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Intensified systemic chemotherapy has the highest primary cure rate for advanced-stage, classical Hodgkin lymphoma but this comes with a cost of severe and potentially life long, persisting toxicities. With the new regimen of brentuximab vedotin, etoposide, cyclophosphamide, doxorubicin, dacarbazine, and dexamethasone (BrECADD), we aimed to improve the risk-to-benefit ratio of treatment of advanced-stage, classical Hodgkin lymphoma guided by PET after two cycles.

Whether high-dose cytarabine-based salvage chemotherapy, administered to induce complete remission in patients with poor responsive or relapsed acute myeloid leukaemia scheduled for allogeneic haematopoietic stem-cell transplantation (HSCT) after intensive conditioning confers a survival advantage, is unclear.

Available treatments for older patients with primary diffuse large B-cell CNS lymphoma (PCNSL) offer progression-free survival of up to 16 months. We aimed to investigate an intensified treatment of high-dose chemotherapy and autologous haematopoietic stem-cell transplantation (HSCT) in older patients with PCNSL.

Extracellular Vesicles (EVs) are membranous vesicles produced by all cells under physiological and pathological conditions. In hematological malignancies, tumor-derived EVs might reprogram the bone marrow environment, suppress antileukemic immunity, mediate drug resistance and interfere with immunotherapies. EVs collected from the serum of leukemic samples might correlate with disease stage, drug-/immunological resistance, or might correlate with antileukemic immunity/immune response. Special EV surface protein patterns in serum have the potential as noninvasive biomarker candidates to distinguish several disease-related patterns ex vivo or in vivo. EVs were isolated from the serum of acute myeloid leukemia (AML), acute lymphoid leukemia (ALL), chronic lymphoid leukemia (CLL) patients, and healthy volunteers. EVs were characterized by transmission electron microscopy and fluorescence nanoparticle tracking analysis, and EV surface protein profiles were analyzed by multiplex bead-based flow cytometry to identify tumor- or immune system-related EVs of AML, ALL, CLL, and healthy samples. Aiming to provide proof-of-concept evidence and methodology for the potential role of serum-derived EVs as biomarkers in leukemic versus healthy samples in this study, we hope to pave the way for future detection of promising biomarkers for imminent disease progression and the identification of potential targets to be used in a therapeutic strategy.

Acute graft-versus-host disease (aGvHD) contributes to about 50% of transplant-related mortality (non-relapse mortality) after allogeneic hematopoietic stem cell transplantation (HSCT). Here the predictive value of a urinary proteomic profile (aGvHD_MS17) was tested together with preemptive prednisolone therapy. Two-hundred and fifty-nine of 267 patients were eligible for analysis. Ninety-two patients were randomized upon aGvHD_MS17 classification factor above 0.1 to receive either prednisolone (2–2.5 mg/kg, N= 44) or placebo (N= 47; N= 1 randomization failure) for 5 days followed by tapering. The remaining 167 patients formed the observation group. The primary endpoint of the randomized trial was incidence of aGvHD grade II between randomization and day +100 post HSCT. Analysis of the short-term preemptive prednisolone therapy in the randomized patients showed no significant difference in incidence or severity of acute GvHD (HR: 1.69, 95% CI: 0.66–4.32, P= 0.27). Prednisolone as preemptive treatment did not lead to an increase in relapse (20.2% in the placebo and 14.0% in the prednisolone group (P= 0.46)). The frequency of adverse events was slightly higher in the placebo group (64.4% versus 50%, respectively). Taken together, the results of the Pre-GvHD trial demonstrated the feasibility and safety of preemptive prednisolone treatment in the randomized patients.

Background

INTRODUCTION

Background

ABSTRACTUreaplasma urealyticumis a fastidious bacterium usually residing in the female genitourinary tract. We present an exceedingly complicated case of a brain abscess secondary to mastoiditis by U. urealyticumin an adult hypogammaglobulinemic patient after rituximab treatment 3 years earlier.

