Search

Introduction: The most common cause of treatment failure after allogeneic hematopoetic stem cell transplantation (aHSCT) is relapse. The combination of venetoclax and the hypomethylating agents (HMA) azacitidine (AZA) or decitabine (DAC) have shown promising efficacy in elderly patients with AML. We here present clinical data on 32 patients, who were treated with an HMA/venetoclax combination therapy (HMAClax) for relapse of a myeloid malignancy after aHSCT, collected retrospectively from 11 German centers. Results: Sixteen patients (50%) were male, median age was 54 years (30.8-71.5). Diagnoses at aHSCT were 25 AML (17 primary, 8 emerging from MDS, CMML or OMF), 5 MDS, 1 CMML and one atypical CML. Twenty six patients were treated for relapse after their 1st and 6 after their 2nd aHSCT. Only 9 patients were in CR at aHSCT. The majority received a graft of a matched unrelated donor (21), 4 from an HLA-identical sibling and 7 from a haploidentical relative. Conditioning was myeloablative in 15 and RIC in 17patients. Median time from aHSCT to last relapse was 5.7ms (1.1-67.8). Five patients had molecular (MR) and 23 had hematologic relapses (HR), 4 patients had extramedullary manifestations 3 with concurrent HR and 1 with MR. Twenty-one patients were treated for 1st and 5 for 2nd relapse after 1st aHSCT. Four patients were treated for 1st and 2 for 2nd relapse after 2nd aHSCT. HMAClax was first line therapy for relapse in 8, 2nd line in 22, 3rd line 1 and 4th line in 1 patient. In 21 patients relapse had been refractory to HMA (+/- DLI, +/- lenalidomide). Median time from relapse to HMAClax was 1.8 ms (0.3-42.9). Twelve patients received AZA and 19 DAC with venetoclax. One patient was switched from AZAClax to DAClax because of rising MRD after 6 cycles and back to AZAClax after another 7 cycles. Six patients received DLI. Median number of cycles was 2 (1-15). Six patients are still on therapy. In total 75 cycles were given. Three patients had non-fatal tumor lysis syndrome. All but one patient had grade 3/4 neutropenia and 25 patients (78%) had grade 3/4 thrombocytopenia. Hospital admission for grade 3/4 infections was necessary in 23 patients (72%), 5 of these infections (22%) were fatal. Overall response rate was 43% (12/28, 2 CR MRD-, 4 CR, 2 CRi, 3 PR, 1 MLFS). Two patients died of infection before first response evaluation and in another 2 response has not been evaluated yet. ORR for patients who received first line HMAClax was 80% (4/5) and 35% (8/23) for salvage treatment. Three of 5 patients with MR reached CR, 2 received HMAClax first line. Time to best response was 1.2ms (0.7-3.8). Six patients lost best response after 1ms (0.4-3.3.) 2 underwent second transplant in remission, 4 have ongoing responses (0.4, 0.7, 3.1 and 8.8ms at last follow up). On July 25th 2019, median follow up was 3.3 ms (0.9-17.3), 20 patients (63%) had died and 12 were alive. Six were continuing HMAClax. One patient developed cGvHD and 4 underwent second aHSCT (2 in remission). Estimated median overall survival was 3.7ms (CI 2.9-4.7). Four responders are continuing treatment with HMAClax. Patients, who responded had an estimated OS of 11.1ms (2 underwent second aHSCT in remission). Median survival of patients with HMAClax first line therapy was 5.8ms and of patients with HMAClax salvage therapy 3.7ms. Conclusion: For patients relapsing after aHSCT, venetoclax plus AZA or DAC seems to be an effective, but also highly hematotoxic therapy. Responses occurred fast and were more frequently seen during 1st line treatment for relapse. Duration of response was short, especially in patients receiving HMAClax as 2nd, 3rd or 4th line therapy. Therefore HMAClax should be explored as 1st line therapy for relapse after aHSCT in combination with DLI or as a bridge to 2nd transplant. Disclosures Schuler: Celgene: Other: travel grants; Novartis: Honoraria, Other: travel grants; Alexion: Other: travel grants. Bug:Gilead Sciences: Membership on an entity's Board of Directors or advisory committees, Other: Travel grants; Hexal: Membership on an entity's Board of Directors or advisory committees; Jazz Pharmaceuticals: Honoraria; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel grants; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees; Sanofi: Other: travel grants; Celgene Neovii: Other: travel grant. Crysandt:Incyte: Membership on an entity's Board of Directors or advisory committees; Amgem: Other: travel grant; celgene: Other: travel grant; Pfizer: Other: travel grant; Gilead: Other: travel grant. Jost:Jazz Pharmaceuticals: Honoraria; Sanofi: Honoraria; Gilead: Other: travel grants; Daiichi: Honoraria. Kaivers:Jazz Pharmaceuticals: Other: Travel Support. Mueller:Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; CTI Life Sciences: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees, Other: Financing of Scientific Research; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees; Astellas: Honoraria; Gentium: Honoraria; Gilead: Honoraria; Janssen: Honoraria; Jazz: Honoraria; Pharmaceuticals: Honoraria; Neovii: Honoraria; Novartis: Honoraria; Sanofi: Honoraria. Rautenberg:Jazz Pharmaceuticals: Other: Travel Support; Celgene: Honoraria, Other: Travel Support. Wolff:Takeda: Honoraria; Mallinckrodt: Honoraria; Novartis: Honoraria; Neovi: Honoraria. Schroeder:Celgene Corporation: Consultancy, Honoraria, Research Funding. Off Label Use: Venetoclax was used in combination with azacitidine or decitabine. The combination is not approved in the EU so far.. Kobbe:Pfizer: Honoraria, Other: Travel support; Abbvie: Honoraria, Other: Travel support; Biotest: Honoraria, Other: Travel support; Roche: Honoraria, Other: Travel support; Jazz: Honoraria, Other: Travel support; MSD: Honoraria, Other: Travel support; Celgene: Honoraria, Other: Travel support, Research Funding; Takeda: Honoraria, Other: Travel support; Amgen: Honoraria, Other: Travel support, Research Funding; Neovii: Honoraria, Other: Travel support; Medac: Honoraria, Other: Travel support; Novartis: Honoraria, Other: Travel support. OffLabel Disclosure: Venetoclax was used in combination with azacitidine or decitabine. The combination is not approved in the EU so far.

Background Adenovirus (ADV) infections can have a high mortality in immunocompromised patients and are difficult to treat. Objectives and study design We retrospectively analyzed occurrence and risk factors of ADV infection in 399 adults with hematological disorders undergoing hematopoietic stem cell transplantation (allo-HSCT), focusing on alternative donor transplantation (ADT) and disseminated disease. Results ADV infection occurred in 42 patients (10.5%). Disease was localized in 18 and disseminated in 6 patients. ADV infection was observed in 15% after ADT, performed in 29% of all recipients, and was less frequent (6%) in T-cell-replete (TCR) haploidentical transplantation using post-transplantation cyclophosphamide (PTCY) than in other ADT protocols. Lower age, the use of alternative donor grafts and acute graft-versus-host disease (GvHD) ≥ grade II were risk factors for ADV infection. After failure of standard antiviral treatment, three patients with disseminated ADV disease received one dose of ADV-specific T cells, resulting in virological response in 2/3 patients, clearance of ADV viremia in 2/2 patients, and survival of 1/3 patients; both patients with pneumonia died. Conclusions ADV infection was of moderate occurrence in our adult recipients of allo-HSCT despite a high proportion of potential high-risk patients receiving ADT. TCR strategies using PTCY might limit ADV complications in haploidentical transplantation. Despite feasible adoptive therapy strategies, outcome of disseminated disease remains dismal.

Post-transplant cyclophosphamide-based haplo-identical transplantation as alternative to matched sibling or unrelated donor transplantation for non-Hodgkin lymphoma: a registry study by the European society for blood and marrow transplantation

In acute myeloid leukemia (AML), primary refractory or relapsed disease, secondary AML, and leukemia with unfavorable genetics are considered high-risk AML (hrAML), with allogeneic stem cell transplantation (SCT) representing the standard treatment. Sequential conditioning has been successfully used for SCT in hrAML in HLA-matched transplants, and found its way into HLA-haploidentical SCT (haplo-SCT) later on. Hence, sequential conditioning had become standard for all patients with hrAML in our two centers, regardless of donor type. Thereby, HLA-matched family or unrelated transplants were first/second choice, post-transplant cyclophosphamide (PTCY)-based haplo-SCT was chosen in patients missing matched donors or requiring urgent transplantation. To compare the outcome after HLA-matched and haplo-SCT for hrAML following sequential conditioning, we performed a retrospective, matched-pair comparison, using disease stage, genetic subgroups and age as matching criteria. Thirty-four well-matched pairs were identified. At SCT, patients (median age 54 years) were untreated (9%), had remission (13%), or active disease (78%). Three-year overall and leukemia-free survival (OS/LFS) of the entire cohort was 56 ± 7%/49 ± 7%, without significant differences between donor types (OS after HLA-matched/haplo-SCT 62 ± 10%/52 ± 9% (p = 0.21), LFS 53 ± 10%/46 ± 9% (p = 0.26)). Similarly, the cumulative incidence of relapse, non-relapse-mortality and chronic GvHD, as well as GvHD-free, relapse-free survival (GRFS), and chronic GvHD-free, relapse-free survival (cGRFS), were comparable. However, a higher incidence of acute GvHD ≥ II° was observed after HLA-matched SCT (15 ± 1% versus 50 ± 2%, p = 0.001). In conclusion, sequential conditioning SCT achieved remarkable results in hrAML, independently from donor type. PTCY-based haplo-SCT produced results that were comparable to HLA-matched SCT and can be used as an alternative option.

