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Clostridium difficile infections (CDI) remain the leading cause of infectious diarrhea among hospitalized patients in this country. Patients with hematologic malignancies, especially those who undergo hematopoietic progenitor cell transplants are particularly at risk for developing CDI. One hundred and forty seven consecutive allogeneic hematopoietic progenitor cell transplants were analyzed for peri-transplant Clostridium difficile infections (PT-CDI). Sixteen patients (11%) developed PT-CDI (Median time = 7 days after transplant). The probability for developing PT-CDI during the peri-transplant period was 12.3%. History of CDI was strongly associated with the development of PT-CDI (P = 0.008) (OR = 5.48) (P = 0.017). These patients also developed PT-CDI much earlier than in those without a history (median 1 day vs. 8 days, P = 0.03). The probability for developing PT-CDI for those with a history was 39%. There was a trend toward significance (P = 0.065) between matched related donor grafts and the development of PT-CDI (OR = 0.245) (P = 0.08). Age, sex, diagnosis, transplant preparative regimens, Graft-versus-host disease (GVHD) prophylaxis, grade 3/4 acute GVHD, or use of antimicrobials within 8 weeks of transplant were not associated with PT-CDI. Non-CDI-related deaths occurred in one patient in the PT-CDI group and nine in the group without PT-CDI. In the remaining 139 patients, the length of hospital stay for those with PT-CDI was significantly longer than those without (mean 27 days vs. 22 days; P = 0.02).

IV pentamidine for primary PJP prophylaxis in adults undergoing allogeneic hematopoietic progenitor cell transplant

While some patients with high-risk acute myeloid leukemia (AML) require one or two cycles of induction chemotherapy to achieve a complete remission (CR), others require more than two cycles. We examined the outcomes of patients with high-risk AML who received allogeneic HPC transplant in CR1. Forty five consecutive high-risk AML patients in CR1 were included. All 45 patients had adverse cytogenetics, FLT 3 mutations, or secondary AML. Group A patients (n = 33) received one or two cycles, and Group B (n = 12) three or more cycles of induction chemotherapy. The patients were comparable in age, sex, white cell count at presentation, and time from diagnosis and from last chemotherapy to transplant. The 100-day mortality rate was higher in Group B patients (50% vs. 9%, P = 0.006). They had a higher non-relapse mortality (33% vs. 6%, P = 0.035) and a longer length of hospital stay from the day of stem cell infusion (median 21 vs. 20, P = 0.02; third quartile 22 vs. 28, P = 0.02). There was also a trend toward inferior event-free survival and overall survival. High-risk AML patients undergoing allogeneic transplant in CR1 after three or more cycles of induction chemotherapy have an inferior outcome and higher mortality when compared to those who only needed one or two cycles of induction chemotherapy. Novel strategies are needed to reduce the transplant-related mortality in high-risk AML patients needing more than two cycles of induction chemotherapy prior to allogeneic transplant in CR1.

Acute myeloid leukemia (AML) represents a major therapeutic challenge in the elderly. Because of the high treatment-related mortality and poor overall outcomes of remission induction therapy, many older patients are not considered candidates for intensive chemotherapy. The current study evaluated prognostic factors for achievement of complete remission (CR) in newly diagnosed elderly AML patients who were treated with initial intensive chemotherapy. The study included 62 newly diagnosed AML patients ≥70 years who were treated with intensive chemotherapy. The overall response rate (CR and CRp) was 56%. Patients with favorable or intermediate cytogenetics (p = 0.0036) as well as those with primary AML (p = 0.0212) had a higher response rate. The median overall survival for all patients was 6.85 months (95% CI 3.7‐13.5 months). The median overall survival for patients achieving remission after intensive induction chemotherapy was significantly higher than those who did not respond to therapy (20.4 months vs. 3.5 months, p

Organ transplant recipients are at an increased risk for subsequent cancer including acute myeloid leukemia (AML). Treatment of AML following solid transplantation represents a clinical challenge since most patients have significant co-morbidities at the time of AML diagnosis. In the current study, we evaluated the treatment and outcomes of patients who developed AML following solid organ transplantation at our institution and reviewed the literature on outcomes for these patients. The study cohort consisted of 14 patients (median age 66 years, range 52-77 years) with newly diagnosed AML following solid organ transplantation. The median interval time between solid organ transplantation and AML diagnosis was 72 months (range 15 – 368 months). Seven patients received standard induction chemotherapy, four patients received intermediate type therapy, and the remaining 3 patients were deemed not fit for therapy and received palliative and supportive care. Six of the 11 treated patients (55%) achieved CR. The median overall survival (OS) for all patients was 6 months. The median OS for the patients who achieved complete remission after therapy was 17 months and 2 months for the remaining patients. Despite initial CR, relapse rates are still high, suggesting that alternative strategies for post-remission therapies are warranted. This article is protected by copyright. All rights reserved.