Stelljes: Amgen: Consultancy, Speakers Bureau; Pfizer: Consultancy, Honoraria, Research Funding, Speakers Bureau. Wäsch:Pfizer: Consultancy; Amgen: Consultancy; Janssen: Consultancy. Haenel:Amgen, Novartis, Roche, Celgene, Takeda, Bayer: Honoraria. Lenz:Janssen: Consultancy, Honoraria, Research Funding, Speakers Bureau; Roche: Consultancy, Honoraria, Research Funding, Speakers Bureau; Celgene: Consultancy, Honoraria, Speakers Bureau; BMS: Consultancy; AstraZeneca: Consultancy, Honoraria, Research Funding; Bayer: Consultancy, Honoraria, Research Funding, Speakers Bureau; Agios: Research Funding; AQUINOX: Research Funding; Novartis: Consultancy; Gilead: Consultancy, Honoraria, Research Funding, Speakers Bureau; Verastem: Research Funding; Morphosys: Consultancy, Honoraria, Research Funding. Brüggemann:Affimed: Research Funding; Regeneron: Research Funding; Celgene: Consultancy; Roche: Consultancy; Incyte: Consultancy; Janssen: Consultancy, Honoraria; Amgen: Consultancy, Honoraria, Research Funding. Goekbuget:Gilead: Consultancy; Kite: Consultancy; Servier: Consultancy, Research Funding; Jazz: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Erytech: Consultancy; Amgen: Consultancy, Research Funding. Alakel:Pfizer: Consultancy.Inotuzumab ozogamicin for induction therapy (1st line therapy)

Because information on management and outcome of AML relapse after allogeneic hematopoietic stem cell transplantation (HSCT) with reduced intensity conditioning (RIC) is scarce, a retrospective registry study was performed by the Acute Leukemia Working Party of EBMT. Among 2815 RIC transplants performed for AML in complete remission (CR) between 1999 and 2008, cumulative incidence of relapse was 32% ± 1%. Relapsed patients (263) were included into a detailed analysis of risk factors for overall survival (OS) and building of a prognostic score. CR was reinduced in 32%; remission duration after transplantation was the only prognostic factor for response (P = .003). Estimated 2-year OS from relapse was 14%, thereby resembling results of AML relapse after standard conditioning. Among variables available at the time of relapse, remission after HSCT > 5 months (hazard ratio [HR] = 0.50, 95% confidence interval [CI], 0.37-0.67, P < .001), bone marrow blasts less than 27% (HR = 0.53, 95% CI, 0.40-0.72, P < .001), and absence of acute GVHD after HSCT (HR = 0.67, 95% CI, 0.49-0.93, P = .017) were associated with better OS. Based on these factors, 3 prognostic groups could be discriminated, showing OS of 32% ± 7%, 19% ± 4%, and 4% ± 2% at 2 years (P < .0001). Long-term survival was achieved almost exclusively after successful induction of CR by cytoreductive therapy, followed either by donor lymphocyte infusion or second HSCT for consolidation.

The differentiation between acute graft-versus-host disease (aGvHD) and infection is still a clinical challenge in patients after allogeneic hematopoietic stem-cell transplantation (HSCT). Definitive diagnosis is based on histologic findings, but a simple blood test for differentiation is missing.

Introduction: Acute lymphoblastic leukemia (ALL) represents approx. 5% of all newly diagnosed leukemias in patients between 55 and 70 years of age. Despite recent advances especially in younger patients, the prognosis of elderly patients with ALL remains dismal, even after moderately intensive chemotherapy. Incorporation of antibody-based therapies in the first line induction therapy bears the potential of a significant increased response rate and survival with the reduction of treatment toxicity.

Alterations of microparticles derived from different cell types are described in a number of diseases associated with inflammation and hemostatic disorders.

