ALBERT

Description: B cells require signals delivered through B-cell activating factor of the TNF family receptor (BAFF-R) and CD40 to survive and produce antibody responses in vivo. In vitro data indicate that these signals are controlled by the homologous RING finger proteins cIAP1 and cIAP2, in collaboration with TRAF2 and TRAF3. There is also mounting evidence that all 4 of these signaling molecules can act as tumor suppressors in human B-lineage malignancies. However, it has not been possible to identify the roles of cIAP1 and cIAP2 in controlling B-cell physiology because of the absence of an appropriate in vivo model. Here we describe a unique genetically modified mouse in which the linked cIap1 and cIap2 genes can be independently inactivated. Deletion of cIAP1 plus cIAP2 (but not either protein alone) rendered primary B cells independent of BAFF-R for their survival and led to their uncontrolled accumulation in vivo. B cells deficient in cIAP1 and cIAP2 were also incapable of forming germinal centers, a key step in antibody-mediated immunity. These data define a fundamental role for cIAP1/cIAP2 in regulating B-cell survival and responsiveness, show this requires direct binding to TRAF2, and suggest how mutations of TRAF2, TRAF3, and cIAP1/cIAP2 contribute to B-lineage malignancies, such as multiple myeloma.

Description: Special AT-rich binding protein 1 (SATB1) is a global chromatin organizer and a transcription factor regulated by interleukin-4 (IL-4) during the early T helper 2 (Th2) cell differentiation. Here we show that SATB1 controls multiple IL-4 target genes involved in human Th cell polarization or function. Among the genes regulated by SATB1 is that encoding the cytokine IL-5, which is predominantly produced by Th2 cells and plays a key role in the development of eosinophilia in asthma. We demonstrate that, during the early Th2 cell differentiation, IL-5 expression is repressed through direct binding of SATB1 to the IL-5 promoter. Furthermore, SATB1 knockdown-induced up-regulation of IL-5 is partly counteracted by down-regulating GATA3 expression using RNAi in polarizing Th2 cells. Our results suggest that a competitive mechanism involving SATB1 and GATA3 regulates IL-5 transcription, and provide new mechanistic insights into the stringent regulation of IL-5 expression during human Th2 cell differentiation.

Description: Reconstitution of adaptive T-cell responses to human cytomegalovirus (CMV) is critical to protection from CMV disease following hematopoietic stem cell (HSCT) or solid organ transplantation (SOT). However, there is an incomplete understanding of which CMV antigens and epitopes are most crucial to providing protective responses. The functional status of cytotoxic T-lymphocyte (CTL) populations recognizing cytomegalovirus IE-1 and pp65 polypeptides was investigated in PBMC from either HSCT or SOT recipients. Our previous finding of differing levels of degranulation between CMV IE1 and pp65/pp50 specific T-cells was complicated by the possibility that differences were epitope and/or HLA-specific. We generalized the approach using a combined flow-based CD107a/b degranulation/mobilization and intracellular cytokine (ICC) assays using peptide libraries as antigens. These assays indicated that a significantly higher proportion of pp65-specific CTLs were in a more mature functional state compared to IE-1-specific CTLs. Degranulation/multicytokine ICC assays also indicated that a significantly higher proportion of the pp65-specific versus IE-1-specific CTLs secreted both IFN-γ and TNF-α, in addition to possessing greater cytotoxic potential. These results support our earlier findings of functional differences between CTLs recognizing individual epitopes within the IE-1 and pp65 antigens in HSCT recipients, and extend them to a broader array of HLA-restricted responses to those antigens. A report that a subset of HIV-1 specific CTLs capable of producing both IFN-γ and TNF-α was associated with improved cytotoxic activity prompted us to investigate whether degranulation, a functional correlate of cytotoxicity, was positively associated with dual cytokine production and predicted differences between IE1 and pp65-specific CD8+ T-cells. A higher proportion of pp65-specific compared to IE1-specific T-cells were present in the trifunctional IFN-γ+,TNF-α+, CD107+ population (p=0.008) in HSCT recipients. We have extended these findings to investigate the role of donor CMV status in terms of functional maturity of CMV-specific T cell response in transplant recipients. T cell maturation/function may act as a mechanistic correlate to the survival advantage of recipients receiving a stem-cell graft from CMV sero-positive donors. These principles have also been applied to investigations of a high risk population of sero-negative recipients of a sero-positive liver allograft. Data from this study will also be reviewed in the context of the model of trifunctional T cells being indicative of enhanced protective capacity against CMV disease and associated with survival.