The development of effective treatment strategies for most forms of acute myeloid leukemia (AML) has languished for the past several decades. There are a number of reasons for this, but key among them is the considerable heterogeneity of this disease and the paucity of molecular markers that can be used to predict clinical outcomes and responsiveness to different therapies. The recent large-scale sequencing of AML genomes is now providing opportunities for patient stratification and personalized approaches to treatment that are based on individual mutational profiles. It is particularly notable that studies by The Cancer Genome Atlas and others have determined that 44% of patients with AML exhibit mutations in genes that regulate methylation of genomic DNA. In particular, frequent mutation has been observed in the genes encoding DNA methyltransferase 3A (DNMT3A), isocitrate dehydrogenase 1 (IDH1) and isocitrate dehydrogenase 2 (IDH2), as well as Tet oncogene family member 2. This review will summarize the incidence of these mutations, their impact on biochemical functions including epigenetic modification of genomic DNA and their potential usefulness as prognostic indicators. Importantly, the presence of DNMT3A, IDH1 or IDH2 mutations may confer sensitivity to novel therapeutic approaches, including the use of demethylating agents. Therefore, the clinical experience with decitabine and azacitidine in the treatment of patients harboring these mutations will be reviewed. Overall, we propose that understanding the role of these mutations in AML biology will lead to more rational therapeutic approaches targeting molecularly defined subtypes of the disease.

Methods: The present study examined the association between fatigue, pain, overall quality of life, and perceived health status with employment at 1-year post-transplant. Participants (N1⁄4404) completed a lifestyle survey 1-year post-SCT. Participants provided current employment status and whether change was attributable to their health status. Results: Participants were predominatelymarried/partnered (81.7%), Caucasian/Non-Hispanic (81.6%), males (52%) between ages 19-76 (mean: 56 years) and majority underwent autologous transplants (70.1%). Prior to illness diagnosis, 60.8% were employed Full-Time, which decreased at the time of transplant (35.5%) and at 1-year post-SCT (31.0%). Employment status was correlated with all variables of interest (p

Introduction: Natural killer (NK) cells mediate direct anti-tumor effects via their cytotoxic and cytokine-secreting functions. We and others have demonstrated that acute myeloid leukemia (AML) patients have a low NK-cell frequency and significantly depressed NK-cell activity. Activated NK cells (aNK) are generated by expansion of a human, interleukin-2 (IL-2)-dependent NK cell line (NK-92). aNK cells express activating receptors, lack most of the inhibitory killer-cell immunoglobulin-like receptors (KIRs) and mediate cytotoxicity against leukemia cell lines as well as primary leukemia blasts. Anti-leukemia effects of aNK cells were demonstrated in vivo in SCID mice xenografted with human leukemia cells. Advances in ex-vivo expansion of aNK cells under cGMP conditions and their strong anti-leukemia activity provided a rationale for conducting a phase 1 clinical trial (NCT00900809) with adoptively transferred aNK cells in patients with refractory/relapsed AML. Method: We conducted a phase 1, open label clinical trial at the University of Pittsburgh to evaluate the safety of aNK cells in patients ≥ 18 years old withrefractory and relapsed AML. Clinical-grade aNK cells were provided by NantKwest and expanded in the GMP facility at the Center for Cell and Gene Therapy at the Baylor College of Medicine, Houston, TX. Two cell-dose levels were used: 1 x 109 cells/m2 and 3 x 109 cells/m2. Patients were enrolled to dose levels based on the traditional 3 + 3 dose-escalation design. aNK cells were administered in the outpatient setting. One treatment course consisted of a total of 2 infusions of the same cell dose, each cell infusion delivered 24h apart (Days 1&2). Bone marrow biopsy was performed 21 days after a treatment course with aNK cells. Patients who had stable disease or reduction of leukemia blasts were eligible to receive additional aNK infusions. Results: Seven patients with refractory/relapsed AML were treated with a total of 20 aNK cell infusions. The median age was 71 years (range, 56-80 years). All patients had previously received multiple therapies for AML. Three patients were treated with the cell dose of 1 x 109 aNK /m2 and four patients with 3 x 109 aNK /m2. All seven patients completed the first course of therapy. None of the 7 patients experienced dose limiting toxicities during the aNK administration or during the 21 days observation period post-infusion. No grade 3-4 toxicities related (probable or definite) to the aNK infusion occurred. One patient developed fever, rigors, and hypotension 2h post infusion that required hospitalization; these known side effects were reversible with supportive care, intravenous hydration, and antipyretics. Three of the seven patients exhibited signs of clinical activity after the first course of treatment; in one patient, the blast percentage was reduced from 70% to 48% after a course of treatment, and the patient received an additional course of aNK cells. In two patients, the blast percentage remained stable after the first course of treatment; one of these 2 patients received additional two courses of treatment with aNK cells. Conclusion: The trial demonstrated the safety and feasibility of therapy with "off-the-shelf" aNK cells, and provided early evidence of efficacy in heavily pretreated patients with refractory/relapsed AML. No grade 3-4 toxicity occurred with the maximal cell dose used. These data provide the foundation for combination immunotherapy trials for the optimization of aNK cell therapy in patients with AML. Disclosures Klingemann: NantKwest, Inc.: Employment, Equity Ownership, Patents & Royalties. Rooney:Viracyte: Equity Ownership; Cell Medica: Membership on an entity's Board of Directors or advisory committees, Patents & Royalties.