A phase 1 diagnostic study was performed to evaluate a novel technology for clinical proteom research based on capillary electrophoresis and mass spectrometry. Urine from 40 patients after hematopoietic stem cell transplantation (HSCT; 35 allogeneic, 5 autologous) and 5 patients with sepsis was collected for a period of 100 days and analyzed. More than 1000 different polypeptides could be detected in individual samples. Polypeptide patterns excreted in the urine of patients were significantly different from those of healthy volunteers. No significant differences were detected comparing different conditioning regimens. The aim of this study was to identify polypeptide patterns functioning as early indicators of graft-versus-host disease (GVHD). Eighteen patients developed GVHD after allogeneic HSCT. Sixteen differentially excreted polypeptides formed a pattern of early GVHD markers, allowing discrimination of GVHD from patients without complications with 82% specificity and 100% sensitivity, cross-validated. Inclusion of 13 sepsis-specific polypeptides allowed us to distinguish sepsis from GVHD with a specificity of 97% and a sensitivity of 100%. Sequencing 2 prominent GVHD-indicative polypeptides led to the identification of a peptide from leukotriene A4 hydrolase and a peptide from serum albumin. The data reveal that capillary electrophoresis and mass spectrometry allow identification of biomarkers for a variety of diseases or related complications. (Blood. 2004;104:340-349)

Poeschel: Roche:Other: Travel, Accommodations, Expenses;Amgen:Other: Travel, Accommodations, Expenses;Abbvie:Other: Travel, Accommodations, Expenses.Habersang:Rheinlandklinikum Neuss:Current Employment.Mahlberg:Janssen:Other: Travel, Accommodations, Expenses;Mutterhaus der Borromaeerinnen, Trier:Current Employment;Novartis:Honoraria, Other: Travel, Accommodations, Expenses;Labor Synlab:Ended employment in the past 24 months;Abbvie:Other: Travel, Accommodations, Expenses;Roche:Honoraria;Amgen:Honoraria, Other: Travel, Accommodations, Expenses;Merck:Honoraria, Other: Travel, Accommodations, Expenses.Keller:Janssen-Cilag:Consultancy, Other: Travel, Accommodations, Expenses;Takeda:Consultancy, Other: Travel, Accommodations, Expenses;Celgene:Consultancy, Other: Travel, Accommodations, Expenses;BMS:Consultancy, Other: Travel, Accommodations, Expenses;Roche:Consultancy, Other: Travel, Accommodations, Expenses;Hexal:Consultancy;Novartis:Consultancy;MSD:Consultancy;Pfizer:Consultancy;Astra-Zeneca:Consultancy;Pentixapharm:Consultancy.Viardot:Kite/Gilead:Honoraria, Other: advisory board;Roche:Honoraria, Other: advisory board;Amgen:Honoraria, Other: advisory board;Novartis:Honoraria, Other: advisory board.Stilgenbauer:Novartis:Consultancy, Honoraria, Other, Research Funding;Pharmacyclics:Consultancy, Honoraria, Other, Research Funding;GlaxoSmithKline:Consultancy, Honoraria, Other: travel support, Research Funding;Janssen-Cilag:Consultancy, Honoraria, Other: travel support, Research Funding;Mundipharma:Consultancy, Honoraria, Other, Research Funding;Genzyme:Consultancy, Honoraria, Other: travel support, Research Funding;Genentech:Consultancy, Honoraria, Other: travel support, Research Funding;F. Hoffmann-LaRoche:Consultancy, Honoraria, Other: travel support, Research Funding;Celgene:Consultancy, Honoraria, Other: travel support, Research Funding;Gilead:Consultancy, Honoraria, Other: travel support, Research Funding;AbbVie:Consultancy, Honoraria, Other: travel support, Research Funding;Boehringer-Ingelheim:Consultancy, Honoraria, Other: travel support, Research Funding;Amgen:Consultancy, Honoraria, Other: travel support, Research Funding.Held:Roche:Consultancy, Other: Travel, Accommodations, Expenses, Research Funding;BMS:Consultancy, Other: Travel, Accommodations, Expenses, Research Funding;MSD:Consultancy;Acrotech:Research Funding;Spectrum:Research Funding;Amgen:Research Funding.Bittenbring:Gilead:Honoraria, Other: Travel, Accommodations, Expenses;Bluebird Bio:Honoraria, Other: Travel, Accommodations, Expenses;Roche:Honoraria, Other: Travel, Accommodations, Expenses, Advisory board;Celgene:Honoraria, Other: Travel, Accommodations, Expenses, Advisory Board;Pfizer:Honoraria, Other: Travel, Accommodations, Expenses.

