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Background Allogeneic stem cell transplantation (AlloSCT) is a curative procedure for many hematologic neoplasms. Majority of the AlloSCT require an initial hospitalization and a mortality rate of up to 8% during the SCT hospitalization has been previously reported (Ballen et al, 2014 BBMT). Role of patient-, disease- and transplant-related factors in predicting early mortality during transplant hospitalization has not been previously investigated. We sought to analyze the predictors of inpatient mortality in patients undergoing AlloSCT from a large administrative database, National Inpatient Sample (NIS). Methods International Classification of Diseases, Ninth Revision (ICD-9) procedure codes were used to identify patients undergoing AlloSCT in the 2002-2015 NIS database whereas ICD-9 diagnosis codes were used to assess complications of Allo-SCT. Early transplant-related mortality was defined as death during the hospitalization for SCT. Chi-square was used for categorical data comparisons (p Results During the study period of 2002-2015, we identified 68,296 hospitalizations (median age 50 years and 58% male) undergoing inpatient AlloSCT (baseline characteristics in table 1 & figure 1); death occurred in 5,198 (7.6%). Age Conclusion Our analysis identified novel prognostic and predictive factors associated with higher inpatient mortality during SCT hospitalization. Identifying at risk patients can provide an opportunity for early intervention and improving post-transplant outcomes.

Introduction Over 8000 allogeneic stem cell transplants (AlloSCT) are currently done in a year in USA. Complications occur frequently in the immediate post transplant course, resulting in adverse outcomes and increased healthcare utilization. The impact of these complications on the length of stay (LOS) and healthcare utilization is not well known. In this retrospective study, we set out to use a large inpatient administrative database (Healthcare Utilization Project National Inpatient Sample-HCUP NIS) to explore predictors for prolonged length of stay. Methods We used International Classification of Diseases, Ninth Revision (ICD-9) procedure codes to identify patients for AlloSCT in the 2002-2014 NIS database (Bone marrow, BM: 41.02, 41.03, Peripheral blood, PB: 41.05, 41.08 and Cord blood, CB: 41.06). We used chi-square for categorical data frequency (p Results During the study period, a total of 63,595 inpatient allogeneic stem cell transplants were done with a median length of stay (mLOS) of 25 days. Using median splitting, we created 3 cohorts: 25 or less, 26-50 and >50 (days). Table 1 shows baseline characteristics and post transplant complications in each cohort. There are15 variables on the multivariate model that predicted for prolonged LOS (figure 1). Mortality increased significantly with a longer LOS (table 1). Healthcare utilization is reported in table 2. Conclusion We identified many predictors affecting length of hospitalization for patients undergoing stem cell transplant. Longer length of stay also predicted for higher utilization of healthcare resources and was associated with higher mortality in our study, suggesting worse outcomes in patients with a prolonged hospital course. This multivariate model can be used to calculate estimated length of stay for patients undergoing allogeneic stem cell transplant.