This study evaluates the role of sequential therapy in HLA-haploidentical transplantation (haplo-HSCT) of high-risk, relapsed/refractory AML/MDS. We analyzed the course of 33 adults with active disease at time of transplantation (AML n = 30; MDS n = 3; median age 58 years, range: 32-71). Sequential therapy consisted of cytoreductive chemotherapy (FLAMSA n = 21; clofarabine n = 12) applied shortly prior to reduced intensity conditioning for T-cell-replete haplo-HSCT using post-transplantation cyclophosphamide as GvHD prophylaxis. No graft rejection was observed. Complete remission at day +30 was achieved in 97% of patients. CI of acute GvHD grade II-IV and chronic GvHD was 24% (no grade IV) and 23%, respectively. NRM at 1 and 3 years was 15%, each. Severe regimen-related toxicities (grade III-IV) were observed in 58%, predominantly involving the gastrointestinal tract (diarrhea 48%, mucositis 15%, transient elevation of transaminases 18%). Probability of relapse at 1 and 3 years was 28% and 35%. At a median follow-up of 36 months, the estimated 1- and 3-year overall survival was 56% and 48%. Disease-free survival was 49% and 40%, respectively. At 3 years, GvHD and relapse-free survival (GRFS) was 24% while chronic GvHD and relapse-free survival (CRFS) was 29%. Thus, our results indicate that sequential haplo-HSCT is an effective salvage treatment providing high anti-leukemic activity, favorable tolerance, and acceptable toxicity in patients suffering from advanced AML/MDS.

Sinusoidal obstruction syndrome, also known as veno-occlusive disease (SOS/VOD), is a potentially life-threatening complication that can develop after hematopoietic cell transplantation. Clinically, SOS/VOD is characterized by hepatomegaly, right upper quadrant pain, jaundice and ascites, most often occurring within the first 3 wk after hematopoietic cell transplantation. Early therapeutic intervention is pivotal for survival in SOS/VOD. Thus, a rapid and reliable diagnosis has to be made. Diagnosis of SOS/VOD is based on clinical criteria, such as the Seattle, Baltimore or recently issued European Society for Blood and Marrow Transplantation criteria, to which hemodynamic and/or ultrasound evidence of SOS were added for the first time. However, to rule out major differential diagnoses and to verify the diagnosis, a reliable imaging method is needed. Ultrasound techniques have been proposed in SOS/VOD. Nevertheless, the sensitivity and specificity of transabdominal ultrasound and Doppler techniques need to be improved. Innovative ultrasound methods such as a combination of Doppler ultrasound with shear wave elastography and contrast-enhanced ultrasound techniques should be evaluated for diagnosis and follow-up of SOS/VOD. The goals of this review are to discuss currently available ultrasound techniques and to identify areas for future studies in SOS/VOD.

We retrospectively compared the incidence of virus infections and outcome in the context of immune reconstitution in two different HLA-haploidentical transplantation (haplo-HSCT) settings. The first was a combined T-cell-replete and T-cell-deplete approach using antithymocyte globulin (ATG) prior to transplantation in patients with hematological diseases (cTCR/TCD group, 28 patients; median age 31 years). The second was a T-cell-replete (TCR) approach using high-dose posttransplantation cyclophosphamide (TCR/PTCY group, 27 patients; median age 43 years). The incidence of herpesvirus infection was markedly lower in the TCR/PTCY (22 %) than in the cTCR/TCD group (93 %). Recovery of CD4+ T cells on day +100 was faster in the TCR/PTCY group. CMV reactivation was 30 % in the TCR/PTCY compared to 57 % in the cTCR/TCD group, and control with antiviral treatment was superior after TCR/PTCY transplantation (100 vs 50 % cTCR/TCD). Twenty-five percent of the patients in the cTCR/TCD group but no patient in the TCR/PTCY group developed PTLD. While 1-year OS was not different (TCR/PTCY 59 % vs cTCR/TCD 39 %; p = 0.28), virus infection-related mortality (VIRM) was significantly lower after TCR/PTCY transplantation (1-year VIRM, 0 % TCR/PTCY vs 29 % cTCR/TCD; p = 0.009). On day +100, predictors of better OS were lymphocytes >300/μl, CD3+ T cells >200/μl, and CD4+ T cells >150/μl, whereas the application of steroids >1 mg/kg was correlated with worse outcome. Our results suggest that by presumably preserving antiviral immunity and allowing fast immune recovery of CD4+ T cells, the TCR approach using posttransplantation cyclophosphamide is well suited to handle the important issue of herpesvirus infection after haplo-HSCT.

Prognosis is poor for patients with biologically aggressive Non-Hodgkin lymphoma (NHL), refractory to chemotherapy or relapsed after autologous transplantation, especially when no disease control before allogeneic transplantation is achieved. In 16 patients (median age 53, median prior regimes 5) with relapsed or refractory non-remission NHL, we analysed retrospectively the efficacy of a sequential therapy comprising clofarabine re-induction followed by a reduced-intensity conditioning with fludarabine, CY and melphalan, and T-cell-replete HLA-haploidentical transplantation. High-dose CY was utilized post-transplantation. All patients engrafted. Early response (day +30) was achieved in 94%. Treatment-related grade III-IV toxicity occurred in 56%, most commonly transient elevation of transaminases (36%), while there was a low incidence of infections (19% CMV reactivation, 19% invasive fungal infection) and GVHD (GVHD: acute III-IV: 6%; mild chronic: 25%). One-year non-relapse mortality was 19%. After a median follow-up of 21 months, estimated 1- and 2-year PFS was 56 and 50%, respectively, with 11 patients (69%) still alive after 2 years. In summary, sequential therapy is feasible and effective and provides an acceptable toxicity profile in high-risk non-remission NHL. Presumably, cytotoxic reinduction with clofarabine provides enough remission time for the graft-versus lymphoma effect of HLA-haploidentical transplantation to kick in, even in lymphomas that are otherwise chemo-refractory.

BACKGROUNDAutologous peripheral blood stem cells (PBSCs) are usually cryopreserved before high-dose chemotherapy (HDCT) and autologous peripheral blood stem cell transplantation (PBSCT). The freezing process requires the addition of cryoprotectants such as dimethyl sulfoxide (DMSO), which is vital for cell viability in frozen aliquots. DMSO has a number of well-described side effects. However, severe neurologic side effects assigned to DMSO are exceedingly rare. CASE REPORTA 64-year-old female underwent HDCT followed by PBSCT as consolidation therapy in relapsed high-grade (Grade 3B) Stage IIIA follicular lymphoma. PBSCs were mobilized using granulocyte-colony stimulating factor and plerixafor after the second cycle of R-DHAP (rituximab, dexamethasone, high-dose Ara-C, cisplatin) salvage chemotherapy. A total of 7.18x10(6)/kg body weight CD34+ cells were cryopreserved using 10% DMSO. HDCT was administered some weeks later followed by reinfusion of two bags of PBSCs, each containing 98 mL with 1.6x10(6)/kg body weight CD34+ cells. Within a few minutes the patient developed a motor aphasia and became very agitated. Brain imaging did not reveal any pathologic finding. After being transferred to the intensive care unit the patient's condition steadily improved and the motor aphasia resolved completely within 6 hours after its onset. CONCLUSIONThis is, to our knowledge, the first report to describe an episode of severe motor aphasia during PBSCT. Given the close timely correlation with PBSCT, this episode appears to be caused by dimethyl sulfoxide (DMSO) and might possibly have been prevented by use of lower concentrations of DMSO.