Description: Leukocyte Alkaline Phosphatase (LAP) Score is valuable in the work-up of certain hematological diseases. Most notably, the score is decreased in Chronic Myelogenous Leukemia and Paraoxysmal Nocturnal Hemaglobinurea but increased in leukemoid reaction to infection and Polycythemia Vera. Last year we reported the LAP scores of 14 patients with Myelodysplastic Syndrome (MDS). Our results showed that patients with less than 5% bone marrow blasts had significantly higher LAP scores than patients with 5–19% bone marrow blasts. We raised the possibility that LAP scores decrease as MDS progresses (Blood, Nov 2006; 108: 4865). In the present study we attempt to further evaluate the utility of LAP in MDS. In addition to our original cohort, bone marrow aspirate results and LAP scores were reviewed from 14 more patients with MDS, for a total of 28 patients. We again assessed the relationship of LAP to bone marrow blast percentage. Furthermore, we recorded a second LAP score, taken at a later date, from 16 of the 28 patients. For those patients with two LAP scores we compared the trend of LAP score to the interval activity of MDS, using transfusion requirement, complete blood cell count (CBC) and clinical assessment as markers of disease activity. In our analysis of LAP score relative to bone marrow blast percentage we again found a significant difference between patients with less than 5% blasts (n=8) and those with 5% to19% blasts (n=20). Patients with less than 5% blasts had significantly higher LAP scores (90.25 ± 18.27) than those with 5 to19% blasts (44.35 ± 52.09) (p

Description: Sphingosine-1-phosphate (S1P), the bioactive product of sphingosine kinase (SK) activation, is a survival factor for endothelial cells. The mechanism of SK-mediated survival was investigated in endothelial cells with moderately raised intracellular SK activity. Overexpression of SK mediated survival primarily through the activation of the phosphatidyl inositol 3-kinase (PI-3K)/protein kinase B (Akt/PKB) pathway and an associated up-regulation of the antiapoptotic protein B cell lymphoma gene 2 (Bcl-2) and down-regulation of the proapoptotic protein bisindolylmaleimide (Bcl-2 interacting mediator of cell death; Bim). In addition there was an up-regulation and dephosphorylation of the junctional molecule platelet endothelial cell adhesion molecule-1 (PECAM-1), which was obligatory for activation of the PI-3K/Akt pathway, for SK-induced cell survival, and for the changes in the apoptosis-related proteins. Thus, raised intracellular SK activity induced a molecule involved in cell–cell interactions to augment cell survival through a PI-3K/Akt–dependent pathway. This is distinct from the activation of both PI-3K/Akt and mitogen-activated protein kinase (MAPK) pathways seen with exogenously added S1P. Cells overexpressing SK showed enhanced survival under conditions of serum deprivation and absence of attachment to extracellular matrix, suggesting a role for SK in the regulation of vascular phenomena that occur under conditions of stress, such as angiogenesis and survival in unattached states, as would be required for a circulating endothelial cell.