Introduction Relapse and graft failure continue to be 2 major problems after allogeneic HSCT. DLI and/or SCB are capable of inducing complete remission in relapsed disease. However, DLI and SCB are associated with significant risks such as graft versus host disease (GVHD) or aplasia. There is a paucity of information regarding DLI/SCB safety, efficacy and toxicity. A better understanding of the risks and benefits of DLI/SCB after HSCT is an important unmet need. Objectives Our objectives are to provide descriptive characteristics of patients receiving DLI or SCB and information regarding the provided cell therapy (CD3+ and/or CD34+ cell dose). We also aim to evaluate relapses, donor chimerism, graft failure, GVHD, DFS and OS after cellular therapy. Methods Retrospective chart review was completed on all patients who received either DLI or SCB at University of Maryland from 2005-2018. Data were analyzed using SPSS v.25.0, SAS v9.4, and R-software v3.5.1. Continuous variables were summarized as median (range), and categorical variables were presented using frequencies (%). Qualitative and quantitative differences between groups were analyzed by the chi-square and the Fisher's exact test for categorical and the Mann Whitney test for continuous variables. The Kaplan-Meier method was used to estimate the OS and GVHD-free survival with the corresponding 95% confidence interval (CI); the log-rank test was used to compare the survival probabilities for different patients' groups. Results A total of 65 patients underwent either DLI or SCB from 2005-2018. Of these, 38 received DLI, and 27 received SCB. Relapsed disease was the most common indication in 78.9% and 61.5% of DLI and SCB, respectively. The average CD3+/kg dose was 5.6 × 10^6 for DLI and 9 × 10^7 for SCB. Average CD34+/kg dose was 3.8 × 10^6 for SCB patients. One-year OS rate was 54.2% for DLI and 37.5% for SCB. Two-year OS rate of OS was 50.3% for DLI and 26.8% for SCB. Remission rates from relapsed disease were 43.4% for DLI and 31.3% for SCB. One-year GVHD-free survival following cell therapy was 51.2% for DLI and 34.4% for SCB. This dropped to 35.3% for DLI and 24.6% for SCB at two years. The differences seen in OS and GVHD between the 2 cohorts were not statistically significant. Conclusion Our overall survival data is favorable compared to recently published data. However, this comes at the expense of GVHD with long-term rates of GVHD-free survival measuring 25-35%. The use of unmanipulated cryopreserved SCB for relapse disease is underreported in the literature. We observed comparable long-term survival and GVHD in both cohorts. Cellular therapy with DLI or SCB remains a viable treatment modality with reasonable long-term outcomes for relapsed/refractory hematologic malignancies after allogeneic HSCT.

Introduction Treatment options for relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL) post-chimeric antigen receptor therapy (CAR-T) are limited. Here, we report the successful treatment of R/R DLBCL with programmed cell death 1 (PD1) inhibition post-allogeneic CAR-T. Case Report A previously healthy 26-year-old Caucasian man developed B-symptoms and cervical lymphadenopathy. Biopsy revealed DLBCL, activated B-cell subtype, double expressor and Ki-67 >80%. PET/CT scan revealed disease above and below the diaphragm. He achieved a partial response (PR) after R-CHOP, progressive disease (PD) after R-ICE, stable disease (SD) after R-ESHAP, and PD one month after autologous CD19-targeted CAR-T with CTL019 (CD3ζ/4-1BB). He then received R-lenalidomide (len) with radiation (24 Gy) to his mediastinal mass achieving a PR, followed by a myeloablative (Cy/TBI-12 Gy) allogeneic stem cell transplant (aSCT) from his 10/10 HLAmatched brother. He achieved 100% donor chimerism 30 days post-aSCT (D+30). Despite persistent full donor chimerism, D+60 PET/CT showed PD with confirmed relapse upon biopsy. Immunosuppression was discontinued, and ibrutinib with len was started, followed by donor lymphocyte infusion (DLI) which led to a mixed response. He then continued on ibrutinib with weekly temsirolimus and received a second DLI achieving a PR, with PD shortly thereafter. He next proceeded to allogeneic CAR-T with axicabtagene-ciloleucel (CD3ζ/CD28), complicated by grade 1 cytokine release syndrome without neurotoxicity. Three weeks post-CAR-T, he developed diplopia due to a cranial nerve palsy. Brain MRI showed new pontine T2 changes. Cerebrospinal fluid (CSF) was negative for lymphoma and infection, but notable for T-cell predominance. One month postCAR-T, PET/CT showed a complete metabolic response (CMR). Repeat brain MRI was unchanged. Two months later, he developed dizziness and intractable nausea, and repeat brain MRI showed a new lesion in the inferior cerebellar vermis, with resolution of previous pontine change. Evaluation of the CSF and peripheral blood revealed no CAR T-cell persistence, and PET/CT confirmed disease relapse in the cerebellum and mediastinum. Patient then received focal radiation (24 Gy) to his cerebellar lesion along with pembrolizumab 200 mg IV every 3 weeks, after which his neurologic symptoms resolved. MRI one day after radiation showed near-complete resolution of enhancing vermis lesion. After 3 cycles of pembrolizumab, PET/CT showed a CMR, with no active disease on brain MRI. Three months into PD1-inhibition therapy, his disease remains in CMR, without GVHD nor treatment-related toxicities. Conclusion This case illustrates the efficacy of allogeneic CAR-T after failure of autologous CAR-T and aSCT. Furthermore, PD1 inhibition can be used safely after allogeneic CAR-T, underscoring the need for prospective clinical studies.

Introduction The spectrum of transplant-associated (TA) thrombotic microangiopathy includes thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). It can result in irreversible organ damage and is associated with high mortality. In this study, we would like to report on 396 cases of TA-TTP/HUS occurring during the hospitalization for undergoing allogeneic stem cell transplant (AlloSCT). To better illustrate the characteristics and outcomes associated with TA-TTP/HUS (transplant-T cohort), we propensity matched these cases with non-transplant TTP/HUS (NT-cohort) using the 2002-2014 National Inpatient Sample, a large nationwide inpatient database. Methods We identified all hospitalizations with International Classification of Diseases, Ninth Revision (ICD-9) primary and secondary diagnosis codes for TTP/HUS (446.6, 283.11) and divided them into 2 cohorts: T-cohort (ICD-9 41.02, 41.03, 41.05, 41.08 and 41.06) and NT-cohort (rest of the cases). Using propensity score matching, we age and gender matched T-cohort and NT-cohort in 1:4 ratios. Chi-square was used for categorical data frequency (p Results We identified a total of 90756 cases with TTP/HUS (overall mortality of 8.85%). 396 cases of TA-TTP/HUS (T-cohort) were matched with 1527 cases of TTP/HUS from NT-cohort. T-cohort had significantly higher mortality of 38% compared to 8% in the NT-cohort (p 65, bacterial sepsis, mechanical ventilation, AKI and hemodialysis were associated with higher mortality (table 3). Use of TBI was not a significant contributor to mortality. Conclusion Our comparative analysis shows that occurrence of TTP in the immediate post-transplant course is associated with significantly high mortality. In this cohort, AKI also occurred more frequently and was associated with high mortality. Plasmapheresis is not the standard of care for TA-TTP/HUS but was used in 15% of the cases and showed a trend towards higher mortality. Our study is limited by the lack of information on the post transplant course beyond the initial hospitalization for stem cell transplant procedure.

Introduction Toxoplasmosis is a well-known intracellular protozoan parasite with seroprevalence varying geographically. Relatively asymptomatic in healthy individuals, it's reactivation can be a devastating opportunistic infection in HSCT patients with rare documentation of associated HLH. Case A 25-year-old woman with Hodgkin lymphoma, refractory to multiple chemotherapies, autologous transplant and Nivolumab, who underwent haploidentical HSCT, was admitted on day +33 with persistent high-grade fevers. Blood counts were unremarkable, except for eosinophilia. She received broad spectrum antibiotics. PET/CT on day +36 demonstrated resolution of metabolic activity in multiple lymph nodes, but revealed ‘revved-up' bone marrow(Image 1). CT-chest (day +41) demonstrated widespread centrilobular nodules. Blood, urine, enteric cultures, HIV, Histoplasma studies, and respiratory viral panel PCR were negative. Pre-transplant serologies noted a positive toxoplasma IgG. Toxoplasma DNA was detected in blood on day +41; she received clindamycin, pyrimethamine, and atovaquone due to sulfa allergy but successfully underwent rapid sulfa desensitization. She developed progressive pancytopenia and hypoxemia (day +43) requiring intubation in the ICU. Ferritin was >50,000 ng/mL, and triglycerides 931 mg/dL. Bone marrow biopsy showed activated macrophages and hemophagocytosis (Image 2). She met 6/8 criteria described in HLH-2004 trial. She received dexamethasone and tocilizumab for HLH, leading to prompt reversal of HLH physiology within 72 hours of HLH-directed therapy initiation. She was extubated on day +48. She was discharged on sulfadiazine and pyrimethamine (day +60) with almost normal ferritin levels and transfusion-independency. Discussion HLH is characterized by cytopenias, extreme systemic inflammatory response, and high mortality. HLH can be triggered by infections, such as toxoplasmosis. Disseminated toxoplasmosis has a high mortality itself (>60 % treated, and 99% untreated), and HSCT recipients appear to have the highest risk. Early detection and treatment of the underlying infection is essential. Novel drugs, such as Tocilizumab, should be prospectively studied in HLH. In conclusion, HLH after HSCT should be suspected in cases of unexplained inflammatory response and cytopenias after successful engraftment; secondary causes must be explored and promptly treated.