The most effective regimen for relapsed acute myeloid leukemia (AML) patients who do not achieve complete remission (CR) after a course of salvage therapy has not been established. We evaluated the efficacy and toxicity of fludarabine and cytarabine in patients with AML in first relapse who did not respond to a course of salvage chemotherapy with mitoxantrone and etoposide. CR was achieved in 39 % of treated patients, and in 47 % of patients with a favorable/intermediate-risk karyotype. The median overall survival was 4.75 months. The median survival for patients achieving CR with fludarabine-cytarabine was significantly higher than for those who did not respond to therapy (9.6 vs. 4.5 months, P = 0.04). Our data suggest that the fludarabine-cytarabine regimen merits further investigation in relapsed AML patients with favorable or intermediate-risk karyotype with persistent leukemia after a course of salvage therapy.

Introduction Regulatory T cells (CD4+CD25high CD127low Foxp3+) (Tregs) are of increasing interest in the context of allogeneic hematopoietic cell transplantation (HCT), as they may be able to prevent or suppress graft-versus-host disease (GVHD). Relatively little is known about Treg profiles during the post-HCT period. We tested the hypothesis that Treg phenotype and function correlates to GVHD status. Methods Peripheral blood was drawn at 100 days and six months post-HCT from adult patients enrolled on an IRB-approved protocol. Eight-color flow cytometric analysis of Treg subsets was performed on peripheral blood mononuclear cells. Patients' FACS-sorted CD4+CD25high CD127low CD49dlow Tregs were cultured with their CD3/CD28-stimulated T cells and analyzed for proliferation via 3H-thymidine incorporation and cytokine production in culture supernatants. Clinical GVHD evaluations were extracted from medical records. Age-matched healthy controls were recruited for comparison. Data were analyzed using univariate regression, Mann-Whitney t-tests, ANOVA, and Wilcoxon matched-pairs signed rank tests. Results Twenty-eight patients (median age 61 years old) were studied. Total percentages of Tregs were similar at +100d and +6m post-HCT (median 9.3% and 9.15% of total CD4+ T cells, respectively), with similar levels of transcription factor Helios and markers of memory/activation (CD45RO), proliferation (Ki-67), and apoptosis (activated caspase-3). Healthy controls' Tregs had higher caspase-3 expression than patients'; all other markers exhibited similar levels. CD45RO+ and Ki-67+ levels were increased among Helios+ Tregs compared to Helios-Tregs, whereas caspase-3 levels were decreased. The absolute number of circulating Tregs was comparable between +100d and +6m, displaying lower numbers compared to healthy controls attributable to overall lower total T cell numbers. In vitro addition of sorted Tregs to stimulated bulk T cells isolated from patients at +100d post-HCT induced median 41% proliferation reduction (i.e., suppression), reduced levels of pro-inflammatory IL-2, IL-5, GM-CSF, IFNγ, and TNFα, and increased levels of anti-inflammatory IL-10 compared to stimulated bulk T cells alone (Treg:T bulk ratio of 1:2). These changes were of equivalent magnitude in cultures from healthy controls. No net change was noted for IL-17, while IL-35 and IL-12 levels were below detection. Univariate analysis revealed linear relationships between cellular proliferation suppression and IL-2, IL-4, IL-10, IL-13, GM-CSF, IFNγ, and TNFα relative changes. Across all +100d samples, higher degrees of Treg proliferation (Ki-67+) corresponded with increased IFNγ and TNFα suppression in culture supernatants (p=0.0462 and p=0.0276, respectively) and specifically correlated with enhanced suppression of IFNγ-producing CD8+ T cells (p=0.0280). Furthermore, higher Treg expansion potential (measured by Treg Ki-67/caspase-3 ratio) suppressed IFNγ and TNFα more potently (p=0.0479 and p=0.0484, respectively) and was associated with a higher proportion of Tregs comprising total CD4+ T cells (p=0.0266). Higher Treg Ki-67 expression at 100 days post-HCT was associated with increased likelihood of de novo GVHD onset by six months post-HCT (p=0.01208). Similarly, a higher Treg expansion potential profile was associated with GVHD onset by six months (p=0.0078). Conclusion Tregs from patients at 100 days and six months post-HCT display similar memory/activation and proliferation profiles and functional suppressive ability as Tregs from healthy controls. Among these patients, a proliferative Treg profile strongly correlates with increased in vitro suppressive function on a cell-per-cell basis and is further associated with reduced apoptotic profile, representing an expansive Treg profile. As these profiles can predict GVHD developing by six months post-HCT, the increased associated cell-per-cell suppressive potential may represent a compensatory yet ultimately inadequate Treg response to early GVHD-associated inflammatory changes. Figure 1. In vitro CD8+ IFNγ production decreases after Treg addition (representative diagram). Figure 1. In vitro CD8+ IFNγ production decreases after Treg addition (representative diagram). Figure 2. Increased Treg proliferative profile (Ki-67+) is associated with greater in vitro IFNγ suppression. Figure 2. Increased Treg proliferative profile (Ki-67+) is associated with greater in vitro IFNγ suppression. Figure 3. Increased Treg (a) proliferative and (b) expansion potential profiles at 100 days post-HCT predict de novo GVHD by six months. Figure 3. Increased Treg (a) proliferative and (b) expansion potential profiles at 100 days post-HCT predict de novo GVHD by six months. Disclosures No relevant conflicts of interest to declare.