Clofarabine is a novel purine nucleoside analogue with immunosuppressive and anti-leukemic activity in acute lymphoblastic and myeloid leukemia (AML, ALL). This retrospective study was performed to evaluate the feasibility and anti-leukemic activity of a sequential therapy using clofarabine for cytoreduction followed by conditioning for haploidentical hematopoietic stem cell transplantation (HSCT) in patients with non-remission acute leukemia. Patients received clofarabine (5 × 30 mg/m2 IV) followed by a T cell replete haploidentical transplantation for AML (n = 15) or ALL (n = 3). Conditioning consisted of fludarabine, cyclophosphamide plus either melphalan, total body irradiation or treosulfan/etoposide. High-dose cyclophosphamide was administered for post-grafting immunosuppression. Neutrophil engraftment was achieved in 83 % and complete remission in 78 % at day +30. The rate of acute graft versus host disease (GvHD) grade II–IV was 22 %, while chronic GvHD occured in five patients (28 %). Non-relapse mortality (NRM) after 1 year was 23 %. At a median follow-up of 19 months, estimated overall survival and relapse-free survival at 1 year from haploidentical HSCT were 56 and 39 %, respectively. Non-hematological regimen-related grade III–IV toxicity was observed in ten patients (56 %) and included most commonly transient elevation of liver enzymes (44 %), mucositis (40 %), and skin reactions including hand-foot syndrome (17 %), creatinine elevation (17 %), and nausea/vomiting (17 %). The concept of a sequential therapy using clofarabine for cytoreduction followed by haploidentical HSCT proved to be feasible and allows successful engraftment, while providing an acceptable toxicity profile and anti-leukemic efficacy in patients with advanced acute leukemia. NRM and rate of GvHD were comparable to results after HSCT from HLA-matched donors.

Aggressive mechanical ventilation can markedly and unpredictably affect cardiac function. The fall in cardiac output (CO) is due to a reduction in left ventricular stroke volume (SV). The aim of the present pilot study was to assess the effects of different positive end-expiratory pressure (PEEP) levels on circulatory function and to compare them with continuous wave (CW)-Doppler ultrasound cardiac output monitoring (USCOM) and a thermodilution-based haemodynamic monitoring system (PiCCO).Twenty mechanically ventilated (PEEPor = 10 mbar) adult patients (female n = 6, male n = 14, mean age 62 years, mean SAPS II-score 48.5), the majority with pneumonia and septic shock) were followed with USCOM and PiCCO at stepwise increased PEEP-levels from 0-10 mbar (1 mbar steps). The changes in CO/SV were recorded.With both methods, an increase of PEEP resulted in a decrease of SV and CO. Although the absolute decrease was consistently higher by USCOM, the changes of the parameters were qualitatively comparable. CO fell from 8.83 L/min (+/- 2.39) by 0.4 L/min to 8.49 L/min (+/- 2.48) with PiCCO and from 9.3 L/min (+/- 3.43) by 1.0 L/min to 8.3 L/min (+/- 3.2) with USCOM. The median CO/SV fell by 4.5%/5.2% with PiCCO and 10.8%/9% with USCOM, respectively. Correlation of CO values with the two methods by Bland-Altman yielded comparable results (mean percentage error at PEEP 0 mbar 13%, PEEP 10 mbar 18%). An adequate flow signal with USCOM was achieved in all patients.A significant influence of mechanical ventilation with PEEP on haemodynamic parameters was evident both with USCOM and PiCCO. While thermodilution methods like PiCCO are well established but time-consuming and invasive, CW-Doppler based USCOM constitutes an important tool for easy, rapid and reliable diagnosis and haemodynamic monitoring of critically ill patients.

Background: The admission of patients with malignancies to an intensive care unit (ICU) still remains a matter of substantial controversy. The identification of factors that potentially influence the patient outcome can help ICU professionals make appropriate decisions. Patients and Methods: 90 adult patients with hematological malignancy (leukemia 47.8%, high-grade lymphoma 50%) admitted to the ICU were analyzed retrospectively in this single-center study considering numerous variables with regard to their influence on ICU and day-100 mortality. Results: The median simplified acute physiology score (SAPS) II at ICU admission was 55 (ICU survivors 47 vs. 60.5 for non-survivors). The overall ICU mortality rate was 45.6%. With multivariate regression analysis, patients admitted with sepsis and acute respiratory failure had a significantly increased ICU mortality (sepsis odds ratio (OR) 9.12, 95% confidence interval (CI) 1.1-99.7, p = 0.04; respiratory failure OR 13.72, 95% CI 1.39-136.15, p = 0.025). Additional factors associated with an increased mortality were: high doses of catecholamines (ICU: OR 7.37, p = 0.005; day 100: hazard ratio (HR) 2.96, p < 0.0001), renal replacement therapy (day 100: HR 1.93, p = 0.026), and high SAPS II (ICU: HR 1.05, p = 0.038; day 100: HR 1.2, p = 0.027). Conclusion: The decision for or against ICU admission of patients with hematological diseases should become increasingly independent of the underlying malignant disease.

Autologous peripheral blood stem cells (PBSCs) are usually cryopreserved before high-dose chemotherapy (HDCT) and autologous peripheral blood stem cell transplantation (PBSCT). The freezing process requires the addition of cryoprotectants such as dimethyl sulfoxide (DMSO), which is vital for cell viability in frozen aliquots. DMSO has a number of well-described side effects. However, severe neurologic side effects assigned to DMSO are exceedingly rare.A 64-year-old female underwent HDCT followed by PBSCT as consolidation therapy in relapsed high-grade (Grade 3B) Stage IIIA follicular lymphoma. PBSCs were mobilized using granulocyte-colony stimulating factor and plerixafor after the second cycle of R-DHAP (rituximab, dexamethasone, high-dose Ara-C, cisplatin) salvage chemotherapy. A total of 7.18 × 10This is, to our knowledge, the first report to describe an episode of severe motor aphasia during PBSCT. Given the close timely correlation with PBSCT, this episode appears to be caused by dimethyl sulfoxide (DMSO) and might possibly have been prevented by use of lower concentrations of DMSO.

Wir beschreiben hier den Fall eines 32-jahrigen Mannes mit schwerer mikrozytarer Anamie und megaloblastaren Veranderungen des Knochenmarks. Durch Fasten hatte er zuletzt deutlich abgenommen. Bei mehreren Verwandten war eine β-Thalassamie bekannt. Beim Patienten selber war ein Eisenmangel und eine leichte Anamie vorbeschrieben. Die weitere Abklarung verifizierte die β-Thalassamie minor, weiterhin wurde ein Vitamin-B12-Mangel mit Nachweis von Anti-“intrinsic factor“-Antikorpern nachgewiesen, pathognomonisch fur die perniziose Anamie. Das Paradoxon erklart sich demnach durch eine perniziose Anamie mit megaloblastaren Veranderungen auf dem Boden mikrozytarer Veranderungen im Rahmen einer β-Thalassamie.

Haploidentical haematopoietic SCT (HSCT) using T-cell-replete grafts and post-transplant high-dose CY has found increasing acceptance. Our purpose was to evaluate the feasibility and outcome of this strategy as second HSCT incorporating donor change for acute leukaemia relapse after a first allogeneic transplantation. The courses of 20 consecutive adults (median age 37 years, 12 male) with AML (n=14), ALL (n=5) and acute bi-phenotypic leukaemia (n=1) were analysed retrospectively. Conditioning consisted of fludarabine, CY and either melphalan or TBI or tresosulfan+/-etoposide. Engraftment was achieved in 17 (85%), and a second remission was induced in 15 patients (75%) on day +30. The rate of grade II-IV acute GvHD was 35%, while chronic GvHD occurred in five patients. Most commonly observed grade III-IV toxicities were mucositis (30%), hyperbilirubinemia (20%), elevation of transaminases (20%) and creatinine (20%), while invasive fungal infection affected 30%. One-year non-relapse mortality (NRM) was 36%. At a median follow-up of 17 months, estimated 1-year OS was 45%, and 1-year relapse-free survival was 33%. This strategy was feasible and allowed for successful engraftment with a moderate rate of toxicity. Early outcome and NRM are at least comparable with results after a second HSCT from HLA-matched donors without donor change at HSCT2.

