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The chiral molecule, methoxetamine (MXE), demonstrated promising biological effects in management of treatment-resistant depression patients. To satisfy the need for a method capable of providing gram quantities of each enantiopure stereoisomer of MXE to enable advanced biological studies of enantiomers, a protocol was developed to access gram scale quantities of (R)- and (S)-MXE in the form of pharmaceutically acceptable HCl salts employing L-(−)-DTTA and D-(+)-DTTA ((−)-O,O′-di-p-toluoyl-L-tartaric acid and (+)-O,O′-di-p-toluoyl-D-tartaric acid, respectively) as two chiral resolving agents. In contrast to ketamine, the measured specific optical rotation and conformational analysis indicated that the most abundant conformers possess a common axial-methoxyphenyl conformation responsible for the conserved direction of optical rotation in both free base and HCl salt forms of the MXE stereoisomers. Finally, the absolute configuration was unambiguously assigned through matching experimental and calculated ECD spectra. This report offers a gateway to obtain gram scale amounts of enantiopure MXE stereoisomers needed to advance the current knowledge on MXE biology.

A rational-based process was adopted for repurposing pyrrolidine-based 3-deoxysphingosylphosphorylcholine analogs bearing variable acyl chains, different stereochemical configuration and/or positional relationships. Structural features were highly influential on activity. Amongst, enantiomer 1e having 1,2-vicinal relationship for the -CH2O- and the N-acyl moieties, a saturated palmitoyl chain and an opposite stereochemical configuration to natural sphingolipids was the most potent hit compound against promastigotes showing IC50 value of 28.32 µM. The corresponding enantiomer 1a was 2-fold less potent showing a eudismic ratio of 0.54 in promastigotes. Compounds 1a and 1e inhibited the growth of amastigotes more potently relative to promastigotes. Amongst, enantiomer 1a as the more selective and safer. In silico docking study using a homology model of Leishmania donovani inositol phosphoceramide synthase (IPCS) provided plausible reasoning for the molecular factors underlying the found activity. Collectively, this study suggests compounds 1a and 1e as potential hit compounds for further development of new antileishmanial agents.

Background We planned to compare the effect of intravenous oxycodone and fentanyl on post-operative pain after laparoscopic hysterectomy. Methods We examined 60 patients were randomized to postoperative pain treatment with either oxycodone (n = 30, Group O) or fentanyl (n = 30, Group F). The patients received 10 mg oxycodone/100 µg fentanyl with ketorolac 30 mg before the end of anesthesia and then continued with patient-controlled analgesia for 48 h postoperatively. Results The accumulated oxycodone consumption was less than fentanyl during 8, 24 and 48 h postoperatively. Numeric rating score of Group O showed significantly lower than that of Group F during 30 min, 2, 4, 8 and 24 h postoperatively. The incidences of adverse reactions were similar in the two groups, though the incidence of nausea was higher in the Group O during the 24 and 48 h postoperative period. Conclusions Oxycodone IV-PCA was more advantageous than fentanyl IV-PCA for laparoscopic hysterectomy in view of accumulated oxycodone consumption, pain control and cost beneficial effect. However, patient satisfaction was not good in the group O compared to group F.

We describe two cases of pulmonary arterial hypertension (PAH) that occurred under dasatinib treatment and were resolved after dasatinib discontinuation. Two patients with chronic phase chronic myeloid leukemia (CML) were switched to dasatinib therapy because of hematological progress while receiving imatinib. These patients had New York Heart Association (NYHA) functional class II dyspnea with elevated right ventricular systolic pressure (RVSP), which progressed under dasatinib treatment. After dasatinib treatment was discontinued, subjective symptoms were improved to NYHA functional class I and the follow-up transthoracic Doppler echocardiography showed improved RVSP. Treatment with an alternate tyrosine kinase inhibitor was initiated and had been continued without development of dyspnea or elevation of RVSP. This report suggests that dasatinib can cause the reversible PAH, therefore, routine cardiopulmonary evaluation before and during treatment with dasatinib may be needed in CML patients with clinical manifestations.