Background Acute myeloid leukemia (AML) in older patients is associated with a poor prognosis, with lower complete remission (CR) rates and worse overall survival compared to younger patients. Moreover, most patients over the age of 70 years do not tolerate standard induction chemotherapy. Alternative therapy with hypomethylating agents can improve CR rates and survival compared to best supportive care, but overall outcomes remain poor with current therapeutic options. Preclinical studies suggest that "epigenetic priming" using decitabine followed by cytarabine increases the cytotoxicity of cytarabine. It is hypothesized that this is due to the reactivation of genes that have been silenced by the malignancy. The aim of this study is to evaluate the efficacy and safety of a novel induction regimen using decitabine followed by cytarabine in older patients with newly diagnosed AML who are not candidates for intensive chemotherapy. Interim response rates were reported at the ASH Annual Meeting in 2014. Here we present updated response rates, treatment-related mortality, and overall survival. Methods This is a phase 2, single arm study at the University of Pittsburgh Cancer Institute (NCT01829503) for patients over the age of 70 years with newly diagnosed AML, or patients over the age of 60 years who are considered not to be candidates for intensive chemotherapy. The induction regimen consisted of decitabine 20mg/m² intravenously (IV) x 5 days followed by cytarabine 100mg/m² continuous IV infusion x 5 days. Patients with no evidence of disease on day 15 bone marrow biopsy proceeded with maintenance decitabine after count recovery; patients otherwise proceeded with a second cycle of induction using the same regimen. Patients with progressive disease after 1 cycle were taken off study. After a second induction cycle, patients who achieved a complete or partial remission proceeded with maintenance decitabine. Maintenance cycles consisted of decitabine 20mg/m² IV x 5 days every 4-8 weeks until disease progression or toxicity. Response rates were determined by the International Working Group Response Criteria in AML. Four-week and 8-week mortality rates were assessed. Results Forty-six subjects were enrolled as of August 2015, 36 of whom were evaluable for response at the time of analysis. Median age was 76 years (range 67-88 years). There were 21 females (45%) and 26 males (55%). The median ECOG performance status was 1. There were 21 patients with poor risk cytogenetics at diagnosis. Of 36 patients who were evaluable for response, 20 patients had a CR and 5 patients had a CRi (CR/CRi rate 69%). Six patients had a partial remission, and 5 patients had resistant disease. All evaluable patients except for 6 received 2 cycles of induction. There were no 4-week mortalities and 4 (8.6%) 8-week mortalities. Deaths were attributed to subdural hemorrhage, multifactorial respiratory failure, progressive AML, and neutropenic sepsis. At a median follow up of 13.5 months, the overall survival is 12.4 months (95% CI:9.7-12.5). Conclusion We have shown that an induction regimen using decitabine as an epigenetic primer followed by cytarabine induces high CR/CRi rates with low treatment-related mortality in older adults with newly diagnosed AML who are not candidates for intensive chemotherapy, a patient population in whom there exists a dire need for novel treatment strategies. In the updated report of this phase 2 study, 69% of patients achieved a CR/CRi, and 4- and 8-week mortality were 0% and 8.6%, respectively. This compares favorably with historical outcomes of both intensive chemotherapy and decitabine monotherapy in older adults in terms of safety and efficacy, respectively. Overall survival was 12.4 months, which also compares favorably to previous reports of survival in this patient population. Methylation analyses at baseline and after decitabine in patients who achieved CR compared to patients who did not respond are ongoing and will be reported. We have demonstrated that decitabine followed by cytarabine is safe and effective in older adults with newly diagnosed AML. Disclosures No relevant conflicts of interest to declare.

