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Hematopoietic Stem Cell Transplantation (HSCT) activity was evaluated in the African (AFR)/EMRO region and compared to the global activity for the years 2006-2013. Data were obtained from 1570 teams in the 6 WHO continental regions. Of these, 29 (1.85%) of all teams were active in 12 of the 68 AFR/EMRO countries. They reported 2.331 (3.3%) of the worldwide 71.036 HSCT, and a transplant rate of 32.8 (TR; HSCT/10 million inhabitants; worldwide 128.5). This reflects still the lowest regional TR despite an increase of 90% since 2006. HSCT activity in AFR/EMRO countries was characterized by a higher use of allogeneic compared to autologous HSCT, an almost exclusive use of family donors, including haploidentical family donors. These findings contrast with the prevalence of autologous over allogeneic HSCT, and a higher frequency of unrelated HSCT in other parts of the world. Of note, the increase by 200% in HSCT for hemoglobinopathies from 2006 to 2013 (72 per year) in the AFR/EMRO region. This reflects the specific role of HSCT for these disease categories with high prevalence and incidence in the AFR/EMRO region. This report provides information for the competent authorities to foster adequate infrastructure. It urges transplant organization to optimize their cooperation.

BACKGROUND: Allogeneic hematopoietic cell transplantation (allo-HCT) is a standard of care for adults with high-risk acute lymphoblastic leukemia (ALL) in first or subsequent complete remission (CR). Myeloablative total body irradiation (TBI) combined with cyclophosphamide (Cy) is the most frequently used conditioning regimen. In order to reduce toxicity Cy may be replaced by fludarabine (Flu). The goal of this registry-based, retrospective study was to compare outcomes of allo-HCT following TBI/Cy vs. TBI/Flu conditioning. PATIENTS AND METHODS: Included in the analysis were 2255 patients aged 18-65 years, treated with allo-HCT from either a matched sibling (43%) or unrelated (57%) donor in CR1 (83%) or CR2 (17%), between the years 2010-2020. Patients with Ph(-) B-ALL, Ph(+) B-ALL, and T-ALL were represented in equal proportions. TBI 12Gy + Cy was used in 2105 cases while TBI 12Gy + Flu was administered to 150 patients. Patients treated with TBI/Flu were significantly older (median 35 years vs. 33 years, p=0.006), with poorer Karnofsky performance score ( RESULTS: Engraftment rate was 99% for both TBI/Cy and TBI/Flu patients. In a univariate analysis the use of TBI/Cy as compared to TBI/Flu was associated with a tendency to reduced incidence of relapse (24% vs. 29% at 2 years, p=0.1), increased incidence of grade 2-4 acute graft versus host disease (GVHD, 35.5% vs. 28%, p=0.08) and improved leukemia-free survival (LFS, 62% vs. 57%, p=0.18). The rates and causes of non-relapse mortality (NRM) did not differ significantly between the two conditioning groups. In a multivariate model adjusted for other prognostic factors, TBI/Cy conditioning was associated with reduced risk of relapse (HR=0.69, p=0.049) and increased risk of grade 2-4 acute GVHD (HR=1.57, p=0.03) without significant effect on other transplantation outcomes. An additional analysis was performed with TBI/Cy treated patients (n=132) matched strictly to those treated with TBI/Flu (n=132) in terms of disease subtype, disease status and donor type with the nearest neighbor for patient age, patient and donor sex, in vivo T-cell depletion, Karnofsky score and source of stem cells; the use of TBI/Cy as compared to TBI/Flu was associated with significantly reduced rate of relapse (18% vs. 30% at 2 years, p=0.015) and a tendency to an improved LFS (65% vs. 59%, p=0.07) and overall survival (OS, 73% vs. 68%, p=0.16) without effect on NRM and GVHD. CONCLUSIONS: The use of myeloablative TBI/CY as conditioning prior to allo-HCT for adult patients with ALL in CR1 or CR2 is associated with stronger anti-leukemic effect leading to significantly lower relapse rate compared to TBI/Flu and therefore should be likely considered a preferable regimen. Disclosures Giebel: Janssen: Honoraria, Speakers Bureau; Pfizer: Consultancy, Honoraria, Speakers Bureau; Novartis: Consultancy, Honoraria, Speakers Bureau; Amgen: Consultancy, Honoraria, Speakers Bureau. Labopin: Jazz Pharmaceuticals: Honoraria. Socie: Alexion: Research Funding. Yakoub-Agha: Jazz Pharmaceuticals: Honoraria. Kröger: Novartis: Research Funding; Riemser: Honoraria, Research Funding; Sanofi: Honoraria; Neovii: Honoraria, Research Funding; Jazz: Honoraria, Research Funding; Gilead/Kite: Honoraria; Celgene: Honoraria, Research Funding; AOP Pharma: Honoraria. Forcade: Novartis: Consultancy, Other: Travel Support, Speakers Bureau; Gilead: Other: Travel Support, Speakers Bureau; Jazz: Other: Travel Support, Speakers Bureau; MSD: Other: Travel Support. Huynh: Jazz Pharmaceuticals: Honoraria. Spyridonidis: Menarini: Current Employment. Perić: therakos: Honoraria; servier: Honoraria; MSD: Honoraria; Astellas: Honoraria; NOVARTIS: Honoraria; Abbvie: Honoraria; Pfizer: Honoraria. Mohty: Pfizer: Honoraria; Celgene: Honoraria, Research Funding; Amgen: Honoraria; Astellas: Honoraria; Gilead: Honoraria; Jazz: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Novartis: Honoraria; Bristol Myers Squibb: Honoraria; Takeda: Honoraria; Sanofi: Honoraria, Research Funding; Adaptive Biotechnologies: Honoraria.

Retinoblastoma (RB) is a childhood cancer developing in the retina due to RB1 pathologic variant. Herein we are evaluating the oncogenic mutations in the RB1 gene and the inheritance patterns of RB in the Jordanian patients. In this prospective study, the peripheral blood of 50 retinoblastoma patients was collected, genomic DNA was extracted, mutations were identified using Quantitative multiplex PCR (QM-PCR), Allele-specific PCR, Next Generation Sequencing analysis, and Sanger sequencing. In this cohort of 50 patients, 20(40%) patients had unilateral RB and 30(60%) were males. Overall, 36(72%) patients had germline disease, 17(47%) of whom had the same RB1 pathologic variant detected in one of the parents (inherited disease). In the bilateral group, all (100%) patients had germline disease; 13(43%) of them had inherited mutation. In the unilateral group, 6(30%) had germline disease, 4(20%) of them had inherited mutation. Nonsense mutation generating a stop codon and producing a truncated non-functional protein was the most frequent detected type of mutations (n = 15/36, 42%). Only one (2%) of the patients had mosaic mutation, and of the 17 inherited cases, 16(94%) had an unaffected carrier parent. In conclusion, in addition to all bilateral RB patients in our cohort, 30% of unilateral cases showed germline mutation. Almost half (47%) of germline cases had inherited disease from affected (6%) parent or unaffected carrier (94%). Therefore molecular screening is critical for the genetic counseling regarding the risk for inherited RB in both unilateral and bilateral cases including those with no family history.