Although recent studies have suggested that cessation of imatinib (IM) in chronic myeloid leukemia patients can be associated with sustained response, further validation is needed to explore predictive factors. In a prospective, multicenter study, chronic phase patients were eligible for cessation of IM therapy after more than 3 years if they had no detectable BCR-ABL1 transcript for at least 2 years. A total of 48 patients with a median age of 47 years (19-74 years) were enrolled. Twenty patients received IM for post-transplant relapse. After a median follow-up of 15.8 months (1.4-28.2 months) after IM discontinuation, nine of the non-transplant group lost undetectable molecular residual disease (UMRD) and major molecular response (MMR), whereas none of the 20 patients in the transplant group experienced UMRD loss. Probabilities for sustained MMR and UMRD were 64.4% and 66.3% in the non-transplant group, respectively. Of nine patients re-treated with IM, eight patients re-achieved MMR at a median of 1.7 months (0.9-2.8 months). Seven of these patients re-achieved UMRD at a median of 5.6 months (2.8-12.1 months). Previous transplantation, IM duration, and UMRD duration were significantly associated with sustained molecular responses. Our data strongly suggest that immunological control contributes to sustained suppression of residual leukemia cell expansion and that IM can be safely discontinued in patients with post-transplant relapse.

The aim of this study was to evaluate the long-term clinical significance of an additional chromosomal abnormality (ACA), variant Philadelphia chromosome (vPh) at diagnosis, and newly developed other chromosomal abnormalities (OCA) in patients with chronic myeloid leukemia (CML) on imatinib (IM) therapy. Sequential cytogenetic data from 281 consecutive new chronic phase CML patients were analyzed. With a median follow-up of 78.6 months, the 22 patients with vPh ( P = 0.034) or ACA ( P = 0.034) at diagnosis had more events of IM failure than did the patients with a standard Ph. The 5-year overall survival (OS), event-free survival (EFS), and failure-free survival (FFS) rates for patients with vPh at diagnosis were 77.8%, 75.0%, and 53.3%, respectively; for patients with ACA at diagnosis, 100%, 66.3%, and 52.1%, respectively; and for patients with a standard Ph, 96.0%, 91.3%, and 83.7%, respectively. During IM therapy, eight patients developed an OCA, which had no impact on outcomes as a time-dependent covariate in our Cox proportional hazards regression models. This study showed that vPh was associated with poor OS and FFS and that ACA had adverse effects on EFS and FFS. In addition, no OCA, except monosomy 7, had any prognostic impact, suggesting that the development of OCA may not require a change in treatment strategy.

Two one-dimensional bismuth-coordination materials, Bi[NC5H3(CO2)2](OH2)xF (x=1 and 2), have been synthesized by hydrothermal reactions using Bi2O3, 2,6-NC5H3(CO2H)2, HF, and water at 180 °C. Structures of the two materials were determined by single-crystal X-ray diffraction. Although they have different crystal structures, both Bi-organic materials shared a common structural motif, a one-dimensional chain structure consisting of Bi3+ cations and pyridine dicarboxylate linkers. Detailed structural analyses include infrared spectroscopy, thermogravimetric analysis, and reversible hydration reactions for the coordinated water molecules were reported. Also, thermal decomposition of the rod-shaped Bi[NC5H3(CO2)2](OH2)F single crystals at 800 °C led to α-Bi2O3 that maintained the same morphology of the original crystals.

Two new merocyanine dyes derived from 7-hydroxycoumarin were prepared, and their signaling ability to detect water content in organic solvents was investigated. The dyes exhibited a pronounced negative solvatochromism, and dramatic changes in absorption spectra and λmax as a function of water content were observed. Solvatochromic behavior was pronounced in regions of less than 5% water content; therefore, these dyes could be used as chromogenic probes for detecting water in common water miscible organic solvents.

