurrent azole therapy, these CTCAE sum scores did not differ between the two randomization groups (β=-0.17, 95% CI: -0.67-0.34, p=0.52). The risk of developing VIPN (no/yes) did not significantly differ between both randomization groups, irrespective whether concurrent azole treatment was given or not (with azole: OR (95% CI)=4.92 (0.60-40.37), p=0.14; without azole: OR (95% CI)=0.97 (0.51-1.82, p=0.92). Conclusions Overall, administration method of VCR given as push injection or 1-hour infusion did not seem to affect the risk of developing VIPN in children treated for ALL or HL when using the current dosing regimen. However, when concurrent azole treatment is given, total CTCAE scores are significantly lower in children in the 1-hour infusion group compared to the push injection group, demonstrating less VIPN. These results indicate that for children treated with VCR and concurrent azole therapy for the prevention or treatment of fungal infections, administration of VCR by 1-hour infusions instead of push injections is recommended. Figure Disclosures Kaspers: Helsinn Healthcare: Consultancy; Boehringer Ingelheim Pharma: Other: Member of a DSMC. van der Sluis:medac: Consultancy; jazz farmaceuticals: Consultancy.

Beschreibung: Key Points REP is an active combination in MM patients refractory to lenalidomide. REP is an all-oral and generally well-tolerated regimen.

Beschreibung: Key Points Pathogen-inactivated platelets were noninferior in preventing bleeding only in intention-to-treat analysis. In contrast to animal models, alloimmunization could not be prevented when using pathogen-inactivated platelets.

Beschreibung: Improved prognostication is required for multiple myeloma (MM). So far, marker development has been based on clinical trials with a study population predominantly younger than 65 years. However, the median age of newly diagnosed MM patients is 66 years old. Based on gene expression profiles of the HOVON-65/GMMG-HD4 dataset, we previously developed the EMC92 prognostic signature, consisting of 92 probe sets for improved prognostication in MM. The EMC92 was validated in the MRC-IX, TT2, TT3 and APEX datasets. These studies were mostly aimed at younger patients with a median age of 57 years. The EMC92 signature was subsequently developed for clinical use as part of the MMprofiler, and termed the SKY92 signature. To assess the validity of the SKY92 signature in older MM patients, we used the HOVON-87/NMSG-18 study, in which induction therapy with melphalan, prednisone and thalidomide, followed by thalidomide maintenance, was compared with melphalan, prednisone and lenalidomide, followed by lenalidomide maintenance (MPT-T vs. MPR-R). The median age of all patients included in this trial was 73 years, with 34% of patients 76 years or older. The median follow up of the patients still alive was 39 months. Of 143 patients both gene expression profiling and clinical data were available (median age 73; 30% ≥76; n=83 MPT-T; n=60 MPR-R). The MMprofiler was used to obtain SKY92 scores, classifying a patient as high risk or standard risk (MMprofiler- CE IVD assay, performed according to the manufacturers' instructions for use at the SkylineDx reference lab, Rotterdam, The Netherlands). The association between survival and the SKY92 signature was evaluated using Cox regression analysis. Kaplan-Meier curves were constructed for visualization. Using the SKY92 signature 22/143 patients were identified as high risk (15.4%). The median overall survival (OS) for high risk patients was 21 months, compared to 53 months for standard risk patients (hazard ratio (HR): 2.9 (95% confidence interval (CI): 1.6-5.4; p=5.6 x 10-4)). The median progression free survival (PFS) in the high risk and standard risk groups were 12 months and 23 months, respectively (HR: 2.2 (95% CI: 1.4-3.7; p=1.2 x 10-3)). In this subset of 143 patients, deletion of 17p (del17p) and gain of 1q (gain1q) were also adversely associated with OS in a univariate analysis. Including SKY92, del(17p) and gain(1q) in a multivariate model demonstrated that SKY92 and del(17p) remained significantly associated with OS (subset of 143 (n=101) with all data known; Table 1). We previously developed the combination of ISS with SKY92: low risk (ISS I-SKY92 standard risk (SR)), intermediate-low (ISS II-SKY92 SR), intermediate-high (ISS III-SKY92 SR) and high risk (ISS I-III, SKY92 high risk; Kuiper et al., ASH 2014, #3358). The Cox model for this combined marker has a p-value for the likelihood ratio test of p=3 x 10-3 for OS (Figure 2) and p=0.016 for PFS. In conclusion, the SKY92 signature (MMprofiler) is a useful prognostic marker to identify a high-risk subgroup in the elderly population. Figure 1. Performance of the SKY92 signature in the HOVON-87/NMSG-18 study. Red line indicates high risk patients (n=22), blue line indicates standard risk patients (n=121). PFS (A); OS (B). Figure 1. Performance of the SKY92 signature in the HOVON-87/NMSG-18 study. Red line indicates high risk patients (n=22), blue line indicates standard risk patients (n=121). PFS (A); OS (B). Table 1. SKY92 in relation to FISH markers in the HOVON-87/NMSG-18 (Hazard ratios (HR), 95% confidence intervals (CI) and p-values (2-sided; p) for Cox proportional hazards analysis). The multivariate analysis (bottom) was performed using the markers significant in the univariate analysis (top). Bold: p

