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Background & Aims: Intrahepatic accumulation of CD8 + T cells following antigen-specific activation has been demonstrated in a number of transgenic models and also in extrahepatic viral infections. In some transgenic models, intrahepatic accumulation of cytotoxic T lymphocytes is associated with hepatitis. This observation suggests that hepatocellular damage may occur in some forms of immune-mediated hepatitis on the basis of a "bystander injury," whereby cytotoxic T lymphocytes accumulating in the liver mediate injury to hepatocytes in a nonspecific manner. Mouse transgenic models were therefore developed to investigate whether bystander damage to non–antigen-bearing hepatocytes occurs in vivo. Methods: T cell receptor transgenic T cells were adoptively transferred into transgenic mice ubiquitously expressing the specific antigen, or into bone marrow radiation chimeras in which hepatocytes did not express the antigen. Results: Selective accumulation of transgenic CD8 + T cells in the liver of intact recipients could be detected within 2 hours of transfer, despite ubiquitous antigenic expression. T cells retained in the liver were activated and induced hepatitis. Similar results were obtained using bone marrow chimeras, suggesting that antigen expression by hepatocytes was not required either for intrahepatic accumulation or for subsequent hepatitis. This "bystander hepatitis" was dependent on tumor necrosis factor α and interferon γ. Conclusions: Intrahepatic accumulation of activated CD8 + T cells and subsequent hepatitis can result from primary activation of CD8 + T cells by liver resident bone marrow–derived cells, inducing bystander damage to non–antigen-bearing hepatocytes. This mechanism may play a role in some forms of biologically significant hepatitis, including autoimmune hepatitis and hepatitis associated with extrahepatic diseases. GASTROENTEROLOGY 2002;123:1252-1264

Although donor leukocytes are only thought to prolong survival when administered before transplantation, recent evidence shows that they are effective at transplantation. This study aims to identify the leukocyte subset that is most active in prolonging kidney allograft survival and examine the cytokine expression in long-term acceptance.PVG rat kidneys were transplanted to completely MHC class I and class II-mismatched DA recipients. Donor B cells or T cells, purified by negative selection, were injected i.v. at the time of transplantation. Expression of interleukin (IL)-2, IL-4, IL-10, interferon (IFN)-gamma, and transforming growth factor-beta mRNA was measured by quantitative real-time polymerase chain reaction (PCR). Immunohistochemical analysis and terminal deoxynucleotide transferase-mediated dUTP nick-end labelling (TUNEL) staining was used to identify infiltrating cells and apoptotic cells, respectively, in sections of kidney allografts.Median kidney graft survival time (MST) of B cell-treated animals (n=5) was300 days, compared with 7 days in untreated animals (n=7) (P=0.003), whereas animals treated with the same number of T cells (n=6) had a MST of 17 days (P=0.1 vs. untreated, P=0.03 vs. B cell-treated). Examination of the long-term (300 days) accepted grafts from B cell-treated recipients showed little evidence of kidney damage but a moderate perivascular infiltrate consisting of T and B cells. This infiltrate seemed to be quiescent because there was no detectable expression of IL-2 receptors or of apoptotic cells. It produced little or no cytokine mRNA, because expression in the long-term accepted grafts was similar to levels in normal kidneys or syngeneic transplants. There was a marked increase of cytokine mRNA early after transplantation in both leukocyte-treated and untreated grafts, with more rapid appearance of IFN-gamma and IL-10 in leukocyte-treated grafts.Donor B cells efficiently induce long-term acceptance of transplanted kidneys in a fully MHC-mismatched rat model when administered at transplantation, by a mechanism that seems to be independent of Th2 cytokine expression within the long-term accepted graft.

Recurrent chronic hepatitis, cholestatic hepatitis, and acute rejection in conjunction with hepatitis C virus (HCV) recurrence are well-recognized clinical sequelae of reinfection of the hepatic allograft with HCV. The aim of this study is to characterize intrahepatic cytokine responses associated with reinfection of the allograft with HCV in these settings. Intrahepatic messenger RNA expression of T helper cell subtype 1 (TH1) cytokines interleukin-2 (IL-2), interferon-gamma, and tumor necrosis factor-alpha and TH2 cytokines IL-4 and IL-10 was measured by real-time polymerase chain reaction system using TaqMan probes in 53 liver specimens from six groups of patients. These were: (1) recurrent chronic hepatitis C (CH-I; n = 15), (2) cholestatic hepatitis (n = 6), (3) acute rejection associated with HCV recurrence (AR-HCV; n = 12), (4) acute rejection in non-HCV-infected allografts (AR non-HCV; n = 5), (5) patients with chronic hepatitis C who did not undergo transplantation (CH-C; n = 10), and (6) non-diseased liver tissue (n = 6). Intrahepatic viral loads were measured using an Amplicor monitor assay (Roche Diagnostic Systems, Branchburg, NJ). The CH-I and CH-C groups had similar TH1 intrahepatic cytokine profiles. Compared with the CH-I group, the cholestatic group expressed increased levels of the TH2 cytokines IL-10 (P =.024) and IL-4 (P =.0024). The AR-HCV group also expressed more TH2 cytokines IL-10 (P =.014) and IL-4 (P =.034) compared with the CH-I group. Both the AR-HCV and AR non-HCV groups showed similar intrahepatic cytokine profiles. Intrahepatic viral loads were highest in the cholestatic group compared with the AR-HCV, CH-I, and CH-C groups (P =.0007). In conclusion, a novel observation is that the cholestatic group showed upregulation of the TH2 cytokines IL-10 and IL-4, in addition to high viral loads. In this setting, the TH2 immune response may favor viral replication and graft damage.

There is accumulating evidence suggesting that hepatic permeability to both naive and activated T lymphocytes may be unique among the solid organs. The possibility that the liver may act as a site of primary activation for CD8+ T lymphocytes is supported by experimental data and may contribute to some of the unique immunological properties of this organ, particularly its ability to induce antigen-specific tolerance. This review discusses the nature of the liver APC inducing primary T-cell activation within the liver: Kupffer cells, liver dendritic cells, liver sinusoidal endothelial cells and hepatocytes are favourably located to allow physical contact with circulating T lymphocytes. Here, we examine the capability of each cell type to act as APC for naive CD4+ or CD8+ T cells and to induce tolerance.

Background: The EUMDS registry is a prospective observational registry to collect data on lower risk MDS. 17 Countries and 133 centers are participating. We analyzed serum from 101 patients for ferritin, hepcidin, growth differentiation factor 15 (GDF15) and C-reactive protein (CRP) at six-month intervals in order to evaluate temporal changes in iron metabolism. Objective: To explore hepcidin and GDF15 levels over time in lower risk MDS patients and their relation with WHO2001 subtype, transfusion history and conventional iron parameters. Results: The median age of the study population was 73 years (range 44-95 years). The majority was male: 64%. Distribution according to WHO2001 MDS subtype was RCMD (41%), RARS (25%), RA (14%), RAEB (11%), 5q-syndrome (6%) and RCMD-RS (3%). Table 1 shows iron parameters at registration, 1 year and 2 years follow-up both in transfusion-dependent (TD) and transfusion-independent (TI) patients and stratified according to MDS subtypes: RS (RARS/RCMD-RS) or MDS Other (RA/RCMD/RAEB/5q-syndrome). Serum ferritin was increased in TD patients with a median concentration at registration of 550µg/L and at 2 years 818µg/L, compared to TI patients (median 10 red blood cell (RBC) units: median at registration 1482µg/L - 2 years 1970µg/L. Ferritin correlated significantly with hepcidin (r=0.57; p50mg/L. Median serum hepcidin levels were elevated in TD patients at registration and remained elevated during follow-up, especially in patients with >10 RBC units transfused (median 27.4nmol/l at registration, 12.8nmol/l at 2 years). Remarkable fluctuation in hepcidin levels occurred in patients with elevated hepcidin during follow-up. Even in the longitudinal cohorts hepcidin fluctuated considerably, maybe due to the interval between the previous transfusion and the measurement of hepcidin or due to diurnal fluctuation. Hepcidin was lowest in MDS RS TI patients and showed a tendency to decrease over time from a median level of 4.4nmol/l at registration to 2.4nmol/l after 2 years, associated with ineffective erythropoiesis. This is supported by the high median GDF15 in these patients. Lowest GDF15 was found in TD patients with ‘MDS Other’ associated with transfusional load. The number of transfused RBC units did not affect the median GDF15 levels. Conclusions: Hepcidin levels were influenced by RBC transfusion history, but hepcidin levels appear to decrease over time in the RS subtype only. Interestingly, increase in hepcidin after transfusions was already visible early in follow-up, depending on the transfusional load and erythropoietic activity of the bone marrow. GDF15 concentration appeared to be most related to MDS subtype, functioning as a marker of ineffective erythropoiesis. Table1: ferritin, hepcidin and GDF15 during-follow-up Registration 1 yr follow-up 2 yrs follow-up N Median (p25-p75) N Median (p25-p75) N Median (p25-p75) Ferritin (µg/L) 101 286 (138 - 558) 83 287 (149 - 845) 66 347 (191 - 818) MDS Other: TI 53 205 (87 - 389) 31 148 (78 - 288) 25 202 (71 - 319) MDS Other: TD 20 479 (279 - 877) 29 845 (481 - 1538) 22 841 (323 - 2387) RARS/RCMD-RS: TI 25 268 (195 - 558) 19 233 (170 - 323) 10 319 (222 - 379) RARS/RCMD-RS: TD 3 610 (108 - 1382) 4 1909 (1206 - 2935) 9 712 (590 - 1222) Hepcidin (nmol/L) 100 5.2 (3.0 - 9.9) 83 5.8 (2.7 - 14.0) 66 5.2 (2.5 - 9.9) MDS Other: TI 53 4.6 (2.8 - 8.4) 31 4.4 (2.3 - 8.1) 25 4.2 (2.5 - 6.8) MDS Other: TD 20 11.1 (4.9 - 21.0) 29 17.2 (9.2 - 22.3) 22 9.6 (4.5 - 17.1) RARS/RCMD-RS: TI 24 4.2 (2.1 - 6.1) 19 3.5 (1.6 - 5.1) 10 2.4 (1.6 - 3.9) RARS/RCMD-RS: TD 3 9.8 (6.0 - 11.1) 4 9.3 (7.3 - 12.1) 9 5.2 (2.9 - 9.3) TI: 0 RBC units 81 4.5 (2.8 - 8.4) 51 4.0 (2.0 - 7.5) 37 3.1 (2.1 - 6.7) TD: ≤10 RBC units 17 10.6 (4.7 - 14.9) 14 9.2 (5.3 - 17.2) 14 4.3 (2.4 - 8.7) TD: >10 RBC units 2 27.4 (15.7 - 39.1) 18 18.1 (12.7 - 24.5) 15 12.8 (9.3 - 21.3) GDF15 (ng/L) 101 1945 (1207 - 3611) 82 2467 (1659 - 4318) 66 2582 (1519- 5332) MDS Other: TI 53 1831 (1100 - 3176) 31 1902 (1076 - 2698) 25 1702 (1136 - 3564) MDS Other: TD 20 1452 (1169 - 2789) 28 2583 (1937 - 4493) 22 2556 (1661 - 4050) RARS/RCMD-RS: TI 25 3532 (2124 - 4211) 19 3148 (2195 - 4560) 10 3661 (1986 - 5524) RARS/RCMD-RS: TD 3 2196 (1869 - 2893) 4 2996 (1806 - 5141) 9 5555 (3204 - 7488) Disclosures Hellström-Lindberg: Celgene: Research Funding. Symeonidis:Celgene: Research Funding; Novartis Oncology: Research Funding; Amgen: Research Funding; Novartis Oncology: Consultancy; Amgen: Consultancy. de Witte:Novartis: Research Funding; Novartis: Honoraria; Celgene: Consultancy; Novartis: Consultancy.