Salvage chemotherapy and autologous stem cell transplantation (auto-SCT) results in the cure of around 50% of patients with Hodgkin lymphoma (HL) failing first line therapy. In historical data, patients who progressed after auto-SCT had a poor outcome, with a median overall survival (OS) of around 1-2 years. Significant progress has been achieved in the last decade with the use of brentuximab vedotin (BV) or check-point inhibitors (CPI) and the increasing use of haploidentical transplant. However, little information is available about the characteristics and real-world outcomes of patients with HL relapsing after auto-SCT in the current era. To assess prognosis of patients with recurrent-HL post auto-SCT over time, we analyzed the European Blood and Marrow Transplant registry data of 1781 adult HL patients who relapsed between 2006 and 2017 after a first auto-SCT. A specific questionnaire was sent to all participant centers to obtain additional data regarding characteristics of the patients, treatment of relapse and outcome after auto-SCT failure. Detailed data were collected for 760 patients [median age 32; interquartile range (IQR) 25-42] included in this study. After a median follow-up for alive patients of 57 months (IQR: 29-89), the 4-year OS after relapse for the 760 included patients was 46% (95%CI: 43-50) and similar to that of 1021 non-included patients (45%, 95%CI: 41-48). The 4-year OS after relapse continuously increased from 35% (95%CI: 27-45) for 136 patients relapsing in 2006-2008, to 43% (95%CI: 37-49) for 258 patients relapsing in 2009-2011, 49% (95%CI: 43-56) for 238 patients relapsing in 2012-2014, and 61% (95%CI: 52-72) for 128 patients relapsing in 2015-2017 (p=0.001) (Figure 1). Improvement over time was predominantly noted in patients who had an early relapse (within 12 months) after auto-SCT (p=0.01) but not in those with a late relapse (p=0.6). On multivariate analysis, patients who relapsed in more recent years and those with a longer interval from transplant to relapse had a better OS, whereas increasing age, poor performance status at relapse, bulky disease at relapse, extranodal disease at relapse and presence of B-symptoms at relapse were associated with a worse OS. Regarding treatment at relapse, BV was used in 233 patients (31%) after a median of 2 months from relapse (IQR: 0.8-8), predominantly as first treatment of relapse (155 patients). BV use increased over the 4 time periods from 3% to 19%, 49% and 49% respectively, and resulted in a complete remission (CR) in 46% and a partial response (PR) in 32%. The 4-year OS from BV use for relapse after auto-SCT was 56% (95%CI: 49-64). CPI were used in 91 patients (12%) including nivolumab in 75 patients and pembrolizumab in 12 patients after a median of 18 months from relapse (IQR: 5-35). CPI use increased over the 4 time periods from 1% to 4%, 14% and 35% respectively, and resulted in a CR of 44%, PR 32%, with a 4-year OS from CPI use of 44% (95%CI: 30-63). Finally, a second SCT (SCT2) was performed in 330 patients (43%) predominantly allogeneic SCT (285 patients, 86%) including a haploidentical SCT in 54 patients (16%). SCT2 was performed in 40% and 37% of patients relapsing in 2006-2008 and 2009-2011 respectively but its use increased to 49% and 51% of patients relapsing in 2012-2014 and 2015-2017 respectively. Four-year OS after SCT2 was 55%. In conclusion, outcome after post-transplant relapse has improved significantly in recent years, particularly in the case of early relapse, possibly reflecting, among other factors, the efficacy of post-transplant salvage including BV, CPI and second transplant. These large-scale real-world data can serve as benchmark for future studies in that setting. Figure 1 Disclosures Blaise: Jazz Pharmaceuticals: Honoraria. Sureda Balari:Incyte: Consultancy; Celgene: Consultancy, Honoraria; BMS: Speakers Bureau; Roche: Honoraria; Sanofi: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Gilead/Kite: Consultancy, Honoraria; Merck Sharpe and Dohme: Consultancy, Honoraria, Speakers Bureau; Celgene/Bristol-Myers Squibb: Consultancy, Honoraria; Takeda: Consultancy, Honoraria, Speakers Bureau; Janssen: Consultancy, Honoraria.

e23507 Background: There remains an unmet need to identify prognostic and predictive molecular biomarkers in advance Ewing sarcoma (ES). We sought to assess the influence of MGMT promoter methylation status on response rate, time to progression (TTP), and overall survival (OS) following salvage irinotecan and temozolomide (IT) chemotherapy. Methods: Data of advanced ES patients, treated with IT chemotherapy from Jan, 2014 to Jan, 2020 were retrospectively collected. Patients were required to have previously received and progressed after vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide (VDC-IE). MGMT promoter methylation status was assessed by Methylation Sensitive Restriction Enzyme quantitative-PCR (MSRE-qPCR) on non-decalcified Formalin-fixed paraffin embedded (FFPE) tissue using internally developed primers and the OneStep qMethyl Kit (ZYMO RESEARCH CORP). Responses were assessed by response evaluation criteria in solid tumors (RECIST v. 1.1). TTP and OS were assessed by the Kaplan-Meier method. Survival comparisons were performed by the Log-rank test. Results: Herein, we present data of the preliminary analysis of the first 18 patients who underwent MGMT promoter methylation testing. Patients had a median age of 18 years (range: 5-34 years), and were predominantly male ( n=11; 61%). The primary tumor was located in the pelvis in 9 patients (50%), femur in 3 (17%), tibia in 2 (11%), kidney in 2 (11%), chest wall in one (6%), and scapula in one patient (6%). IT was given in a second ( n=15) or third-line setting ( n=3). At the time of initiation of IT, 13 patients (72%) had distant metastasis, and 5 (28%) had unresectable local progression in the pelvis ( n=4) or chest wall ( n=1). The mean percentage of MGMT promoter methylation was 29% (range: 3-98%). Five patients (28%) had methylated MGMT promoter, whereas the remaining had partially methylated ( n=6; 33%) or unmethylated ( n=7;39%) promoter. Five patients (28%) had objective response, with no observed difference according to MGMT promoter methylation ( p=0.58 for comparison between methylated and unmethylated/ partially methylated). Median TTP was 4.9 and 2.2 months for patients with methylated and partially methylated/ unmethylated MGMT respectively; p=0.76. The corresponding median OS was 69.4 and 14.3 months in favor of the methylated group; p=0.3. Conclusions: This preliminary data suggests a possible prognostic role for MGMT promoter methylation, with a markedly extended median OS for the methylated group. Nevertheless, the median OS difference did not reach statistical significance in this preliminary analysis. We plan to report data of the final analysis after finalizing MGMT testing for the rest of our study patients.

Introduction: ETV6-RUNX1 is the most common genetic aberration in childhood acute lymphoblastic leukemia (ALL), occurring in approximately 25% of cases with a precursor-B phenotype. The presence of ETV6-RUNX1 has been associated with a relatively low rate of relapse in multiple studies. Relapses tend to occur late and have a better salvage rate than other ALL subtypes. Moreover, conflicting data in literature regarding the prognostic significance of ETV6-RUNX1 after accounting for age, initial count and treatment intensity. We sought to study the clinical features, therapy response in newly diagnosed ETV6-RUNX1-positive treated at King Hussein Cancer Center. Methods: Patients were treated per modified St Jude Total (XV) study, risk stratification was further refined by including minimal residual disease (MRD)measurements on day 15 and day 46 of remission induction therapy. Patients with the ETV6- RUNX1 fusion or hyperdiploidy without CNS or testicular disease and a satisfactory early MRD decline ( Results: Seventy patients (n=70) with ETV6-RUNX1-positive treated at our institution between May 2006 to October 2017. The median age at diagnosis, 5.8 years (range, 1.5-10.8). ETV6-RUNX1 was associated with favorable age between 1- and 6-years in 55 patients (79%), male gender in 41 patients (59%), initial leukocyte count Conclusion: MRD treatment schema in ETV6/RUNX1 -positive patients have excellent outcomes if they achieved favorable response at day 15 and end of remission induction regardless of the age and Initial leukocyte count. Treatment reduction is feasible and declared safe for children with NCI-HR who are predicted to have a low risk of relapse on the basis of rapid clearance of MRD post remission induction therapy. Disclosures No relevant conflicts of interest to declare.

