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In three cases of acute nonlymphocytic leukemia we observed a translocation (8;16)(p11;p13); in one case it was the sole karyotypic change and in the other two cases it was associated with other structural anomalies. All three cases were nonhyperleukocytic myelomonocytic leukemias with erythrophagocytosis by some blast cells and cytochemistry results consistent with leukemic proliferation of a common monocytic-granulocytic precursor. The importance of this translocation is discussed, and the implication of band 16p13 in myelomonocytic leukemia is stressed.

We report a promyelocytic blast crisis in a case of Ph-positive thrombocythemia with both t(9;22) and t(15;17). Our patient confirms the specificity of t(15;17) in malignant proliferation of promyelocytes and suggests its appearance as a second genetic event in the genesis of blast crisis occurring in a Ph-positive clone.

Cytogenetic analysis was performed in 47 newly diagnosed patients with agnogenic myeloid metaplasia (AMM); 32 had a normal karyotype (68%, group I), whereas 15 had clonal abnormalities (32%, group II). The most frequent abnormal findings were a 20q- deletion in six cases (either alone or within complex anomalies), interstitial 13q- deletion in three cases (and monosomy 13 in one case), and acquired trisomy 21 or 21p+ in three cases. Four cases exhibited complex aberrations involving several chromosomes, sometimes with a mosaicism. In two patients with an initial abnormal karyotype, further cytogenetic analysis during the disease course showed the appearance of additional clonal anomalies, and particularly of a probable Philadelphia (Ph1) variant in one case. Treatment was essentially supportive. Survival was significantly shorter in group II (median, 30 months) compared with group I (median, not reached at 6 years; P = .015). In univariate analysis, other parameters significantly associated with a poor prognosis (P less than .05) were higher age, anemia, and increased percentage of circulating blasts. However, in a multivariate analysis, only cytogenetic abnormalities and age retained their independent prognostic value.

We report clinical, immunologic, and cytogenetic characteristics of six patients with a t(1;19)(q23;p13) that was balanced in one case and of the unbalanced type [−19,der (19)t(1;19)(q23;p13)] in the remaining five cases. Intracytoplasmic immunoglobulins (cIg) were positive in the three cases where they were found. We also report on another patient, with a t(17;19) involving 17q11 and probably 19q13 regions, although involvement of 19p13 could not be excluded. In this patient, cIg were also present, thus raising the issue of whether such a rearrangement could be a variant of t(1;19). Clinically, five patients belonged to the high-risk acute lymphoblastic leukemia (ALL) group, because of high leukocytosis, central nervous system (CNS) disease at presentation, or massive organomegaly. Cytologically, all cases were FAB type L1. Except for the two cases allografted in the first complete remission (CR) all patients relapsed, three of them within 13 months. Two CNS relapses were seen in spite of adequate CNS prophylaxis. ALL with t(1;19) appears to be a poor-risk ALL subgroup and probably requires a reinforcement of therapeutic modalities that might include, when possible, allografting at first CR.

To improve the results in the treatment of adult acute lymphoblastic leukemia patients, different strategies have been proposed. The intensification could concern the induction and early consolidation phases, the conditioning regimen before allogeneic bone marrow transplantation (alloBMT), or both. We analyzed 2 consecutive trials for adult patients in first remission and with the same prognostic features. The Leucemie Aigue Lymphoblastique Paris-Ouest-France (LALPOF) protocol proposed alloBMT with standard conditioning after a classic induction and intensified consolidation scheme; the Groupe Ouest Est des Leucemies Aigues Lymphoblastiques (GOLEAL1) protocol tested an intensified induction and consolidation course before alloBMT with a reinforced conditioning regimen. The 4-year survival rates after alloBMT for LALPOF and GOELAL1 were, respectively, 71% +/- 12% and 36% +/- 13% ( P = .009). The 4-year disease-free survival reached 75% +/- 11% in the LALPOF study and 69% +/- 13% in the GOELAL1 study ( P = .30). The toxic death rate was significantly lower in the LALPOF (2/18) than in the GOELAL1 (6/15) group. Event-free survival at 4 years was significantly higher in LALPOF than in GOELAL1: 66% +/- 11% and 35% +/- 11%, respectively ( P = .02). For adult acute lymphoblastic leukemia patients in first remission, the intensification of chemotherapy before a reinforced conditioning regimen before alloBMT may lead to an increased toxic death rate.

This study investigated the impact of human herpesvirus type 6 (HHV6) reactivation within 100 days of allogeneic stem cell transplantation (allo-SCT) on patient outcomes. HHV6 plasma loads were monitored weekly by quantitative PCR. Of 235 consecutive patients, 112 (48%) had an early positive HHV6 PCR test (group A) and 123 (52%) did not (group B). HHV6 reactivation was less frequent in patients who received reduced-intensity conditioning (P = .028). In group A, only 6 patients (5%) were asymptomatic; the most common clinical manifestations were fever (n = 60), skin rash (n = 57), diarrhea (n = 51), pulmonary complications (n = 19), and neurologic disorders (n = 12). Compared with the patients in group B, those in group A experienced delayed platelet engraftment (P = .003) and more frequent grade II-IV acute graft-versus-host disease (GVHD) (47% versus 30% in group B; P = .009). In multivariate analysis, the most important factors influencing the development of grade II-IV acute GVHD development were early HHV6 reactivation (P = .03) and unrelated donor status (P < .001). HHV6 reactivation adversely influenced 6-month survival (P = .04). Of the 38 evaluable patients receiving antiviral treatment, 34 had a significantly decreased HHV6 load. Our findings indicate that HHV6 reactivation after allo-SCT is associated with delayed platelet engraftment, early posttransplantation mortality, and the development of acute GVHD. Careful monitoring of HHV6 by PCR is warranted during the early posttransplantation period.