Allogeneic stem cell transplantation (HSCT) is a curative treatment for adult patients with hematologic malignancies, but is limited by severe, life-threatening complications such as acute graft-versus-host disease (aGvHD). We have developed a proteomic urine pattern “aGvHD_MS17”, consisting of 17 differentially excreted peptides, capable to predict aGvHD grade II or more (1, 2). In 2008, a multicenter, randomized, placebo-controlled, double blind clinical trial (Pre-GvHD) was initiated testing aGvHD_MS17 for prediction of aGvHD and to initiate pre-emptive therapy using prednisolone 2-2.5mg/kg.

No relevant conflicts of interest to declare.

von Tresckow: Takeda: Honoraria, Travel grants, Travel grants Other; Novartis: Honoraria, Research Funding. Off Label Use: Everolimus in relapsed or refractory Hodgkin Lymphoma. Topp:Affimed: Consultancy, Honoraria, Research Funding; Amgen: Consultancy, Honoraria. Engert:Millennium: Consultancy, Honoraria, Research Funding; Takeda: Consultancy, Honoraria, Research Funding; Affimed: Consultancy. Borchmann:Takeda: Honoraria, Research Funding, Travel grants Other.

26 of 36 pts had cGvHD (6 with limited and 20 with extensive disease). 22 had aGvHD before and 4 did not. 8 of the 36 pts had neither aGvHD nor cGvHD, 2 pts suffered from aGvHD. Regarding to aMA a moderate grade was found in 14 pts, a mild form was detected in 15 pts, and 7 pts did not have any signs of aMA. The levels of maximal elevation of lactatdehydrogenase (LDH) and maximal decrease of platelets (each p value < 0,02) were as followed: absent grade LDH mean 248 U/L and platelets decrease mean 36 %; mild grade LDH 299 U/L and platelets 52 % and moderate grade LDH 505 U/L and platelets 70%. Additional parameters (each p<0,01) were evidence of fragmentocytes, increase of retikulocytes, anemia, minimal aPTT and minimal fibrinogen. 20 of 36 pts had aGvHD stage II-IV. 14 of these had moderate grade of aMA (5 mild, 1 absent). Otherwise none of 16 pts without aGvHD had moderate aMA (p=0,000). 10 had mild and 6 absent aMA. Additionally 14 of the 26 pts with cGvHD had a moderate grade of aMA before in contrast to none of the 10 pts with or without aGvHD (p=0,003). The grading of MA at the time of cGvHD based of minimal platelets count and maximal LDH elevation (cMA) as followed: for grade absent platelets 163 G/L and LDH 219 U/L, for mild platelets 98 G/L and LDH 331 U/L and for moderate platelets 38 G/L and LDH 344 U/L. Additional parameters were platelet decrease, anemia, elevation of reticulocytes as well as level of vWf in serum (169, 308 respectively 480%) (p < 0,04).11 of 26 pts with cGvHD had a moderate grade cMA vs none of 10 pts without cGvHD (p=0,013). The cumulative level of Ciclosporin A in serum was higher in mild and moderate grade of cMA vs absent (13,3 vs 7,3g p=0,036). The duration were 190 vs 88 days (p=0,06). The numbers of vWf+ vessels, of plaqesinus and plaques were higher in pts with cGvHD than non-cGvHD (16 vs 7/mm2 p=0,000, 3,4 vs 0,7/mm2, p=0,000, respectively 1,2 vs 0,3/mm2 p=0,054). cMA mild and moderate grade had more vWf+ vessels, plaquesinus and plaques than absent grade (each p<0,022). A change into severe grade of MA was prevented by discontinuation of immunosuppression and infusions of fresh frozen plasma (3 pts) as well as of IVIG for suspected ITP.Low grade MA was more often observed than expected from the literature. MA can be demonstrated morphologically by vWf+ deposits in endothelial-cells in bone marrow and can be graded also at the time of cGvHD. The high frequency of moderate grade at the time after engraftment with or without aGvHD is remarkable for development of a cGvHD with prognostic, pathogenetic and therapeutic relevance. From clinical, laboratory and morphological point of view microangiopathy seems to be part of aGvH reaction, followed by deposits of vWf+ material in the bone marrow, consumption of platelets by fixation to uncleaved multimere of vWf with the consequence of thrombocytopenia.Hill: Novartis: Research Funding.