Background: Acute myelogenous leukemia (AML) is characterized by recurrent variants that have implications in diagnosis, prognosis and management. We analyzed all variants that were detected in our patients since the inauguration of our Next-Generation-Sequencing (NGS) facility. Methods: This is a retrospective study that analyzed all variants that were reported at our institution from Jan 2018 to Dec 2019 in patients with de-novo AML. NGS was performed using illumina miseq platform utilizing an amplicon panel that includes 50 genes known to be altered in AML. Variant Call Format (VCF) files were analyzed in a weekly meeting. For the purpose of this study, all VCFs were concatenated into a single MAF file. The Bioconductor package maftools was utilized to analyze this MAF file. Results: 78 patients (24 children, 48 males, median-age=31 yrs) were studied. 193 variants were detected in 63 samples (81% of patients). The median number of variants-per-sample were 2 (range, 1 to 6). Most commonly mutated genes wereTET2(26%),NPM1(21%), FLT3(17%), DNMT3A(15%),NRAS(13%)CBLC, CEBPA, KIT(8%). The most commonly found nucleotide alteration was C>T transition which represented 50% of all mutations. Enrichment analysis showed the following significant associations (p Conclusion: We reported variants in 81% of our patients. Prognosis is significantly altered in patients withDNMT3AandNRASvariants. A wealth of actionable mutations were detected. Our results carry many similarities to the TCGA cohort, but significant difference in alterations involving 6 genes were reported. Our study lay the foundation for future studies that can evaluate big-data results obtained from our growing NGS facility. Figure Disclosures No relevant conflicts of interest to declare.

The aim of this short paper or extended abstract is develop an intelligent lifelong learning cancer care framework that will be adapted by the King Hussein Cancer Center in Jordan. Cancer Care is defined as "Comprehensive care for the cancer patient as a whole including all their needs - not just the medical and physical ones - using the services of many professionals working together" [3] . Lifelong learning is about continuous development throughout a life time. Our lives, as humans, span many decades in which the environment we grew up in is in a continuous state of change. Therefore, we need to be empowered to deal with emerging challenges and thrive in a continuously changing environment. Clearly, there are multiple interactions that take place between an individual human and the surrounding environment. The Oxford dictionary defines "interaction" as "Communication or direct involvement with someone or something". Another definition: "A particular way in which matter, fields, and atomic and subatomic particles affect one another, e.g., through gravitation or electromagnetism" [4] . Therefore, communication though interactions takes place and in certain times for precious causes and purposes. On the one hand, such communication is didactic with complex interactions between an individual and the environment, and on the other hand between an individual and other members of the community - who themselves are continuously changing.

A new method for deriving informational entities based on business process models in a cancer care setting is presented in this research. This method may lead to develop system models in early stages. We have used an example of business process in Blood and Marrow Transplant (BMT) process, to illustrate the hypothesis (argument), and to show the application of this method. The process of BMT shows its ease and timeliness. Finally, further work is planned to validate and evaluate the proposed method using several cases with different domains.

Analysis of raw data generated from Next Generation Sequencing (NGS) equipments is critical in detection of pathogenic and non-pathogenic variants. Illumina MiSeq for instance has a software called Miseq-Reporter [1] which performs the analysis of the sequencing raw data. Miseq-Reporter was built to handle several workflows along with amplicon workflow such as assembly and enrichment workflows. Moreover, many procedures, such as removing non-unique alignments and remov-ing reads with N bases, need to be applicable for the analysis. There are also other pipelines available but none meets all the following features: oriented to the analysis of NGS amplicon data, uses a range of flexible procedures, and is academically free. In this paper, we report the development and implementation of an in-house pipeline which is oriented to the analysis of NGS amplicon data, applies a range of parameterized procedures that are needed to be applicable in the variant-calling analysis using amplicon data, and is academically free.

Business Process Modelling has been widely used to understand, document, and improve organizational processes in an attempt to semi- or fully- automate these processes. This paper is an attempt to better understand and model organizational processes, in a Cancer Care organization, and in particular, the processes of Cell Therapy and Applied Genomics and to improve current practice and workflow by the stakeholders, using a standardized business process modelling language, namely the Business Process Modelling Notation (BPMN). This research has highlighted the significance of using role-based business process modelling languages, in discovering gaps and to improve adhering to some internal policies, procedures and protocols.

The aim of this study is to explore the usefulness of a reverse-engineering approach compared to a conventionally used, forward-engineering Riva approach, to identify Essential Business Entities (EBEs) that can be converted to Units of Work (UOWs). The conventional approach uses 14 Riva heuristics, whereas, the reverse engineering approach uses selected, role-based business process models and workflows, linked to organisational policies and protocols, to develop object-based Business Process Architectures (BPAs). The reverse engineering approach requires limited input from the concerned stakeholders, and saves considerable time and effort in identifying candidate EBEs and calculating subsequent UOWS. This approach has demonstrated usefulness in application at a Cancer Care organisation where readiness of validated process models (of the Cell Therapy and Applied Genomics (CTAG)) and also the limited time busy key stakeholders have to conduct brainstorming sessions. Additionally, this paper has demonstrated that domain representative BPAs can be developed bottom-up from business process models that have been utilised to inform adherence to organisational policies and protocols. Finally, the linkages between the CTAG detailed business process models with the respective BPA processes provided a magnifying lens over what can be in-sourced, outsourced, semi or fully-automated processes as observed through the BPA case study and feedback obtained through concerned stakeholders.

Cancer Care systems have increasingly evolved into Systems-of-Systems (SoS) arrangements. However, these emerging arrangements bring about increased levels of complexity; mainly due to the different characteristics of the constituent systems and their nature of participation in the respective Cancer Care SoS arrangement. Consequently, achieving effective traceability of changes related implications, maintaining a high-level of Business-IT Alignment (BIA), and achieving effective coordination and communications processes are considered key challenges when applying change management in a large-scale context such as the Cancer Care SoS context. To address these challenges in such a context, novel frameworks are needed. This paper introduces the development of a key constituent of such a framework, namely a ‘Business Process Architecture (BPA)-driven Linkages and Interactions component’ based on adopting a Design Science Research Methodology (DSRM) approach. This component integrates between BPA-driven change management elements and BPA-driven SoS context elements in order to guide the application of the change management processes in the cancer care SoS context. The integration also focuses on achieving a high-level of Business-IT alignment, holistic forward and backward traceability of change related candidate implications, and facilitating the coordination and communication processes while applying change management in SoS context. A case study has been conducted at the King Hussein Cancer Center (KHCC) to demonstrate, evaluate, and further mature the developed component.

The Riva method identifies an organisation’s business process architecture. Unfortunately, the research literature does not contain evidence that the heuristics used in the method’s key steps have been validated. To begin to address this shortcoming, the co-researchers have applied Riva to aspects of the cancer care domain at the King Hussein Cancer Center (KHCC) in Amman, Jordan. A subset of the results was presented to KHCC domain experts, who were invited to evaluate the validity and completeness of the heuristics used in each of the method’s steps. Their evaluation indicates that the large majority of the heuristics associated to the various steps of the method was seen as valid; with the exception that there was a perceived lack of specific guidance by means of heuristics related to Case Strategy Processes.

Cancer care centers aim at automating the carried out procedures in their labs in order to reduce staff effort and increase test accuracy. This has motivated the researchers undertaking Ig/TCR clonality testing at a cancer care organisation to derive a requirements model for a process-based and service-oriented intelligent framework in diagnosing malignant lymphoproliferative neoplasms. However, eliciting the requirements for such a framework has been challenged by the incomplete specifications of the Ig/TCR testing in the cancer care lab protocols. Workflow models using Business Process Modelling Notation (BPMN) has been developed to deliver a validated set of Ig/TCR workflow models. These BPMN workflow models constituted the base for deriving functional and service requirements for Ig/TCR testing linked with related quality requirements. The triangulation between Ig/TCR process models, the functional/service-oriented requirements and quality requirement formed the foundations to propose an intelligent framework for Ig/TCR clonality testing with process mining and data analytics driven by current and historical Ig/TCR events in a particular lab of a cancer care centre.