Background The use of lipid soluble opioids such as fentanyl, alfentanil and sufentanil are recently on the increase for patient-controlled epidural analgesia (PCEA). In this study, the effects and adequate dose of sufentanil in arthroplasty were investigated. Methods Eighty patients scheduled for arthroplasty were enrolled for the study. Seventy-one patients (ASA physical status I-III) were randomly allocated into four groups. All groups received 0.1% ropivacaine through PCEA and each group received either fentanyl (group F: fentanyl 4 µg/ml) or sufentanil (group S1: sufentanil 0.5 µg/ml, group S2: sufentanil 0.75 µg/ml, and group S3: sufentanil 1.0 µg/ml). Postoperative pain scores were evaluated using VAS (visual analog scale, 0-10) and side effects such as hypotension, nausea/vomiting, pruritus and the degree of satisfaction were evaluated at 1, 6, 12, 24, 48 hours after surgery. Results Postoperative pain score (VAS) decreased gradually and the highest VAS score was recorded at 1 hour postoperative for all four groups. There were no differences in the degree of satisfaction and postoperative pain score between all groups. The incidence of pruritus was significantly lower in group S1 than in groups S2 and S3. Conclusions The incidence of side effects were significantly lower in group S1 (0.1% ropivacaine plus sufentanil 0.5 µg/ml). Therefore, 0.5 µg/ml of sufentanil through PCEA is the recommended dose for postoperative pain control in arthroplasty.

Background Hepatoduodenal lymph node (HDLN) positivity is considered distant metastasis in gastric cancer according to the seventh American Joint Committee on Cancer (AJCC) classification. In contrast, the International Union Against Cancer seventh edition and the Japanese Gastric Cancer Association both consider HDLN as a regional lymph node that can be included in the context of a curative resection. The purpose of this study was to determine whether there was justification for considering HDLN involvement as a distant metastasis for which resectional surgery could not have survival benefit. Methods This study enrolled consecutive patients with gastric cancer having D2 or greater resections, with removal and pathological assessment of the HDLN, between 1989 and 2009. The pathological stage of all patients was determined based on the seventh AJCC criteria, with HDLN included as a regional lymph node. Results A total of 1872 patients had their HDLN removed, of whom 68 had a metastatic lymph node in the hepatoduodenal ligament. The 5-year survival rate of these 68 patients was 30 per cent, compared with 47·7 per cent for those with stage III (P < 0·001) and 9·8 per cent for those with stage IV (P = 0·007) HDLN-negative tumours. The 5-year survival rate of 41 patients with HDLN metastasis and no evidence of distant metastasis at any other site was significantly higher than that among 120 patients with stage IV disease without HDLN metastasis (P < 0·001), whereas 5-year survival did not differ between the 41 patients with stage I–III disease with HDLN metastasis and 568 patients with stage III tumours without HDLN metastasis (P = 0·184). HDLN metastasis was not a significant factor for survival in multivariable analysis. Conclusion It is inappropriate to include the HDLN in the distant metastatic lymph node group in gastric cancer. The seventh AJCC criteria for node grouping should be revised.

The aim of this study was to estimate the prognostic factors for the outcomes of chronic myeloid leukemia (CML) patients receiving allogeneic stem cell transplantation (SCT) in chronic phase (CP) in the era of tyrosine kinase inhibitors (TKIs). Ninety-seven patients who underwent allogeneic SCT in CP were analyzed. Forty-seven were TKI-naive at the time of transplant, and 50 received TKI(s) treatment before transplantation. After a median follow-up of 115.8 months, the 4-year overall survival and event-free survival were 80.4 and 58.8%, respectively. Multivariate analysis showed that there were no differences in survival outcomes based on prior TKI therapy. Older age was a prognostic factor for higher treatment-related mortality (TRM), and the type of graft source and younger age were associated with relapse, but prior TKI therapy and disease status at the time of transplant were not associated with either TRM or relapse. Additionally, a major molecular response at 1 month and an MR(4.5) at 3 months were important predictors of favorable long-term outcomes. This study demonstrates the prognostic factors for the outcomes of allogeneic SCT in CP CML and shows that survival outcomes were not affected by the administration of long-term multi-TKI treatment prior to transplantation.