Regulatory T cells (Treg) are important regulators of immune responses. In acute myeloid leukemia (AML) patients before/after immunotherapy (stem cell transplantation or donor lymphocyte infusion), their suppressive role can contribute to suppress severe graft-versus-host reactions, but also to impair antileukemic reactions. As leukemia-derived dendritic cells (DCleu) are known to improve the antileukemic functionality of T cells, we evaluated the composition and development of distinct Treg subtypes in AML patients (n=12) compared with healthy probands (n=5) under unstimulated conditions and during stimulation with DCleu-containing DC (DC) or blast-containing mononuclear cells (MNC) in 0- to 7-day mixed lymphocyte cultures by flow cytometry. T-cell subgroups in AML patients were correlated with antileukemic functionality before and after DC or MNC stimulation by functional fluorolysis assays. (1) AML patients' T cells presented with significantly higher frequencies of Treg subgroups in unstimulated T cells compared with healthy probands. (2) After 7 days of DC or MNC stimulation, all Treg subtypes generally increased; significantly higher frequencies of Treg subtypes were still found in AML patients. (3) Antileukemic cytotoxicity was achieved in 36% of T cells after MNC compared with 64% after DC stimulation. Antileukemic activity after DC but not after MNC stimulation correlated with significantly lower frequencies of Treg subtypes (CD8Treg/Teff/em reg). Furthermore, cut-off values for Treg subpopulations could be defined, allowing a prediction of antileukemic response. We demonstrate a crucial role of special Treg subtypes in the mediation of antileukemic functionality. High CD8 Treg, Teff/em reg, and CD39 T cells correlated clearly with a reduced antileukemic activity of T cells. DC stimulation of T cells contributes to overcome impaired antileukemic T-cell reactivity. Refined analyses in the context of clinical responses to immunotherapies and graft versus host reactions are required.

Background: Anthracyclines are agents with a well known documented anti-tumoral activity. Cardiac side effects are the principal toxicity. Here we evaluate and monitor the onset of late anthracycline-induced cardiotoxicity with real-time CW-Doppler ultrasound cardiac output monitoring (USCOM®) and echocardiography in combination with serum biomarkers. Methods: Fifty-two patients without cardiac disease who had received an anthracycline-based regimen for various cancer types were included in this study. Patients' hemodynamic parameters as stroke volume (SV USCOM (mL)) and ejection fraction (EF ECHOCARDIOGRAPHY (%)) were measured with USCOM and echocardiography and correlated to serum biomarkers (NT-pro-BNP and cTnT). Results: Eighteen patients (34.6%) developed cardiac disease (NYHA I-III). An increasing cumulative anthracycline dose was associated with a decrease of the EF determined by echocardiography as well the SV by USCOM and with a higher NYHA class. Those patients who experienced cardiac disease showed a reduction of the EF and SV and increased serum biomarkers. Conclusions: Real-time CW-Doppler USCOM, is a fast and reliable method to monitor late hemodynamic changes as a symptom of anthracycline-induced cardiotoxicity comparable to the findings by echocardiography and serum biomarkers. doi: http://dx.doi.org/10.4021/wjon635w

Antileukemic T-cell responses induced by leukemia-derived dendritic cells (DC(leu)) are variable, due to varying DC/DC(leu) composition/quality. We studied DC/DC(leu) composition/quality after blast culture in four DC media by flow cytometry (FC) and combined fluorescence in situ hybridization/immunophenotyping analysis (FISH-IPA). Both methods showed that DC methods produce variable proportions of DC subtypes. FISH-IPA is an elaborate method to study clonal aberrations in blast/DC cells on slides, however without preselection of distinct cell populations for FISH analysis. FISH-IPA data proved previous FC data: not every clonal/blast cell is converted to DC(leu) (resulting in various proportions of DC(leu)) and not every detectable DC is of clonal/leukemic origin. Preselection of the best of four DC methods for "best" DC/DC(leu) generation is necessary. DC(leu) proportions correlate with the antileukemic functionality of DC/DC(leu)-stimulated T-cells, thereby proving the necessity of studying the quality of DC/DC(leu) after culture. FC is the superior method to quantify DC/DC(leu), since a blast phenotype is available in every given patient, even with low/no proportions of clonal aberrations, and can easily be used to study cellular compositions after DC culture.

Anthracyclines are agents with a wellknown cardiotoxicity. The study sought to evaluate the hemodynamic response to an anthracycline using realtime continuous-wave (CW)-Doppler ultrasound cardiac output monitoring (USCOM) and echocardiography in combination with serum biomarkers.50 patients (26 male, 24 female, median age 59 years) suffering from various types of cancer received an anthracycline-based regimen. Patients' responses were measured at different time points (T0 prior to infusion, T1 6 h post infusion, T2 after 1 day, T3 after 7 days, and T4 after 3 months) with CW-Doppler ultrasound (T0-T4) and echocardiography (T1, T4) for hemodynamic parameters such as stroke volume (SV; SVUSCOM ml) and ejection fraction (EF; EFechocardiography%) and with NT-pro-BNP and hs-Troponin T (T0-T4).During the 3-month observation period, the relative decrease in the EF determined by echocardiography was -2.1% (▵T0-T4, T0 71 ± 7.8%, T4 69.5 ± 7%, p = 0.04), whereas the decrease in SV observed using CW-Doppler was -6.5% (▵T0-T4, T0 54 ± 19.2 ml, T4 50.5 ± 20.6 ml, p = 0.14). The kinetics for serum biomarkers were inversely correlated.Combining real-time CW-Doppler USCOM and serum biomarkers is feasible for monitoring the immediate and chronic hemodynamic changes during an anthracycline-based regimen; the results obtained were comparable to those from echocardiography.

Purpose. Bone loss is a common phenomenon following allogeneic haematopoietic stem cell transplantation (allo-HSCT). The study aimed on tolerance and efficacy of zoledronic acid (ZA) in patients after allo-HSCT. Methods. 40 patients’ with osteoporosis or osteopenia were recruited on this phase II study. ZA was given at a dose of 4 mg IV every 3 months for 2 years (yrs). BMD was determined by dual-energy X-ray absorptiometry (LS lumbar spine, FH femur hip). Patients were evaluated for deoxypyridinoline (Dpd) and calcium excretion by longitudinal measurements. Results. 36 patients who had received at least 3 doses of ZA were evaluable. 26 patients had at least two BMD measurements since baseline (BMD group). Among these patients, BMD increased from 0.97±0.15 to 1.10±0.18 g/cm² (LS baseline—2 yrs, Δ+11.6±6.0%, P<0.001) and from 0.82±0.10 to 0.91±0.10 g/cm² (FH baseline—2 yrs, Δ+7.5±7.0%, P<0.001). Factors associated with an increase in BMD were younger age, female donor sex, and immunosuppression with CSA/MTX. Conclusion. ZA was generally well tolerated; it increases BMD and reduces Dpd excretion significantly in patients with bone loss after allo-HSCT.

Hematopoietic stem cell transplantation is a potent curative treatment option for patients suffering from high-risk AML and MDS. However, not in all of our patients a suitable HLA-matched donor could be identified in time. To evaluate the feasibility and outcome of T-cell-replete (TCR) HLA-haploidentical hematopoietic stem cell transplantation (haplo-HSCT) utilizing post-transplantation high-dose cyclophosphamide (PTCY) in the context of sequential therapy in patients with high-risk, relapsed/refractory and progressive AML and MDS, we retrospectively analyzed the course of 64 patients (AML n=61, MDS n=3; median age: 50 years; male n=30) transplanted between 2009 and 2015 at our center. Disease was advanced in 55 patients including 24 patients with relapse after a first allogeneic transplantation. 54 patients presented with active disease at time of haplo-HSCT. Donors (median age: 38 years; male n=30) were fully HLA-haplotype mismatched (5/10 HLA-loci) in 48 cases (77%). All patients received sequential therapy prior to haplo-HSCT combining cytoreductive chemotherapy (clofarabine n=34; FLAMSA n=25; FLAG-Ida n=2; others n=3) and reduced-intensity conditioning (RIC) which was started after three days of rest thereafter. Conditioning was drug-based in 42 patients receiving fludarabine, cyclophosphamide (CY) and melphalan (110 mg/m2) while it was TBI-based in the others (n=22) consisting of fludarabine and CY plus either 4 (n=20) or 2 Gy TBI (n=2). Post-grafting immunosuppression was high-dose CY given on day + 3 and +4, tacrolimus and mycophenolate mofetil (both started on day +5) in all patients. Unstimulated bone marrow was the graft source in 37 patients. One graft rejection was observed after conditioning with 2 Gy TBI. Neutrophil/platelet engraftment was achieved in 49/58 evaluable patients at a median of 16 (range: 14-27) and 20 (range: 13-74) days, respectively. Acute GvHD grade II-IV occurred in 19 patients (30 %) while it was severe (grade III-IV) in only 3 (5 %). Chronic GvHD was most frequently mild (n=9) to moderate (n=8); one severe chronic GvHD occurred. Severe (grade III-IV) mucositis, hemorrhagic cystitis and hand-foot syndrome/rash were observed in 10, 5 and 2 patients, respectively; no patient developed VOD. Kidney failure requiring hemodialysis occurred in 7 patients. CMV reactivation was observed in 28 of 47 patients at risk (59 %) and EBV in 3, while only one patient developed CMV disease (pneumonia) and no patient developed PTLD. Probable or proven (n=2) invasive aspergillosis was diagnosed in 10 patients. One-year non-relapse mortality was 27.5 % (95% CI 17-41). After a median follow up of 21 months (range: 3-64), estimated one-year overall survival (OS) was 55 % (95 % CI 41-66), and one-year disease-free survival (DFS) was 43 % (95 % CI 26-51). At two-years after sequential haplo-HSCT OS and DFS were both 39 % (95 % CI 26-51). In summary, sequential therapy in the setting of RIC-TCR haplo-HSCT using PTCY is well tolerated with low rates of GvHD and acceptable NRM in patients with high-risk AML and MDS, while providing an effective anti-leukemic activity in advanced disease. Results are comparable to data of a historical cohort of patients with high-risk AML and MDS undergoing sequential therapy using the FLAMSA-RIC protocol in a HLA-matched setting, as reported by our group previously. Thus, we suggest that donor availability can be expanded in patients with high-risk and advanced AML/MDS who lack a conventional donor or need promptly access to a donor due to aggressive disease. Disclosures Hausmann: Sanofi-Aventis: Other: advisory board. Tischer:Sanofi-Aventis: Other: advisory board. Off Label Use: clofarabine in adults; efficacy is shown in myeloid blasts;.