Background: Complex karyotypes in patients with myelodysplastic syndromes (MDS) are defined by the presence of 3 or more cytogenetic abnormalities and are considered indicators of a poor prognosis by nearly all models in clinical use. There is evidence that the prognostic significance of complex karyotypes in MDS can be refined by considering the number of cytogenetic abnormalities or the presence of specific lesions, the presence of monosomy, and the mutation status of the TP53 gene. Mutations of TP53 are strongly associated with adverse clinical features including complex karyotypes, yet still have independent prognostic significance. Whether these mutations or other elements associated with complex karyotypes carry the greatest prognostic significance is unknown and has been the subject of recent contradictory findings. Here we examine the relationship between TP53 mutations, the number and type of chromosomal abnormalities, and clinical features including overall survival in a combined analysis of MDS patients with complex karyotypes. Methods: Data on 258 complex karyotype MDS patients from the US and Europe gathered by members of the International Working Group for Prognosis in MDS-Molecular Committee were combined for this analysis. Patients gave informed consent to have their data and clinical samples collected at their respective institutions in accordance with the Declaration of Helsinki. Tumor samples were examined for TP53 mutations primarily with next generation sequencing techniques. Categorical variables were compared using a Fisher exact test or Kruskal-Wallis test as appropriate, while continuous variables were compared using a Wilcoxon rank-sum test. All p-values reported are two-sided, unadjusted for multiple testing, and considered significant at the 0.05 level. Results: Of the 258 complex karyotype MDS samples examined, TP53 mutation status was determined in 223, of which 133 (60%) carried a TP53 mutation. Patients with TP53 mutations were slightly older than unmutated patients (median age 70.8 vs. 65.5 years, p=0.055), were more thrombocytopenic (median platelet count 42 vs. 78 x109/L, p=0.002), and had a greater percentage of bone marrow blasts (7.75% vs 4%, p=0.03). Mutated patients were also more likely to have a monosomal karyotype (85% vs. 59%, p Patients with TP53 mutation had a significantly shorter median overall survival of 7.7 months compared to 23.4 months for patients with unmutated TP53 (p Discussion: Despite strong associations with adverse clinical and cytogenetic abnormalities incorporated into existing prognostic scoring systems, TP53 mutations carry significant independent prognostic value for patients with MDS. In our multivariable analyses, TP53 mutation appears to dominate over monosomal karyotype as an adverse prognostic marker in MDS patients with complex cytogenetics. Many of the TP53 mutations identified had a small variant allele fraction suggesting that they were present in a disease subclone. The small number of mutant cells in these cases may be insufficient to alter clinical measures, but could still indicate a poor prognosis if they represent a clone capable of treatment resistance and rapid disease progression. This combined analysis is a work in progress that will include data from additional groups and explore mutation status of other MDS-related genes, TP53 variant allele fraction, clinical risk scores, and data from patients without complex karyotypes. Conclusions: Somatic TP53 mutations are highly enriched in MDS patients with complex karyotypes and identify a group with significantly shortened overall survival. Sequencing of TP53 can improve the prediction of prognosis in MDS patients with 3 or more chromosomal abnormalities. Figure 1 Figure 1. Disclosures Bejar: Genoptix Medical Laboratory: Consultancy, Honoraria, Licensed IP, no royalties Patents & Royalties, Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees. Haferlach:MLL Munich Leukemia Laboratory: Other. Garcia-Manero:Celgene: Research Funding. Sekeres:Celgene: Membership on an entity's Board of Directors or advisory committees; Amgen Corp: Membership on an entity's Board of Directors or advisory committees; Boehringer-Ingelheim Corp: Membership on an entity's Board of Directors or advisory committees. Campbell:14M Genomics Limited: Consultancy, Equity Ownership.

Donor leukocytes play a dual role in rejection and acceptance of transplanted organs. They provide the major stimulus for rejection, and their removal from the transplanted organ prolongs its survival. Paradoxically, administration of donor leukocytes also prolongs allograft survival provided that they are administered 1 wk or more before transplantation. Here we show that administration of donor leukocytes immediately after transplantation induced long-term acceptance of completely MHC-mismatched rat kidney or liver transplants. The majority of long-term recipients of kidney transplants were tolerant of donor-strain skin grafts. Acceptance was associated with early activation of recipient T cells in the spleen, demonstrated by a rapid increase in IL-2 and IFN-γ at that site followed by an early diffuse infiltrate of activated T cells and apoptosis within the tolerant grafts. In contrast, IL-2 and IFN-γ mRNA were not increased in the spleens of rejecting animals, and the diffuse infiltrate of activated T cells appeared later but resulted in rapid graft destruction. These results define a mechanism of allograft acceptance induced by donor leukocytes that is associated with activation-induced cell death of recipient T cells. They demonstrate for the first time that posttransplant administration of donor leukocytes leads to organ allograft tolerance across a complete MHC class I plus class II barrier, a finding with direct clinical application.

The hallmarks of chronic liver diseases are chronic inflammation, cellular damage, regeneration and fibrosis. An appreciation of intrahepatic molecular expression patterns in normal and diseased liver provides clues for understanding pathogenic pathways whilst studies of the structure and function of molecules implicated in liver disease provide insights into their potential as therapeutic targets. We have examined the expression, function, molecular structure and structure-function relationships of type IV dipeptidyl aminopeptidases. In particular, the roles of CD26/DPPIV in T-cell proliferation and chemotaxis and of fibroblast activation protein in human cirrhosis are discussed. We have investigated the pathogenesis of liver disease by characterising patterns of cytokine and growth factor expression in experimental and human cirrhosis. We have quite recently expanded this approach to use differential gene expression analyses to elucidate overall pathways of gene activation and suppression in human cirrhosis. In addition, our detailed molecular and cellular studies of the mechanisms of spontaneous liver transplant tolerance have generated novel insights into this process. This review touches on these diverse aspects of liver function and disease.

Background: Push enteroscopy is a new technique for investigation of the small intestine. The clinical indications are still being defined. It also offers the potential for therapeutic intervention in suitable cases. Aims: To evaluate further the role of push enteroscopy in the diagnosis and treatment of patients with suspected or known small bowel disease. Methods: A prospective record was kept of all patients having enteroscopy at Royal Prince Alfred Hospital between March 1995 and July 1997. The procedure was performed 73 times in 68 patients. Indications and diagnoses were noted. The outcome in patients with obscure gastrointestinal bleeding or anaemia in whom a vascular lesion was treated with a heater probe was also determined. Results: Enteroscopy was performed in 23 patients for gastrointestinal bleeding of obscure origin. An active or possible bleeding source was found in 13 (57%). The commonest of these was jejunal angiodysplasia. In the 21 patients with chronic iron deficiency anaemia a lesion was found in ten (48%). The majority of these were in the stomach, as described by others. The diagnostic yield in the 16 patients having enteroscopy for known or suspected small bowel disease was 56%. One patient underwent balloon dilatation of a postoperative jejunal stricture. Eleven patients with obscure bleeding or anaemia had ablation of a vascular lesion with a heater probe. Transfusion requirements fell after this procedure, particularly in those with active bleeding at the time of the examination. In five of the 11 no further transfusions were required in over six months of follow-up. Conclusions : The most common indications for enteroscopy are obscure gastrointestinal bleeding, chronic anaemia and known or suspected small bowel disease. A positive result can be expected in over 50% of patients. The treatment of vascular lesions via the enteroscope has a significant impact of subsequent transfusion requirements.