Background Hematologic manifestations are common in systemic lupus erythematosus (SLE). Lymphopenia is most commonly found among leukopenia, but neutropenia is also found in about 50–60% of SLE patients. Most patients experience mild neutropenia while less than 5% of those experience moderate to severe neutropenia which can increase susceptibility to recurrent infection. Although it is crucial to understand risk factors associated with neutropenia in SLE patients, there is a paucity of clinical data regarding neutropenia in patients with SLE. Objectives This study was performed to identify the clinical and serologic factors that are associated with neutropenia in patients with systemic lupus erythematosus (SLE). Methods A total 160 admissions of 85 SLE patients between 2006 and 2013 were retrospectively reviewed. Neutropenia was defined as absolute neutrophil count (ANC) below 1,500/mm 3 . Baseline characteristics of the patients were compared between patients who experienced neutropenia and those without. Clinical and serological factors related to neutropenia episode during admission were analyzed using generalized estimating equation (GEE) and multivariate analysis. Results Thirty two (37.6%) patients experienced neutropenia, and neutropenia episode was found in 35 (21.9%) of admissions. Most of the neutropenia episodes were mild to moderate. Severe neutropenia of ANC 3 occurred in 14.3% of the cases. Patients with neutropenia had higher frequencies of ANA (100.0 vs 86.8%, P =0.042) and anti-dsDNA (87.5 vs 60.4%, P =0.008), and satisfied more SLE classification criteria at the time of the diagnosis than those without (4.8 vs 4.1, P =0.014) Clinical characteristics at admission such as comorbidities, concomitant medications, and SLEDAI were not different between admissions with and without neutropenia episode. Anemia, leukopenia, thrombocytopenia and low complement levels were frequently associated with neutropenic episodes. Co-existence of chronic kidney disease (OR,16.91; 95% confidence interval (CI), 2.09–136.6; P =0.008) and Sjogren9s syndrome (OR, 6.48; 95% CI, 1.46–28.66; P =0.014) was associated with increased risk of developing neutropenia. Conclusions This study demonstrates that most of neutropenia in SLE patients occur as part of hematologic and immunologic abnormalities. SLE patients with renal damage and Sjogren9s syndrome should be closely monitored for development of neutropenia. Disclosure of Interest None declared