Background Chronic graft-versus-host disease (cGVHD) is a leading cause of morbidity and mortality after allogeneic hematopoietic stem cell transplant (SCT). Median duration of systemic immunosuppression (IS) for cGVHD is approximately 2 years; however, 15% of patients still require IS 7 years after SCT. Previous studies identified factors that were associated with longer duration of IS or cGVHD. Our aim was to identify clinical and immunologic factors associated with cGVHD that is persistent ≥7 years after cGVHD diagnosis. Methods Patients were drawn from a prospective cross-sectional study of the natural history of cGVHD at the National Institutes of Health (NCT00092235). A cohort of patients who enrolled on the study ≥7 years from the time of cGVHD diagnosis, and thus had persistent cGVHD (pcGVHD), was compared to those who enrolled Results There were 38 patients with pcGVHD and 83 control patients Conclusions Although cGVHD is often self-limited, late forms requiring long duration of IS exist, and the predictive factors or underlying pathogenesis are unknown. Our analysis of cGVHD patients who enrolled on a clinical trial ≥7 years after diagnosis showed more lung and sclerotic skin involvement, less inflammatory signs, and higher B cells, immunoglobulins, and autoantibodies. These new findings suggest that pcGVHD may reflect irreversible damage rather than an active immune process; however, standardly accepted measures of disease severity were not associated with pcGVHD, suggesting that further tools are needed to differentiate accumulated damage from active disease. Distance from transplant center, which may contribute to access to care, was not associated, although increasing IS was recommended more frequently for pcGVHD patients. Factors that were previously identified as associated with longer duration of IS were not different or conflicted with our findings, suggesting that further study is needed. To further elucidate potential immune dysfunction in patients with pcGVHD, our ongoing studies are measuring BAFF, cytokine, and chemokine levels. Our results contribute to further hypotheses in the pathogenesis and contributing factors in patients who have pcGVHD. Table 1. Univariate analysis - factors significantly associated with pcGVHD ≥7 years from diagnosis (N=38) Disclosures No relevant conflicts of interest to declare.

Mifepristone is a synthetic selective progesterone-receptor modulator (SPRM) that is widely used around the globe in the field of reproductive medicine. At present mifepristone is approved in a number of countries for early termination of pregnancy (TOP), cervical dilatation before surgical TOP, and management of early embryonic loss or fetal death. A number of new clinical applications are being developed in gynecology, endocrinology and oncology. Mifepristone has also served as an invaluable tool in the study of steroid hormone biology.Current indications for mifepristone are reviewed. New applications for mifepristone under clinical investigation are discussed. In addition, the unique molecular and cellular effects of mifepristone are described.The reader will understand the mechanisms of action of mifepristone and the underlying steroid hormone biology. The reader will know the approved clinical indications for mifepristone and appreciate the ongoing basic and clinical research into new applications.Mifepristone is the first-discovered and still most widely used antiprogestin. It has several indications in reproductive medicine and is under investigation for a variety of potential applications in other fields of medicine. The molecular and cellular effects of mifepristone illuminate important aspects of steroid hormone biology.