Cancer Care Informatics (CCI) and its impacts are assessed using the United Nations Sustainable Development Goals (SDGs). The positive and negative impacts of CCI on the SDGs are considered through a literature review and expert assessment. There has not been a prior publication of such an assessment and this could contribute to more holistic governance of CCI. The paper reviews the individual SDGs along with consideration of the 17 SDGs as a whole. Whilst the relationship of CCI with the achievement of SDG3 (Good Health and Well-Being) is the obvious impact, CCI also has impacts on other underpinning targets or indicators within the SDG framework. For example, the Greenhouse Gas emissions from the electricity consumed by CCI computer systems will have a negative effect on SDG13 Climate Change. Using the SDG lens helps us to identify the other direct and indirect impacts of CCI on Sustainable Development and affords the opportunity to manage deliberately such impacts as improving equality of access, elimination of modern slavery and delivering CCI education.

Metastatic neuroblastoma (NB) is the leading cause of cancer death in children under the age of 5. Interestingly, infants develop a special pattern of metastasis to skin, liver and bone marrow (stage 4s) and typically undergo spontaneous remission with very low mortality. There is accumulating evidence that patients with intermediate risk group, e.g. infants with bone metastasis, have the same natural history of spontaneous regression and they do not require intensive therapy [1]. This highlights the importance of characterizing this group of patients at molecular level. We searched open repositories for quantitative gene expression data and identified GSE49711 as a suitable data source. This series includes data on 498 patients with NB including extensive phenotypic data and RNA-seq counts generated by Illumina Hiseq 2000 platform. First, we applied exploratory analysis to check the quality of data and the need for normalization before further analysis. Also, patients were categorized into 3 groups: Very low risk (VLR, N= 45), very high risk (VHR, N=92) and others (N= 361). The first 2 groups were further analyzed for differential gene expression (DGE) to identify genes responsible for their contrasting outcome. The edgeR package was used to define the top 100 differentially expressed genes with lowest adjusted p-values. These genes were applied to segregate samples using principal component analysis (PC). Interestingly, PC2 identified a special subset of patients who belong the VLR but have a unique gene expression pattern. Indeed, a small subset of VLR patients (N=6) clustered away from the main group and at extreme PC2 values. When the rotation of PC2 was analyzed, a group of 20 genes were found to have contributed to its values. The selected top 100 genes were then used to build a model of hierarchal clustering and constructing a heatmap. The same subset of samples appeared on a distinct limp of the dendogram with remarkable increased expression in the same exact group of 20 genes mentioned above. Gene ontology (GO) enrichment analysis of these specific genes was performed using an online tool developed by the GO Consortium [2], [3] revealed involvement of the following processes: Acute inflammatory response, regulation of blood coagulation, regulation of hydrolase activity and platelet degranulation. These processes indicate the role of immune system in the process, possibly combined by platelet activation. Interestingly, recent literature is highlighting the role of platelets in initiating inflammatory processes in neural tissue [4]. The model (top 100 genes selected by previous analysis) was used to test the original dataset (N=498) and segregated patients into 3 groups of patients based on outcome. Differential expression of MYCN, NME2(C-Myc transcription factor) and NCAN (neuronal adhesion) were most significantly associated with variable mortality. In conclusion, when 2 extreme groups of NB patients were defined and DGE was applied, a model was developed that showed similarity between the groups with categorization of a small subset of VLR with unique pattern of gene expression. The model worked well in defining risk of mortality and identified certain genes that can serve for prognostication.

Early cancer diagnoses, combined with treatment, enhance survival and cure rates. In Jordan, more than 20% of breast cancer patients present with advance stage disease, where cure rates are low and cost of treatment is increased. Cancer diagnosis requires both clinical and psychological counseling for compliance and successful treatment. Referrals for cancer genetic counseling should be offered for individuals with hereditary or familial cancer history. During counseling, high-risk patients undergo a designated risk assessment and management processes through reviewing their prospective risks, and the undertaking risk reduction strategies such as regular screening with the designated treatment that is geared towards reducing morbidity and mortality. Furthermore, the patient who is educated in the genetic counseling process, is a key a partner in the decision making process while being psychologically supported. Advancement in technology is reshaping the way we practice medicine, and genetic counseling is no exception. Herein, we present our genetic counseling experience for Breast and Ovarian cancers as the main genetic counseling function at King Hussein cancer Center, and discuss the potential role of technology in making this practice more efficient and robust.

Since the post genome era nearly two decades ago, genomic sciences had enormously progressed at two interdepen- dent dimensions, the experimental and computational genomics. This was aided by the advanced technical (instrumental) side, combined with sequencing and high density genotyping technolo- gies. Not only mega size data had accumulated as one expects, but this was paralleled with the development of an endless list of computational genomics algorithms that are needed for genome assembly, alignment, variants annotation, imputation, network analysis, that are all together are opening the way for the implementation of a realistic personalized medicine. All these advancements also resulted in the establishment of many genomic databases that represent most of the global citizens across the continents. Unfortunately, the Arabs were underrepresented in these democratized genomic efforts, and left a major gap to be filled. Fortunately, few Arab countries including Saudi Arabia, Kuwait, UAE and Qatar had begun to embark on the Arabian genomics quest. However much is needed, and that calls for an efficient complementary steps to put the Arabian genetics on the global map of genomics. Furthermore, disease genomics is also needing the appropriate attention. Genomics of complex and non- communicable disorders such as diabetes and cancer, should be a priority, and both of which are heavily dependent on cancer care informatics. The challenge is not little, the tools are many, much of the required resources are publically available, but needing an efficient guidance, at high level, to make the Arabian genomics visible, accessible and transnational, to bring about the Arabian genomic medicine for real. Gaps and opportunities are presented next.

Specimen tracking at cancer centers is done to inform the physicians, nurses, patients and donors, as well as other lab staff, about the current status of ordered test or procedure. At present, specimen states are identified manually by the stakeholders in labs and by accounting department, responsible to charge for the services. This means that the lab specimen states are identified in the tracking system without taking into consideration the lab business process. This creates a gap between the current identified states and the lab’s business process. Moreover, the detailed tracking of a specimen is manually carried out using lab sheets attached into the patient file. The absence of an automated, end-to-end states tracking at labs, may diminish the quality control of lab data. This paper presents the work of deriving specimen states from lab business processes. The work applies the case study of the Cell Therapy and Blood and Marrow Transplant (BMT) lab at a cancer center in Jordan. The work contributes in bridging the gap between manually identified specimen states and the lab business processes. Also, it contributes in enhancing the quality control of lab data and accordingly to cancer center data.

Quality Governance of Systems of Systems (SoS) is a very complex challenge, given that participating systems in the arrangement are often not under direct control and they have different life cycles; yet one has to ensure that the required level of quality be achieved over time. In an SoS environment, one of the biggest issues is achieving the required inter-operation among multiple, heterogeneous systems. This paper introduces a quality governance framework namely the OntoSoS.QM.Gov framework, which aims to resolve this challenge. This framework consists of four integrated quality governance components: SoS standards, SoS processes, SoS policies and SoS quality requirements. This framework was applied to a case study in the cancer care domain to demonstrate and evaluate the framework components. The early results of the case study enable identifying initial conflicts between some of the constituent systems of the SoS arrangement.