Beschreibung: Introduction Acute myeloid leukemia (AML) is characterized by uncontrolled proliferation of malignant myeloid progenitor cells in the bone marrow that are arrested in differentiation. In AML, genetic aberrations often involve the same genes and play an important role in risk assessment and treatment of AML. In the WHO classification 2016 (Arber et al., Blood 2016), nine AML subtypes of clinical and prognostic importance are distinguished by distinct and practically mutually exclusive mutations, covering 50-60% of AML cases. By analysing an extended panel of genes, Papaemmanuil et al. (NEJM 2016) developed a purely genomic classification of AML. In this system, 11 groups are defined including 6 entities characterized by chromosomal translocations. Similar as in WHO 2016, these 6 entities each account for less than 5% of AML and are identified by metaphase cytogenetics. Of these 6 entities, 5 groups are defined by fusion genes and one group by inv(3)/t(3;3) leading to overexpression of EVI1. The 5 remaining classes include 4 entities with cytogenetically normal AML defined by mutations in NPM1 (27%), bi-allelic CEBPA (4%), genes regulating RNA splicing, chromatin or transcription (18%) and IDH2 R172 mutations (1%) and one entity characterized by mutations in TP53, a complex karyotype or specific aneuploidies (13%). Although the majority of patients can be classified by this new system, 15% of patients still lack class-defining lesions and expression levels of structurally normal genes, which can also have a decisive prognostic impact, are not considered. We propose that whole transcriptome messenger RNA sequencing provides a single and flexible platform to identify the diversity of genetic aberrations relevant for classification of AML. Methods A panel of hundred AML were analysed and HAMLET (Human AMLExpedited Transcriptomics) was developed as bioinformatics pipeline to detect fusion genes, small variants in thirteen genes, long tandem duplications in FLT3 and KMT2A and overexpression of EVI1. In HAMLET, a new algorithm based on soft clipped reads was developed to detect long tandem repeats in FLT3 and KMT2A. All genetic aberrations called by HAMLET were validated by diagnostic data and targeted re-sequencing. Results The data showed that HAMLET correctly called all genetic aberrations relevant for current classification of AML with high sensitivity and specificity. Moreover, the new soft clipped approach that has been integrated in HAMLET proved to be useful not only to detect long tandem duplications in FLT3 and KMT2A, but also to determine the allelic ratio of mutant-to-wild type FLT3, which is predictive for overall survival. By filtering small variants for predicted importance according to large AML sequencing data sets (Jaiswal et al., NEJM 2017), we classified the 100 AML according to genomic classification and showed that 87 cases were classified in single entities, 4 cases in two subgroups and 9 cases had no class-defining lesions. Of the 9 cases without class-defining lesions, 8 cases had detectable driver mutations and one case had no detectable driver mutation. These numbers perfectly match percentages reported by Papaemmanuil et al. (NEJM 2016). Apart from genetic aberrations that are relevant for current classification of AML, HAMLET also identified additional abnormalities. Of particular interest is NUP98-NSD1 (Hollink et al., Blood 2011), a cryptic fusion gene that is missed by metaphase cytogenetics in three AML with no class-defining lesions, and EVI1 overexpression in 5 cases without inv(3)/t(3;3) including three KMT2A-rearranged AML with extremely poor prognosis (Groschel et al., JCO 2013). Conclusions HAMLET correctly called all genetic aberrations relevant for current classification of AML and provides a wealth of additional information with potential consequences for patient management. In conclusion, HAMLET is a comprehensive and reliable pipeline for RNA sequence analysis that may contribute to better risk assessment and personalized treatment of AML. Disclosures Borras: GenomeScan B.V.: Employment. Janssen:GenomeScan B.V.: Employment.