A case of secondary chronic myelomonocytic leukemia with t(1;7)(p11;p11) is reported. This patient had been treated without interruption with chlorambucil for multiple sclerosis since 1970. The t(1;7), to our knowledge, is the first described in secondary chronic myelomonocytic leukemia.

Summary Between 1981 and 1987, L3 ALL was diagnosed in 18 adult patients, with a median age of 26 (range 16-66) and M/F ratio of 3.5. At diagnosis, 11 patients had splenomegaly, 11 had enlarged lymph nodes, and 15 patients had central nervous system (CNS) disease, of whom 10 had mental neuropathy. Anaemia was found in 13 patients, thrombocytopenia in 17 and the median white cell count was 25.5 × 109/1(range 8.6-89). Surface immunoglobulins were found on the blasts of every patient. Seventeen patients had a t(8;14) (q24;q32) translocation. One had an apparently normal karyotype, but only six mitoses could be examined. During the period of the study different treatment protocols, which comprised increasingly intensive systemic and CNS chemotherapy, were used. Six patients died less than 3 weeks after admission, two of them of acute tumour lysis syndrome and two of CNS haemorrhage. In two other patients, rapid progression of CNS leukaemia was seen in spite of the treatment. Ten patients (56%) achieved complete remission (CR). Two were allografted and two were autografted early in CR. Four patients relapsed, three of the four relapses involving the CNS. A median actuarial disease-free survival was not attained, and a plateau was achieved at 57% after 7 months, with no later relapse. Median actuarial survival of the 18 patients was only 6 months, but a plateau was obtained at 31% after 11 months. Prognosis seemed related to the intensity of chemotherapy: recent patients, treated more aggressively, achieved CR more often than earlier patients, treated with less intensive protocols, although the number of patients was too small to draw any firm conclusion. The initial white cell count was also a prognostic factor, as none of the patients with more than 30 × 109/1 leucocytes achieved CR. Our results suggest that the outcome of adult L3 ALL can be improved, as in children, by increased intensity of treatment, particularly with regard to CNS leukaemia therapy. Early deaths are still frequent, however, but their incidence can probably be reduced by better prevention and early management of the acute tumour lysis syndrome.

We report 60 cases of chronic and subacute myelomonocytic leukaemias (CMML and SMML) in the adult, using the FAB group criteria. The M/F sex ratio was 3.3 and the mean age 67.5 years. Splenomegaly was found in 32% of cases, hyperleucocytosis in 52% of cases and mean blood monocytosis was 4.3 X 10(9)/l. Marrow smears showed an excess of blasts in 57% of patients, a moderate increase in monocytes in most cases and frequent myelodysplastic features. An increase in serum lysozyme and polyclonal hypergammaglobulinaemia were usual and clonal cytogenetic anomalies found in about half of the patients tested. Treatment was usually palliative and the median survival was 28 months, a blastic transformation being responsible for a third of the deaths. Prognostic factors at diagnosis were analysed retrospectively in the 46 patients who had sufficient follow up. Percentage of marrow blasts haemoglobin level and blood monocytosis at diagnosis, were subject to multivariate analysis, resulting in a discriminant 'score'. This allowed assignment of each patient into one of two prognostic subgroups (10.9% probability of error): a poor prognosis one, with a life expectancy of less than 1 year and a high risk of acute transformation (subgroup termed SMML) and a better prognosis subgroup (termed CMML), with some CMML patients surviving over 5 years.

A case of chronic myelogenous leukemia in an elderly man with a new translocation, t(8;11)(q24;q13), associated with a Philadelphia t(9;22) translocation is described. The clinical and hematologic aspects of the disease did not seem to differ from those of the usual cases of chronic myelogenous leukemia except for a basophilic blast crisis.

Between 1980 and 1986, we diagnosed refractory anaemia (RA), according to the FAB classification, in 69 patients, who constituted 22% of the 312 cases of myelodysplastic syndromes (MDS) seen over that period. The haematological features were variable, with pancytopenia in 14 cases (20%), bicytopenia in 24 (36%) and mono-cytopenia in the remaining patients, including 21 (30%) cases of anemia alone, 8 (12%) cases of refractory neutropenia and 2 (3%) cases of refractory thrombocytopenia. Myelodysplastic features were also quite variable, involving one, two or all three lineages. In patients with a single cytopenia or only one dysplastic lineage, FAB criteria appeared insufficient for adequate inclusion among RA and we suggest more precise diagnostic criteria, resulting from the utilization of cytogenetics, ferrokinetics, progenitor cultures and perhaps molecular biology, in such cases. Median survival was 42 months. 12 patients (17%) progressed to RAEB (of whom 7 finally developed ANLL) and 4 patients (6%) to CMML. In spite of the heterogeneity of haematological features, only two factors were associated with poor prognosis, namely age greater than 70 yr at diagnosis and haemoglobin less than 10 g/dl, whereas, to a lesser extent, neutropenia was associated with progression to RAEB.