New hematopoietic cell transplant (HCT) approaches are urgently needed for patients with severe aplastic anemia (SAA) who lack an HLA-identical donor. Haploidentical HCT with post transplant cyclophosphamide (PTCy) represent a potential universal available option for almost all children with SAA. We present a novel conditioning regimen for haploidentical HCT in children with SAA in a center where horse ATG is not available. Conditioning regimen consists of rabbit ATG 2.5 mg/kg/day from day -9 to -7, Fludarabine 30 mg/kg/day from day -6 to -2, Cyclophosphamide 14.5 mg/kg/day from day -6 to -5, Thiotepa 5 mg/kg/day from day -4 to -3, and 4 Gy TBI on day -1 in in two fractions. GvHD prophylaxis consist of PTCy 50 mg/kg/day on days +3 and +4 along with Cyclosporine A and Mycophenolate mofetil (MMF) starting on day +5. Four consecutive children with SAA referred to our center for haploidentical HCT starting in 2018. Median age at HCT was 9 years (5-16) with 3 males and 1 female. All patients were heavily transfused with both blood and platelets prior to referral for HCT. Two patients had strong and one had weak positive anti-HLA antibodies (DSAs) and received desensitization with IVIG, Rituximab and plasmapheresis. One patient received buffy coat infusion on day -1 due to persistent strong DSAs despite desensitization. Median CD34+ dose received was 12 x 10e6, and median CD3+ dose was 29 x 10e6. Donors were all same blood group to patients. All patients successfully engrafted neutrophils at median of 13 days (12-14). Platelets engraftment in 3/4 patients at median of 7 days (5-10). All patients received peripheral blood as stem cell source. Three of four patients survived and doing well at last follow up. One patient had toxic death on day +38 due to chemotherapy related toxicity causing multi-organ failure. Chimerism analysis was full donor in all four patients at median follow up time of 11 months (2-12). Patients were sent home at median of 24 days post HCT. None developed grade 2-4 acute GvHD nor chronic GvHD. Acute GvHD of skin grade 1 stage 1 developed in 2 patient and managed with topical steroids. Viral reactivations consisted of CMV viremia and BK hemorrhagic cystitis in all patients, and have all resolved. No post transplant autoimmune complications. Haploidentical HCT with PTCy represents a quick and first line approach in heavily transfused children with SAA. Although yet limited number of patients, this regimen is feasible and appears to be safe. A great advantage of this regimen is the rapid engraftment of both neutrophils and platelets. Moreover, although using peripheral blood as a stem cell source, there was no severe acute or chronic GvHD. Disclosures No relevant conflicts of interest to declare.

Introduction Fanconi anemia (FA) is an inherited bone marrow failure syndrome (IBMFS) due to a DNA repair mechanism defect. FA generally leads to marrow failure and/or leukemia-myelodysplasia in the first decades of life. Hematopoietic stem cell transplantation (HCT), using conditioning regimens adapted for the increased sensitivity for chemo- and radiotherapy induced damage, is the only curative therapy. The Severe Aplastic Anemia Working Party recently showed greatly improved HCT results, especially if patients were transplanted at a young age (Peffault de la Tour et al, Blood 2013). However, some patients are diagnosed at an adult age or are not transplanted at a young age for varying reasons. Data on HCT results in adult FA patients are very limited. We report here the final results of a retrospective study on transplant results in FA patients over 18 years of age at time of HCT. Results Both EBMT as well as non-EBMT centres contributed to this study, involving one hundred ninety nine patients, transplanted between 1991-2014. Median age of FA diagnosis was 16 years (ranging from birth up to the age of 48 years).In twenty nine cases (76% of evaluable patients) the genotype was A, in four it was C (11%). Median age at transplant was 23 years (range 18-48). Thirty seven patients (19%) aged more than 30 at time of HCT. Median time from diagnosis to transplant was 7 years (range1-14), also depending on donor availability (median 2 years for sibling donors, 9 years for an unrelated donor, up to 13 years for other/mismatched related donors).Indication for transplant was clonal disease in fifty four patients, 46 % of evaluable cases (14 leukemia/ 40 MDS). In ninety one patients (46%) the donor was an identical sibling, while forty seven (24%) received a matched unrelated donor, and forty patients (20%) a mismatched unrelated HCT. Stem cell source was bone marrow in 115 cases (58%), peripheral blood stem cells in 72 (36%) and cord blood in 11 cases (6%). The conditioning regimen contained cyclophosphamide in 173 cases (96%), fludarabin in 116 (64%), busulfan in 33 (18%) and low dose TBI in fifty five patients (29%). Engraftment occurred in one hundred fifty nine patients (82%, 95%CI 76-87).In eightteen patients there was a primary graft failure, in ten a secondary. Acute GvHD 2-4 occurred in thirty nine patients (22%, 95%CI 16-28). cGvHD was present in forty four patients (Cumulative incidence (CI) 26% at 96 months, 95%CI 20-33). CI of non relapse mortality at 96 months: 56% (95%CI 47-63). CI of secondary malignancies: 19 of 131 evaluable patients (17%) at 96 months post-HCT (95%CI10-25). Probability of overall survival at 96 months was 34% (95%CI 27-43). Main causes of death included infection (n=44, 37%), GvHD (n=29, 24%), organ damage (n=15, 12%) and secondary malignancies (n=12, 10%). In multivariate analysis identical sibling donor availability and the use of fludarabin in the conditioning regimen were statistically significantly associated with better chance of survival (p Conclusion. This study reports on the largest dataset of adult patients with FA undergoing HCT. We confirm that adult age has a negative impact on HCT outcome, compared to younger patients with FA undergoing transplantation. The use of fludarabin in the conditioning regimen has a positive effect on outcome. HCT should be considered for every patient with FA at an early age, if deemed necessary. International efforts are necessary to treat adult FA patients in need of HCT in clinical trials, especially when only less well matched donors are available. Disclosures Peffault De La Tour: PFIZER: Consultancy, Honoraria, Research Funding; NOVARTIS: Consultancy, Honoraria, Research Funding; ALEXION: Consultancy, Honoraria, Research Funding. Niederwieser:Amgen: Speakers Bureau; Novartis Oncology Europe: Research Funding, Speakers Bureau. Michallet:Bristol-Myers Squibb: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Astellas Pharma: Consultancy, Honoraria; MSD: Consultancy, Honoraria; Genzyme: Consultancy, Honoraria. Risitano:Novartis: Research Funding; Alnylam: Research Funding; Rapharma: Research Funding; Alexion Pharmaceuticals: Other: lecture fees, Research Funding.

INTRODUCTION: Allogeneic hematopoietic cell transplantation (HCT) is a diffuse curative option for transfusion dependent thalassemia (TDT) and sickle cell disease (SCD). To verify transplant activity, distribution, demography, policies and outcomes the Hemoglobinopathy Registry was established inside the European Group for Blood and Marrow Transplantation (EBMT). After a previous analysis limited to TDT for the 2000-2010 period data (BMT 2016; 51:536-41), we performed an updated report considering TDT and SCD patients transplanted in the last eighteen years (years 2000-2017). METHODS: Data on pediatric patients transplanted between Jan 1st, 2000 through Dec 31st, 2017 were extracted by the EBMT promise Hemoglobinopathy registry database. Only first transplants were considered. Data are expressed as median with range unless specifically indicated. Survival probabilities were calculated with the method of Kaplan and Meier and expressed as means and 95% confidence intervals (95%CI). Differences between survival probabilities were tested by means of the log-rank test. RESULTS: In the above-specified period 3856 consecutive pediatric patients affected by TDT (2936, 76%) or SCD (920, 24%) were transplanted in 166 HCT centers distributed in 36 countries in Europe, Asia and Africa. Median age at transplant was 7.2 years (range 0.48-17.9). 3342 (87%) transplants were performed on patients Figure 1 reports pediatric transplant activity inside the EBMT showing an increased numbers of patients transplanted after year 2010. After a median follow up of 24 months, the 2 years overall survival (OS) and event-free survival (EFS) were 91% (95%CI 90-92) and 86% (95%CI 85-87) for the entire population. In TDT, OS and EFS were 90% (95%CI 89-92) and 84% (95%CI 82-85), respectively. In SCD, OS and EFS were 94% (95%CI 92-96) and 92% (95%CI 90-94), respectively. In both diseases no outcome difference was recorded on the basis of year of transplant (data not shown). Source of hematopoietic cells was bone marrow in 70% of TDT transplants and 81% of SCD transplants. In both diseases better results were recorded with the use of bone marrow versus peripheral blood [OS 91% versus 85% (P< 0.001); 95% versus 84% (P= 0.004) for TDT and SCD, respectively]. Similar results were recorded when EFS was analyzed. 176 patients received hematopoietic cells from single cord blood donors. Of them only 21 were from an unrelated donor. 119 patients received cord blood + bone marrow. Results of related HLA identical cord blood were similar to that of HLA identical related bone marrow (data not shown). Transplantation from an HLA identical sibling offered the best results in OS and EFS compared to other donor options (P< 0.001), both for TDT and SCD. Transplant results by donor type are reported in table 1. The threshold age for optimal transplant outcomes is confirmed 14 years, with OS 92% (95%CI 91-93), EFS 87% (95%CI 85-88) versus OS 85% (95%CI 82-89), EFS 81% (95%CI 77-85) ( P The two years incidence of cumulative extensive chronic graft versus host disease was 4.1% in TDT and 4.4 % in SCD (P=ns). CONCLUSIONS: Allogeneic HCT for TDT and SCD is a widely available curative approach; the procedure has been increasing and internationally performed during the years with excellent results. The emerging gene therapy approach will have to be compared to these well-established results. Disclosures Zecca: Chimerix: Honoraria. Forni:Novartis: Other: travel expenses, Research Funding; Celgene: Research Funding; Roche: Consultancy; Shire: Research Funding; Apopharma: Other: DSM Board. Bader:Medac: Patents & Royalties, Research Funding; Neovii: Research Funding; Novartis: Consultancy, Speakers Bureau; Riemser: Research Funding; Cellgene: Consultancy. Angelucci:Vertex Pharmaceuticals Incorporated (MA) and CRISPR CAS9 Therapeutics AG (CH): Other: Chair DMC; Novartis: Honoraria, Other: Chair Steering Comiittee TELESTO Protocol; Roche Italy: Other: Local (national) advisory board; Jazz Pharmaceuticals Italy: Other: Local ( national) advisory board; Celgene: Honoraria, Other: Chair DMC.