BCR-ABL negative myeloproliferative neoplasms (MPNs), such as polycythemia vera (PV), essential thrombocythemia (ET) and myelofibrosis (MF) are chronic myeloid malignancies characterized by overproduction of hematopoietic cells. JAK2 mutations are found in most patients with PV, and in only 50-60% of patients with ET and MF. JAK2 mutation testing has greatly simplified MPN diagnosis, but distinguishing JAK2-wildtype ET from reactive thrombocytosis remains a diagnostic challenge. Mutations in signalling pathways (MPL, LNK) and epigenetic regulators (TET2, DNMT3A, IDH1/2, EXH2, ASXL1) have been found in a minority of MPNs. However genome-wide data are lacking and the pathogenesis of MPNs that do not harbor JAK2 or MPLmutations remains obscure. Methods Exome sequencing was performed in 151 MPN patients on matched tumor and constitutional samples. CALR status was assessed in 3412 samples using Sanger sequencing and analysis of exome/genome sequencing data. Presence of CALR mutations in hematopoietic stem and progenitor cells was assessed by flow sorting and sequencing. Phylogenetic trees were established using hematopoietic colonies. Calreticulin cellular localisation was assessed in patient samples and cell lines expressing CALR variants by flow cytometry and immunofluorescence. Results Exome sequencing identified 1498 somatic mutations with a median of 6.5 mutations in PV and ET, and 13 in MF (MF vs ET, P=0.0002; MF vs PV, P=0.008). JAK2V617F was found in all cases of PV (n=48), 56% of ET (35/62), and 69% of MF (27/39), and MPL mutations in 7 ET and MF cases. Mutations in epigenetic regulators TET2, DNMT3A, ASXL1, EZH2, and IDH1/2 were identified in 22, 12, 12, 4, 3 patients respectively, and components of the splicing machinery (U2AF1, SF3B1 or SRSF2) were mutated in 9 patients. Mutations in rare genes reported to be mutated in MPNs were found in four patients (1 CBL; 2 NFE2; 1 SH2B3/LNK). We found novel somatic mutations in CHEK2 (1 PV, 1 ET and 1 MF) which have not been previously reported in MPNs. The mutation spectrum showed a predominance of C>T transitions. Pairwise associations between MPN genes demonstrated that ASXL1 and SRSF2 mutations were positively correlated with mutations in epigenetic modifiers. Novel somatic mutations in calreticulin (CALR) were identified by exome sequencing in the majority (26/31) of JAK2 or MPL unmutated patients. CALR and JAK2/MPL mutations were mutually exclusive, and 97% of patients harbored a mutation in 1 of these 3 genes. In an extended follow up screen of 1345 hematological malignancies, 1517 other cancers and 550 controls we found CALR mutations in 71% of ET (80/112), 56% of idiopathic MF (18/32), 86% of post ET-MF (12/14) and 8% of myelodysplasia (10/115), but not in other myeloid, lymphoid or solid cancers. Compared to JAK2-mutated MPNs, those with CALR mutations presented with higher platelet counts (Wilcoxon rank-sum, P=0.0003), lower hemoglobin levels (Student’s t test, P=0.02) and showed a higher incidence of transformation to MF (Fishers exact, P=0.03). All CALR mutations were insertions or deletions affecting exon 9, with 2 common variants L367fs*46 (52 bp deletion) and K385fs*47 (5 bp insertion). Loss of heterozygosity over CALR was seen in a minority of patients. Of 148 CALR mutations identified, there were 19 distinct variants. Remarkably, all generated a +1 basepair frameshift, which results in loss of most of the C-terminal acidic domain of the protein as well as the KDEL Golgi-to-endoplasmic reticulum (ER) retrieval signal, raising the possibility of compromised ER retention. Mutant proteins were readily detected in transfected cell lines and localised to the ER in the same manner as wildtype CALR, without Golgi or cell surface accumulation. These results are consistent with studies reporting KDEL-independent mechanisms of ER retention. Mutation of CALR was detected in highly purified hematopoietic stem/progenitor cells. Clonal analyses demonstrated CALR mutations in the earliest phylogenetic node in 5/5 patients, consistent with it being an initiating mutation in these individuals. Conclusions We describe the mutational landscape of BCR-ABL negative MPNs and demonstrate that somatic mutations in the endoplasmic reticulum chaperone CALR are found in the majority of patients with JAK2-unmutated MPNs. These results reveal a novel biological pathway as a target for tumorigenic mutations and will simplify diagnosis of MPN patients. Disclosures: Bowen: Celgene: Honoraria. Harrison:S Bio: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Shire: Speakers Bureau; Celgene: Honoraria; YM Bioscience: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Sanofi: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Speakers Bureau; Novartis: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding, Speakers Bureau; Gilead: Honoraria, Membership on an entity’s Board of Directors or advisory committees. Vannucchi:Novartis: Honoraria, Membership on an entity’s Board of Directors or advisory committees.

Introduction Outcomes in core binding factor AML have improved over the past 25 years from a 5 year survival of 59% in 1988 to 84% post 2008. Patients were originally treated with 2 courses of DA followed by consolidation with MACE (amsacrine/etoposide) and MidAC (mitoxantrone/Ara-C). In 2002, the AML15 trials introduced an induction randomisation including FLAG-Ida, a 1:1 randomisation to add gemtuzumab ozogamicin (GO) to induction, and a 1:1 randomisation to high dose Ara-C consolidation (2 courses). For younger patients with non-CBF AML survival has improved partially because of a reduction in induction deaths and deaths in CR attributable to improved supportive care. We previously reported that GO significantly improved OS in AML [Burnett AK et al J Clin. Oncol. 2011,29: 369-377], and have recently confirmed that high dose Ara-C was superior to MACE/MidAC. Here we investigate which factors have contributed to the improvements in survival, by performing a prognostic factor analysis including date of diagnosis, and the introduction of GO and high-dose ara-C as covariates. Methods A total of 896 patients with cytogenetically confirmed core binding factor leukaemia from the MRC AML10, 12, 15 trials and the NCRI AML17 trial were included in the analysis. Date of diagnosis ranged from 1988 to 2012. Patients were aged between 16 and 60 years of age. A prognostic model was built using Cox regression with forward selection, at an entry probability of p Results In multivariate analysis of survival, the following variables were significant, in order of entry to the model: use of GO in induction (HR 0.40 (0.26-0.61) p Conclusions Core binding factor leukaemia is now highly curable with the most important contribution being the introduction of GO in induction followed by the adoption of high dose Ara-C (2 courses) in consolidation. When combined we observe an OS of 89% Disclosures: Off Label Use: Gemtuzumab Ozogamicin for AML.

Background There is conflicting data on the effect of the addition of ATRA to chemotherapy in AML. Two large randomised trials showed no benefit (Estey et al Blood 1999; 93, 2478 (n=215); Burnett et al. Blood 2010, 115: 9482 (n=1075)), or benefit which was limited to patients with an NPM1 mutation (n=14) when given in combination with ICE (Idarubicin/Ara-C/Etoposide) (Schlenk et al, Leukemia 2004, 18; 1798 (n=242)) but not with DA alone. In an effort to prospectively clarify if this is predictive treatment for NPM1+ patients and whether the effect was etoposide dependent, we randomised 616 patients to DA vs ADE and ATRA vs no ATRA in a 2x2 factorial design. Methods Between August 2010 and May 2012, 616 patients were randomised. The median age was 67(53-82) years: 75% had de novo, 16% had secondary, and 8% had high risk MDS (marrow blasts 10-19%): 4%, 75% and 21% had favourable, intermediate or poor risk cytogenetics: ITD and NPM1 data was available on 422 and 404 patients, with mutation rates of 19% and 24%. A total of 56 patients (14% of those with data) were molecularly good risk (NPM1 mutant, ITD wild type). By Wheatley risk score, 24%, 40% and 36% had good, standard or poor risk disease. The demographic, cytogenetic, molecular and allocated treatments were balanced between the arms. Follow-up is complete to 1st January 2013 (median follow-up 18.7 months) Patients were given Daunorubicin 50mg/m2 days 1-3 + Ara-C 100mg/m2 bid days 1-10 (course 1) or days 1-8 (course 2). Those allocated ATRA were treated at 45mg/m2/day for 60 days; Etoposide in the ADE arm was given at 100mg/m2/day on days 1-5 of courses 1 and 2 of chemotherapy. Results The overall response rate (ORR) was 69% (CR 53%+ CRi 16%) and survival at 2 years was 35%. The ORR was not different between DA: 68% (CR 53%, CRi 15%) and ADE: 70% (CR 53%, CRi 17%), odds ratio (OR) 0.92 (0.65-1.30) p=0.6, although remission rates were non-significantly lower in patients given ATRA (ORR 66% (CR 53%, CRi 13%) vs 73% (CR 54%, CRi 19%), OR 1.39 (0.98-1.95) p=0.06) with significantly higher 30-day (16% vs 8%, p=0.005) and 60-day mortality (20% vs 12%, p=0.005). There were no differences in early mortality between ADE and DA arms. At 2 years, neither survival nor RFS differed between the arms: (ADE vs DA OS: 33% vs 36%, HR 1.07 (0.86-1.32) p=0.6; RFS: 23% vs 36% HR 1.15 (0.88-1.49) p=0.3; ATRA vs Not OS: 35% vs 35% HR 1.13 (0.91-1.40) p=0.3; RFS: 31% vs 30% HR 0.93 (0.71-1.20) p=0.6). Overall there was no interaction between the two treatments (OS, test for heterogeneity p=0.12). In an analysis stratified by Etoposide and by NPM1/ITD risk group there was no significant heterogeneity of the effect of ATRA (p=0.1, Figure). Importantly, when looked at by the underlying chemotherapy, no beneficial effect of ATRA in NPM1 mutant/ITD WT patients appeared for patients receiving ADE (p=1.0 for heterogeneity). Conclusions Neither the addition of Etoposide nor ATRA improves outcomes in this group of patients, with ATRA being associated with significantly greater early mortality. Importantly, an analysis by NPM1/FLT3 genotype fails to reproduce the large benefits seen by Schlenk et al in ATRA treated patients with an NPM1 mutant/ITD wild type genotype, either overall or for patients treated with ADE, thus failing to substantiate a benefit for ATRA in either context. Based upon the results of AML16, neither Etoposide nor ATRA improve outcomes for older patients given intensive DA chemotherapy. Acknowledgments This study received research support from Cancer Research UK, and the Cardiff Experimental Cardiff Medicine Centre. Disclosures: No relevant conflicts of interest to declare.