Summary Background: Cisplatin-based combination chemotherapy is regarded as standard of care for patients with advanced germ cell tumors. In patients with lung metastases and a high tumor load, an association between induction chemotherapy and the development of a ‘tumorassociated’ acute respiratory distress syndrome (ARDS) has been hypothesized. Case Report: We report the clinical course of a 19-year-old patient who rapidly developed fatal ARDS during the first cycle of chemotherapy using the PEI regimen (cisplatin, etoposide and ifosfamide) for a metastasized (lung, liver, lymph nodes) germ cell tumor of the testis. Conclusion: Further clinical research in order to better define risk factors for developing ARDS in this patient population as well as novel strategies for the prevention and treatment of ARDS in those patients are necessary.

Gemcitabine in combination with the oral epidermal growth factor receptor tyrosine kinase inhibitor erlotinib is a new treatment option for patients with advanced pancreatic cancer. The nonhematological side effects of this regimen mainly include diarrhea and skin rash. For each of these drugs, gemcitabine and erlotinib, lung toxicities have been described previously. In this report, we present the first case of a nonlung cancer patient experiencing not only acne-like skin toxicity, but subsequently also severe interstitial lung disease during therapy with gemcitabine and erlotinib. Both therapeutic agents were suspected as a possible cause of this adverse event. An interaction between gemcitabine and erlotinib might have also contributed to the pathogenesis of this pulmonary toxicity. Treatment with high-dose steroids was, however, very effective in our patient and a complete recovery appeared within a few days. Thus, pulmonary side effects should be regarded carefully in pancreatic cancer patients receiving palliative therapy with gemcitabine and erlotinib.

Background: Allogeneic stem cell transplantation (SCT) can provide long-term disease control in selected patients with relapsed refractory NHL. Restricted availability of a matched sibling donor limits its use especially for patients with rapidly progressing disease in whom unrelated donor search cannot be awaited and in patients from ethnic minorities. Donor sources such as haplo-identical relatives or cord blood represent reasonable alternatives but data of alternative donor transplants in lymphoma is sparse. We therefore intended to compare outcome after transplants performed with sibling or fully matched unrelated donors with alternative sources such as cord blood and haplo-identical donors. Methods: Information of patients with mantle cell lymphoma (MCL), DLBCL, T-cell lymphoma (TCL) and follicular lymphoma (FL) who received an SCT from a sibling donor (SIB), 10/10 matched unrelated donor (MUD), haplo-identical donor (HAPLO) or cord blood (CORD) between 2007 and 2012 was downloaded from the EBMT database. Comparisons of outcome after transplants from different donors were performed with regard to overall survival (OS), non relapse mortality (NRM), relapse (REL) and acute GVHD incidence. For comparisons between donors SIB has been chosen as the reference group. Results: 2798 patients with NHL were identified in the EBMT database meeting the inclusion criteria. 2065 received a transplant from a SIB, 447 from a MUD, 167 from CORD (18 MCL, 36 DLBCL, 43 FL, 70 TCL) and 119 from a HAPLO donor (16 MCL, 30 DLBCL, 22 FL, 51 TCL). 66% were male and 34% female patients. Median age at transplant was 49 years (range: 18-72). 24% (n=684) had DLBCL, 27% (n=755) FL, 17% (n=464) MCL and 32% (n=895) TCL. 56% received their transplant in CR, 17% in PR and 27% had active disease at SCT. Active disease was more common in the HAPLO group (p Median follow-up after SCT was 27 month (CI 25 to 29). OS of patients who received an alloSCT from a SIB or MUD was not significantly different, whereas OS of HAPLO and CORD transplants was significantly worse than SIB transplants (HR 1.9 CI 1.5 -2.5, HR 1.8 CI 1.4 -2.2, p < 0.0001, Figure 1). Worse OS after alternative donor transplant (reference SIB) was observed across all studied disease entities. Relapse incidence after conventional transplants (SIB, MUD) and alternative donor transplants (HAPLO, CORD) was not significantly different within the whole group (HAPLO: HR 1.2 95% CI 0.9-1.8 p= 0.23; CORD: HR 1.1 95% CI 0.7-1.4, p=0.74; Figure 1) and across all studied disease entities. In contrast, whereas NRM incidence was not significantly different between SIB and MUD, it was, but significantly higher with alternative donor transplants (HAPLO: HR 1.8 95% CI 1.3-1.8, p80%) and conditioning intensity (RIC vs. MAC) confirmed worse OS for HAPLO (HR 1.5 CI 1.2-2.0, p=0.003) and CORD (HR 1.6 CI 1.3-2.0, p Conclusions: Alternative donor transplants are a valuable option if no suitable SIB or MUD donor is available. With the limited number of patients studied here, relapse incidence after alternative donor transplants was not significantly different from conventional transplants. Higher NRM incidence in alternative donor transplants might be improved with increasing refinement of the procedure, such as post-transplant cyclophosphamide approaches. Figure 1) Outcome (OS, Rel, NRM) after alloSCT with different donors Figure 1). Outcome (OS, Rel, NRM) after alloSCT with different donors Disclosures No relevant conflicts of interest to declare.