Description: Background: Patient report of disease- and treatment-related symptom burden in acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) is scarce. Symptom burden is the combined impact of disease and treatment symptoms on daily functioning. Lack of recognition and monitoring of symptoms and symptom burden can lead to inadequate management and possible treatment non-adherence. Aims: Our aim is to develop a short, valid, reliable patient-reported outcome measure of symptoms and symptom burden experienced by AML and MDS patients and to determine the validity of a single measure for research and practice. Methods: After obtaining IRB approval, patients with AML (N=152) and MDS (N=97) were recruited to this cross-sectional study. Patients rated the 13 core symptom items (pain, fatigue, nausea, disturbed sleep, distress, shortness of breath, trouble remembering, lack of appetite, drowsiness, dry mouth, sadness, vomiting, and numbness and tingling), 6 proposed AML/MDS symptom items (muscle weakness, malaise, fever, headache, diarrhea, skin problems), and 6 interference items (general activities, mood, work, relations with others, walking, and enjoyment of life) of the MD Anderson Symptom Inventory (MDASI) on 0-to-10 scales (0 = not present or no interference; 10 = as bad as can be imagined or complete interference) twice 1-2 days apart. Clinical and demographic information was collected from medical records and analyzed using descriptive statistics. Means of the symptom and interference ratings for the AML and MDS patients were compared using T-tests. Standard psychometric techniques were used to determine the reliability, stability, and validity of the instrument in patients with AML and MDS. Results: All MDS patients were outpatients while 75 of the AML patients were inpatients and 77 were outpatients. The AML and MDS patients had been diagnosed a mean of 13.8 months (standard deviation [SD]=23.9) and 30.5 months (SD=32.4) respectively. The mean (Mn) symptom and interference ratings respectively for the AML inpatients (Mn=2.8, SD=1.6; Mn=4.0, SD=2.4) were significantly higher than for the AML outpatients (Mn=1.8, SD=1.4, p

Description: We performed a case-control study to determine the association of BK plasma viremia with hemorrhagic cystitis (HC) in hematopoietic cell transplant (HCT) recipients. Thirty cases of HC (14 of which occurred after platelet engraftment with documented BK viruria [BK-HC]) were compared with matched controls. Weekly plasma samples were tested for BK virus DNA by polymerase chain reaction (PCR). BK viremia detected before or during the disease was independently associated with HC (adjusted odds ratio = 30, P 〈 .001); BK viremia was even important before clinical symptoms of HC occurred (odds ratio = 11, P 〈 .001). Cases of HC and BK-HC had a significantly higher peak of BK plasma viral load than controls. BK virus was detected by in situ hybridization in bladder biopsies of 2 cases with severe HC and long-lasting BK viremia. BK virus seems to play a role in the development of HC and quantitative detection of BK DNA in plasma appears to be a marker of BK virus disease in HCT recipients.

Description: Introduction: The objective of study was to determine the risk factors, stroke mechanisms and outcome following a stroke in Multiple myeloma (MM) patients. Materials and Methods: We conducted a matched cohort study from a prospective database of MM patients enrolled in TT2, TT3A, TT3B protocols who developed a vascular event (transient ischemic attack, ischemic stroke and intracerebral hemorrhage) from 1998 to 2014 with age, sex and treatment matched controls. Comparison of baseline demographics, risk factors, myeloma characteristics, laboratory values and mortality between both groups was performed using Pearson's Chi-square test for categorical variables and student T test for continuous variables. Multivariate logistic regression analysis was performed to identify risk factors associated with stroke. For statistical analysis SAS 9.4 software was used and p value of ≤ 0.05 was considered significant. Strokes were classified using the modified Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Results: Of 1148 patients, 46 developed a vascular event (Ischemic stroke (TIA)-33, Transient ischemic attack-11, Hypertensive intracerebral hemorrhage-2). On univariate analysis, predictors of stroke were a positive smoking history (26.1% vs 13% p=0.0381), renal insufficiency (23.9% vs 8.0% p=0.0039), hemodialysis (10.9 vs 0.7% p=0.004) and MM Stage I and II as opposed to Stage III (Stage I - 23.9% vs 9.4%, Stage II - 17.4% vs 12.3, Stage III - 58.7% vs 78.3% p=0.025). Despite the lack of significant difference in the baseline laboratory values between both groups, among the cases, there was a significant decrease in the platelet count (112.6 vs 255.2, p