Background The EUMDS registry was initiated to provide an overview of the real-world demographics, diagnostics and disease-management of MDS. The first patient was registered in December 2007 and today 16 countries and 131 centers are participating. In 1997 the International Prognostic Scoring System (IPSS) was developed to predict clinical outcomes for patients with MDS and is still the most widely used prognostic scoring system. Recently, the IPSS has been revised (IPSS-R). Objective To validate the prognostic discrimination of the IPSS and IPSS-R in the first 1000 newly diagnosed lower risk MDS patients. Results The median age of the population at diagnosis was 75 years (range 19-95). WHO 2001 classification was RCMD (35%), RARS (18%), RA (18%), RAEB-1 (12%), RCMD-RS (7%), 5q- syndrome (6%), MDS-U (3%) and RAEB-2 (0.4%). Within the first two years of follow-up 57% of the patients received MDS specific treatment: 48% received erythropoiesis stimulating agents (ESA), 11% granulocyte colony-stimulating factor (G-CSF), 51% received at least one red blood cell transfusion and 8% iron chelation therapy. IPSS risk score was Low in 49%, Intermediate-1 in 45% (0.5=32%, 1=13%) and unknown in 6% (no cytogenetic analysis) of the patients. IPSS-R risk score was Very Low in 25%, Low in 44%, Intermediate in 16%, High/Very high in 4% of the patients, and 10% unknown (Figure 1; Table 1). 77% of IPSS karyotypes were Good, 15% Intermediate, 1% Poor and unknown in 6%. 7% of the IPSS-R cytogenetic groups were Very good, 72% Good, 11% Intermediate, 1% were each Poor or Very poor and 8% unknown. Overall survival (OS) and disease progression (DP) (high risk MDS/Leukaemia) were both evaluated. Median follow-up time was 2.1 years (range 0 - 4.9 years). The mortality rate in patients with IPSS Low was 23% and 38% among those with an Intermediate IPSS (HR 2.09, 95%CI: 1.64-2.66; Figure 2A). The mortality rate in patients according to the IPSS-R was Very Low (21%; HR 0.77, 95%CI: 0.55-1.07), Low (26%; HR 1), Intermediate (51%; HR 2.53, 95%CI: 1.90-3.38) and High/Very high (65%; HR 4.47, 95%CI: 2.94-6.78) (Figure 2B). The prognostic discrimination of the scoring systems was assessed using the Akaike Information Criterion (AIC) from univariate proportional hazards models; the lower the AIC value the more informative the prognostic scoring system. The AIC of the IPSS and IPSS-R models were 3198.77 and 3154.48, respectively for OS and 1323.16 and 1274.19, respectively for DP (Table 1). A similar assessment of the components of the IPSS and IPSS-R scores revealed comparable fits to both OS and DP, regardless of which component was considered (Table 2). Conclusion IPSS and IPSS-R both predict OS and DP very well. IPSS-R was slightly superior in evaluating the clinical outcome, but it identified a subgroup (4.5% of all patients) of High and Very High-risk patients with a very poor prognosis, and another subgroup of good prognosis patients (IPSS-R Very Low) within the IPSS INT-1 cohort (13.6% of IPSS INT-1). Both scoring systems appear to be more strongly associated with predicting the risk of developing DP than OS. This observation may be due to the average high age at diagnosis of MDS reflecting the effect of competing causes of death associated with high age. Disclosures: Guerci-Bresler: Novartis: Honoraria; BMS: Honoraria; Celgene: Honoraria; Amgen: Honoraria.

Introduction AC220 (Quizartinib) is a novel FLT3 inhibitor that has shown a high level of activity as monotherapy in patients with advanced FLT3 +ve disease, and more modest activity in FLT3 -ve patients across Phase 1 and 2 studies. This is the first presentation of quizartinib use in combination with chemotherapy in newly diagnosed (FLT3 +ve and FLT3 -ve) older AML patients. Study Aim In preparation for a prospective Phase 3 trial (NCRI AML 18) in older patients with newly diagnosed AML, we tested the feasibility and dose of AC220 which could be sequentially given two days after each of two courses of ADE (Ara-C/ Daunorubicin/ Etoposide) followed by one course of DA (2+5) in patients over age 60 with FLT3 +ve or FLT3 –ve newly diagnosed AML. Six cohorts with escalating doses (60mg, 90mg or 135mg based on doses used in the Phase 2 ACE study with quizartinib) for 7 or 14 days were planned. If 60mg was not tolerated there was provision to de-escalate to 40mg for 7 or 14 days. The study was based on a 3+3 design whereby if 1 of 3 developed a DLT a cohort expansion was required but if >2 of 6 had a DLT, the cohort failed. A DLT was defined as any grade 4 non-haematological toxicity or failure of count recovery by day 42 in the absence of marrow blasts, or a grade 3 toxicity that did not recover to at least grade 2 within 7 days. Because of the increased sensitivity in females to QTc prolongation, each cohort required a minimum of 3 females. The day of safety evaluation was on completion of the chemotherapy in course 2. Results 55 patients with a median age of 69 years (62-87) entered of whom 48 were evaluable. 4 patients were FLT3 ITD +ve. 13 patients (4 males, 9 females) entered cohort 1 (AC220 60mg for 7days). No DLTs were seen in males but 3 DLTs occurred in females (all grade 4:1 cardiac (MI), 1 hypokalaemia; 1 mucositis) so this cohort exceeded tolerability for females. 8 patients (all males) entered cohort 2 (AC220 60mg for 14 days) where 4 DLTs (all grade 3; 3 QTC, 1 appetite loss) were seen, so this cohort exceeded tolerability for males. The de-escalation cohort (cohort 3) was activated (AC220 40mg for 7 days). 2 DLTs (1 grade 4 lung; 1 lung infection grade 3 >7days) in 7 evaluable females and 0 DLTs in 9 evaluable males were seen, so both males and females progressed to Cohort 4 (AC220 40mg for 14 days). There was 1 DLT (haematological) of 5 evaluable males and 0 of 8 evaluable females had a DLT. The DLTs were similarly distributed between males (5/25) and females (5/23). Induction death (death with 30 days) occurred in 3/46 (6.5%) evaluable patients. CR was achieved in 33/42 (79%; including all 4 FLT3 ITD +ve) of patients evaluable for CR or 60% of all 55 patients. Overall median time to neutrophil and platelet count recovery (neutrophils to 1.0x109/l; platelets to 100x109/l) was prompt (28 and 22 days post course 1; 22 and 19 days post course 2 respectively). No patients received SCT. The median OS is currently 15 months. Conclusion AC220 at 40mg for 14 days can safely be given sequentially after chemotherapy in older patients with newly diagnosed AML. The Phase 3 AML 18 study is planned to start in early 2014 and will incorporate AC220 into multiple courses of DA therapy as well as maintenance therapy. On behalf of the UK NCRI AML Working Group. We acknowledge the support from Ambit Biosciences for this study. Disclosures: Burnett: Ambit: Membership on an entity’s Board of Directors or advisory committees, Research Funding. Off Label Use: AC220 for newly diagnosed AML. Hills:Ambit: Consultancy.