[Graphic][1] Background: To explore a real incidence of dasatinib-induced pulmonary arterial hypertension (D-PAH) in clinical practice, we investigated 82 imatinib or other 2G tyrosine kinase inhibitor (TKI)-failed chronic myeloid leukemia (CML) patients who received dasatinib as a second-line therapy. Methods: Routine chest X-ray and Doppler echocardiography were regularly evaluated in all patients and additional tests were performed if dyspnea developed on treatment. Results: Median age at the time of starting dasatinib was 48 (16-82) years. Of 82 patients, 8 patients (9.8%) showed an elevation of right ventricular systolic pressure (RVSP>35mmHg) by Doppler echocardiography. Among them, 7 patients (8.5%) were considered D-PAH with a median dasatinib treatment duration of 32.6 (10.3-108.7) months. They underwent follow-up Doppler echocardiography median 5 (2-9) times. Five patients showed severe D-PAH (RVSP >70mmHg), 1 was moderate (RVSP 46mmHg), and 1 was mild (RVSP 41mmHg). Advanced studies such as pulmonary angiographic catheterization (patient 1 and 2) or pulmonary arterial computed tomography (patient 3 and 4) were performed for confirming D-PAH or ruling out PAH due to pulmonary vascular abnormality. Six patients had bilateral pleural effusion and 1 had unilateral pleural effusion. With sildenafil (n=5) + dose reduction (n=1) + switch to other TKI (n=6), all of patients improved dyspnea, and RVSP level was completely resolved in 3 patients. In addition, previous nilotinib therapy and concomitant pleural effusion were significant contributing factors for D-PAH. Conclusion: Regardless of complete resolution of pleural effusion, a patient with sustained dyspnea on dasatinib treatment should be carefully evaluated by Doppler echocardiography and a regular monitoring will be needed for early intervention. | Cohort | Age at PAH diagnosis (year) | Sex | Treatment duration before dasatinib (month) | Previous therapy for CML | Duration between initiation of dasatinib and diagnosis of PAH (month) | Daily mean dose of dasatinib (mg/d) | Duration between diagnosis of D-PAH and last follow up (month) | Treatment of D-PAH | Switch to other TKI | Outcome | | ------ | --------------------------- | --- | ------------------------------------------- | ------------------------------------------------------- | --------------------------------------------------------------------- | ----------------------------------- | -------------------------------------------------------------- | ------------------------------------ | ----------------------- | -------- | | 1 | 53 | M | 54.4 | Interferon, Hydroxyurea, Imatinib, nilotinib | 26.4 | 123 | 73.5 | Sildenafil | nilotinib and ponatinib | partial | | 2 | 50 | M | 36.6 | Interferon, Hydroxyurea, Imatinib, dasatinib, nilotinib | 50.3 | 112 | 55.2 | Sildenafil | nilotinib and radotinib | partial | | 3 | 37 | F | 31.7 | Imatinib, nilotinib | 21.7 | 88 | 39.7 | Sildenafil Dose de-escalation | radotinib | partial | | 4 | 45 | M | 70.9 | Hydroxyurea, Imatinib | 69.8 | 101 | 35.2 | Sildenafil Dose de-escalation | ponatinib | complete | | 5 | 59 | F | 107.4 | Interferon, Hydroxyurea, Imatinib | 83.6 | 92 | 14.3 | none | radotinib | partial | | 6 | 46 | F | 12.6 | Imatinib | 29.1 | 76 | 13.0 | Steroid, Sildenafil | radotinib | complete | | 7 | 38 | F | 30.2 | Imatinib | 33.1 | 98 | 10.2 | Dose reduction | NA | complete | Abstract 5535. Table 1. Characteristics of patients with dasatinib-induced PAH Disclosures No relevant conflicts of interest to declare. [1]: /embed/inline-graphic-2.gif

Awareness of intraoperative events in patients under general anesthesia is rare, but awareness during anesthesia is a serious complication that leads to anxiety and post-traumatic stress disorder. The Bispectral Index (BIS) has generally been accepted as a measurement of hypnosis under anesthesia. It is derived from a processed electroencephalogram and computer algorithm that assigns a numerical value based on the probability of consciousness. A 46-year-old, 65-kg male without underlying disease underwent elective surgery for ventral hernia. The patient in this case was administered an anesthetic that we frequently use and then average BIS value are 35. But he experienced awake during general anesthesia. We describe the first case of intraoperation awake under BIS 40 using desflurane.