By reducing treatment intensity allogeneic hematopoietic stem cell transplantation (allo-HSCT) has become feasible for elderly patients. Different reduced-intensity conditioning (RIC) regimens are available, but there is little consensus about the optimal preparative regimen to use, in particular with regard to the outcomes counterbalancing the aim of feasibility and tolerability with higher rates of relapse. Here, we retrospectively evaluate the outcome of sequential therapy employing RIC with fludarabine 30 mg/m2, cytarabine 2g/m2 and amsacrine 100 mg/m2 for 4 days (FLAMSA; Schmid C et al. JCO 2005) followed by busulfan 10 x 0.8 mg/kg (FLAMSA-Bu) compared to RIC utilizing fludarabine 5 x 30 mg/m2, carmustine (BCNU) 2 x 150 mg/m2 and melphalan 110 mg/m2 (FBM; Marks R et al. Blood 2008) in elderly patients treated consecutively at our institution between July 2005 and October 2012. We analyzed the course of 114 patients (pts) with acute myeloid leukemia (AML; n=99) or myelodysplasia (MDS; n=15) aged ≥ 59 years with 59 pts aged ≥ 66 years who were treated with either FLAMSA-Bu (n=66; n=24 ≥ 66 years) or FBM (n=48; n=35 ≥ 66 years). All patients received sero-therapy with anti-thymocyteglobuline (ATG). Median patient age was 66 years for the entire cohort (68 years FBM; 64 years FLAMSA-Bu). 36 patients (75%) of the FBM and 42 patients (63 %) of the FLAMSA-Bu group suffered from high risk disease defined as relapsed or refractory AML or refractory anemia with excess of blasts in transformation (RAEB-T). The hematopoietic cell transplantation comorbidity index (HCT-CI) was higher for the patients of the FBM group than for the FLAMSA-Bu group with 26 (54 %) versus (vs) 24 patients (36 %) scoring ≥ 2 (p 0.085). Graft source after conditioning with FBM/FLAMSA-Bu was bone marrow (1/2), G-CSF mobilized peripheral blood stem cells (40/62) and double-umbilical cord-blood (7/1). In 23 pts (20 %) HLA-matched related and in 91 pts (80 %) HLA-matched unrelated donor transplantation was performed. Engraftment failure was observed in 1 patient after FLAMSA-Bu, while engraftment was achieved in all evaluable patients of the FBM group in a median of 23 days vs 18 days after FLAMSA-Bu (p 0.003), while 7 pts with double-umbilical cord-blood transplantation where included in the FBM group vs 1 pt in the FLAMSA-Bu group. Non-hematological treatment-related acute toxicity ≥ CTC III (gastrointestinal, hepatic, cardiovascular, renal, centralnervous system) occurred in 12/48 pts (25 %) after FBM and in 18/66 pts (27 %) after FLAMSA-Bu. Incidence of severe acute (III-IV) and chronic GvHD was 22.9 %/16.6 % for FBM vs 18.2 %/19.7 % for FLAMSA-Bu, respectively. After conditioning with FBM 2/48 pts vs 9/66 pts after FLAMSA-Bu were diagnosed with a secondary malignancy (p 0.08). Non-relapse mortality (NRM) after 12 months was 26.8 % for FBM versus 25.2 % for the FLAMSA-Bu group. Incidence of relapse after FBM vs FLAMSA-Bu conditioning was 22.9 % vs 15.2 % after 1 year and 31.3 % vs 16.7 % after 2 years. Occurrence of relapse was significantly related to an incomplete or mixed chimerism (donor cells ≤ 95 % in peripheral blood and/or bone marrow) at day +30 (p 0.001). After a median follow up of 31.4 months (range 4.4-97.5) estimated overall survival (OS) and relapse-free survival (RFS) after 2 years was 55.4 % and 51.4 % for the FBM vs 58 % and 56.7 % for the FLAMSA-Bu group, respectively. Analyzing different subgroups, FBM conditioning might be favorable for pts aged ≥ 66 years when suffering from high risk AML (n=26): Within this group 1-year OS after FBM vs FLAMSA-Bu was 71.4 % vs 66.7 % (p 0.58) and 1-year RFS was 71.4 % vs 58.3 % (p 0.59), respectively. Notably, for pts at highest risk (aged ≥ 66 years and suffering from secondary or therapy-related AML; n=24) the benefit of FBM conditioning becomes more pronounced: 1-year OS after FBM vs FLAMSA-Bu was 62.5 % vs 37.5 % (p 0.26) and 1-year RFS 54.2 % vs 37.5 % (p 0.17). Both conditioning regimens are feasible, and provide similar rates of acute toxicity, NRM and GvHD. There might be evidence for a benefit of conditioning with FBM for the subgroup of “the oldest patients at highest risk”. Taking into account that there is an increasing group of ‘medically fit’ elderly patients in the field of allogeneic transplantation, prospective clinical trials are needed to investigate different conditioning regimens considering their special requirements. Disclosures No relevant conflicts of interest to declare.

Background: Relapse of acute leukemia (AL) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is frequently treated with 2nd allo-HSCT. Donor change has not yielded a significantly different outcome over choosing the original HLA-identical donor (Christopeit et al., JCO 2013). Using a haploidentical donor at second allo-HSCT might represent a feasible option (Tischer et al., BMT 2014) Study design and population: To define the role for second haploidentical allo-HSCT for AL relapsing after 1st allo-HSCT, a retrospective analysis was conducted 63 consecutive patients (female n=30, male n=33; AML n=51, ALL n=12) from 9 German centers were included. Median age was 40 years (range, 16-65). Grafts at 1st allo-HSCT were from matched related (32%), matched unrelated (33%), mismatch unrelated (18%), haploidentical donors (6%), and other donors, including cord blood (8%). Median duration of complete remission (CR) after 1st allo-HSCT was 414 days (range, 18-1633). Relapse was initially treated by cytoreductive chemotherapy in all cases; stage at start of conditioning for haploidentical second allo-HSCT was CR in 27%, active disease in 66% and not evaluated in 8%. Conditioning for second HSCT was myeloablative/reduced in 14%/86% To overcome the HLA barrier, 23 patients (36%) received ex vivo T-cell depletion (TCD), following either CD3/CD19 negative or CD34 positive selection. 4 patients received in vivo TCD only, two received no TCD at all, and 35 patients (55%) received high-dose cyclophosphamide post-transplant according to the Baltimore protocol. Results: Neutrophil engraftment was achieved after a median of 12 days (range, 8-26). 50 patients (78%) achieved CR after 2nd haploidentical allo-HSCT, out of which 23 (46%) relapsed again. After a median follow-up of 425 days, 47 patents had died, 22 from leukemia, and 25 from treatment-related causes. Kaplan-Meier estimated overall survival at one and two years from haploidentical second HSCT was 41+/-6% and 19+/-6%. Conclusions: Haploidentical second allo-HSCT is a promising approach to the treatment of AL relapse after first allogeneic transplant. OS rates at least comparable to alternative treatments were observed. Different strategies to overcome the HLA barrier seem feasible. This retrospective study was registered as NCT01997918 at clinicaltrials.gov. Maximilian Christopeit and Johanna Tischer as well as Wolfgang Bethge and Christoph Schmid contributed equally to this work. Disclosures No relevant conflicts of interest to declare.

Allogeneic hematopoietic stem cell transplantation (HSCT) is a valuable treatment option for patients with relapsed or refractory lymphoma including patients with relapse after a first autologous HSCT. However, outcome in non-remission patients is still poor. Here we report the feasibility and efficacy of a protocol using the concept of sequential therapy with clofarabine induction chemotherapy followed by a HLA-haploidentical HSCT in the treatment of patients with advanced non-remission lymphoma. 16 adults (11 male, median age: 53 years, median comorbidity index: 3) with MCL (n=7), CLL (n=1), AITL (n=2), secondary DLBCL (n=2), DLBCL (n=2), follicular lymphoma (n=1), B- lymphoblastic lymphoma (n=1) were treated between September 2010 and February 2013. After induction-chemotherapy with clofarabine (5x30 mg/m² IV), followed by 3 days of rest, a reduced intensity conditioning (RIC) consisting of fludarabine/cyclophosphamide plus melphalan 110 mg/m2 IV was performed prior to a T-cell replete HLA-haploidentical HSCT. High dose cyclophosphamide (Cy) was administered for post-grafting immuno-suppression followed by mycophenolate mofetil and tacrolimus. The median number of immuno-chemotherapy attempts prior to haploidentical HSCT was 4 including 8 autologous HSCT. None of the patients were in complete remission (CR) prior to haploidentical HSCT. After salvage therapy and prior to haploidentical HSCT, progressive disease (PD) was documented in 9 patients with one patient being primarily refractory, while in 7 patients a partial remission (PR) was observed. Neutrophil engraftment was achieved in 16 patients (100%) within a median of 21 days (range 14-36) and platelet engraftment in 14 patients (88%) within a median of 30 days (range 18-115). No primary graft rejection occured. By day +30 CR was achieved in 4 patients (25%) and PR in 11 patients (69%), whereas 1 patient (6%) showed PD. Full donor chimerism on day +30 was detected in all 16 patients. By day +100, 8 of the 14 evaluated 14 patients (57%) achieved CR, 4 (29%) PR, and only 2 (14%) had relapsed. Full donor chimerism was detected in 13 (93%) patients. The rate of acute GvHD grade II-IV was 31%, while chronic GvHD occurred in 3 of 14 (21%) evaluable patients (21%). Non hematologic regimen-related grade III-IV toxicity was observed in 9 patients (56%), and included most commonly transient elevation of liver enzymes (38%), mucositis (19%), and nausea and vomiting (19%). Creatinine elevation (6%), hand-foot syndrome (6%) and haemorrhagic cystitis (6%) were rare. After a median follow up of 14.5 months (range 5.7-35) 4 patients had relapsed, and 4 patients had died, while death was lymphoma-associated only in one patient. Causes of non-relapse mortality (NRM) were haemorrhagic cerebral bleeding in one patient (day +101), and toxicity/infection in 2 patients (day +141; day +156). Cumulative incidence of NRM was 0% on day +100 and increased up to 20% (7-50) on day +360. Estimated one-year overall survival and progression-free survival were 75% (95 CI 46-90) and 56% (95 CI 30-76), respectively. Sequential therapy combining cloforabine induction-chemotherapy and HLA-haploidentical HSCT using RIC, a T-cell replete graft and high dose Cy post-transplant is feasible, shows a favourable toxicity profile and furthermore achieves significant anti-lymphoid activity in patients with advanced non-remission lymphoma. These early results are promising, but longer follow up is needed. Disclosures: Off Label Use: Clofarabine off label use in adults. Hausmann:Sanofi: Travel support Other. Tischer:Sanofi: Travel support Other.