E. Papaemmanuil1, M. Gerstung1, L. Malcovati2, S. Tauro3, G. Gundem1, P. Van-Loo1, A. Pellagati4, M. Groves3, N. Cross5, C. Gambacorti-Passerini6, A. Green7, J. Boultwood4, P. Vyas8, E. Hellstrom-Lindberg9, D. Bowen10, M. Cazzola2, M.R. Stratton1, P.J. Campbell1. 1Cancer Genome Project, Wellcome Trust Sanger Institute, Cambridge, United Kingdom; 2Haematology Oncology, Fondazione IRCCS Policlinico San Matteo & University of Pavia, Pavia, Italy; 3Haematology, Ninewells Hospital, Dundee, United Kingdom; 4LRF Molecular Haematology Unit, Nuffield Department of Clinical Laboratory Sciences, Oxford, United Kingdom; 5Wessex Regional Genetics Laboratory, University of Southampton, Southampton, United Kingdom; 6Health sciences, Milano Biccoca, Milano, Italy; 7Haematology, University of Cambridge, Cambridge, United Kingdom; 8Molecular Heamatology Unit and Dept of Haematology, Weatherall Institute of Molecular Medicine and John Radcliffe Hospita, Oxford, United Kingdom; 9Medicine Hematology, Karolinska Institutet, Stockholm, Sweden; 10Haematology, St. James’s Institute of Oncology, Leeds, United Kingdom

Introduction: Although several staging systems exist for HCC, the most widely accepted system is the Barcelona Clinic Liver Cancer (BCLC) staging system. All patients with vascular invasion and/or distant metastases are categorized as BCLC C with similar with prognosis and treatment. The aim of this study is to compare the clinical presentation and prognosis of HCC patients who present with BCLC C. Methods: We conducted a retrospective analysis of a prospective database of patients diagnosed with HCC between January 2005 and December 2011. All patients who presented with extrahepatic metastasis (EHM) or vascular invasion (VI), consisting of either a portal venous or hepatic venous thrombus, at presentation were included for analysis. Patients with either a Child Pugh score C or ECOG performance . 2 were excluded from analysis. Demographics, tumor characteristics, treatment regimens, and survival were compared between the following groups of patients: patients with both VI and EHM (group C1), patients with VI but without EHM (group C2), and patients with EHM but without VI (group C3). Differences between groups were determined with oneway ANOVA and Chi-squared tests. Survival curves were generated using Kaplan-Meier plots.Results: Of the 448 patients diagnosed with HCC, 130 patients presented at BCLC C stage, 45 patients in group C1, 54 patients in group C2, and 31 patients in group C3. There was no difference in age, gender, race/ethnicity, presence of symptoms, or etiology of cirrhosis between the three groups of patients. Patients with both EHM and VI (Group C1) had a significantly higher AFP than the other groups (mean, 93491+/164819,19488+/-49375, and 13948+/-5248, p,0.001). These patients also had significantly worse survival than those with VI or EHM alone (2.3 mths vs. 5.9 mths, p ,0.001). Patients with VI alone (group C2) and those with EHM alone (group C3) had similar survival (5.7 vs. 6.1 mo, p= 0.62). On multivariate analysis treatment, AFP , 400 ng/ml, absence of both EHM and VI, and lack of symptoms on presentation were associated with prolonged overall survival. Conclusion: Patients with BCLC stage C tumors comprise a heterogeneous group of patients with different prognoses. Patients who present with both VI and EHM have significantly worse prognosis than those who present with VI or EHM alone.

Abstract 700 Purpose: Prognosis of lower (IPSS low/int-1) risk MDS is heterogeneous. Current prognostic systems rely on single time point cytopenia values (Hb level, ANC, PLT counts) at diagnosis (classical or revised IPSS [IPSS-R] Greenberg, Blood 2012) or during evolution (time-dependent IPSS/WPSS). Capturing the dynamics of continuous parameters can yield independent prognostic information as exemplified by lymphocyte time doubling in CLL. We analyzed the prognostic relevance of the kinetics of Hb, ANC and PLT in lower-risk MDS patients (pts) included in the prospective EUMDS registry. Methods: Among the first 1000 pts included in the EUMDS registry, those fulfilling the following criteria were analyzed here: a) IPSS low/int-1; b) ≥3 visits (planned every 6 months) with ≥12 months follow-up; c) not treated with hypomethylating agents, G-CSF, hydroxyurea or lenalidomide. Dynamics of Hb, ANC, and PLT were studied by deriving linear models of each variable for each pt. Only pts with ≥3 measures of Hb, ANC and PLT and with stable or worsening corresponding cytopenia (model slope ≤0) were considered in each analysis, regardless of the goodness of fit (R2) of models. Time (T) to lose 1 g/dL of Hb (THb), 1.0 x109/L of ANC (TANC) and 50 x109/L of PLT (TPLT) were derived with the formula: T ∼ 1/slope. All survival analyses were made from the date of registry entry to last follow-up, death, or progression to AML. Unless specified, survival analyses were Cox models using continuous variables accounting for interactions. Results: 530 pts met study inclusion criteria (M/F: 314/216, median age: 73y). WHO diagnosis was 5q- syndrome, RA, RARS, RCMD, RCMD-RS, RAEB-1 and MDS-U in 5, 21, 20, 38, 7, 8 and 2% respectively (resp). IPSS risk was low, int-1 and low/int-1 (cytogenetics not available) in 55%, 38% and 7% resp. At registry entry, median Hb, ANC and PLT were 10.4 g/dL, 2.4 x109/L and 187 x109/L resp. and 23% were RBC transfusion-dependent; 293 received an ESA. The median number of available blood counts was 4 (range 3–9). THb, TANC and TPLT could be determined because of a stable or worsening cytopenia (slope ≤0) in 250/508, 258/495 and 301/509 pts with ≥3 values. There was no significant correlation between the number of values available and the goodness-of-fit (R2) of linear models (all P>0.3). Median THb TANC and TPLT were 23.5 (interquartile range [IQR]: 42.2), 28.7 (IQR: 52.1) and 26.9 (IQR: 49.2) months respectively. Because these figures are derived from linear models, they can be simply rescaled by a proportional extrapolation for daily practice (eg. −1 x109/L ANC at 28.7 months = −0.41 x109/L [12/28.7] at 12 months). THb, TANC and TPLT were not correlated to age, cytogenetic risk, IPSS, IPSS-R or baseline simplified WPSS (Malcovati. Haematologica 2011; all P>0.2). TANC and TPLT (but not THb) were shorter in pts with baseline RBC transfusion dependence (P=.02 and .003, resp.). With a median follow-up of 20.9 months in the 530 pts, 19 patients have progressed (AML: 14, RAEB: 5) and 71 patients have died; 3-year estimates of overall (OS) and progression-free (PFS) survivals were 74.4% and 73.6%. All further analyses are shown for OS and give similar results for PFS. In univariate analysis, longer TANC (hazard ratio [HR] for 6-months increments: 0.88 [95% CI: 0.80–0.97], P=.008) and TPLT (HR: 0.01 [95% CI: 0.001–0.30], P=.007) but not THb (P=.07) were associated with prolonged OS. Pts with a ≥1 x109/L decrease in ANC in less than the median time of 28.7 months (N=129) had a 3-year OS of 66.3% [95% CI: 55.0–79.9%] vs 89.3% [79.7–100%]. Pts with a ≥50 x109/L decrease in PLT in less than the median of 26.9 months (N=151) had a 3-year OS of 59.4% [46.8–75.4%] vs 85.6% [77.5–94.6%] (Figure, both P Conclusion: In lower-risk MDS with stable or worsening cytopenias, kinetics of decline can be approximated to be linear to allow easy prognostic use in clinical practice. Faster decline of ANC and to a lesser extent of PLT counts, but not of Hb level (possibly because of transfusions and use of ESA), is associated with shorter OS and PFS, independently of IPSS, IPSS-R and WPSS. Disclosures: Germing: Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Abstract 3830 Background: The EUMDS registry was established to obtain an overview in the real world MDS demographics, diagnostics and disease-management. From April 2008 until December 2010, 1000 newly diagnosed patients with IPSS low and int-1 risk MDS were included in 14 countries and 118 participating centers. The major clinical problems in MDS are the consequences of cytopenias and disease-progression. Therefore, the most important treatment goals are improvement of cytopenias and prevention of leukemia. Objectives: To describe the causes of early mortality and to analyze the outcome of the first 1000 patients in the registry with and without disease-progression at 24 months follow-up. Results: The median age of the population was 74 years (range 18–95), 60% were male. The most frequent co-morbidities were hypertension (46%), diabetes mellitus (18%), arrhythmias (12%), and thyroid diseases (12%). The WHO subgroups are RCMD (39%), RA (19%), RARS (17%), RAEB-1 (13%), RCMD-RS (7%), MDS-U (3%), and del5q (2%). IPSS score (n=935) was 0 in 48%, 0.5 in 31% and 1 in 14% of the patients. WPSS score (n=924) was Very Low in 32%, Low in 38%, Intermediate in 19% and High in 4% of the patients (Table1). 184 of 1000 patients (18%) had started MDS specific treatment within 3 months after diagnosis: this increased to 43% at 24 months of follow-up. 15% of the patients (in 12 of the 14 countries) started ESA treatment at registration and this increased to 31% at 24 months, combined with G-CSF in 7%. At registration, 29% of the patients had received at least one RBC transfusion with a mean pre-transfusion Hb level of 8 g/dL. The percentage of transfusion-dependent (TD) patients remained stable during follow-up with 31%, 29%, 26% and 29% at 6, 12, 18, 24 months of follow-up, respectively. At 24 months, overall survival (OS) is 83%. Median time from date of inclusion until progression to higher risk MDS or leukemia is 293 days. Most patients (123) have died without disease-progression (DP) versus 45 patients who have died after DP at 24 months (Table1). DP has been defined as an increase in bone marrow blasts to a higher WHO category. The main causes of death in patients without DP were infections (21%) and cardiovascular events (11%). The mortality rate in transfusion-independent (TI) and TD patients without DP was 5% and 24%, respectively. In TI and TD patients with DP, the mortality rate was 32% and 66%, respectively (Table1; Graph 1). To define the prognostic relevance of serum ferritin (SF) and TD, the SF levels divided in two groups (1. Conclusions: The great majority of deceased lower risk MDS patients have died before they have developed clinical signs of disease-progression. Transfusion-dependent patients without disease-progression have a four times higher mortality rate than transfusion-independent patients. This indicates that the pathophysiology of cytopenias and related complications are a major point of interest in early mortality, especially in patients without disease-progression. Disclosures: No relevant conflicts of interest to declare.