INTRODUCTION Fanconi anemia (FA) is an inherited bone marrow failure syndrome that carries a high risk of transformation to myelodysplasia (MDS) and acute leukemia. Hematopoietic stem cell transplantation (HSCT) is used to treat FA patients in clonal evolution. The roles of chemotherapy before HSCT and the intensity of conditioning regimens in transformed FA patients are controversial, because of the high sensitivity of FA patients to DNA-damaging agents increases the risk of severe toxicities, the duration of aplasia, the risk of infective complications thus limiting the possibility to administer full dose cytoreductive treatments. The sequence chemotherapy-HSCT has been reported by some groups (MehtaPA et al Pediatr Blood Cancer 2007, Talbot A et al Haematologica 2014, Mitchell R et al Br J Haematol 2014, Ayas M et al J Clin Oncol 2013), but conclusive information is lacking because of small number of patients described without a risk factors' analysis. The aim of this retrospective study is to report the outcome of a large cohort of transformed FA who underwent allo-HSCT and to define the factors that may impact on its outcome. PATIENTS AND METHODS The study was conducted on behalf of the Severe Aplastic Anemia (SAAWP) and Chronic Malignancies Working Parties (CMWP) of the EBMT and was based on data of patients who underwent allo-HSCT between 1999-2016 for transformed FA, defined as a diagnosis of FA in presence of any hematological malignancies or cytogenetic abnormalities, registered in the EBMT Data Base. Clinical and biological information of the disease and details on transplant procedures and outcome were collected by a specific form distributed to Centres participating in the study. RESULTS Data of 71 patients (35 males-36 females) affected by transformed FA (42 MDS, 25 AL, 4 with cytogenetic abnormalities but without blasts) undergoing allo-HSCT were collected from 25 Centres . A matched related donor (MRD) was used in 31% of cases, an unrelated donor (UD) in 56.3% and a mismatched related donor (MMRD) in 12.7%. Bone marrow was the main source of cells (54.3%) followed by cord blood (22.9%), peripheral blood (21.4%) and bone marrow plus peripheral blood (1.4%). The median age at allo-HSCT was 12.7 years (range 9.3-23.4). Thirty seven (52.1%) patients received a chemotherapy before HSCT. Pre-HSCT status of malignancy in available patients was complete remission (CR) in 24% (n = 12/50) and an active disease (no-CR) in 76 % patients (n = 38/50). The conditioning regimen included total body irradiation (TBI) in 37 (52.1%) (radiation dose: ≤ 4.0 Gy in 30; > 4.0 Gy in 7), busulphan (BUS) in 16 (22.6%), no-TBI nor BUS in 18 (25.3%). Median follow-up was 93.7 months (71-110.6). GvHD prophylaxis and transplants' details are summarized in Table 1. All patients engrafted. Median time for neutrophils was 17 days (14-23) and it was 25 days (23-42) for platelets. The 2-and 5-year overall survival (OS) probability were 54% (41-66%) and 45% (32-57%) respectively; the 2- and 5-year event-free survival (EFS) (events being death, relapse and graft loss) 52% (40-65%) and 45% (32-58%). The cumulative incidence of relapse were 15% (7-24%) and 21% (11-31%), , of non-relapse mortality (NRM) were 37% (25-49%) and 39% (27-51%) respectively at 2 and 5-year. Most frequent causes of death were GvHD (33.3%), infections (23.3%) and relapse of malignancy (16.7%). Patients transplanted in CR, (neither blasts, nor major dysplastic features) and from matched related donor had a significantly better outcome (5-year OS: CR 83% (62-100%) vs no-CR 36% (19-52%) [p 0.01], MRD 60% (37-83%) vs UD 47% (31-64%) vs MMRD 12% (0-35%) [p 0.03]; 5-year EFS: CR 83% (62-100%) vs no-CR 34% (17-51%) [p 0.01], MRD 61% (38-83%) vs UD 48% (31-64%) vs MMRD 12% (0-35%) [p 0.02]; 5-year NRM: CR 0% vs no-CR 44% (27-61%) [p 0.007]) vs those engrafted in no-CR and from no-MRD. (Fig 1 a, b, c). No other tested variable (therapy before transplant and conditioning regimen) significantly affected the outcome. CONCLUSION This study on large cohort of FA patients transplanted because of transformation shows that allo-HSCT from MRD has a better outcome and that CR from malignancy before transplant appears to be a major determinant for a favorable outcome. Disclosures Peffault De Latour: Alexion Pharmaceuticals, Inc.: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Amgen Inc.: Research Funding; Pfizer Inc.: Consultancy, Honoraria, Research Funding. Ganser:Novartis: Membership on an entity's Board of Directors or advisory committees. Risitano:Pfizer Inc.: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Alexion Pharmaceuticals, Inc.: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Alnylam Pharmaceuticals, Inc.: Consultancy, Honoraria, Research Funding; Ra Pharmaceuticals, Inc.: Consultancy, Honoraria, Research Funding; Amyndas Pharmaceuticals: Consultancy; Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

The Wilms tumor antigen 1 (WT1) antigen is over-expressed in human leukemias, making it an attractive target for immunotherapy. Most WT1-specific Cytotoxic T Lymphocytes (CTLs) described so far displayed low avidity, limiting its function. To improve the immunogenicity of CTL epitopes, we replaced the first-amino-acid of two known immunogenic WT1-peptides (126 and 187) with a tyrosine. This modification enhances 126Y analogue-binding ability, triggers significant number of IFN-gamma-producing T cells (P = 0.0003), induces CTL that cross-react with the wild-type peptide, exerts a significant lytic activity against peptide-loaded-targets (P = 0.0006) and HLA-A0201-matched-leukemic cells (P = 0.0014). These data support peptide modification as a feasible approach for the development of a leukemia-vaccine.