Objective: This study explored whether average urinary estrogenmetabolites in breast cancer high-risk women can be used to iden-tifyasubgroupofwomenatparticularlyhighrisktodevelopbreastcancer, to which prevention strategies should be addressed.Methods: The population consisted of 77 high-risk women, 30breastcancerpatientsand41controls.Allsubjectsansweredastan-dardized questionnaire; height and weight and spot urine sampleswere also obtained. Urine hydroxyestrogen metabolites were mea-sured in triplicate by enzyme immunoassay, and the estrogen me-taboliteratiosforeachindividualwerecalculated.Results:The2:16OHE ratio (2-hydroxyestrone/16-alpha-hydroxyestrone) in womenat high risk for breast cancer was similar to that observed in thebreastcancer group(1.76 ± 2.33 versus1.29 ± 0.80) andlower thanin controls (2.47 ± 1.14; P 5 0.00). At the multivariate linearregression model, the 2:16 OHE ratio was significantly associatedwith diagnosis (P 5 0.000 for both the high risk and breast cancergroupversusthecontrols)andbodymassindex( P 5 0.005), but notwith age (P 5 0.604), or smoking history (P 5 0.478). Conclusions:This study suggests that lower urinary 2:16 OHE ratios are predic-tors of breast cancer risk. Profiling estrogen metabolites may iden-tify women who are more probably to develop breast cancer withina population of women with known risk factors and may help tofurther elucidate the clinical relevance of urinary 2:16 OHE ratiosas clinical markers and prognostic indicators in this population.IntroductionBreast cancer is a major public health concern because of its heavycontribution to both morbidity and mortality in the USA and in theworld. Several risk factors have been associated with breast cancer,most of which reflect the cumulative estrogen exposure during a wom-an’s lifetime (1). This has initiated a large body of research on the roleof estrogen and estrogen metabolites as both cancer initiators andpromoters.Estrogen metabolites have been examined in several breast cancerstudies, particularly 16-alpha-hydroxyestrone (16a-OHE1) and 2-hydroxyestrone. The estrogenic properties of these two compoundsvary according to their ability to bind to the estrogen receptor. The16a-OHE1 metabolite is an estrogen-like product through its bind-ing to the estrogen receptor; in contrast, the 2-hydroxyestrone me-tabolite has low or no estrogen activity because of its low affinitywith the estrogen receptor. The production of the two metabolitesis mutually exclusive; therefore, any external factor modifyingthe production of one of the two compounds is also responsiblefor the indirect modification of the other. For example, a dietrich in cruciferous vegetables may favorably increase the 2:16OHE ratio (2).To date, the studies that have evaluated the relationship betweenestrogenmetabolitelevelsandbreastcancer(3–14)haveobtainedincon-sistent results.Earlier studies (3,4) first measured the role of 16a-OHE1using a radiometric assay in a small sample of women with breast andendometrial cancer and suggested elevated levels of 16a-OHE1 amongwomen with breast and endometrial cancer as compared with the con-trols. Since then, at least 11 studies have evaluated the associationbetween estrogen metabolites in both urine and serum and breast can-cohort study (5–15). The results are mixed results but tend to support anassociation between estrogen metabolism and breast cancer.Though the role of estrogen metabolites has been studied in breastcancer patients, estrogen metabolism in patients who are at high risk fordeveloping breast cancer has not been clarified as yet. Most recently,one study compared urinary estrogen metabolites, conjugates and dep-urinating DNA adducts between 12 high-risk women, 17 women withbreast cancer and 46 control women and found a significant differencein the ratio of these compounds in breast cancer and high-risk womencompared with controls; however, the sample size was small (15).The present study was designed to measure estrogen metabolism ina large group of high-risk women and assess if this urinary biomarkercan be a predictor of future breast cancer development. In addition,the study addresses whether the urinary 2:16 OHE ratio may be linkedto specific epidemiologic risk factors. Understanding the relationshipbetween metabolites, environmental and dietary factors interactingwith estrogen metabolites production or elimination may help eluci-date the underlying mechanisms of breast cancer as well as identifypotential measures of prevention.Methods