Abstract 582 We previously showed in the MRC AML15 Trial (Burnett et al JCO 2011:29(4):369-77 that 70% of younger patients with AML derived a 10% survival benefit by the addition of the immuno-conjugate, Gemtuzumab Ozogamicin (GO) (Mylotarg™), to induction chemotherapy. In a second trial (AML16 non-intensive) its addition to Low dose Ara-C doubled the CR rate but did not improve OS (Burnett et al. Blood 2010:116 (21): Abstract 18). We now report the result of the NCRI AML16 (Intensive) Trial in which older patients were randomised to receive, or not, GO 3mg/m2 on day 1 of course 1 of induction chemotherapy. Patients were randomised to two courses of DA (daunorubicin/ara-C) or DClo (daunorubicin/clofarabine), followed, or not, by a 3rd course (DA) with or without Azacytidine maintenance. Between December 2006 and July 2010, 1115 patients were randomised to the GO vs no GO comparison from 149 centres in the UK & Denmark. The median age was 67 years (range 51–84). 806 had de novo AML, 194 secondary disease and 115 high risk MDS (>10% marrow blasts). Of the 806 patients with cytogenetic data, 33 were favourable/629 intermediate/204 adverse risk (Grimwade et al, Blood 1998: 92:2322-33). 96% of those allocated GO received it. The overall response rate was 69% (CR 60%; CRi 9%) with 52% of patients achieving response after course 1. Overall survival at 4 years was 17% with a median follow up of 29.5 months (range 0.5–54.6 months).CR%CRi%ORR%Res Dis %Ind Death %30d mortality %60d mortality %GO629711712915No GO5810682111814p-value0.180.30.070.40.80.8 Induction Results: There was no significant difference in blood count recovery kinetics; other toxicities and resource usage were not significantly increased with the exception that for course 1 nausea and oral toxicity were marginally higher with GO, more platelet transfusions were given (13.7 vs 9.6 mean units; p Relapse/RFS/OS: The rate of relapse was significantly reduced (GO vs no GO: CIR at 2 years 61% vs 70%; p=0.004), leading to significantly better RFS (28% vs 23% at 2 years; p=0.03), and survival from CR and OS were significantly better on the GO arm (2 year survival from CR 47% vs 39%; p=0.02; 2 year OS 35% vs 29%; p=0.04). While the benefit appeared lower in patients with secondary disease or with adverse cytogenetics (GO vs no GO 2 year OS 19% vs 21% and 13% vs 6%) compared to those with de Novo disease or intermediate cytogenetics (2 year OS 38% vs 32% and 41% vs 36%), as was seen in our previous AML15 trial, in this trial there was no significant evidence of interaction between treatment and any demographics or underlying chemotherapy. Conclusion: The addition of GO to induction chemotherapy did not lead to unacceptable increases in toxicity. It improved disease control and delivered a significant OS benefit for older patients overall. While there is no significant interaction, the greater benefit in patients with de novo disease or intermediate risk cytogenetics is consistent over the 2228 patients randomised in the AML15 and AML16 trials. Disclosures: Burnett: Pfizer: Consultancy. Off Label Use: Gemtuzumab Ozogamicin in AML.

activity predominantly in higher-risk MDS patients, with CR rates approaching 50%, and overall response rates of two-thirds. Adverse event profiles appear similar. However, the only comparative phase 2 study demonstrated similar activity of azacitidine + entinostat to azacitidine alone, with trilineage response rates of 24% and 31%, respectively. Subpopulations of patients defined by disease biology who appear to have better responses to combinations are emerging. Advanced phase studies comparing combination strategies to standard single agents are being developed or are actively accruing patients. Dosing of combination drugs and schedules are being modified in an effort to enhance activity. Conclusion: Combination drug strategies represent the next frontier in MDS therapeutics, though it has yet to be demonstrated prospectively their superiority to established single agent approaches.

Abstract 2917 Background: The European LeukemiaNet MDS (EUMDS) registry is designed to collect information about the demographics and disease-management of newly diagnosed low-risk and intermediate-1 risk MDS patients. From April 2008 until July 2010, 828 patients have been registered in eleven participating countries through a web-based reporting system. Objectives: This report describes the disease-management of the first 800 registered patients, including transfusion-related issues like secondary iron overload and its treatment. Results: 159 of 800 patients (20%) started MDS specific treatment within three months before registration; this percentage increased to 50% at 18 months of follow-up. Most patients received erythroid-stimulating agents (ESA), like erythropoietin (Table 1). In patients with a clinical indication for ESA, the percentage of transfusion-independency was similar to the transfusion-independent group without indication for ESA at 18 months of follow-up (Table 1). Overall, 27% of the patients received blood transfusions at registration. This percentage remained stable during follow-up, probably due to the therapeutic effect of ESA (Table 1). The number of units transfused, per 6 months, in these patients increased from 5 to 13 units at 18 months of follow-up, with a mean pre-transfusion Hb level of 7.6 g/dL. The serum ferritin levels of the transfusion-dependent patients at registration were available in 159 patients. The serum ferritin level at registration was ≥2000 μg/L in 4% of the patients who received a mean number of 10 units (SD 7). This increased to 28% of the patients who received a mean number of 20 units (SD 11) at 18 months of follow-up. The percentage of patients on iron chelation therapy increased from 1% to 9% during follow-up (Table 1). In these patients the mean serum ferritin levels remained stable: 1913 μg/L (SD 1183) at registration and 1626 μg/L (SD 1232) at 18 months of follow-up. In contrast, transfusion-dependent patients not treated with iron chelation or ESA had increasing ferritin levels, with a mean ferritin of 630 μg/L (SD 597) at registration and 1586 μg/L (SD 1017) at 18 months of follow-up. 37 patients (5%) progressed to high-risk MDS or acute myeloblastic leukemia at a median of 155 days from registration. 62 patients (8%) have died within a median of 269 days from registration, 32 deaths were MDS related. The overall survival was 93% at 18 months of follow-up, with a progression-free survival of 90%. Differences in overall survival between transfusion-independent and transfusion-dependent patients were significant: 97% versus 85%, respectively (p Conclusions: Despite a high transfusion load the mean serum ferritin levels remained stable during treatment with iron chelation. Transfusion-dependent patients had a worse overall survival and progression-free survival with higher ferritin levels and higher IPSS score as compared to transfusion-independent patients. This report demonstrates the importance of detailed disease-management in low- and intermediate-1 risk MDS patients. Disclosures: Fenaux: Celgene: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Janssen Cilag: Honoraria, Research Funding; ROCHE: Honoraria, Research Funding; AMGEN: Honoraria, Research Funding; GSK: Honoraria, Research Funding; Merck: Honoraria, Research Funding; Cephalon: Honoraria, Research Funding. Bowen:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; AMGEN: Honoraria; Celgene: Honoraria, Research Funding; Chugai: Honoraria, Research Funding.

Abstract 18 In a significant proportion of older patients with AML intensive chemotherapy is not considered a viable option[1]. Such patients may receive low-dose Ara-C (LDAC), best supportive care (BSC) with hydroxyurea or an experimental agent but outcomes are poor. We have shown that LDAC is superior to BSC [2], but only in patients who enter CR (fewer than 20%).[2]. There is therefore scope to improve outcomes in these patients, and a number of possible treatments have been evaluated in the randomised UK NCRI AML16 trial, one of which is gemtuzumab ozogamicin (GO), which we have shown to benefit the majority of younger patients when given in conjunction with standard chemotherapy[3]. In AML16 novel agents or combinations are tested in untreated older patients with AML or high risk MDS (marrow blasts >10%) using a “pick a winner” design. The design allows unpromising treatments to be identified early (typically after 50 or 100 patients per arm): only those arms which show promise will continue to a trial with OS and DFS as endpoints. The aim is to at least double the remission rate from 15% to 30%, and thus improve overall survival. We now report the results of LD Ara-C (20mg bd days 1–10 for 4 courses) versus LDAC combined with GO (at a fixed dose of 5mg on day 1 of each course for 4 courses at 6–8 week intervals). Patient Details: The comparison opened as part of the UK LRF AML14 trial and was carried forward to AML16 unchanged. Between June 2004 and June 2010, 495 patients were randomised, 249 to LDAC plus ATO, 246 to LDAC. The median age was 75 years (range 54–90); 83% of patients were aged over 70 years, and 61% were male. To be eligible patients’ LFTs had to be less than twice ULN. Treatment arms were balanced for age, gender, performance status, de novo/secondary AML/high risk MDS, presenting WBC and cytogenetic risk group. Follow-up is complete to 1st January 2010, with median follow up of 21 months. Survival and remission data is available on 412, 404 patients respectively. Treatment Results: The trial passed through both stopping hurdles based on CR/CRi rates and therefore continued to full accrual, with overall survival as primary outcome measure. The table shows the distribution of outcomes: there was no heterogeneity by recruitment period (AML14 vs AML16). The causes of death (316) were:- There were no significant interactions between treatment and any of the baseline variables on either remission or survival outcomes. Likewise there were no major toxicity implications, although resource usage tended to be higher in patients given GO. Discussion: While the addition of GO significantly improves CR rate, achieving the 30% response originally sought, this does not translate into survival. This is predominantly due to an increase in relapse, indicating that if GO is to have a role in this setting, it will require effective treatment to maintain remission. [1] Juliusson G et al. Blood 2009; 113: 4179 – 4187 [2] Burnett et al. Cancer 2007 109: 1114–1124 [3] Burnett et al. JCO 2010 to appear. Disclosures: Off Label Use: Mylotarg (gemtuzumab ozogamicin).