The development of type 1 diabetes in animal models is T cell and macrophage dependent. Islet inflammation begins as peripheral benign Th2 type insulitis and progresses to destructive Th1 type insulitis, which is driven by the innate immune system via secretion of IL-12 and IL-18. We now report that daily application of IL-18 to diabetes-prone female nonobese diabetic mice, starting at 10 wk of age, suppresses diabetes development (p < 0.001, 65% in sham-treated animals vs 33% in IL-18-treated animals by 140 days of age). In IL-18-treated animals, we detected significantly lower intraislet infiltration (p < 0.05) and concomitantly an impaired progression from Th2 insulitis to Th1-dependent insulitis, as evidenced from IFN-γ and IL-10 mRNA levels in tissue. The deficient progression was probably due to lesser mRNA expression of the Th1 driving cytokines IL-12 and IL-18 by the innate immune system (p < 0.05). Furthermore, the mRNA expression of inducible NO synthase, a marker of destructive insulitis, was also not up-regulated in the IL-18-treated group. IL-18 did not exert its effect at the levels of islet cells. Cultivation of islets with IL-18 affected NO production or mitochondrial activity and did not protect from the toxicity mediated by IL-1β, TNF-α, and IFN-γ. In conclusion, we show for the first time that administration of IL-18, a mediator of the innate immune system, suppresses autoimmune diabetes in nonobese diabetic mice by targeting the Th1/Th2 balance of inflammatory immune reactivity in the pancreas.

Abstract 3071 Background: Prognosis of relapse after first allogeneic hematopoietic stem cell transplantation (allo-HSCT) is poor, and no standard treatment is available. Second HSCT (HSCT2) is a valuable treatment option for selected patients. Change of donor for HSCT2 is a frequently used strategy to enhance the graft-versus leukemia-activity, although its role for improving the outcome is still unclear. However, identification and activation of a new donor for HSCT2 is time consuming and might delay or even prevent a second transplant. In contrast, haploidentical family donors are rapidly available in the vast majority of patients and might therefore be an alternative for HSCT2, once change to a new donor is planned. Based upon these considerations, HSCT2 from haploidentical family donors was used as preferred treatment for acute leukemia relapse after allo-HSCT in our transplant center since August 2009. According to the concept of sequential therapy (as introduced by the FLAMSA-RIC regimen), patients initially received cytoreductive chemotherapy, followed, after three days of rest, by reduced intensity conditioning (RIC). Based on the Baltimore protocol for haploidentical HSCT using RIC and post-transplant cyclophosphamide for depletion of allo-reactive T-cells, individual and disease-specific modification of this regimen were used for preparation before HSCT2. Patients and Methods: Fourteen adult patients (7 male, median age: 37 years) suffering from AML (n=11) or ALL (n=3) with an ECOG score of Results: Neutrophil and platelet engraftment was achieved in 12 (85,7%) and 10 (71,4%) patients, respectively. Median time to neutrophil engraftment was 32 days (range 24–90). No primary graft rejection was observed. Complete remission could be induced by day +30 in 11 patients (78,6%), whereas 1 patient died early and 2 patients had refractory disease. Full donor chimerism by day +30 was achieved in 10 patients (71,4%). After a median follow-up of 6 months (range 4 days–33 months) cumulative incidence of non-relapse mortality at day + 30, + 100 and +360 was 7%, 24% and 24 %, respectively. Rate of grade II-IV acute GvHD was 24,7%. Mild or moderate chronic GvHD was seen in 2 patients (14,3%). 8 patients died from relapse (n=4), infection (n=3) or infection and toxicity (n=1). Estimated overall survival and progression-free survival at one year from HSCT2 was 53 % (+/− 14 %) and 36 % (+/− 17 %), respectively. Infection was frequent detected in 13 (92,9%) patients with at least one episode of neutropenic fever in 8 patients, probably or proven invasive aspergillosis in 5 patients and a moderate rate of virus-reactivation/-infection (CMV 21,4%, HSV 14,2%, EBV 28,6%, HHV-6 28,6%, Polyomavirus 28,6%, Adenovirus 21,4%,). No patient developed a post-transplant lympho-proliferative disorder. Regimen related grade III-IV toxicity was observed in 9 (64,3%) patients with transient elevation of liver enzymes in 7 (50%), mucositis in 5 (35,7%), headache in 5 (35,7%), hand-foot syndrome in 3 (21,4%), hyper-bilirubinemia in 3 (21,4%) and severe deterioration of kidney function in 2 (14,3%) patients, respectively, as the most common observed toxicities. Conclusion: Haploidentical HSCT2 following initial cytoreduction with clofarabine, RIC and high-dose cyclophosphamide post-transplant is feasible in patients with acute leukemia relapsing after first allo-HSCT. Early results are promising, but long-term results are still pending. Disclosures: Off Label Use: Clofarabine is a novel purine nucleoside with immunosuppressive and anti-leukemic activity in hematologic malignancies, off-label use in adults.

Background: Critically ill and septic patients often require emergency orotracheal intubation. Etomidate is associated with a reversible adrenal insufficiency which potentially increases the in-hospital

Abstract 4540 Microangiopathy (MA) and graft-versus-host disease (GvHD) are serious complication after allogeneic hematopoietic cell transplantation (HCT). MA is comparable to a slight form of thrombotic thrombocytopenic purpura (TTP), characterized as de novo thrombocytopenia, hemolysis, evidence of fragmentocytes in the blood, hypertension, cerebral confusion and uremic syndrome. Conglomerates of platelets and uncleaved multimere of vWillebrand-Factor (vWf)) are the pathophysiological correlate and result in multiple occlusions of microvessels. Up to now the exact pathomechanism for chronic GvHD (cGvHD) is unknown but oftenly associated with decreasing platelets counts. In patients (pts) with cGvHD we previously described an increased number of vWf +and CD34+ microvessels and of CD8+ T-cells in the bone marrow (Hill,W Blood 112 abstract No 1166, 2008). The aim of this study is to screen bone marrow biopsies of pts after HCT for histological changes of vascular quality regarding to MA and correlate these findings with the development of cGvHD. Bone marrow biopsies of 36 pts (25 male, 11 female, 45 years median, range 18–64) after HCT (day 105 to 4623) were screened for overall number of vWf+ vessels, the number of sinus with a thick wall of vWf + deposit with a size > 15 × 8μ (plaquesinus) and the number of vWf+ deposit without evidence of sinus (plaques) as well as the number of megakaryocytes between Oct 2001 and Jul 2006. Morphological findings were correlated with GvHD or non-GvHD and with MA by the well known grading (aMA) at the time of acute GvHD (aGvHD) and with as a modificated grading (cMA) at the time of simultaneous cGvHD. Results: 26 of 36 pts had cGvHD (6 with limited and 20 with extensive disease). 22 had aGvHD before and 4 did not. 8 of the 36 pts had neither aGvHD nor cGvHD, 2 pts suffered from aGvHD. Regarding to aMA a moderate grade was found in 14 pts, a mild form was detected in 15 pts, and 7 pts did not have any signs of aMA. The levels of maximal elevation of lactatdehydrogenase (LDH) and maximal decrease of platelets (each p value < 0,02) were as followed: absent grade LDH mean 248 U/L and platelets decrease mean 36 %; mild grade LDH 299 U/L and platelets 52 % and moderate grade LDH 505 U/L and platelets 70%. Additional parameters (each p Conclusion: Low grade MA was more often observed than expected from the literature. MA can be demonstrated morphologically by vWf+ deposits in endothelial-cells in bone marrow and can be graded also at the time of cGvHD. The high frequency of moderate grade at the time after engraftment with or without aGvHD is remarkable for development of a cGvHD with prognostic, pathogenetic and therapeutic relevance. From clinical, laboratory and morphological point of view microangiopathy seems to be part of aGvH reaction, followed by deposits of vWf+ material in the bone marrow, consumption of platelets by fixation to uncleaved multimere of vWf with the consequence of thrombocytopenia. Disclosures: Hill: Novartis: Research Funding.