Background: Acute myeloid leukemia (AML) in older patients is associated with a poor prognosis, with lower complete remission (CR) rates and worse overall survival compared to younger patients. Moreover, most older patients over the age of 70 years do not tolerate standard induction chemotherapy. Alternative therapy with hypomethylating agents can improve CR rates and survival compared to best supportive care, but overall outcomes remain poor after current therapeutic options in this patient population. Preclinical studies suggest that “epigenetic priming” using decitabine followed by cytarabine increases the cytotoxicity of cytarabine. It is hypothesized that this is due to the reactivation of genes that have been silenced by the malignancy. The aim of this phase II study is to evaluate the efficacy and safety of a novel induction regimen using decitabine followed by cytarabine in older patients with newly diagnosed AML who are not candidates for intensive chemotherapy. Here we present response rates and treatment-related mortality for the first 23 evaluable subjects. Methods: A phase II, single arm study of decitabine and cytarabine is ongoing at the University of Pittsburgh Cancer Institute (NCT 01829503) for patients over the age of 70 years with newly diagnosed AML, or patients over the age of 60 years who are considered not to be candidates for intensive chemotherapy. The induction regimen consists of decitabine 20mg/m² intravenously (IV) x 5 days followed by standard dose cytarabine 100mg/m² continuous IV infusion x 5 days. Patients with no evidence of disease on day 15 bone marrow biopsy proceed with maintenance decitabine. Patients with persistent disease but no evidence of progression proceed with a second cycle of induction using the same regimen. Patients with progressive disease after 1 cycle are taken off study. After a second induction cycle, patients with no evidence of disease, or persistent disease but no evidence of progression, proceed with maintenance decitabine. Maintenance cycles consist of decitabine 20mg/m² IV x 5 days every 4-8 weeks until disease progression. Response rates are evaluated by the International Working Group Response Criteria in AML. Treatment-related mortality is defined at mortality within 8 weeks of initiation of induction therapy. Results: Twenty-five subjects of a planned 37 subjects have been enrolled as of August 2014, 23 of whom were evaluable for response at the time of analysis. At the time of this preliminary analysis, the median age was 76 years (range 68-82 years). There are 11 females (44%) and 14 males (56%). The median ECOG performance status was 1 (range 0-2). There were 14 patients with poor risk cytogenetics at diagnosis. Of the 23 patients who are evaluable for response, there were 14 (61%) patients with a CR and 2 patients with a CRi (CR+CRi rate 70%). Two patients had a partial remission, 1 patient had a morphologic leukemia free state, and 4 patients had resistant disease. All patients except for 2 received 2 cycles of induction. Of the 14 patients who had poor risk cytogenetics at diagnosis, 10 (71%) had a CR, and 8 had normalization of their previous cytogenetic abnormalities. There have been no treatment-related mortalities to date. Conclusion: We have shown that an induction regimen using decitabine as an epigenetic primer followed by cytarabine induces high CR+CRi rates with no treatment-related mortality in older adults with newly diagnosed AML who are not candidates for intensive chemotherapy, a patient population in whom there exists a dire need for novel treatment strategies. In the first report of this phase II study, 70% of patients achieved a CR or CRi, and there were no treatment related mortalities. This compares favorably with historical outcomes of both intensive chemotherapy and decitabine monotherapy in older adults in terms of safety and efficacy, respectively. Final analysis of this clinical trial will include overall survival analysis, rate of grade III and IV adverse events, and epigenetic correlative studies. We have demonstrated that decitabine followed by cytarabine is a safe and effective regimen in older adults with newly diagnosed AML. Disclosures No relevant conflicts of interest to declare.

Abstract 4531 Background: Hematopoietic cell transplantation (HCT) can be curative for patients with acute myeloid leukemia (AML) refractory to initial chemotherapy or refractory to re-induction after relapse. However, HCT for AML not in complete remission (CR) can be associated with high treatment related mortality and disease relapse or progression. Pre-transplantation variables that have previously been shown to influence survival in these patients include performance status, duration of first CR, cytogenetic risk group, donor type and presence of circulating blasts. In the current study, our aim was to evaluate outcomes of HCT in patients with refractory AML, and to determine factors that may be predictive of survival. Methods: Patients with refractory AML were identified from a database of patients who received allogeneic HCT at the University of Pittsburgh Cancer Institute from 2000–2012. Subjects were included if they had relapsed AML that did not respond to re-induction chemotherapy (n=35), or had persistent leukemia after initial induction chemotherapy at diagnosis (primary induction failure) (n=36). Rates of CR and CR with incomplete blood count recovery (CRi) were calculated at day 30 and day 100 after HCT, and 3-year and 5-year overall survival (OS) rates were determined using the Kaplan Meier method. Cox proportional hazards regression was used to examine associations between factors of interest and overall survival. The factors of interest included gender, age, relapsed AML versus primary induction failure, primary or secondary AML, cytogenetic risk group, duration of initial CR (for patients in relapse), performance status, number of previous induction chemotherapy cycles, presence of circulating blasts, percentage of blasts in bone marrow prior to transplant, matched unrelated versus sibling donor, donor-recipient sex match, donor-recipient CMV status, and incidence of acute GVHD. Patients were then assigned risk scores based on 5 pre-transplantation predictive factors previously described (J Clin Oncol 2010;28:3730–3738), and overall survival between the risk groups based on these scores were compared. Results: The study cohort consisted of 71 patients (median age 44 years, range 19–64 years) who underwent allogeneic HCT for refractory AML. Fifty-eight of 71 (82%) patients received myeloablative conditioning regimens using busulfan and cyclophosphamide or cyclophosphamide and total body irradiation, and the remaining (18%) received reduced-intensity fludarabine-containing regimens. The majority of patients received cyclosporine with methotrexate for GVHD prophylaxis. At day 30 after HCT, CR rate was 31%, and CRi rate was 49%, for a total 80% response rate. At day 100 after HCT, 51% remained in CR or CRi. Three-year OS rate was 12.3% (CI 5.6–21.8), 5-year OS rate was 10.5% (CI 4.4–19.7), and median OS was 0.57 years (CI 0.35–0.75). Among the factors evaluated, donor type was found to be significantly associated with OS in univariate and multivariate analyses, with higher risk of death from matched unrelated versus sibling donor (HR 1.74, 1.02–2.96). Younger age at HCT was also associated with improved survival (p Conclusion: Despite high CR and CRi rates after HCT for patients with refractory AML, 3-year and 5-year OS rates were 12.3% and 10.5%, respectively. Only donor type was significantly associated with OS, though there was a trend for patient age. Though patients with AML in relapse or primary induction failure represent a high-risk group to undergo HCT, the initial high response rates through day 100 suggest the potential role of maintenance therapy after HCT or strategies for modulating immunosuppressive therapy in order to improve survival in this population. Disclosures: No relevant conflicts of interest to declare.