Abstract 3999 A prospective, multicenter European Registry (EUMDS) for newly diagnosed IPSS low and intermediate-1 MDS was initiated under the auspices of the EuropeanLeukemiaNet. As data on health-related quality of life (HR-QoL) in newly diagnosed MDS patients are rare, the EQ-5D (European quality group 5 dimensions) descriptive system was introduced in this evaluation. The EQ-5D evaluates HR-QoL in five dimensions: mobility, self-care, usual activities, pain/discomfort, anxiety/depression at level 1 (no problem), 2 (moderate problem) or 3 (severe problem, unable to do). Moreover HR-QoL is rated by the patient on a visual analog scale (VAS) ranging from 0–100. In 683 out of 800 EUMDS patients (85.4%) analyzed so far, the EQ-5D score has been applied at initial presentation. Median age was 72.8 yrs (18.7-95.3) with 61.9% male patients. Whereas a reduced performance status as defined by a Karnofsky Index Disclosures: Stauder: Celgene: Research Funding. Fenaux:Celgene: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Janssen Cilag: Honoraria, Research Funding; ROCHE: Honoraria, Research Funding; AMGEN: Honoraria, Research Funding; GSK: Honoraria, Research Funding; Merck: Honoraria, Research Funding; Cephalon: Honoraria, Research Funding. Hellstrom-Lindberg:Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding. Bowen:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; AMGEN: Honoraria; Celgene: Honoraria, Research Funding; Chugai: Honoraria, Research Funding.

Abstract 4854 Background Approximately 60–80% of patients with myelodysplastic syndromes (MDS) require ongoing red blood cell (RBC) transfusions due to impaired hematopoiesis. Iron chelation therapy has been extensively studied in thalassemia major patients; however, there are fewer data available on the efficacy and safety in transfusion-dependent patients with MDS who have a completely different clinical scenario (Angelucci E and Di Tucci AA. Leuk Res 2009;33:743–4). Increasing evidence is being reported in the literature on the rate and site of iron accumulation (Di Tucci AA et al. Haematologica 2008;93:1385–8), on the impact of transfusion dependency and iron overload on survival (Malcovati L. Leuk Res 2007;31:S2–6, Sanz G et al. Blood 2008;112(11):Abst 640) and on the efficacy of deferasirox (Exjade®) in removing iron in MDS patients. Nevertheless, the possibility to modify clinical outcome by iron chelation in MDS patients is still debated (DeLoughery TG. Am J Hematol 2009;84:263–4). Recent retrospective and prospective non-randomized data (Rose C et al. Blood 2007:110(11);Abst 249) suggest that iron chelation could have a positive impact. A Phase III, prospective, randomized, double-blind, placebo-controlled, parallel-group design clinical trial has therefore been planned to assess the effects of iron chelation therapy with deferasirox on clinical outcomes in patients with MDS (Low/Int-1 risk) and transfusional iron overload. Methods For inclusion, patients must be chelation-naïve, aged ≥18 years with Low/Int-1 risk MDS and serum ferritin (SF) levels of >1000– Conclusions This prospective multicentre study has been designed to investigate the clinical benefit of chelation therapy with deferasirox in patients with MDS, a matter that has assumed increasing relevance during recent years. Disclosures Bowen: Novartis: Honoraria, Research Funding. Magalhães:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen-Cilag: Research Funding. Lawniczek:Novartis Pharma AG: Employment. Douma:Novartis Pharma AG: Employment. Jakobs:Novartis Pharma AG: Employment.

Myelodysplastic syndromes (MDS) comprise a diverse range of hematological conditions, all of which involve impaired or disturbed hematopoiesis, cytopenias, marrow dysplasia and the risk of progression to acute myeloid leukemia (AML). MDS and AML are believed to involve a multi-step process arising within bone marrow stem cells, but the specific defects responsible remain poorly understood. In cases of inherited, familial forms of the disease two genes have been implicated: the hematopoietic transcription factors CBFA2 (core binding factor a2) and CEBPA (CCATT box enhancer binding protein a) and these account for only a small number of the familial cases so far reported. The uncharacterized families represent an ideal resource for identifying the primary pathology of the disease. In this study we have screened 21 families where MDS/AML appears to be familial for mutations in the telomerase enzyme components TERC (telomerase RNA component) and TERT (telomerase reverse transcriptase). In two families, we have identified novel mutations in TERC and in another two we have identified mutations in TERT directly resulting in MDS/AML. Functional analysis has demonstrated that all mutations adversely impact telomerase activity in vitro and affected individuals have short telomeres (see Table 1 for summary). These results have several important implications: First, they identify a novel genetic pathway (defective telomere maintenance) that can lead to familial MDS/AML; second, they suggest that TERC and TERT act as tumour suppressors and; finally, they have implications for the biology, treatment and screening regimen for de novo cases of MDS/AML. Family Number of affected individuals Mutation Telomerase activity compared to wild type Age-adjusted telomere length 1 3 TERC c.212C>G 1% −4.62 2 5 TERC c.309G>T 4% 0.01 3 2 TERTc.1892G>A 0% −4.45 4 2 TERTc.2354C>T 11% −3.12 Table 1 – Summary of clinical and molecular analyses of four families with MDS/AML

Background: AMG 531 is a novel thrombopoiesis-stimulating peptibody that is being studied for its ability to increase platelet production by stimulating the thrombopoietin receptor. This report updates outcomes in Part A of the study as of May 2007 on pts who continued into the extension phase of this ongoing phase 1/2, open-label, sequential-cohort, dose-escalation study to evaluate the safety and efficacy of AMG 531 in low risk MDS pts with severe thrombocytopenia (Kantarjian et al., ASCO, 2007). Methods: Pts with low- risk MDS (IPSS Low or Intermediate-1, excluding CMML), a mean baseline platelet count ≤50×109/L, and only receiving supportive care were eligible to enter this study. Pts were enrolled into sequential cohorts of 300, 700, 1000, and 1500μg, receiving 3 weekly subcutaneous injections of AMG 531. After evaluation of platelet response at week 4, pts could continue AMG 531 in an optional treatment extension at their assigned dose or dose adjust to achieve or maintain a response. Results: The mean duration of exposure to AMG 531 was 23±15.5 (SD) weeks. Of 44 pts enrolled, 40 continued into the extension phase; 16 pts remain on treatment. Eighteen pts (41%) achieved a durable platelet response (per IWG 2006 criteria for at least 8 consecutive weeks). Evaluation of durable responses based on baseline platelet count showed that responses occurred in 12/29 (41%) pts with a baseline count of ≥20×109/L, and in 6/15 (40%) pts with a baseline count of Conclusions: In this study, AMG 531 appeared to be well-tolerated in severely thrombocytopenic low-risk MDS pts, and resulted in increased and sustained platelet counts in the responding pts. AMG 531 may have a role in the treatment of low-risk MDS pts who are thrombocytopenic or have a history of bleeding. These data suggest that further exploration is merited in this pt population. Pt recruitment is ongoing until reaching the planned 84 pts.

Reflections on a teacher's experience in a context in which it became clear that personalobservation and involvement were required, if recourse to misleading stereotypes was to beavoided. The basic argument is that work on contemporary Hindu communities and on empiricalevidence offers a better pedagogical opening than do initially historical approaches.

Abstract 1867 Background: The European LeukemiaNet MDS Registry programme is the largest and most comprehensive prospective population-based registry of ‘low-risk’ MDS patients followed from diagnosis. Objective: The primary objective of this study is to describe the demographics and the disease-management of newly diagnosed MDS patients within IPSS low and intermediate-1 categories. Methods: The project recruits patients from 107 sites in 11 countries, ranging from 2–25 sites per country and including a high proportion of non-University centres in small cities. Consecutive eligible adult patients are registered within 3 months of diagnosis. Local diagnosis is accepted and a large dataset is collected including laboratory data, clinical information (including co-morbidity and concomitant medication) plus health utility (EQ-5D). Data are entered via a web portal and are source verified by study monitoring visits to sites. Results: As of July 2010, 828 patients are registered; data are presented for the first 800 patients. Recruitment is highest from France (n=237) then UK (104), Greece (99), Spain (92), and Sweden (73). Median age is 74.2 yrs (range 18.7–95.3) and from the four largest recruiting countries is 74.6–77.1 yrs. Sixty one percent of patients are male. Twenty patients are non-Caucasian (n=763). Body mass index is overweight (WHO definition) in 43.4% pts and obese in 18.3%, comparable to WHO data for the general adult population (http://apps.who.int/bmi/index.jsp). RCMD is the largest WHO subgroup (34%), followed by RARS (19%), RA (18.4%), RAEB-1 (12.5%), del5q (5.4%), MDS-U (3.5%) and RAEB-2 (0.5%). All WHO subgroups have male predominance except del5q with a striking female excess (79%). IPSS score (n=743) is 0 (52.3%), 0.5 (33.2%), and 1 (14.4%). 84.5% patients have IPSS ‘good’ cytogenetics. 19% patients have 0 cytopenias, 53% 1 cytopenia, 20% 2 cytopenias and 8% 3 cytopenias. WPSS category (with transfusion dependence assessed at time of registration, n=727) is Very Low (35.5%), Low (39.5%), Intermediate (21%), High (4%). Bone marrow features: mean no. of dysplastic lineages = 1.9, bone marrow ring sideroblasts percent = 0 (60% pts), 11.5, 10, 500 IU/l. Mean creatinine clearance was 71 mls/min with a marked reduction with age (P Discussion: This registry records data from the ‘real world’, namely what the hematopathologists in 100 sites diagnose locally as low-risk MDS and will as such be managed as MDS. Median age is consistent with other population-based data (US Medicare, Yorkshire Haematological Malignancy Research Network [www.hmrn.org]). In comparison with registries from specialist MDS centres, median age is higher and a lower proportion have del(5q) WHO subtype. Conclusion: The ELN registry clearly maps the diagnosis and management of low-risk MDS in routine clinical practice in hospitals large and small, specialist and non-specialist and is a unique resource. Acknowledgments: The Steering Committee (SC) acknowledges the commitment and enthusiasm from all 107 sites contributing high quality data to the project. The SC is also grateful for the funding commitment of Novartis Oncology Europe through the University of Nijmegen. Disclosures: Bowen: Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; AMGEN: Honoraria; Celgene: Honoraria, Research Funding; Chugai: Honoraria, Research Funding. Fenaux:Celgene: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Janssen Cilag: Honoraria, Research Funding; ROCHE: Honoraria, Research Funding; AMGEN: Honoraria, Research Funding; GSK: Honoraria, Research Funding; Merck: Honoraria, Research Funding; Cephalon: Honoraria, Research Funding. Hellstrom-Lindberg:Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding.