Hematopoiesis of the host is a primary target organ of the graft-versus-host reaction. However histological analyses of the bone marrow are rarely reported. Here we report histological changes in the bone marrow of patients (pts) with and without chronic graft-versus-host disease (cGvHD). Bone marrow biopsies were obtained between 101 days and 4623 days (median:419 days) after transplantation as part of a controlled prospective phase ll study of patients with osteopenia/osteoporosis after allogeneic hematopoietic stem cell transplantation (HCT). Previously we reported an increased density of microvessels using an antibody against v. Willebrand factor (vW) (Hill W. et al Blood110, abstract No 1963; 2007). Here we report additional immunohistological and immunocytological findings in marrow and blood. We analyzed the number of CD34+ and vW+ microvessels as well as CD8+ suppressor/cytotoxic T-cells/mm² (T-S) in sequential biopsies of pts with (n=9) or without (n=6) cGvHD after median 2 years apart. Biopsies of 3 pts without HCT and without lymphoma involvement served as controls. Simultaneously lymphocyte subpopulations were evaluated in peripheral blood samples of pts with (n=16) or without (n=8) cGvHD. The pts were divided in 5 groups: neither aGvHD nor cGvHD; no cGvHD but acute GvHD before entry; cGvHD limited; cGvHD extensive without immunosuppression; cGvHD extensive with immunosuppression. Results: In the first biopsies the content of CD34+, vW+ microvessels and T-S cells were significantly higher in pts with cGvHD (group 3–5) than in those without cGvHD (group 1–2) (21,3 vs 8,2 p=0,03; 22,0 vs 9,2 p=0,002 respectively 106,2 vs 32,1 p=0,04). In the second biopsies these parameters were also increased in cGvHD: CD34+ (18,3 vs 11,2 p=0,02), vW+ (17,3 vs 9,0 p=0,08) microvessels and T-S cells (63,2 vs 37,8 p=0,27). The increased density of CD34+ and vW+ microvessels correlated with the number of T-S cells (p=0,05). As compared to normal controls we observed a significantly higher content of vW+ microvessels in all groups of transplanted pts (16,9 vs 4,2 p=0,03). In pts with cGvHD (group 3–5) CD34+ and vW+ microvessels were further increased (p=0,02 respectively p=0,002). At the time of the first biopsy the absolute T-S cell content in peripheral blood was moderately increased in group 5 (1124/ul) and minimally increased in group 2 (993/ul) (normal 270 – 880), whereas the overall T cell (CD3) content was normal in all groups. The percentage of activated T-S (HLA-DR+) cells was increased in all groups of transplanted pts (61,8% vs normal =33%; p=0,05). After two years T-S cells content was reduced in pts under immunosuppressive therapy (group 5) (1415 vs 900/ul; p=0.000) but remained increased over the norm. In group 4 T-S cell content was increased over the norm (800 vs 920/ul; p=0,043). In conclusion, sequential immunohistology and immunocytology analyses on bone marrow biopsies and peripheral blood provide evidence for the existence of a chronic graft-versus-host reaction of the bone marrow in pts with cGvHD. This is characterized by an increased content of CD34+ and vW+ microvessels and an increased content of T-S cells at least initially. However this reaction does not lead to a generalized hematopoietic insufficiency.

Allogeneic stem cell transplantation produces a strong graft-versus-leukemia effect which may be enhanced by HLA-mismatches and immune recognition as a result of pregnancy. Therefore we compared the results of HLA-haploidentical transplantation (N=113) to those of HLA-identical sibling (N=195) transplantation performed in the same time. Cases were matched by disease category (acute myeloid leukemia-myelodysplastic syndromes, AML/MDS, acute lymphoid leukemia ALL and lymphoma-chronic lymphocytic leukemia NHL/CLL) and stage of the disease (early, intermediate and advanced). HLA-haploidentical transplants were performed with unmodified bone marrow followed by CD6-depleted mobilized blood stem cells on day 6.; patients with leukemia were in more advanced disease in leukemia, they were younger and more often male. In multivariate analysis survival was influenced by HLA-mismatch, stage of the disease and age of the patient, but conditioning treatment and CMV-seropositivity had no significant effect. Transplant related mortality was influenced by the age of the patient and HLA-match, to a lesser extent by the disease category and the stage, whereas CMV-seropositivity and conditioning had no influence. Remission duration was dependent on the stage of the disease, the donor recipient gender combination and the conditioning treatment in univariate analysis; in multivariate analysis only CMV-seropositivity had a poor prognostic impact. In comparable disease stages the relapse rate was not different in HLA-haploidentical from HLA-identical transplantation as was the rate of acute GVHD. In contrast the rate of chronic GVHD was lower in HLA-haploidentical transplantation. In ALL, relapse rate and remission duration was inferior with non-myeloablative conditioning as compared to myeloablative total body irradiation. In HLA-haploidentical transplantation the response rate of leukemia was better in patients homozygous for the cross reactive HLA-C group given a transplant from a heterozygous donor suggestive of NK activity. This GVL activity was not associated with GVH activity. Similarly maternal donors were superior to paternal donors and female donors in male recipients better than other gender combinations for the control of leukemia without increased GVHD. Non-inherited maternal antigen (NIMA) and inherited paternal antigen (IPA) in the graft-vs-host direction had a weak influence on the relapse rate, but no influence on GVHD. On an observational basis several sons and daughters transplanted with stem cells from the mother had a strong GVL effect without any signs of GVHD. However two have been lost due to untreatable pulmonary complications. Donors with cytotoxic antibodies have been excluded from donation, but cellular reactivity will have to be assessed in more detail. Recent progress in controlling EBV-associated disease by selection of donor T cells without expansion will improve HLA-haploidentical transplantation and show the way to selecting donor with the appropriate immune repertoire including reactivity to leukemia.

Chronic GvHD (cGvHD) is associated with endothelial injury mediated by cytotoxic T lymphocytes and loss of microvessels in skin biopsies as well as increase of von Willebrand factor in plasma (BC Biedermann, Lancet 2002). Moreover an increased quantity of CD45RO positive lymphocytes has been observed in bone marrow biopsies (bmb) in CML pts with acute GvHD (aGvHD) grade III and lV, who were transplanted from unrelated donors (J Thiele, Bone marrow transplantation 2001). We analysed factors of T-cell activation and microvessels in bmb of pts with cGvHD to evaluate the function of the bone marrow in cGvHD. Methods: In an associated protocol of a prospective phase II study in 35 pts for the therapy of bone loss following HSCT with a bisphosphonate one bmb was taken prior of entry into the study and embedded in paraffin after decalcification. The interval between HSCT and time of biopsy was median 477 +/−998 days. For conventional semiquantitative evaluation of marrow and spongiosa a Giemsa staining was used. For immunological quantitative evaluation the following monoclonal antibodies were used with the APAAP method: CD34 and von Willebrand factor (VWF) for endothels of microvessels and CD45RO and CD8 for T-lymphocytes subsets. The pts were divided in 5 groups: 1. neither aGvHD nor cGvHD; 2. no cGvHD but aGvHD before entry; 3. cGvHD limited; 4. cGvHD extensive inactive; 5. cGvHD extensive active, needing immunosuppression. Results: Conventionally analysed no pt had evidence of vasculitis. 1 pt of group 4 had one small immunoreactive aggregate of lymphocytes another pt of group 5 had a diffuse infiltration with lymphocytes. 32 pts had no or very small reduction of spongiosa and 3 had severe reduction of spongiosa < 15%. The significant immunological results were: | Number/mm2 | 1. no GVHD (n=6) | 2. aGvHD before (n=4) | 3. cGvHD limited (n=5) | 4. cGvHD ext. inactive (n=8) | 5. cGvHD ext. active (n=12) | p (group No) | |:------------- | ---------------- | --------------------- | ---------------------- | ---------------------------- | --------------------------- | ---------------------- | | CD34+ vessels | 12,6 | 10,4 | 8,5 | 20,7 | 27,9 | < 0,001 (1,2,3 vs 4,5) | | V. Willebrand | 6,5 | 13,2 | 18,6 | 17,6 | 18,9 | 0,005 (1,2 vs 3,4,5) | | CD8+ | 5,8 | 4,0 | 6,8 | 10,2 | 25,3 | 0,034 (1,2,3 vs 4,5) | The number of CD34 as well as the number of vWF positive microvessels increased with the grade of involvement and activity of cGvHD (11,1 vs 25,3 respectively 8,7 vs 18,1). Additionally the content of CD8 positive lymphocytes increased with the grade and activity of disease. In contrast to reported skin biopsies, bone marrow capillaries were not destroyed by cytotoxic lymphocytes with increased activity. The bone marrow seems to show a different immunological reaction in contrast to pts with cGvHD of whom the target organs are skin, liver or gut. This was not observed on conventional biopsies. Further studies will be directed to the pattern of microvessels with regard to hematopoietic function and relapse.

Decreased bone mineral density (BMD) has been found to be a relatively common complication following haematopoietic cell transplantation (HCT). Only some studies exist about therapy with antiresorptive substances such as bisphosphonates. These studies analyse either short time therapy or only the use for female patients (pts). The aim of this study was to test the effect and tolerance of zoledronic acid in long time survival pts after HCT. Methods: 40 pts with osteoporosis (WHO T-score Table 1: baseline ° 1 yr°* 2 yrs°* % 1 yr* % 2 yr* °g/cm² mean values (+/−SD) *p=0.000 vs baseline LS 0.97+/−0.15 1.04+/−0.18 1.10+/−0.18 7.4+/−4,8 11.6+/−6.0 FH 0.82+/−0.10 0.87+/−0.11 0.91+/−0.10 5.6+/−5.3 7.5+/−7.0