Beschreibung: Primary alterations of the mesenchymal niche can induce myelodysplasia and acute myeloid leukemia in mouse models, introducing a concept of niche-driven leukemogenesis (Raaijmakers et al, Nature 2010). The molecular mechanisms and human relevance of this concept, however, have remained elusive. We addressed these key questions by modelling Shwachman-Diamond-Syndrome (SDS), a human monogenic congenital disorder caused by loss-of function mutation in the SBDS gene and characterized by skeletal defects, bone marrow failure and a striking propensity for leukemic evolution. Targeted Sbds deletion from mesenchymal progenitor cells (MPCs) in mice (OsxCre/+Sbdsf/f; OCSf/f) resulted in bone abnormalities faithfully recapitulating human disease, including short stature and early-onset osteoporosis. Skeletal defects were associated with genotoxic stress in hematopoietic stem and progenitor cells (HSPCs) as demonstrated by mitochondrial membrane hyperpolarization, oxidative stress, DNA damage and cell cycle checkpoint activation (transcriptional modulation of DNA damage response/repair pathways and G0-G1 cell cycle arrest). DNA damage could be partially rescued by in vivo administration of the ROS scavenger N-acetylcysteine supporting the notion of niche induced DNA damage in HSPCs induced by mitochondria-derived superoxide radicals. Mechanistically, Sbds deficiency caused activation of the p53 tumor suppressorpathway in MPCs (upregulation of P53 and transcriptional activation of downstream targets (GSEA). Genetic deletion of Trp53 from MPCs (Osxcre/+Sbdsf/fTrp53f/f mice) rescued the skeletal phenotype and genotoxic stress in HSPCs. Comparison of the transcriptome of MPCs from OCSf/f mice to their highly FACS-purified mesenchymal (CD45-CD235-7AAD-CD31-CD271+CD105+) human equivalents from SDS patients (RNAseq; n=5) demonstrated a striking overlap in disrupted gene programs (GSEA), including ribosome biogenesis and significant overexpression of the proinflammatory molecules such as S100A8 and S100A9, bona fide p53 downstream targets. Activation of p53 and inflammatory molecules was an MPC-autonomous consequence of Sbds depletion as demonstrated by ex vivo knockdown of the gene in OP9 cells. S100A8/A9 overexpression and secretion from MPCs from OCSf/f mice was confirmed by FCM and serum ELISA. Exposure of HSPCs to recombinant murine S100A8/9 resulted in increased DNA damage and apoptosis associated with transcriptional activation of TLR4 downstream signaling, a bona fide S100A8A9 receptor. In vivo TLR4 blockade by neutralizing antibodies resulted in reduced γH2AX foci in HSPCs from OCSf/f mice, in support of the existence of a Tpr53-S100A8/A9-TLR4 axis driving genotoxic stress. Formal demonstration that niche-derived S100A8/9 is sufficient to drive genotoxic stress in HSPCs was provided by transplantation of wild-type hematopoietic cells into recipient S100A8/A9 transgenic mice (Cheng et al., 2008) resulting in accumulation of mitochondrial superoxide radicals and DNA-damage in wild-type HSPCs. Finally, to further define the clinical relevance of this inflammatory MPC-HSPC axis to human disease, we performed massive parallel RNA-sequencing of FACS purified mesenchymal cells from homogeneously treated low-risk MDS patients (n=45). Overexpression of S100A8 and S100A9 in MPCs(confirmed by IHC) was found in a considerable subset of patients (17/45; 38%). S100A8/9+ mesenchymal cells displayed transcriptional activation of p53 and TLR programs, in line with findings in the mouse model. Strikingly, patients in the niche-S100A8/9+ group displayed a higher frequency of leukemia evolution (29.4% vs. 14.2%) with significantly shorter evolution time (average 3.4 (1-7.5) vs 18.5 (7-40); p=.03) and progression-free survival (median 11.5 vs. 53 months, p=.03), independent of established prognostic factors and risk classification systems. Collectively, the data define niche-HSPC inflammatory signaling through the p53-S100A8/A9-TLR axis as an actionable determinant of genotoxic stress and disease outcome in human preleukemia, opening the way to niche-instructed, therapeutic targeting to attenuate leukemic evolution. Disclosures No relevant conflicts of interest to declare.

Beschreibung: Key Points Loss-of-function mutations in CD37 occur predominantly in diffuse large B-cell lymphoma at immune-privileged sites. CD37-mutated lymphoma B cells show impaired CD37 cell-surface localization, which may have implications for anti-CD37 therapies.