We designed a multicenter randomized trial comparing chemotherapy with daunorubicin-Ara C (chemotherapy group) and all transretinoic acid (ATRA) combined to the same chemotherapy (ATRA group) in newly diagnosed APL patients aged 65 years or less. The major endpoint of the study was event-free survival (EFS) (“events” being defined as failure to achieve complete remission [CR], occurrence of relapse, or death in CR). Early termination of the trial was decided after the first interim analysis, as EFS was significantly higher in the ATRA group. At the time, 101 patients had been randomized (54 in the ATRA group and 47 in the chemotherapy group). In the ATRA group, 49 (91%) patients achieved CR, 5 (9%) had early death, and 0 had resistant leukemia, compared with 38 (81%), 4 (8%), and 5 (10%) patients, respectively, in the chemotherapy group. The difference in CR rate between the two groups was not significant. The duration of coagulopathy was significantly reduced in the ATRA group, compared with the chemotherapy group. In the ATRA group, six patients relapsed after 7 to 15.5 months. In the chemotherapy group, 12 patients relapsed after 1 to 16 months, and 2 died in CR. Kaplan-Meier EFS was estimated at 79% +/- 7% and 50% +/- 9% at 12 months, respectively, in the ATRA and the chemotherapy group (P = .001). Kaplan-Meier estimate of relapse was 19% +/- 8% and 40% +/- 12% at 12 months (P = .005). In conclusion, ATRA followed by chemotherapy increases EFS in newly diagnosed APL. These results strongly suggest that ATRA should be incorporated in the front line therapy of newly diagnosed APL.

It is generally accepted that naive T cells recirculate via the blood and lymph, but do not enter nonlymphoid tissues without prior activation and differentiation. In this study, we demonstrate that the liver is an exception to this rule. Naive Des-TCR transgenic CD8+ T cells specific for H-2Kb were selectively retained in the liver within a few minutes of adoptive transfer into transgenic Met-Kb mice expressing H-2Kb in the liver. Activated CD8+ cells were found in the liver, but not the blood, as soon as 2 h after transfer and underwent cell division and started to recirculate within 24 h of transfer. In contrast, CD8+ cells activated in the lymph nodes remained sequestered at that site for 2 days before entering the blood. Our results therefore suggest that, in addition to its previously described role as a non Ag-specific activated T cell graveyard, the liver is involved in Ag-specific activation of naive recirculating CD8+ T cells. This particular property of the liver, combined with the previously demonstrated ability of hepatocytes to induce tolerance by means of premature CD8+ T cell death, may be a major mechanism contributing to the acceptance of liver allografts and the chronicity of viral hepatitis.

Abstract 3 Myelodysplastic syndromes (MDS) are myeloid neoplasms characterized by dysplasia in one or more cell lines, ineffective hematopoiesis, and variable risk of progression to acute myeloid leukemia (AML). As any other neoplasm, MDS is expected to be driven by mutation, and its clonal evolution is likely a multistep process in which several genetic events occur. Somatic mutations of TET2 have been found in about 25% of MDS patients, while additional mutant genes (including ASXL1, ETV6, EZH2, IDH1, IDH2, RUNX1, and TP53) have been detected in smaller proportions of patients, particularly in those with poor prognosis. Refractory anemia with ring sideroblasts (RARS) is a phenotypically well-defined subtype of MDS, characterized by 15% or more ring sideroblasts (RS, erythroblasts with perinuclear iron-loaded mitochondria) in the bone marrow. We reasoned that the identification of recurrently mutated genes in RARS could provide novel insights into molecular pathogenesis of MDS, and used massively parallel sequencing technology to identify somatically acquired point mutations across all protein-coding exons in the genome in 8 patients with RARS. We identified 62 point mutations across the 8 patients, and the mutation spectrum showed a predominance of transitions, especially C>T/G>A mutations. Within 5/8 patients studied, the observed proportion of reads reporting a mutant allele showed significantly greater variability than expected by chance, indicating that the population of malignant cells was genetically heterogeneous. In 6/8 RARS patients, we identified recurrent somatic mutations (found in granulocytes but not in T-lymphocytes) in a gene that encodes a core component of the RNA splicing machinery, SF3B1. Based on the proportion of reads reporting the mutant allele, the mutations all appeared to be heterozygous and present in the dominant clone of cells. To characterize the spectrum and frequency of SF3B1 mutations in greater detail, both in myeloid malignancies and other cancers, we undertook targeted resequencing of the gene. In particular, we studied patients with MDS, myelodysplastic/myeloproliferative neoplasm (MDS/MPN) or AML evolving from MDS. Somatic mutations of SF3B1 were found in 150/533 (28.1%) patients with MDS, 16/83 (19.3%) patients with MDS/MPN, and 2/38 (5.3%) patients with AML. The gene was also mutated in 1–5% of diverse other tumor types. All mutations appeared to be heterozygous substitutions, and we observed no frameshift indels, splice site mutations or nonsense substitutions. The mutations clustered in exons 12–15 of the gene, and K700E accounted for 97/168 (57.7%) of the variants observed. SF3B1 mutations were less deleterious than expected by chance, implying that the mutated protein retains structural integrity with altered function. Gene expression profiling revealed SF3B1 mutations are associated with down-regulation of key gene networks, including core mitochondrial pathways. Close relationships were found between mutant SF3B1 and presence of RS (P In conclusion, mutations in SF3B1 implicate abnormalities of mRNA splicing, a pathway not previously known as a target for mutation, in the pathogenesis of MDS. The close relationship between this molecular lesion and RS is consistent with a causal relationship, and makes SF3B1 the first gene to be strongly associated with a specific morphological feature in MDS. Finally, SF3B1 mutations are independent predictors of favorable clinical outcome, and their detection may improve risk assessment in MDS. The first two authors equally contributed to this paper, which is on behalf of the International Cancer Genome Consortium Chronic Myeloid Disorders Working Group. Disclosures: No relevant conflicts of interest to declare.

Abstract 2775 Background: The ELN EUMDS registry collects information about demographics and disease-management of newly diagnosed low- and intermediate-1 risk MDS patients. Objective: To define the prognostic impact of transfusion-dependency and serum ferritin levels. Results: From April 2008 until December 2010, 1000 patients have been registered in fourteen European countries. The median age is 74 years (range 18–95), 60% are male. The WHO subgroups are RCMD (35.8%), RARS (18.2%), RA (17.6%), RAEB-1 (11.6%), del5q (6.2%), MDS-U (3.1%) and RAEB-2 (0.4%). IPSS score (n=935) is 0 in 48.8%, 0.5 in 31.2% and 1 in 13.5%. At time of registration 19% of the patients had started MDS specific treatment, increasing to 46% at 18 months of follow-up, usually consisting of erythroid-stimulating agents (ESA). At registration 29% of the patients were transfusion-dependent, which remained stable during follow-up. The number of transfusion-dependent patients with ESA treatment decreased from 58% to 27% at 18 months of follow-up. Overall survival at 18 months of follow-up was 89%. The mortality rate in transfusion-independent and transfusion-dependent patients at 18 months of follow-up was 5% and 21%, respectively (P300 20 units. The mortality rate in these groups was 5%, 18% and 30%, respectively. The adjusted HRs were 3.67 (95% CI; 2.28–5.91) and 5.50 (95% CI; 3.18–9.52), respectively (Table 1). Conclusion: After 18 months of follow-up serum ferritin levels appear to be an important prognostic factor for transfusion-dependent patients only. However, transfusion burden is the most important prognostic factor for survival in patients with more than 20 units transfused compared to non-transfused patients. An increased risk was also apparent for moderately transfused patients ( Disclosures: Fenaux: Celgene: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Janssen Cilag: Honoraria, Research Funding; Roche: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Glaxo Smith Kline: Honoraria, Research Funding; Merck: Honoraria, Research Funding; Cephalon: Honoraria, Research Funding. Germing:Celgene: Consultancy, Research Funding.