Abstract #4080 Background: Variations in estrogen metabolism may be associated with increased breast cancer risk. Women who have preferential metabolism via 16α-hydroxylation are reported to have a higher risk of developing breast cancer compared to women who have preferential metabolism via 2α-hydroxylation. Profiling estrogen metabolites may identify women who are more likely to develop breast cancer within a population of women with known risk factors. Our aim was to evaluate estrogen metabolism in a group of high risk women. Methods: Women were recruited from the Magee-Women's Hospital High Risk Breast Cancer program. Risk factors included first degree family history, atypia, fibrocystic breast disease, BRCA1/2, Ashkenazi Jewish descent. Urine 2:16 OHE ratios were compared among the high risk group, an average risk control group, and a group of women with breast cancer. We also evaluated the relationship between urine 2:16 OHE ratios and epidemiological risk factors including BMI, alcohol use, smoking history and first degree family history. Results: There were 65 high risk patients, 30 breast cancer patients, and 41 controls. The Kruskaul-Wallis rank test and Wilcoxon rank-sum test were used for analysis. There was a significant difference in 2:16 OHE ratios among all three groups, p=0.0001. Urine 2:16 OHE ratios were lower in the high risk group (median 1.15) compared to the control group (2.22), p=0.00, and were lower in the breast cancer group (1.09) compared to the controls, p=0.00. There was a difference in BMI among all three groups, p=0.002. Overall, the 2:16 OHE ratio was positively associated with BMI, p=0.0006, and with alcohol use, p=0.02. Smoking history did not differ among all groups, and there was no association between smoking history and 2:16 OHE ratio. Within the high risk group, family history was not associated with 2:16 OHE ratio. Conclusions: Our research suggests that there is an association between lower urine 2:16 OHE ratios and high risk breast cancer. This association may be linked to specific risk factors such as BMI and alcohol use. This information may help to further elucidate the clinical relevance of using urinary 2:16 OHE ratios as clinical markers and prognostic indicators in this population. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4080.

Background An important aspect of the link between estrogen and breast cancer is whether urinary estrogen levels are representative of the intra-tissue levels of bioavailable estrogens. Methods This study compares 15 estrogen and estrogen metabolite levels in breast tissue and urine of 9 women with primary breast cancer using a quantitative liquid chromatography-mass spectrometry method. Results The average levels of estrogens (estrone, 17 beta-estradiol) were significantly higher in breast tissue than in urine. Both the 2 and the 16-hydroxylation pathways were less represented in breast tissue than urine; no components of the 4-hydroxypathway were detected in breast tissue, while 4-hydroxyestrone was measured in urine. However, the 2/16 ratio was similar in urine and breast tissue. Women carrying the variant CYP1B1 genotype (Leu/Val and Val/Val) showed significantly lower overall estrogen metabolite, estrogen, and 16-hydroxylation pathway levels in breast tissue in comparison to women carrying the wild type genotype. No effect of the CYP1B1 polymorphism was observed in urinary metabolites. Conclusions The urinary 2/16 ratio seems a good approximation of the ratio observed in breast tissue. Metabolic genes may have an important role in the estrogen metabolism locally in tissues where the gene is expressed, a role that is not readily observable when urinary measurements are performed.