BACKGROUND Features of T-cell/histiocyte rich large B-cell lymphoma (THRLBCL) overlap with those of lymphocyte predominant Hodgkin lymphoma (LPHL). The two lymphomas may represent a spectrum of the same disease, and differentiation between the two can sometimes be difficult. We looked at histomorphologic, immunophenotypic and clinical information that may help differentiate the two entities. METHODS Cases of THRLBCL and LPHL were blindly reviewed and studied for histological pattern (nodular vs. diffuse), nuclear features and pattern of expression of CD20, CD30, CD57, epithelial membrane antigen (EMA) and Epstein-Barr virus (EBV). A score encompassing diffuse histology, high nuclear grade, CD20 single-cell pattern, CD30 +, CD57-, EMA-, and EBV + was estimated for the diagnosis of TCHRLBCL. RESULTS There were 58 cases, including 30 cases of TCHRLBL and 28 cases of LPHL. The median age was 36 years for TCHRLBCL and 21 years for LPHL (P = 0.0001). Three types of nuclei were identified (lymphocytic/histocytic, Reed-Sternberg and centroblast-like). The latter two high-grade nuclei were suggestive of TCHRLBCL. TCHRLBCL and LPHL, respectively, showed diffuse histology, 90% vs. 4% (P = 0.001), single CD20 + cells, 93% vs. 3.5% (P = 0.00004), CD30 + cells, 30% vs. 0% (P = 0.01), CD57 + cells, 41% vs. 93% (P = 0.008), EMA + cells, 27% vs. 60% (P = 0.113), EBV + cells, 24% vs. 0% (P = 0.117), high nuclear grade, 70% vs. 0% (P = 0.001), total score 2-7 (mean 4.68) vs. 0-2 (mean 0.72) (P = 0.001), high stage, 86% vs. 7% (P = 0.0001). CONCLUSION Our findings indicate that a combination of multiple parameters can help differentiate between the two diseases. Two cases originally diagnosed as LPHL were re-assigned the diagnosis of THRLBCL.

Background: The treatment and prognosis of follicular lymphoma (FL) is dependant on the grade of the disease. In the World Health Organization classification of lymphoma, grading of FL into low grade (1 and 2) and high grade (3) is recommended. Grading of FL is possible in excision biopsy; histological grading is subjective and inconsistent. Grading is extremely difficult in needle core biopsies and fine needle aspirates. We attempted to grade FL using flow cytometry (FCM) and CD19/ forward scatter. Materials and Methods: Cases of FL seen in our institution and submitted for FCM were evaluated for the percentage of cells detected beyond the 500-channel mark (on a 1024 scale) on a CD19/forward scatter dot plot. We hypothesized that these cells most likely represent centroblasts and their percentage would reflect the grade of the disease. Histological grading of the lymphoma on the open biopsies constituted the reference for FL grade. Results: Thirty-six cases of FL, including 22 males and 14 females, ranging in age from 19 to 92 years (median, 42 years), were studied. There were 17 cases of low grade (grade 1; n=10 and grade 2; n=7) and 19 cases of high grade (grade 3) FL. The percentage of cells identified beyond the 500-channel mark on CD19/forward scatter dot plot ranged from 0.12% to 12.55% (median, 4.9%) in low grade (grade 1 and 2) whereas the percentage of those cells in high grade FL ranged from 6.22% to 51.95% (median, 21%; P=0.00001). Conclusion: Our findings suggest that using a CD19/forward scatter dot plot can help identify centroblasts in FL making grading possible on FCM, especially in small biopsies and fine needle aspirates.

The antiphospholipid syndrome (APS) is a thrombophillic disorder characterized by the presence of antiphospholipid antibodies (APA). It often occurs in patients with systemic lupus erythematosus (SLE) and may be associated with recurrent abortions and thrombocytopenia and, occasionally, catastrophic thrombotic events.To examine, retrospectively, the clinico-pathological features of patients with APS detected by the presence of the lupus anticoagulant (LAC).Patients were selected for study on the basis of a positive LAC test on review of the laboratory computer records of the King Faisal Specialist Hospital and Research Center. Following this, a clinical chart review was conducted in order to determine the clinical presentations, treatment and the course of patients identified. The information obtained was entered into an electronic database and subsequently analyzed.Seventy-seven patients were identified and reviewed. Fifty-six (73%) were female and 16 (21%) were children less than 15-years-old. Thirty-two patients (42%) had no clinical events (incidental APS). The syndrome was classified as primary in 40 (52%) patients and secondary in 37 (48%). Out of the 45 (58%) patients who presented with symptoms related to APA 22 (49%) had thrombosis, 24 (53%) had pregnancy failure, and 4 (9%) presented with catastrophic APS. The activated partial thromboplastin time (aPTT) was elevated and not corrected by mixing with normal plasma in 47 (61%). On the other hand, the prothrombin time (PT) was normal in 66 (90%). There is a significant difference between aPTT and PT as a screening test with P value of0.0001. Tests for anticardiolipin antibodies (ACA) were positive in 39 patients (70%). Only 13 (17%) patients had thrombocytopenia. All patients who presented with thrombosis were treated with warfarin but only 5 (23%) had received aspirin. Out of the 22 patients presenting with thrombosis, 12 (55%) had one or more recurrent thrombotic events while only 6 (25%) out of the 24 patients who presented with pregnancy failure had events other than pregnancy failure. Fifty-two patients were followed up regularly and were alive.We find that thrombosis, venous or arterial, and obstetric complications are the most frequent clinical findings in our patients with circulating LAC. Incidental APS is not an uncommon finding in patients screened for APS. There is a clear association between the presence of LAC and an abnormal aPTT, which is much less obvious with the PT.

BACKGROUND: The use of testicular sperm in assisted reproduction depends on the availability of sperm in wet preparations. It is not always possible to recover sperm from the testis, even with previous sperm-positive histopathological findings. The purpose of this study was to evaluate the sperm-negative wet preparation search results with flow cytometric ploidy analysis and histopathological examination. METHODS: Two pieces of testicular tissue were obtained from azoospermic patients to investigate the spermatogenic status of the testis, and to determine the presence of sperm through a wet preparation. The testicular tissue was shredded and then vortexed; the cellular suspension was then processed for a wet preparation sperm search, while the residual tissue was exposed to enzymatic digestion for flow cytometric ploidy analysis. RESULTS: A total of 38 patients had sperm-negative wet preparation results. Of those, six (16%) were shown to have haploid cells after flow cytometric analysis. Histopathological examination showed three samples with maturation arrest at the spermatid stage, and the other three at the spermatocyte stage. CONCLUSIONS: Flow cytometric ploidy analysis can be used to verify the results of a wet preparation sperm search when no sperm were detected. Flow cytometric ploidy analysis can also reveal the presence of spermatids when no sperm are available.

CD40 is a member of the tumor necrosis factor receptor superfamily, expressed on a wide range of cell types including B cells, macrophages, and dendritic cells. CD40 is the receptor for CD40 ligand (CD40L), a molecule predominantly expressed by activated CD4+T cells. CD40/CD40L interaction induces the formation of memory B lymphocytes and promotes Ig isotype switching, as demonstrated in mice knocked-out for eitherCD40LorCD40gene, and in patients with X-linked hyper IgM syndrome, a disease caused byCD40L/TNFSF5gene mutations. In the present study, we have identified three patients with an autosomal recessive form of hyper IgM who fail to express CD40 on the cell surface. Sequence analysis ofCD40genomic DNA showed that one patient carried a homozygous silent mutation at the fifth base pair position of exon 5, involving an exonic splicing enhancer and leading to exon skipping and premature termination; the other two patients showed a homozygous point mutation in exon 3, resulting in a cysteine to arginine substitution. These findings show that mutations of theCD40gene cause an autosomal recessive form of hyper IgM, which is immunologically and clinically undistinguishable from the X-linked form.