Introduction Recent randomized trial (DASISION trial), compared clinical outcomes between dasatinib and imatinib in newly diagnosed (chronic myeloid leukemia) CML patients. Results showed that dasatinib had faster and deeper responses compared with imatinib, and thus dasatinib became to be considered as a first-line therapy in CML patients. However, the long-term administration of dasatinib has been reported to have a risk of pleural effusion and dasatinib-related (pulmonary arterial hypertension) PAH. So, we have prospectively evaluated for emergence of PAH in all CML patients treated with dasatinib in our institute. Materials and methods Between May 2005 and July 2013, a total of 89 CP CML patients on dasatinib treatment were tested with laboratory studies, Brain natriuretic peptide (BNP), echocardiography (echo) in the Catholic University of Korea, Seoul, and baseline functional capacity (NYHA or WHO functional class) was assessed. PAH was defined as mean pulmonary artery pressure (mPAP) of >25mmHg at rest, with wedge pressure < 15mmHg, or Rt. Ventricular systolic pressure (RVSP) of 40 mmHg on echocardiography. And patients who had abnormal RVSP and/or symptoms (New York heart association-NYHA class 3, 4) were performed with additional studies such as pulmonary angiographic catheterization or pulmonary arterial computed tomography. Results So far, 62 patients (70%) of total 89 were evaluated with echocardiography (46 male, 16 female). The median age was 48 year old (range, 22∼72). The median duration of disease was 8.5 years (range, 0.8∼16.1). The median mean daily dosage of dasatinib was 102mg (range, 73∼140mg). The duration of dasatinib treatment was 34.6 months (range, 0.5∼99.6). 8 of 66 patients (12.1%) showed abnormal echocardiographic findings as increased right ventricular systolic pressure or symptom. All of 8 patients had treated with dasatinib as second line, and had exertional dyspnea (2 patients on class 2, and 5 patients on class 3 of NYHA). 5 patients of these showed abnormal BNP levels. The mean RVSP in screened patients was 65.2 mmHg (range, 40∼108mmHg), 2 of 8 patients were confirmed diagnosis with overt PAH on as pulmonary angiographic catheterization, and right ventricular hypertrophy on pulmonary angiographic computed tomography. Clinical, functional, or hemodynamic improvements were observed within 5 months of dasatinib discontinuation and then, in 5 patients the treatment was switched to radotinib, and another 3 patients received reduced dosage of dasatinib. Conclusion Although the lowest estimate of incident PAH occurring in patients exposed to dasatinib was 0.45% in France group. our preliminary data show more higher incidence rates (8 of 66 patients, 12.1%) in Korea. So, we suggest that the long-term dasatinib treatment for CML requires careful attention to cardiopulmonary adverse effects. and routine cardiovascular and pulmonary evaluation on regular basis is strongly recommended before and during treatment with dasatinib. Disclosures: No relevant conflicts of interest to declare.

Background BCR-ABL1 kinase domain (KD) point mutation causes resistance to tyrosine kinase inhibitors (TKI) in chronic myeloid leukemia (CML) patients through impaired binding of TKI to the target site. Recent studies have reported that multiple mutations detected in 2-9% of patients with imatinib (IM)-resistant CML were associated with poor response rate and survival outcomes. However, biological characteristics and dynamics of multiple low-level mutations are still not assessed with a quantitative serial follow-up data in the same populations. Aims The aim of this study was to investigate biological characteristics and dynamics of low-level mutations in the serial samples from the patients carrying multiple mutations using subcloning and sequencing. Methods Since 2002, 414 CML patients were screened for mutation analysis due to sign of resistance to TKIs including imatinib (IM), nilotinib (NIL), dasatinib (DAS), bosutinib (BOS), radotinib (RAD) or ponatinib (PON) at Seoul St Mary’s Hospital using direct sequencing and allele specific oligonucleotide-polymerase chain reaction (ASO-PCR). Among them, 31 patients carried ≥ 2 BCR-ABL1 kinase domain mutations. We analyzed 137 samples from these 31 patients using subcloning and sequencing (in total, 2737 colonies were sequenced). By cloning and sequencing, two or more missense mutations present in the same clone were defined as compound mutation and co-existence of single missense mutations in the separated clones was defined as polyclonal mutation. Co-existence of single missense mutation and compound mutation harboring two or more missense mutations in the same clone was defined as mixed mutation. Missense mutations detected by direct sequencing are defined as predominant mutations. Missense mutations detected by cloning and sequencing but not by direct sequencing are defined as low-level mutations. Results In a total of 2737 colonies from 137 samples, 1596 (58%) colonies harbored ≥ 2 missense mutations with a median 2 (range, 2 – 7) mutations, and 905 (33%) colonies with a single mutation and 236 (9%) colonies with wild type were observed. In 2737 colonies, 692 different low-level mutations were detected by cloning and sequencing but not by direct sequencing. Among them, M244V, G250E, Y253H, E279K, T315I, F317L, M351T, E355A, F359I, and F359V were detected by direct sequencing in the followed-up samples, and the others remain undetectable by direct sequencing. To address whether these low-level mutations were distinct in the patients with TKI resistance, we applied the cloning and sequencing to samples from 3 healthy controls and 3 patients with optimal response to IM. 38 different mutations were detected healthy controls. 52 different mutations were detected in optimal responders. S349P, N374S, E450G, and S485P were detected in both healthy controls and optimal responders. All mutations detected in optimal responders except 3 missense mutations (V335A, F382V, and A395S) were detected as low-level mutations in the 31 patients’ cohort with TKI resistance. Of 38 different mutations detected in healthy control, 31 mutations except 7 missense mutations (Y264H, M343R, A350V, E373G, G298R, E462K, and T495K) were also detected as low-level mutations in the 31 patients’ cohort. Conclusions We showed basic characteristics and dynamics of low-level mutations by subcloning and sequencing. Some of the low-level mutant clones harboring previously known (clinically common) TKI resistant mutations changes to the predominant in the followed-up samples. Except them, most low-level mutant clones were not detected repeatly and did not increase gradually in the serial samples, implying that they may not have clinical significance. Disclosures: No relevant conflicts of interest to declare.