Beschreibung: Sepsis is a life threatening organ dysfunction caused by a dysregulated host response to infection. It is a global health care problem and the leading cause of death in ICU patients. A rather unknown but effective mechanism to protect ourselves from such pathogen invasion is immune-adherence clearance (IAC). During IAC pathogens (including bacteria, fungi and viruses) can bind to red blood cells (RBCs) through complement opsonization and subsequent binding to complement receptor 1 (CR1, CD35) expressed on their cell surface. After binding of the pathogen to CR1, the RBCs deliver the pathogens to macrophages of the spleen and liver, where they are phagocytosed and degraded. To study the underlying mechanisms of IAC in more detail, we have developed an assay to monitor the transfer of opsonized pathogens bound to RBCs to human monocytes and/or macrophages under flow conditions, using confocal microscopy. The transfer of a variety of different pathogens, including S. aureus, E. coli and C. albicans, was studied in this assay. When looking at the transfer process in detail, it was noticed that RBC attach to the phagocyte prior to the transfer and remain attached shortly after the transfer, suggesting that RBC might be interacting with phagocytes through adhesion molecules such as integrins to establish firm binding between these two cell types. To test this hypothesis several adhesion molecules, on the phagocytes as well as on the RBC, were blocked by monoclonal antibodies and IAC was quantified. First, complement receptor 3 (CR3, amb2 CD11b/CD18 integrin) an important receptor for adhesion, migration and phagocytosis was blocked by monoclonal antibodies on the phagocytes, after which bacterial transfer was impaired. This indicated that CR3 is crucial for efficient IAC. To confirm the involvement of CR3 in IAC, we analyzed the monocytes of a known LAD-1 patient. This rare immunodeficiency is characterized by an inherited molecular defect of the β2integrin subunit (CD18) which results in impaired adhesion and migration of the patient's leukocytes and clinically manifests in recurrent infections. Our results showed a highly reduced interaction between the phagocytes and the RBCs, resulting in a decrease in bacterial transfer of 〉70%. Next, we tested the effects of blocking antibodies directed against several RBC adhesion molecules on the transfer process. When blocking CD147 (Basigin, Ok blood group) and ICAM-4 (CD242, Landsteiner-Wiener), but not Glycophorin A (GPA, CD235a) on the RBC the transfer process was largely inhibited. These findings demonstrate the involvement of direct cell-cell interactions between RBC and macrophages in IAC and provide evidence that RBC adopt a "sticky" phenotype after binding a pathogen through CR1, which enables phagocytes to bind them under flow. We anticipated that blood bank filters (currently used for leukocyte depletion) might be used to bind and filter RBC-pathogen complexes from blood due to their "sticky" phenotype. This was found to be possible in a series of experiments, not only using in vitrogenerated RBC-pathogen complexes, but also using blood from septic patients. Filtration using a standard leukocyte reduction filter showed reduction of RBC-pathogen complexes close to 100%, independent of the type of pathogen. We foresee that this knowledge can be used to develop a generic approach to deplete RBCs carrying pathogens specifically from the blood stream, and thereby filter RBC-pathogen complexes from the blood of patients suffering from sepsis. Disclosures No relevant conflicts of interest to declare.

Beschreibung: Introduction Elderly non-transplant eligible newly diagnosed multiple myeloma (nte-NDMM) patients also benefit from novel therapies, however, overall survival (OS) is inferior in unfit and frail compared to fit patients as defined by the International Myeloma Working Group (IMWG) frailty index. This is caused by a high discontinuation rate due to toxicity. Therefore, a less toxic effective treatment for unfit and frail patients is needed. In view of the favorable safety profile of ixazomib (Ixa) and daratumumab (Dara), we investigated the efficacy and feasibility of treatment with Ixa and Dara plus low dose dexamethasone (Ixa-Dara-dex) in unfit and frail patients. This trial was registered at www.trialregister.nlwww.trialregister.nl as NTR6297. Methods In this prospective multicenter phase II trial, treatment consisted of nine 28 day-induction cycles consisting of Ixa 4 mg (days 1, 8, 15), Dara 16 mg/kg (cycle 1-2: days 1, 8, 15, 22; cycle 3-6: days 1, 15; cycle 7-9: day 1) and dex (in combination with Dara; cycle 1-2: 20 mg; subsequent cycles 10 mg) followed by maintenance therapy with Ixa (days 1, 8, 15, 29, 36, 43) and Dara (day 1) of 8-week cycles, until progression for a maximum of 2 years. A pre-specified efficacy analysis was planned for the first eligible 23 unfit and 23 frail patients separately at the time the data of the first 9 cycles induction therapy was available. Inclusion criteria were unfit or frail NDMM patients according to the IMWG frailty index. Main exclusion criteria were severe cardiac dysfunction, chronic obstructive pulmonary disease with an FEV1

Beschreibung: Key Points In a multicenter, randomized phase 3 trial, MPR-R was not superior over MPT-T with respect to response rate, PFS, and OS. Grade 3/4 hematologic toxicity requiring growth factor support occurred with MPR-R vs clinically significant neuropathy with MPT-T.