16 adult idiopathic thrombocytopenic purpura (ITP) patients, with mean age 51 years, were treated by 5 weekly slow intravenous infusions of vinblastine (0.1 mg/kg). When a complete or partial response (CR or PR) was obtained, slow infusions were repeated at 2-weekly then monthly intervals, as maintenance therapy. In 4 cases with ITP of recent onset, but presenting contraindication or failure to prednisone and high dose intravenous immunoglobulins, CR was obtained in all patients after 4 to 15 days (mean 9.5). Only one of these patients relapsed. In 12 cases of refractory chronic ITP (of whom 10 had been splenectomized), there were 2 CR, 6 PR and 4 failures. The 8 responding patients had a mean interval to response of 20 days. The 6 PR were short and did not exceed 15 days. Our results do not support a superiority of this treatment compared to other modes of administration of vinca alkaloids in ITP (intravenous bolus, vinca loaded platelets).

Objective: To describe the use and results of imatinib mesylate (IM) treatment for chronic myeloid leukemia (CML) in the Nord-Pas de Calais Region in Northern France (~ 4 millions inhabitants). Methods: we identified all IM treated patients (pts) within the population of all confirmed diagnosis of CML occurred during the period 1985–2004. IM resistance (haematological and cytogenetic imatinib failure and suboptimal response) was evaluated according to the European LeukemiaNet consensus. Results: 302 pts (38.6% of the global cohort of diagnosis) were included in this retrospective study. If we consider new diagnosis occurred after Januar 1st 2001, 163 pts (90.6%) have been treated by IM. At the initiation of IM: 18 pts (6%) were in advanced phase (accelerated and blastic), 245 pts (81,1%) in chronic phase (CP) (with Ph+ metaphases > 35%), 35 (11,6%) had major cytogenetic response (MCyR) obtained with interferon (IFN) or bone marrow transplantation (BMT). Four pts (1,3%) had an unknown status. The percentage of alive pts at the last update (December 31th 2005) according to the disease stage at initiation of treatment is given in the table 1.In the sample of 245 CP pts, 139 (56.7%) had been previously treated by IFN, the median CML duration prior to IM was 4.7 months [0–174], the median IM treatment duration was 31.3 months [0.5–72.3] and the median follow-up after IM initiation was 36 month [5.2–72.3]. 214 pts (87.30%) were alive at the last update with 169 (79%) still on IM and 161 (75.2%) on IM as monotherapy. The median and mean IM daily doses of alive pts are 400 mg and 409.5 mg, respectively. Seventeen pts (6.9%) stopped IM for intolerance. The haematological and cytogenetic follow-up was informative for 206 CP pts (84.1%): MCyR 155 pts (75.2%) and CCyR 144 pts (69.9%). IM resistance occurred in 73 (35.4%) of these 206 evaluable pts, including 23 (11.1%) accelerations and blastic transformations. In the subgroup of IM resistant pts 47 (64.4%) have increased their IM posology. The mean of the maximum daily dose in the resistant subgroup was 607.5 mg (median 600 mg). BCR-ABL kinase domain mutations were found in 15 (20.5%) pts amoung IM resistant population. The estimated 5-years survival rate of the CP pts is 81.3%. Previous treatment by IFN doesn’t influence significantly the survival, nor the duration of the disease before IM initiation, even if we found a trend for a better survival when this period was inferior to 6 months (5 years survival rate 90.4% vs 77.5%, p=0.16). BMT was performed for 31 pts (10.3%) including 19 pts (6.3%) after the initiation of IM therapy. Conclusion: these real life observations show the large use of IM in the last years and its great impact on the management and the survival of CML pts. IM resistance occurs in 1/3 of pts but the disease duration prior to IM is heterogeneous. An increase of IM dose has been tried in most IM resistant pts. The response to the different therapy adaptations is under study and will be presented. The vast majority of pts are still on IM therapy at the last update. Table 1

Peripheral G-CSF-mobilized blood stem cells (PBSC), use as alternative to marrow stem cells (MSC), is associated with enhanced engraftment and accelerated hematopoietic recovery after allo-SCT. However, despite an increased number of donor T cells infused, the incidence of acute GVHD with PBSC appears to remain identical or less than with MSC. Recent works on the heterogeneity of the human CD4+ and CD8+ T cells have individualized 4 subsets: namely, naive (CCR7+CD45RA+), central memory (TCM, CCR7+CD45RA−), effector memory (TEM, CCR7−CD45RA−), and CD45RA+ effector memory cells (TEMRA, CCR7−CD45RA+). To our knowledge, the T cell subsets proportions in MSC and PBCSP grafts remain unknown. The impact of the infused T cell subsets on patients’ outcome is still to be investigated. Between September 2003 and July 2004, 25 consecutive hematopoietic allo-SCT (12 MSC and 13 PBSC) were considered for this study. Multiple combinations of immunophenotyping analysis were used to prospectively examine immune parameters related to graft as well as to early reconstitution. Early post-transplant complications including acute GVHD, relapse and infections were assessed. As expected, T cells subsets, B cells and NK cells numbers were significantly higher in PBSC grafts (versus MSC). However, proportions of CD4+ and CD8+ T-cell subsets were comparable in the 2 types of graft and similar to normal values observed with peripheral blood of healthy adults. Table below summarize the distribution of T cell subsets within T CD4+ and T CD8+ in the two types of graft. The incidence of acute GVHD was significantly higher in pts receiving > 5% of CD8+ TEM cells among infused CD8+ cells (p MSC PBSC CD4+ naive 45% 48% CD4+ TCM 25% 24% CD4+ TEM 20% 16% CD4+ TEMRA 5% 2% CD8+ naive 40% 50% CD8+ TCM 4% 7% CD8+ TEM 23% 14% CD8+ TEMRA 29% 22%

From October 1987 to December 1990, 101 patients with acute myeloid leukemia (AML) were randomized to be transplanted in first complete remission (CR1). Preparative regimen including Cytoxan (120 mg/kg) with total body irradiation (CYTBI) (N = 50) or busulfan (16 mg/kg) (BUSCY) (N = 51) was followed by allogeneic bone marrow transplantation (BMT) from an HLA-identical sibling. Mean time between diagnosis and BMT was 119 days. The outcome for CYTBI at 2 years is better for probability of disease-free survival (DFS) (72% v 47%) (P less than .01), survival (75% v 51%) (P less than .02), relapse (14% v 34%) (P less than .04), and transplant mortality (8% v 27%) (P less than .06). In multivariable analysis, higher relapse and decreased survival and DFS were associated with BUSCY regimen, while chronic graft-versus-host disease also influenced independently the probability of relapse. This demonstrates the present limitation of busulfan use in this setting, possibly due to probable individual variations in biodisponibility. Furthermore, besides the anti-leukemic effect of preparative regimens, this trial points out the progress accomplished in BMT management (transplant mortality = 8% in CYTBI) over the last 20 years as well as the effectiveness of transplant in early first CR after CYTBI (DFS = 72% at 2 years).

Since the early 2003 with the encouraging preliminary results of our pivotal study (Seguy, transplantation), all pts refereed to our unit for myeloablative Allogenic Stem Cell Transplantation (allo-CST) were offered right away enteral feeding via a naso-gastric tube (NGT). The aim of this work was to investigate the evolution of our practices regarding nutritional support and its impact on early outcomes over the last five years. During a systematic individual pre-transplantation interview, all pts were provided with comprehensive information regarding NGT feeding. They received advice on an ongoing basis from a multidisciplinary team. Between Jan 01 and Dec 05, 121 pts who underwent myeloablative allo-SCT were offered EN. Among them, 94 (78%) agreed to receive EN (EN group) and 27 (22%) refused the NGT (without EN group: WEN group) and received either parenteral nutrition (PN) (n=22) or oral feeding only (n=5). The NGT was inserted shortly after transplantation. Bacteriological high-controlled oral diet intake was encouraged for as long as the patient was able to sustain it. The daily oral intake was scheduled to provide 100% of estimated requirements for energy (30–35 kcal/kg/day). Overnight NGT feeding, was gradually increased depending on the patient’s tolerance in order to reach 50–70% of energy requirement within 5 days. In case of intolerance toward EN, additional or total PN was given. In the WEN group, pts received PN when total oral intake was less than two-thirds of the average energy requirement over 5 days. Except for the pts’ age (EN-group, 38y vs WEN 28y, p=.038), the two groups were comparable in terms of initial pts’ characteristics and transplantation modalities. Median duration of EN was 14 days (1–59) and 61 pts received no additional PN while the median duration of the PN was 12 days (2–70). There was no significant difference between the two groups regarding duration of hospitalization, nutritional status at discharge and duration and grade of mucositis. Significant differences were observed, however: engraftment, 100% vs 93%, p=.05, duration of neutropenia, 20d (10–64) vs 25d (18–100), p=.0001 and thrombopenia 27d (6–100) vs 56d (50–100), p=.014; serum albumine level at discharge < 35g/L, 45% vs 76%, p=.005 for EN-group vs WEN-group, respectively. Pts with EN developed less often acute grade III/IV GVHD (9% vs 37%; p=0.001) and non-bacterial infections (9% vs 41%; p=.0002). In addition, pts with enteral feeding had better 100-day survival (92% vs. 67%, P=0.001) with less infection-related deaths. In multivariate analysis the absence of enteral nutrition was the only factor adversely influencing 100-day survival (CI 95%: 1.55–14.9 0.646; P=.007). In order to evaluate the practices over time regarding nutritional support in our unit, we compared the initial period (2001–02) when pts (n=41) had the choice between EN and PN with the second period (2003–05) when EN was offered systematically (n=80). In the second period, pts received less often PN (73% vs. 31%, p CONCLUSION: EN has been well tolerated and dramatically reduced the proportion of pts requiring PN. This study confirms the positive impact of EN on early outcome of pts undergoing myeloablative allo-CST. When possible EN should be preferred to PN.

The curative potential of allo-SCT for malignancies derives from the progressive reconstitution of the immune system and the development of effective anti-tumor immunity, but GVHD and disease relapse remain considerable obstacles to improvement in overall outcomes. Because in recipients target antigens are persisting, donor-derived T-cell responses may be expected to lead to the accumulation of a sizable proportion of differentiated T-cells, as happens following infection with persisting pathogens. A few cross-sectional studies have pointed to the preponderance of certain memory T-cell subsets associated with chronic GVHD (cGVHD), but the subset identified differed between studies. Inasmuch as qualitative T-cell recovery takes months to years to complete and there is substantial variability in time to development of GVHD or relapse, serial analysis might be more suitable to unveil early changes in T-cell subset composition attributable to transplantation-related events. From October 2003 on, 55 pts who underwent an allo-SCT after myeloablative conditioning were monitored prospectively in terms of clinical post-graft complications, including graft rejection, infections, GVHD and relapse. Blood samples were obtained on days 30±2, 60±3, 90±5, 180±10 and 365±15 post-transplant. Naive (CD45RA+CCR7+), central memory (TCM, CD45RAnegCCR7+), effector memory (TEM, CD45RAnegCCR7neg), and terminally differentiated effector (TTD, CD45RA+CCR7neg) were enumerated within the CD4+ and CD8+ pools, and the percentage of cells coexpressing CD28 was calculated within each eight subsets. The degree of donor-derived T-cell chimerism was assessed by real time PCR (sensitivity ≤ 1%). Median follow-up was 733 d (404–1251). Dynamics of CD4+ and CD8+ naive, TCM, TEM, and TTD were similar between the pts who developed cGVHD (n=15) and those who did not and between pts who relapsed and those who did not. However, costaining to detect CD28 demonstrated contrasting differences between cGVHD and relapse. At day 30, pts who subsequently relapsed (n=17) had elevated percentages of cells keeping CD28 expression within CD8+ T-cell subsets (TCM, p=.001; TCM, p=.021; and TTD, p=.007). Conversely, pts who subsequently developed cGVHD (n=15; only one relapsed) had diminished percentages of CD28+ cells within the two CD8+CCR7+ subsets at day 30 (p=.002 and p=.034, respectively). Loss of CD28 expression is known to be a hallmark of CMV infection but multivariate analysis ruled out, however, a confounding effect of CMV. Adjusted hazard ratios were 0.10 (95% CI, 0.01-0.76; p=.026) and 5.56 (95% CI, 1.16-25.00; p=.032) with CD28neg cells 16.7% of all CD8+ TCM at day 30 for relapse and cGVHD, respectively. Furthermore, pts with relapse had more often mixed chimerism at day 30 while those with cGVHD had more often full-donor chimerism (p=.042 and p=.023, respectively). CONCLUSION: This prospective study is the first to associate an early contrasting change in CD8+CD28neg T-cells with the risk of relapse and cGVHD after a myeloablative conditioning. Determination at day 30 of the proportions of CD8+ T-cell subsets expressing CD28 and of the level of T-cell chimerism could assist in predicting risk of relapse and cGVHD and help build an algorithm for the management of immunosuppressive treatment.

Purpose: To assess the incidence of chronic myeloid leukemia (CML) in the Nord-Pas de Calais Region in Northern France (~ 4 millions inhabitants) and to describe the patients (pts) characteristics and evolution. Methods: A retrospective study was conducted to record all confirmed diagnosis of CML that occurred during the period 1985–2004. All pts were actually living in the region at the diagnosis. CML was diagnosed by cytogenetic and molecular tests (Philadelphia chromosome and/or BCR-ABL fusion gene). Pts were screened through the results of the two cytogenetic and molecular laboratories of the region. The possibility of pts diagnosed outside the region is negligible and under study. Age-standardized incidence rate calculation was based on the standard world population. Results: 783 pts with confirmed diagnosis of CML were included. Age-standardized incidence rate is 0.82/100,000 people during the 1990–2004 period, with a raw incidence rate of 1.02/100,000 people during the same period. In the whole 20 years cohort, 55.7% of the pts are of male gender and the median age at diagnosis is 55.3 years (5.4–93.4). Haematological status at diagnosis was available for 83.5% of pts: chronic phase (CP) for 623 pts (95.3%), accelerated phase (AP) for 21 pts (3.2%), and blastic crisis (BC) for 10 pts (1.5%). Sokal index was available for 67% of pts, and was low for 40.5%, intermediate for 35.9%, and high for 23.6% of them. At December 31th 2004, 331 (42.3%) pts were still alive, 370 (47.2%) were deceased and 82 (10.5%) of unknown status. Taking into account the patients who have left the region, the raw prevalence rate is 8.1/100,000 people at this date. During the follow-up, an advanced phase was documented for 206 pts (26.5%) of the whole cohort and 189 (48.5%) of deceased patients. Allogeneic bone marrow transplantation was performed in 140 (17.9%) pts with a 5-years overall survival rate of 60%. 354 pts (45.2%) received interferon alfa (IFN) (median treatment duration 13.5 Mo (0.5–157.1)) with 24.6% pts achieving a major cytogenetic response (MCyR). 302 pts (38.6%) were treated by imatinib mesylate (IM) (median treatment duration 31.3 Mo (0.5–72.3)) with a rate of MCyR of 75.2% for pts in CP at IM initiation (206 informative pts). The overall median survival of the whole cohort was 72 months. For the diagnosis periods 1985–1989, 1990–1994, 1995–1999, and 2000–2004, the 5-years overall survival rates were respectively 41.6%, 51%, 57.5%, and 78.5% (p Conclusion: our findings in a well defined region corroborate the results of other cancer registries for the CML incidence. The prognosis of this disease has been modified by bone marrow transplantation and the use of interferon alfa but the major survival improvement seems related to the large use of tyrosine kinase inhibitors since 2000–2001, suggesting a great increase of CML prevalence in the future. Overall Survival According to year diagnosis Overall Survival According to year diagnosis

Abstract 2380 Nonmyeloablative, or reduced-intensity conditioning (RIC), regimens before allo-SCT have emerged as an attractive modality to decrease transplant-related toxicity while preserving the graft-versus-tumor effect. However, as for standard myeloablative allo-CST, only one third of patients have an HLA-identical sibling donor. Indeed, with the increase in the number of single-child families, stem cell grafts from unrelated donors are being increasingly used. We have previously reported, that in patients with standard-risk malignancy undergoing allo-SCT with CPM and TBI as conditioning treatment, unmodified marrow as a source of graft, and Cs-A plus short-course MTX as GVHD prophylaxis, there were no significant differences between the outcomes of patients receiving graft from siblings and those from unrelated fully HLA-matched donors (Yakoub-Agha et al, JCO 2006). However, no conclusions can be drawn with certainty concerning patients with more advanced disease, those who received a peripheral blood graft or especially those with a non-myeloablative conditioning regimen. Here we report a retrospective study of 58 consecutive patients who received RIC allo-CST. Donors were HLA-identical sibling (n=35) and unrelated molecularly HLA-identical donor. All donor/recipient pairs were typed at the allelic level. They were first typed at 2-digit level for HLA class I (HLA-A, B and Cw) and class II (HLA-DRB1 and DQB1) using published HLA class I PCR-SSO and/or SSP typing protocols. For unrelated donors, HLA-A, B, Cw, DRB1, B3, B4, B5 and DQB1 subtyping was performed using different PCR-SSP kits. HLA typing was performed according to the current use of the EFI Histocompatibility Laboratory standards. Only donor/recipient unrelated pairs matched for both alleles were included in this study. Diagnosis were AML (n=27), ALL (n=3), myelodysplastic syndrome (n=13), and myeloproliferative syndrome (n=15). Of the 32 (55%) males patients, 14 (43%) received graft from female donor (classical sex-mismatch). Medians age of recipients and donors at transplantation were 58 years (41.3-65.5) and 47.1 years (22.2-67.5), respectively. Patients received either low-dose TBI (2Gy) (n=46) or Busulfan-based (n=12) conditioning regimen. Antithymoglobulin was given to 12 patients. As usual in RIC setting, Peripheral Blood Stem Cells was the main source of graft (n=38; 65%), otherwise marrow graft (n=20). Results: with the median of follow-up of 27.2 months (range, 8.1–79.4), 24 patients died including 9 from TRM. Relapse was recorded in 21 patients. Eighteen patients experienced acute GVHD (aGVHD) including 12 with II-IV grades and 7 with III-IV grades. Contrary to what we have previously reported in myeloablative allo-CST sittings, patients who underwent RIC and received graft from unrelated HLA-matched (10/10) donor, experienced worse outcomes compared to those transplanted with an HLA-identical sibling. Indeed, in multivariate analyses, donor type (unrelated HLA-matched 10/10 vs HLA-identical sibling) was the most important risk factors negatively influenced the overall survival and EFS [p=.01; HR=3.068; [95%CI: 1.312–7.174]) and (p=.050; HR=2.081; [95%CI: 1.001–4.347]), respectively. To our knowledge, this is the first study which compares results of sibling transplantation to HLA-allellically-matched (10/10) unrelated transplantation. Even though, results of the latter did not compare favorably to those obtained with an HLA-identical sibling donors, grafts from HLA-matched unrelated donors, are still an attractive option especially for patients with high-risk malignancy. Our data emphasis the need of prospective studies evaluating factors influencing outcomes of HLA-allellically-matched (10/10) unrelated transplantations. Disclosures: No relevant conflicts of interest to declare.

Allogeneic stem cell transplantation has become standard therapy for haematological malignancies through the positive immunologic graft-versus-leukaemia effect. Initial immune recovery relies on peripheral expansion of infused T-cells which switch to a memory-like phenotype. This study prospectively investigated whether changes in subset composition precedes late complications after myeloablative HLA-matched transplantation. Of 80 recipients, 51 experienced neither early infection nor acute graft-versus-host disease (GVHD), of whom 18 were still free of clinical complication throughout 395 – 1564 days of follow-up. Compared with this complication-free subgroup, patients who developed chronic GVHD as the only event recovered similar numbers of circulating T-cells with predominance of CD8+ T-cells lacking CC-chemokine receptor-7 and CD28 expression. Conversely, poor CD8+ T-cell recovery with diminished numbers of CD28neg CD8+ T-cells (~1/4th of that of relapse-free patients) preceded occurrence of relapse. In multivariate analysis, lower CD28neg CD8+ T-cell counts by day 60 were associated with greater risk of subsequent relapse (HR 0.33; 95% CI 0.14 - 0.76; P = 0.01). Enumeration of CD28neg CD8+ T-cells in patients without early clinical complication could assist in predicting risk of relapse and help build an algorithm for accelerating the immune recovery by reducing the immunosuppressive regimen and considering the introduction of prophylactic donor lymphocyte infusions.