Myelodysplastic syndrome (MDS) and secondary acute myeloid leukemia (sAML) are diseases of the hematopoietic stem cell that are potentially curable by allogeneic stem cells transplantation (ASCT). MDS and sAML are most frequent in elderly patients with significant co-morbidity. Here we report our results with reduced intensity conditioning regimen and preemptive donor lymphocyte transfusions that have been successful in patients with advanced and refractory AML. Sixty seven patients were treated for MDS and 90 patients for sAML. The FLAMSA regimen consisted of a 4 day course of chemotherapy (Ara-C 2g/m2, Fludarabin 30 mg/m2, and amsacrin 100 mg/m2) followed by 3 days rest and reduced intensity conditioning with 4 Gy total body irradiation (TBI), cyclophosphamide (CY) +/− antithymocyte globulin (ATG). Overall survival at 10 years was 50% for MDS and 26% for sAML (p=0.014, log rank). In the MDS group most patients had preleukemic forms (IPSS 3 and 4). Survival at 5 years was 58% with FLAMSA, 44% with myeloablative conditioning with TBI and 67% with Busulfan (BUS). Non-relapse mortality at 5 years was 41% with FLAMSA, 20% for BUS and 50% for TBI. The relapse or progression rate was 0% for FLAMSA, 24 % for BUS and TBI respectively. In sAML the 5 year survival was 17% for FLAMSA, 57 % for BUS and 30% for TBI. Non-relapse mortality was 60% for FLAMSA, 36% for BUS and 66% for TBI, whereas the relapse rate was 62% for FLAMSA, 12.5 % for BUS and 37% for TBI (p=0.04). In multivariate analysis adjusted for disease, conditioning treatment and source of stem cells – marrow vs. mobilized blood – differences were not significant and the only significant prognostic factor was age less than 30 years (p=0.003). Therefore patients of the age of 60 years and older with AML were treated with FLAMSA containing BUS (8mg/kg in two days) instead of 4 Gy TBI. The overall survival at 2 years was 64%, 61% with FLAMSA-TBI and 70% with FLAMSA-BUS. The non-relapse mortality was 9% for FLAMSA-BUS and 37% for FLAMSA-TBI; the relapse rate was 25% at 2 years. At day 120 patients received donor lymphocytes (DLT) in 3 escalating doses from 1 × 106/kg, 5 × 106/kg on day 150 and 1 × 107/kg on day 180, if they had no GVHD, infection or relapse. Preemptive DLT appear to prevent relapse when compared to a historical control and contemporary patients not given DLT. We conclude from these data that MDS/sAML may have a different biology in young patients, and that in the elderly we can optimize the treatment with FLAMSA-BUS as a dose reduced regimen and preemptive immunotherapy for maintenance of remission.