Description: Objective: Patient report of symptom burden from acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) is scarce. Symptom burden is the combined impact of symptoms from disease and treatment on daily functioning. We are developing a measure of symptom burden in AML and MDS. The purpose of this interim analysis is to compare the symptom burden of patients with AML and MDS. Methods: Patients with AML or MDS rated the 13 core symptom items, 6 proposed AML/MDS-specific symptom items, and 6 interference items of the MD Anderson Symptom Inventory on a 0-10 scale (0 = not present or no interference; 10 = as bad as can be imagined or complete interference). Patient clinical and demographic information was collected from medical records. The symptom burden of AML/MDS was determined and compared using descriptive statistics and t-tests. Results: Mean ages of the 45 AML patients and 48 MDS patients were 62.4 (standard deviation [SD] = 11.3) and 68.5 years (SD = 9.2; p = 0.005), respectively; 61% and 60% (p = not significant), respectively, were male; 76% and 92% (p = 0.043), respectively, were white. The composite mean severity score of the core symptom items was 2.75 (SD = 1.58) and 1.84 (SD = 1.52; p = 0.006), the composite mean of the AML/MDS specific items was 2.51 (SD = 1.87) and 1.49 (1.60; p = 0.005), and the composite mean score of the interference items was 3.96 (SD = 2.72) and 2.81 (SD = 2.69; p = 0.042) for the AML and MDS patients, respectively. The means, ranks, significance of difference in ratings, and prevalence of the individual symptom and interference items for the AML and MDS patients are in Table 1. Cronbach α for all symptom items was 0.94 and for all interference items was 0.92. Conclusions: Patients with AML and MDS experience similar symptoms. However, patients with AML report significantly more severe pain, fatigue, nausea, lack of appetite, dry mouth, vomiting, fever, and headache than patients with MDS. Only prevalence of shortness of breath and diarrhea was higher in MDS patients, but there was no difference in reported mean severity of these symptoms. Except for general activity, rating of symptom interference with daily activities is similar for the two groups. Lack of recognition of symptoms experienced by patients with AML and MDS can lead to inadequate management of symptoms, interfere with patients' ability to function and enjoy life, and impact the tolerability of and adherence to treatment regimens. Validation of this measure of symptom burden for patients with AML and MDS to allow more accurate and consistent monitoring of symptoms by clinicians and in clinical research is ongoing. Table 1. Individual MDASI Item Means and Significance for AML and MDS Patients Core Symptom Items N Mean SD p-value Rank Prevalence (%) Pain MDS 48 2.00 2.760 0.009* 9 58 AML 45 3.69 3.309 3 69 Fatigue MDS 47 3.45 2.947 0.037* 1 79 AML 45 4.69 2.653 1 91 Nausea MDS 48 .50 1.368

Description: PURPOSE: Myelodysplastic syndrome (MDS) is a group of clonal bone marrow disorders leading to bone marrow failure and acute myeloid leukemia. With better understanding of the biology of MDS, newer treatment options like therapy with the hypomethylating agents, azacitidine and decitabine have proven beneficial. Major randomized controlled trials by CALGB and others have demonstrated the efficacy of azacitidine. Growth factor use was prohibited in these trials. However, in the community, most patients have continued to get growth factor support along with azacitidine therapy. Since there is lack of evidence backing such clinical practice, we attempted to review response to therapy in patients receiving combination therapy with azacitidine and erythropoietin. METHODS: We identified MDS patients treated with concomitant azacitidine and erythropoietin at our institution over the last five years. Data collected from retrospective chart review of these patients was statistically analyzed. RESULTS: Sixteen patients with concomitant azacitidine and erythropoietin therapy were identified. Complete remissions were seen in 31%(5/16) of the patients. Induction of partial remissions in our study was 25% (4/16). Thirty one percent (5/16) of patients had hematologic improvement not meeting criteria for partial remission. Thirteen percent of patients (2/16) did not benefit at all from azacitidine and erythropoietin support. The median number of cycles received for adequate response was six. A total response (complete remission, partial remission and hematological improvement) of 87%(14/16,) was seen with combination therapy, which is significantly higher than previously published total response of 44–60%. CONCLUSION: Azacitidine with erythropoietin support provides important clinical benefits for patients with MDS. There was a trend towards a higher rate of complete and partial responses in these patients than reported earlier in patients who received azacitidine alone. Randomized controlled studies will be needed to validate this further. Comparison of response to therapy in high risk MDS: Responses *CALGB-9221(azacitidine) **Combined analysis(azacitidine) Study patients treated with azacitidine and growth factors *JCO May 15 2002: 2429–2440.**JCO Aug 20 2006: 3895–3903. Complete Remission 7% 10–17% 31% Partial Remission 16% Rare 25% Hematological Improvement 37% 23–36% 31% Total response 60% 44% 87%