Introduction The exact biological and clinical complications related to iron overload in adult non thallassemic patients receiving blood units (BU) are not well known. This is mainly due to the many confounding factors both in the evaluation of iron overload (mainly estimated by ferritin measurement) and its consequences on liver dysfunction (hepatitis, GVH) and cardiac or pancreatic function (toxicity, ageing). Patients and Methods We prospectively evaluated biological (glycemia, liver function) and clinical (cardiomyopathy, arythmia) consequences of post-transfusionnal iron overload, as sole risk factors, in a very closely selected population of long term BM transplant survivors. We quantified liver iron content (LIC) by MRI and studied the relationship between the number of BU, LIC and liver dysfunction. Exclusion criteria were extremely strict: transplant performed after 1999, any form of GVH, hepatitis B or C, alcoholism (CAGE Questionnaire), any presence of hepatotoxic drug, requirement of BU after the one year period following transplant, inflammation, neoplastic diseases or relapse, homozygous for HFE mutation. Results 104/150 adult patients transplanted before December 1999 were enrolled. 39/104 were excluded: GVH n=11, viral hepatitis n=3, alcoholism n=1, hepatotoxic drug n=4, active bleeding n=2, neoplastic disease or relapse n=11, chronic inflammation n=7. 65 patients were analyzed (34M,31F). Median age at transplant was 36. Median follow up was 9 years. The median number of BU received was 18 (0–77) (definitive evaluation in 60/65 patients). The median ferritin was 532 ng/ml (42–4023). 27/65 pts had AST and or ALT above normal value. Hyperlycemia was present in 11 cases. There was a significant correlation between the number of BU and the ferritin value (r= 0.81) (p300). The group with ferritin above normal value (n=38) differed significantly from the group with ferritin of normal range in terms of number of BU transfused (p Conclusion The magnitude of persistent iron overload in long BM transplant survivors correlates closely to the number of BU received and is well quantified by MRI. In this group having no cofactor of iron toxicity, our results suggest that the impact in the medium term of post transfusionnal iron overload on liver dysfunction, diabetes mellitus and cardiac disease is moderate.

In a fully molecular HLA-matched setting, the outcome of allogeneic stem-cell transplantation (allo-SCT) can be affected by mismatches in minor histocompatibility antigens (mHAs) that might impact on the risk of graft-versus-host (GvH) and graft-versus-leukemia (GvL) effects. The association between mHA disparities and outcome was investigated in 96 consecutive patients who underwent myeloablative HLA-matched allo-SCT (from 69 HLA-identical siblings and 27 HLA-matched unrelated donors, all typed and matched at both allelic levels for HLA-A, -B, -Cw, -DRB1, and -DQB1 loci) for standard-risk hematological malignancy (AML n = 41; ALL n = 29; MDS n = 12; CML n = 8; others n = 6). All patients but 9 received bone marrow graft. Allelic mHAg typing was performed by PCR with sequence-specific primers for 9 autosomally encoded mHA and H-Y (PCR-SSP; Spierings et al. PLoS ONE. 2006 Dec 20; 1:e42). The distribution of autosomal mHAs among donor and recipients conformed to the expected frequencies for this population. As expected, the prevalence of mHAg mismatches was higher in unrelated compared to related recipient/donor pairs (p < .003). In univariate analysis, patients who received a graft with more than 2 mHAg mismatches developed more often grade II-IV acute GvH disease (p = .01; HR=2.92 [1.28–6.64]). In multivariate analysis, HA2 mismatch emerged as an independent determinant of acute GvH disease (p = .05; HR = .42). When only mismatches in the GvL/GvH direction were considered, mismatch for HA-1, that is expressed mainly by the hematopoietic system, tended to influence the incidence of both acute and chronic GvH disease (p = .06; HR=1.47 [0.97–2.21] and p = .049; HR = 1.45 [1.00–2.10], respectively) but also to confer a reduced risk of relapse (p = .07; HR = .58 [0.32–1.05]). Mismatch for HA-8, that has a broad tissue distribution, emerged as an independent risk factor of grade II-IV acute GvH disease (p = .02; HR = 1.77 [1.08–2.89]). This study confirms the impact of mHAg mismatches on patients’ outcome after fully HLA-matched allo-SCT and highlights both the cumulative effect of mHAg disparities on outcome and the distinctive contribution of individual mHAs on GvH versus GvL effects of allo-SCT.

Abstract 2378 Allogeneic stem cell transplantation (allo-SCT) offers potential curative treatment of for a wide range of otherwise fatal hematological diseases. However, only one third of patients have an HLA-identical sibling donor. We have previously reported that in patients with standard risk malignancy, transplantation from unrelated HLA-allellically matched donors (10/10) led to outcomes similar to those from HLA-identical sibling donors (Yakoub-Agha et al, JCO 2006). Indeed, with the increase in the number of single-child families, stem cell grafts from unrelated donors are being increasingly used and more than 30% of patients eligible for allo-CST, are still lacking a well-matched donor. In the attempt to investigate the impact of unrelated one-antigen HLA-mismatched graft, we report a single center retrospective study on 209 patients who underwent allo-CST from identical HLA-sibling donor (n=123), unrelated HLA-matched donor (10/10) (n=73) and unrelated one-antigen-HLA-mismatched donor (9/10) (n=13) over the last 5 years. In order to homogenize our cohort, patients with CML, aplastic anemia or lymphoproliferative disorder were excluded from the study. Therefore, underlying diseases were AML (n=104), ALL (n=54), myelodysplastic syndrome (n=30), and myeloproliferative syndrome (n=21). Of the 117 (56%) males patients, 49 (23%) received graft from female donor (classical sex-mismatch). Medians age of recipients and donors at transplantation were 45.2 years (4.4-65.5) and 40.8 years (2.0-67.5), respectively. Patients received conditioning regimens using either myeloablative (n=149) including 81 who received High-dose TBI (12Gy) or nonmyeloablative (n=60) including 48 who received low-dose TBI (2Gy). Antithymoglobulin was given to 25 pts. Bone marrow was the main source of stem cells (n=150; 72%). Results: with the median of follow-up of 37.9 months, 78 patients died including 25 from TRM. Relapse was recorded in 70 patients. Seventy-two patients experienced acute GVHD (aGVHD) including 47 with II-IV grades and 30 with III-IV grades. In multivariate analyses, donor type (unrelated regardless the degree of HLA-matching vs related) and conditioning (nonmyeloablative vs myeloablative) were the most important risk factors negatively influencing the overall survival [p=.002; HR=2.038 and p=.016; HR=1.81, respectively) and event-free survival (p=.005; HR=1.783 and p=.015; HR=1.728, respectively). As expected, the only factor that influenced the risk of relapse was the conditioning type (nonmyeloablative vs myeloablative) (p=.048; HR=1.699) while donor type was found to influence TRM (p=.030; HR=2.428). Graft from unrelated one-antigen HLA-mismatched donor (9/10) was the foremost risk factor for acute grade II-IV GVHD (p=.019; HR=2.663; [95%CI: 1.178–6.019]). In conclusion, except for acute II-IV GHVD, allo-CST from unrelated one-antigen HLA-mismatched donor (9/10), seemed to led to outcomes similar to those from HLA-identical unrelated donor (10/10) and may be considered as an alternative option for patients without a full-matched donor. Prospective studies are warranted, however, to confirm our data in larger cohort of patients. Disclosures: No relevant conflicts of interest to declare.

Abstract 794 Introduction: Human herpes virus 6 (HHV6) is known to reactivate after allo-SCT. It has been suggested that HHV6 may be associated with severe clinical manifestations, but little is known about its exact role in patients' outcomes following allo-CST. Patients and methods: Here we report our findings in 225 consecutive patients who underwent allo-SCT in our unit between January 2004 and March 2009. The median age was 42 years (3-62). Donors were HLA-identical sibling (n=110), and unrelated (n=115). Source of stem cells was bone marrow (BM; n=124), peripheral blood stem cell (PBCS; n=69) and cord blood (CB; n=32). Conditioning regimen was myeloablative (n=151), or reduced intensity (RIC; n=74). HHV6 plasma loads were measured almost weekly by quantitative PCR. We treated symptomatic patients when no other cause than HHV6 reactivation could explain the symptoms. However, patients with associated CMV reactivation were also treated with anti-viral therapy. At the time of analysis on July 31st 2009, the median follow-up was 33 months (4-68). A total of 105 (46%) patients had early positive HHV6-PCR within the first 100 days following transplantation (group I). In this retrospective study we compared the outcome of patients in group I to those who did not reactivate HHV6 or those who had positive HHV6-PCR after day 100 (group II; n=120). Results: Patients with PBSC and those who received RIC showed evidence of HHV6 reactivation less often than the others (p=0.049 and p=0.076, respectively). When HHV6-PCR was positive, only 10 patients in group I were asymptomatic while 95 patients experienced either fever (n=55), skin rash (n=51), diarrhea (n=41), pulmonary complications (n=16), neurological disorders (n=12), liver dysfunction (n=8) and/or others (n=7). Of note, 73 patients (70%) experienced more than one symptom concomitant to HHV6 reactivation. Thirty-seven patients received anti-viral therapy for HHV6-reactivation alone (n=18) or associated with CMV reactivation (n=19) resulting in negative HHV6-PCR in 31 of them. Out of the 6 patients who failed to have negative HHV6-PCR, 2 died 25 and 90 days after anti-viral therapy initiation, respectively. Although, there was no significant difference in overall survival or relapse-free survival between the two groups, patients in group II had earlier platelet engraftment (> 50 G/L) than those in group I with a median of 22 versus 28 days (p=0.003). In addition, patients in group I developed more often acute grade III-IV graft-versus-host disease (GvHD) than those in group II (34/105 versus 15/120, p=0.008). Of note, for 53% patients in group I with acute grade III-IV GvHD, HHV6 reactivation was observed before the development of acute GvHD. In multivariable analysis, the most important factors influencing acute grade III-IV GvHD were early HHV6 reactivation, [HR: 2.10; 95%CI, 1.20-3.66] (p=0.011) and unrelated donor, [HR: 1.17; 95%CI 1.04-1.32] (p=0.007). Conclusions: HHV6 reactivation is common after allo-SCT and is responsible for platelet engraftment delay and high-grade acute GvHD. Careful monitoring of HHV6-PCR is warranted during the early period of transplantation, as symptomatic patients require treatment. Disclosures: No relevant conflicts of interest to declare.