Abstract 1677 Background: BCR-ABL1 kinase domain (KD) point mutation causes resistance to tyrosine kinase inhibitors (TKI) in CML patients through impaired binding of TKI to the target site. One of the characteristics of patients with BCR-ABL1 kinase domain point mutations is the fact that some patients have multiple mutations. However there have not been many studies showing that data about clinical relevance or dynamics of multiple mutation during CML treatment. Methods: Since 2002, 414 CML patients were screened for mutation analysis due to sign of resistance to TKI including imatinib, nilotinib, dasatinib, bosutinib, radotinib or ponatinib at Seoul St Mary's Hospital using direct sequencing and ASO-PCR. Among them, 31 patients showed multiple mutations. We analyzed serial samples from the 31 patients using subcloning and sequencing to investigate whether the multiple mutations are on same clone (defined as compound clone), separated clones (defined as multiple clone) or co-existent clones (defined as mixed clone) and characterize its clinical relevance and dynamics. Results: Status of the patients with multiple mutations is shown in Table 1. In order to investigate whether the multiple mutations are on same clone or on separated clone, we cloned serial samples from the 31 patients. Cloning of cDNA region corresponding to BCR-ABL1 KD into plasmid was performed and followed by transformation into competent cells, colony formation, plasmid preparation of 20 colonies from each sample, and then direct sequencing. Multiple mutations of 65% patients (20 out of 31) existed compound mutation which means the individual mutant types are located on the same BCR-ABL1 molecule. In addition of major mutation types which were detectable in direct sequencing analysis, all the patients showed to have minor types of mutations which were found only through BCR-ABL1 KD cloning and subsequent colony sequencing. To make sure that this minor mutation types were not caused by sequencing error, we also analyzed of 3 patients who showed TKI resistance, but had no BCR-ABL1 mutation. In addition, samples from 3 normal persons were analyzed with the same method. The frequency of appearance of the minor types of point mutation was reduced in the patient group who showed TKI resistance, but had no BCR-ABL1 mutation, and then dramatically decreased in the normal person group, indicating that BCR-ABL1 gene in patients with point mutation are relatively unstable. Among 20 patients with compound mutation, 9 patients were available for serial timepoint samples under same TKI therapy. In all nine patients (100%), portion of compound clone was increased as treatment went on. With a median follow-up 53.3 months (range, 0–113.2 months), of 31 patients with multiple mutation, 7 patients remained alive; 4 of 11 (36%) in the multiple clone group vs 3 of 20 (15%) in the mixed clone group (P = 0.066). Conclusion: Analysis of serial samples from a same patient provided evidence of dynamic change of portion of compound mutation. In most case, portion of the clone containing compound mutation was increased as treatment went on, indicating the clone harboring compound mutation can take survival advantage over TKI treatment in comparison of the clone containing individual type of mutation. In addition, some patients showed change in individual mutation type comprising multiple mutations as treatment went on. Patients with compound clone showed poor outcomes compared with multiple clone group in our cohort, further investigation on a large patient cohort will be needed. Updated data with longer follow-up duration will be presented in the meeting. Disclosures: No relevant conflicts of interest to declare.