The t(9;22)(q34;q1 1) between the abl and bcr genes plays a pivotal role in the diagnosis and pathogenesis of chronic myelogenous leukemia (CML). Its detection is routinely accomplished by Southern blot analysis and karyotyping. Interphase fluorescence in situ hybridization (FISH) and reverse transcriptase-polymerase chain reaction (RT-PCR) are emerging molecular techniques that offer viable alternatives. We analyzed 40 samples of peripheral blood and bone marrow (CML, 16; acute myelogenous leukemia, 6; acute lymphoblastic leukemia [ALL], 1; chronic lymphoblastic leukemia, 2; myelodysplasias, 4; myeloproliferative disorders, unclassified, 3; nonleukemic hematologic malignancies, 3; hypercellular bone marrow, 1; normal control samples, 2; and K562 cell line samples, 2) for the presence of bcr-abl fusion gene and its messenger RNA (mRNA) transcript by FISH and RT-PCR, respectively. We compared the results with results of Southern blot analysis and karyotyping when available. Cost analysis was performed. Thirty-three samples were evaluable by FISH; 14 of 14 evaluable CML samples and one ALL sample were positive for bcr-abl by FISH (100%). The other 15 evaluable samples were negative; 16 of 16 (100%) and 13 of 16 (81%) of CML cases were positive for bcr-abl mRNA by RT-PCR (chemiluminescent blot method) and RT-PCR (colorimetric method), respectively. The ALL sample was positive by both RT-PCR methods. All other samples were negative by RT-PCR (chemiluminescent blot method), and all but 1 case of myeloproliferative disorder tested negative by RT-PCR (colorimetric method). We conclude the utility of FISH and RT-PCR is associated with certain limitations, such as insufficient RNA for RT-PCR and the occasional absence of internal positive FISH control signals. However, each procedure offers (with a high concordance rate) a specific and cost-effective alternative to Southern blot analysis and karyotyping and improved turnaround time for the detection of bcr-abl fusion gene or its mRNA transcript.

The mortality and neurological morbidity in heatstroke have been attributed to the host's inflammatory responses to heat stress, suggesting that anti-inflammatory therapy may improve outcome. We tested the hypothesis that a high dose of dexamethasone protects baboons against the lethal effects of heatstroke. Ten anesthetized baboons (Papio hamadryas) were assigned randomly to dexamethasone (n = 5) or control group (n = 5). Dexamethasone (2 mg/kg i.v.) was administered in four divided doses every 6 h starting immediately before heat stress and continuing during cooling. All animals were heat-stressed in a prewarmed neonatal incubator at 44 degrees C to 47 degrees C until systolic blood pressure fell less than 90 mmHg and then cooled passively at the ambient temperature. Mortality and neurological morbidity were noted, and biochemical markers of tissue injury/organ dysfunction were determined. Circulating interleukin (IL) 6 and complement components (C3 and C4) were measured sequentially. All heat-stressed animals had systemic inflammation indicated by increased plasma IL-6 and decreased C3 and C4 levels. Dexamethasone attenuated the complement system activation and maintained a higher plasma concentration of IL-6, with a significant augmentation of arterial blood pressure. Dexamethasone did not prevent the occurrence of severe heatstroke but unexpectedly aggravated significantly the tissue injury and multiorgan system dysfunction. Two animals (40%) in the control group and one in the steroid group survived (P > 0.05). Dexamethasone failed to protect the baboons from the lethal effects of heatstroke. These results do not support clinical testing of corticosteroids as beneficial in preventive or therapeutic strategies for the treatment of heatstroke in humans.

More than 1,000 kidney transplants were performed at King Faisal Specialist Hospital and Research Center (KFSHRC) between 1981-2005. The majority were from living donors. The renal transplant program at KFSHRC was fundamentally transformed in 2001 with the introduction of renal transplant physicians and the emphasis on multidisciplinary teamwork. This fundamental change has resulted in tripling of the size of the program and in expanding its scope of services to include high-risk patients (highly sensitized with a positive crossmatch). These achievements were coupled with excellent outcome data. The 5-year patient and graft survival rates for adult transplants performed during 2000-2005 were 97% and 94%, respectively, for 268 living donor transplants and 97% and 76%, respectively, for 73 deceased donor transplants. The kidney transplant program at KFSHRC is now a leading center in the Region and it ranks among the leading kidney transplant centers in the world in terms of size, scope of services and outcomes.

From 1996 to November 2004, 131 consecutive patients with relapsed or refractory diffuse large cell lymphoma (DLCL) and Hodgkin's lymphoma (HD) received ESHAP as mobilization chemotherapy before autologous peripheral blood stem cell transplant (ASCT). Patients received fixed dose G-CSF 300 microg SC bid starting 24-36 h after finishing mobilizing ESHAP. In all, four patients failed mobilization and are excluded. Characteristics of 127 patients: 68 males: 59 females. DLCL 49: HD 78. Initial stage I:II:III:IV:unknown was 15:34:33:42:3. Median age at ASCT 26 years. Median prior chemotherapy cycles were six [6 (17 patients), 6-8 (90 patients),8 (20 patients)]. Median ESHAP cycle used as mobilizer was third. Patients required 1, 2, 3, 4 apheresis were 93:25:8:1. Median total CD34+ cells/kg collected were 6.9 x 10(6) (DLCL 5.17 x 10(6) and HD 7.6 x 10(6)), patients weighingor = 70 kg (93 patients) 6.54 x 10(6) and70 kg (34 patients) 7.44 x 10(6) (P = 0.59), one apheresis (93 patients) 8.6 x 10(6)/kg and1 apheresis (34 patients) 4.5 x 10(6) (P = 0.001). We conclude that ESHAP and G-CSF 300 microg SC bid is an effective mobilizing regimen even in patients70 kg and most patients require only 1-2 apheresis.

Chimerism and graft-versus-host disease (GVHD) pose significant risks to liver transplant patients. The risk of chimerism and GVHD is higher among cases of living-related liver transplant (LRLT). Donors homozygous at all HLA loci carry a higher risk for GVHD. Herein we present a case of LRLT. The recipient suffered from end-stage liver disease and received a right lobe graft from his son. After 8 months posttransplant, the patient developed profound bone marrow depression. The patient was negative for CMV, Brucella, HHV6, HHV8, HBV, HCV, and parvovirus. No skin or GI signs of GVHD were noted. The patient and donor were HLA typed by SSP. The donor was homozygous for all HLA loci while the patient shared the class II homozygosity and was class I heterozygous. Chimerism studies were prompted after noting that the neutrophil compartment of the patient was homozygous for all HLA loci. This initiated further studies of the PMN and lymphocytes by microsatellite analysis. A total 15 microsatellites were analyzed. The results suggest that the majority (75%) of the PMNs and 45% of the lymphocytes were of donor origin. The patient was treated with G-CSF; his WBC counts returned to normal. At 2.5 years posttransplant the patient had not developed GVHD, despite the large number of donor lymphocytes circulating in his bloodstream. The only complaint he had was severe arthritis, which was treated with steroids. It must be investigated whether this was the result of GVHD.

In all, 22 patients with confirmed Fanconi anemia (FA) underwent stem cell transplantation (SCT) from HLA-matched, related donors at KFSHRC. Median age at SCT was 7.6 years (range, 2.5-14.6 years). Conditioning regimen consisted of cyclophosphamide (CY) 15 mg/kg/day intravenously (i.v.) for 4 consecutive days, in addition to equine antithymocyte globulins (ATG) given i.v. at 40 mg/kg/day for four doses pre-SCT. No radiation therapy was given. For graft-versus-host disease prophylaxis, we used cyclosporin at the standard doses; ATG was added at 20 mg/kg/dose i.v. on days 2, 4, 6, 8, 10, and 12 post-SCT (total of six doses). All patients engrafted and are alive and transfusion independent with a median follow-up time of 20.2 months (range, 3.3-59 months). One patient however developed a decrease in her WBC and platelet count. Her work-up revealed slightly hypocellular bone marrow, and a series of chimerism studies over 1 year confirmed that she has stable mixed chimerism; she remains transfusion independent. We conclude that low-dose CY without radiation therapy can be used satisfactorily in the conditioning of patients with FA undergoing related SCT.

*Correspondence to: Mahmoud Aljurf, Department of Oncology and Laboratory of Tumor Immunology, King Faisal Specialist Hospital & Research Center, MBC 64, PO Box 3354, Riyadh 11211, Saudi Arabia. Tel: +966-1-442-3937; Fax: +966-1-442-3941; E-mail: jurf@kfshrc.edu.sa Departments of Oncology and Pathology & Laboratory of Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia