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Pre-transplant measurable residual disease (MRD) predicts relapse and outcome of allogeneic haematopoietic cell transplantation (allo-HCT). The impact of MRD on the outcomes of post-transplant cyclophosphamide (PTCy)-based allo-HCT from a matched unrelated donor (UD) is unknown. This study assessed the impact of MRD in acute myeloid leukaemia (AML) in the first complete remission (CR1). A total of 272 patients (MRD negative [MRD−], n = 165; MRD positive [MRD+], n = 107) with a median follow-up of 19 (range: 16–24) months were studied. The incidence of grades II–IV and grades III–IV acute GVHD at day 180 was 25.2% and 25% (p = 0.99), and 10.6% and 6.8% (p = 0.29), respectively, and 2-year chronic GVHD was 35% and 30.4% (p = 0.96) in MRD+ and MRD− cohorts, respectively. In multivariate analysis, MRD+ status was associated with a higher incidence of relapse (RI) (hazard ratio [HR] = 2.56, 95% CI: 1.39–4.72), lower leukaemia-free survival (LFS) (HR = 2.04, 95% CI: 1.23–3.39), overall survival (OS) (HR = 1.83, 95% CI: 1.04–3.25) and GVHD-free, relapse-free survival (GRFS) (HR = 1.69, 95% CI: 1.10–2.58). MRD status did not have a significant impact on non-relapse mortality (NRM), or acute or chronic GVHD risk. Among patients with AML undergoing UD allo-HCT with PTCy, pre-transplant MRD+ status predicted a higher relapse rate, lower LFS, OS and GRFS.

The best stem cell source for T-cell replete human leukocyte antigen (HLA)-haploidentical transplantation with post-transplant cyclophosphamide (PTCy) remains to be determined. In this European Society for Blood and Marrow Transplantation retrospective study, we analyzed the impact of stem cell source on leukemia-free survival (LFS) in adult patients with primary refractory or relapsed acute myeloid leukemia (AML) given grafts from HLA-haploidentical donors with PTCy as graft-versus-host disease (GVHD) prophylaxis. A total of 668 patients (249 bone marrow [BM] and 419 peripheral blood stem cells [PBSC] recipients) met the inclusion criteria. The use of PBSC was associated with a higher incidence of grade II-IV (HR = 1.59, p = .029) and grade III-IV (HR = 2.08, p = .013) acute GVHD. There was a statistical interaction between patient age and the impact of stem cell source for LFS (p < .01). In multivariate Cox models, among patients = 55 years of age, the use of PBSC versus BM was associated with higher non-relapse mortality (NRM) (HR = 1.7, p = .01), lower LFS (HR = 1.37, p = .026) and lower overall survival (HR = 1.33, p = .044). In conclusions, our data suggest that in patients >= 55 years of age with active AML at HLA-haploidentical transplantation, the use of BM instead of PBSC as stem cell source results in lower NRM and better LFS. In contrast among younger patients, the use of PBSC results in at least a comparable LFS.

Background: Post-transplant cyclophosphamide (PTCY) is increasingly used for allogeneic peripheral blood stem cell transplantation (allo-PBSCT) from an HLA-matched unrelated donor (MUD) as an alternative to the standard anti-thymocyte globulin (ATG) graft-versus-host disease (GvHD) prophylaxis. Following the demonstration that the use of PBSC haploidentical grafts results in more GvHD than bone marrow grafts, groups have attempted to reduce GvHD in haploidentical-PBSCT by adding ATG to PTCY. The experience of combined PTCY+ATG in the MUD allo-PBSCT is minimal and whether ATG brings any added value when PTCY is used in this setting is still unclear. Methods: In this registry-based study, we compared outcomes of 421 patients with PTCY and 151 patients with PTCY+ATG who underwent a first MUD allo-PBSCT for acute myeloid leukemia (AML) in complete remission. Results: Characteristics of PTCY and PTCY+ATG patients were well balanced, including the number of additional immunosuppressive drugs, with the only significant difference between the two cohorts being the median year of transplant, and the follow-up period (19.6 versus 31.1 months, respectively, pConclusions: To date, the question of the best combination of GvHD-preventing drugs in the MUD-PBSCT setting remains unanswered. Our results highlight that in PTCY-based MUD-PBSCT for AML, the addition of ATG does not provide any extra benefit in terms of further GvHD reduction, better GRFS or better survival.

HLA-haploidentical allogeneic hematopoietic stem cell transplantation (Haplo-HCT) is frequently used as treatment for patients with active acute myeloid leukemia (AML). Here, we investigated whether 9/10 HLA-mismatched unrelated donor transplantation (MMUD-HCT) with post-transplant cyclophosphamide (PTCy) is an adequate alternative. Inclusion criteria in this retrospective registry study consisted of adult patients, first HCT with a Haplo donor or MMUD between 2010 and 2020 using PTCy as graft-versus-host disease (GVHD) prophylaxis, and primary refractory or relapsed disease. MMUD patients were pair-matched 1 to 2 with Haplo-recipients. A total of 73 MMUD patients met the inclusion criteria. Their data were compared to those of 146 Haplo patients in a matched-pair analysis. Median follow-up was 27 months in MMUD patients and 36 months in Haplo recipients. Two-year incidences of relapse and non-relapse mortality (NRM) were 40% and 18% in MMUD patients, respectively, versus 50% (P = 0.23) and 24% (P = 0.18) in Haplo recipients. Two-year leukemia-free survival (LFS) and overall survival (OS) was 42% and 46% in MMUD recipients, respectively, versus 26% (P = 0.1) and 28% (P = 0.061) in Haplo-patients. In conclusions, in AML patients with active disease at transplantation, MMUD-HCT results in at least comparable outcomes to Haplo-HCT when PTCy is applied. We report a paired-matched analysis of HLA-mismatched unrelated donor transplantation (MMUD, n = 73) versus HLA-haploidentical transplantation (n = 146) in AML patients with active disease at transplantation. Two-year leukemia-free survival and overall survival was 42% and 46% in MMUD recipients, respectively, versus 26% (P = 0.1) and 28% (P = 0.061) in Haplo-patients.

Post-transplant cyclophosphamide (PTCy) is being increasingly used as graft-versus-host disease (GVHD) prophylaxis post allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with acute myeloid leukemia (AML) transplanted in first complete remission (CR1). However, results may differ in patients transplanted in CR2. We retrospectively evaluated transplant outcomes of adult AML patients transplanted between 2010–2019 from 9–10/10 human leukocyte antigen (HLA)-matched unrelated donor (UD) in CR2. In total, 127 patients were included (median age 45.5 years, 54% male). Median follow-up was 19.2 months. Conditioning was myeloablative (MAC) in 50.4% and the graft source was peripheral blood in 93.7% of the transplants. Incidence of acute (a)GVHD II-IV and III-IV was 26.2% and 9.2%. Two-year total and extensive chronic (c)GVHD were 34.3% and 13.8 %, respectively. Two-year non-relapse mortality (NRM), relapse incidence (RI), leukemia-free survival (LFS), overall survival (OS), and GVHD-free, relapse-free survival (GRFS) were 17.2%, 21.1%, 61.7, %, 65.2%, and 49.3%, respectively. Time from diagnosis to transplant (>18 months) was a favorable prognostic factor for RI, LFS, OS, and GRFS while favorable risk cytogenetics was a positive prognostic factor for OS. The patient’s age was a poor prognostic factor for NRM and cGVHD. Finally, the female-to-male combination and reduced intensity conditioning (RIC) were poor and favorable prognostic factors for cGVHD, respectively. We conclude that PTCy is an effective method for GVHD prophylaxis in AML patients undergoing allo-HCT in CR2 from UD.

Baseline cytogenetics and disease status are key factors predicting the outcomes of allogeneic hematopoietic cell transplantation (HCT) in patients with acute myeloid leukemia (AML). The importance of cytogenetic risk in patients with primary refractory or relapsed (R/R) AML undergoing haploidentical (Haplo) HCT is unknown. We studied the impact of cytogenetic risk in patients with R/R de novo AML with active disease who underwent non-T-cell-depleted Haplo-HCT with post-transplantation cyclophosphamide from 2010 to 2020. Four hundred forty patients with active disease at transplantation from the European Society for Blood and Marrow Transplantation database were analyzed (291 [66.1%] with intermediate-risk [AMLint] and 149 [44.1%] with adverse-risk cytogenetics [AMLadv]). Impact of baseline cytogenetic risk on various transplantation outcomes was evaluated. Pre-transplantation disease status was relapse in 48.1% and 26.8% and primary refractory in 51.9% and 73.2% of the patients with AMLint and AMLadv, respectively (P.0001). Two-year leukemia-free survival (LFS, 35.5% versus 15.5%, P = .001) and overall survival (OS, 39.2% versus 20.1%, P = .001) were better in AMLint versus AMLadv. In multivariate analysis, the relapse rate was significantly higher (hazard ratio [HR] = 2.17 [95% confidence interval {CI} 1.57-3.0]) and LFS (HR = 1.71 [95% CI, 1.31-2.22]) and OS (HR = 1.69 [95% CI, 1.29-2.22]), significantly lower for patients with AMLadv compared to AMLint, conditioning intensity did not affect leukemia relapse rate. Non-relapse mortality (HR = 1.1 [95% CI, 0.7-1.74]) and graft-versus-host disease-free, relapse-free survival (HR = 1.37 [95% CI, 1.06-1.77]) did not differ significantly between the risk groups. Disease status before transplant (primary refractory versus relapsed) or conditioning intensity did not impact main transplant outcomes. Baseline cytogenetic risk remains a key prognostic factor for patients with R/R AML with persistent disease before non-T-cell-depleted Haplo-HCT.

BK polyomavirus (BKPyV) persists lifelong in renal and urothelial cells with asymptomatic urinary shedding in healthy individuals. In some immunocompromised persons after transplantation of hematopoietic stem cells (HSCT), the BKPyV high-rate replication is associated with haemorrhagic cystitis (HC). We tested whether the status of BKPyV immunity prior to HSCT could provide evidence for the BKPyV tendency to reactivate. We have shown that measurement of pretransplant anti-BKPyV 1 and 4 IgG levels can be used to evaluate the HC risk. Patients with anti-BKPyV IgG in the range of the 1st–2nd quartile of positive values and with positive clinical risk markers have a significantly increased HC risk, in comparison to the reference group of patients with “non-reactive” anti-BKPyV IgG levels and with low clinical risk (LCR) (p = 0.0009). The predictive value of pretransplant BKPyV-specific IgG was confirmed by determination of genotypes of the shed virus. A positive predictive value was also found for pretransplant T-cell immunity to the BKPyV antigen VP1 because the magnitude of IFN-γ T-cell response inversely correlated with posttransplant DNAuria and with HC. Our novel data suggest that specific T-cells control BKPyV latency before HSCT, and in this way may influence BKPyV reactivation after HSCT. Our study has shown that prediction using a combination of clinical and immunological pretransplant risk factors can help early identification of HSCT recipients at high risk of BKPyV disease.

Donor lymphocyte infusion (DLI) is a treatment option to prevent or treat relapse after allogeneic hematopoietic cell transplantation (HCT). We here report data for 173 patients who received one or multiple DLIs after haploidentical-HCT with post-transplant cyclophosphamide (PTCY) at 47 EBMT centers from 2009 to 2018. Indication for DLI was: prophylactic for 59 (34.3%), preemptive for 20(11.6%), and therapeutic for 93(54.1%). For the prophylactic group, the median number of DLIs was 1 (IQR:1-2.5) with a median first dose of 0.1 × 10

Introduction Survival rate of patients with chemorefractory acute myeloid leukemia (AML) or myelodysplastic syndrome with excess blasts (MDS-EB) is poor. Allogeneic hematopoietic cell transplantation (HCT) is the only potentially curative therapy in these patients. Patients and Methods We report a retrospective analysis of outcomes of therapy of 24 patients with AML or MDS-EB refractory to high-dose salvage chemotherapy or who had failed previous HCT, who received T-cell–replete HLA haploidentical HCT in aplasia after cladribine/cytarabine-based chemotherapy followed by reduced intensity or myeloablative conditioning. All patients had active disease before commencement of the treatment. Results Of the patients, 91.7% achieved complete remission (CR), whereas 2 patients (8.2%) died in aplasia. One-year relapse rate was 49.3%. Cumulative incidence of nonrelapse mortality (NRM) was 25.6%. In a subgroup of patients with HCT–comorbidity index score ≤ 3, NRM was 15.4%. Two-year overall survival and relapse-free survival were 30.6% and 22.6%, respectively. Incidence of grade 3 and 4 acute graft versus host disease was 21.3% and 8.3, respectively. Conclusion We found that sequential therapy with HCT in aplasia after cladribine/cytarabine chemotherapy is feasible, results in high CR rates, and has acceptable toxicity profile; however, posttransplant relapse is common in patients treated with active disease.

Unmanipulated haploidentical hematopoietic stem cell transplantation (HCT) with post-transplantation cyclophosphamide as graft-versus-host disease (GVHD) prophylaxis (haplo-PTCY) and unrelated double-unit umbilical cord blood transplantation (dUCBT) are feasible options for treating patients with high-risk acute myelogenous leukemia (AML). This study compared outcomes after dUCBT and haplo-HCT using peripheral blood stem cells (PBSCs) in adult patients with AML in complete remission (CR) who underwent transplantation in European Society for Blood and Marrow Transplantation (EBMT)-affiliated centers. In a population of adults with de novo AML in first or second CR, we compared outcomes after dUCBT (n = 165) and after haplo-PTCY PBSC (n = 544) performed between January 2013 and December 2018. Patients receiving in vivo antithymocyte globulin, Campath, or ex vivo T cell depletion were excluded. The median follow-up was 33 months for the haplo-PTCY arm and 52 months for the dUCBT arm. No statistically significant differences were observed between the 2 arms in the rates of grade II-IV acute graft-versus-host disease (GVHD) (hazard ratio [HR], 1.31; P =. 18), grade III-IV acute GVHD (HR, 1.17; P =. 56), chronic GVHD (HR,. 86; P =. 48), relapse (HR, 1.07; P =. 77), nonrelapse mortality (NRM) (HR,. 94; P =. 77), leukemia-free survival (LFS) (HR,. 99; P =. 95), or overall survival (OS) (HR,. 99; P =. 97). Favorable cytogenetic risk was the sole factor predictive of lower relapse incidence (RI). Younger age at transplantation was associated with lower NRM and higher LFS and OS. Both dUCBT and haplo-PTCY with PBSCs can be considered valid approaches for adult AML patients in CR. New strategies should be investigated in both settings to define the most appropriate conditioning regimen and potentially decrease RI and NRM through better immune reconstitution and optimal supportive care.

BK polyomavirus (BKV) persists lifelong in the urinary tract with asymptomatic urinary shedding in healthy individuals. In immunocompromised persons after transplantation of hematopoietic stem cells (HSCT) the BKV high-rate replication is associated with haemorrhagic cystitis (HC) with a reported incidence of 17 %. Numerous studies of reconstitution of the immune system after HSCT have established the principal role of T cell effectors in the control of viral replication and reactivation. The value of pretransplant BKV-specific antibodies in transplanted patients for the protection from viral disease was long considered insignificant. We hypothesized that the status of BKV immunity prior to HSCT could provide evidence for the BKV tendency to reactivate and that examining the level of subtype-specific antibodies and T-cell response in individual patients could help to predict the risk of BKV reactivation and HC. Evaluation of the risk of HC in relation to pretransplant anti-BKV1,2,4 IgG levels together with clinical factors known before transplantation revealed that patients with „medium” anti-BKV IgG and significant clinical risk (SR) have a very significantly increased HC risk in comparison with the reference group of “low” anti-BKV IgG level and low clinical risk (LR) (P=0.0009). Predictive value of pretransplant BKV specific IgG was confirmed on the level of virus genotypes. Analysis of pretransplant T cell immunity to BKV antigens VP1 and LTag has shown that magnitude of IFN-gamma T cell response inversely corelated with posttransplant DNAuria. We hypothesize that the control of BKV latency by BKV specific T cells before HSCT would be one of the factors that influence BKV reactivation after HSCT. Our study has shown that prediction using a combination of clinical and immunological pretransplant risk factors can help early identification of patients who are at risk of developing BKV disease after HSCT.

Background: Haploidentical allogeneic hematopoietic cell transplantation (haplo) has expanded applicability of the procedure to patients for whom a suitable HLA compatible donor was not available in the past. A small multicenter retrospective study of 185 patients with hematologic malignancies who received a nonmyeloablative preparative regimen followed by infusion of bone marrow (BM) hematopoietic cells from haploidentical donors showed no significant association between the number of HLA mismatches (HLA-A, -B, -C, and -DRB1 combined) and risk of acute grade 2-4 graft-versus-host disease (GVHD) (hazard ratio [HR]=0.89; P=0.68 for 3-4 mismatches vs fewer antigen mismatches). This haploidentical transplant platform has certainly evolved. Nowadays, G-CSF mobilized peripheral blood stem cells (PBSC) are commonly used owing to its increased convenience vis-à-vis performing a BM harvest. Study population: Here, we evaluate post transplant outcomes when using haploidentical donors with T-replete PBSC and PTCy in AML in CR1. A total of 494 patients (4/8 HLA mismatch (group 1)=360, 2-3/8 HLA mismatch (group 2)=134) underwent the procedure at an EBMT participating center. The primary endpoints were cumulative incidences of grade 2-4 acute GVHD and chronic (all grades) GVHD. Secondary endpoints included cumulative incidence of relapse (RI), non-relapse mortality (NRM), leukemia-free (LFS) and overall survival (OS) and GVHD-free relapse-free survival (GRFS). Results: Group 1 and group 2 were not statistically different in regards to median age at allografting (54.1 vs. 56.1 years, p=0.51), median year of haplo transplantation (2018 vs. 2018, p=0.36), incidence of de novo AML (86.4% vs. 88.1%, p=0.63), Karnofsky equal or more than 90 (77.5% vs. 79.1%, p=0.70), and use of myeloablative conditioning (MAC) (44.7% vs. 48.5%, p=0.45). Patients in group 1 had a longer time from diagnosis to haplo-transplantation (5.3 vs. 4.9 months, p=0.03). In multivariate analysis, group 1 and group 2 did not differ in cumulative incidence of grade 2-4 acute GVHD (Hazard ratio (HR)=0.89 (95%CI=0.62-1.26), p=0.51) but group 1 had a significantly higher incidence of chronic (all grades) GVHD (HR=1.49 (95%CI=1.02-2.16), p=0.04). There was no difference in RI (HR=0.73 (95%CI=0.47-1.14), p=0.17), NRM (HR=1.25 (95%CI=0.78-2.02), p=0.36), LFS (HR=0.95 (95%CI=0.69-1.31), p=0.76), OS (HR=1.09 (95%CI=0.76-1.55), p=0.64) and GRFS (HR=1.07 (95%CI=0.81-1.42), p=0.64) between the groups. Presence of adverse cytogenetics was independently associated with higher RI (HR=1.90 (95%CI=1.20-2.99), p=0.006), inferior LFS (HR=1.59 (95%CI=1.15-2.19), p=0.005), inferior OS (HR=1.48 (95%CI=1.05-2.08), p=0.03), and worse GRFS (HR=1.54 (95%CI=1.17-2.04), p=0.002). Conclusion: Results show that patients undergoing haplo-transplantation with 4/8 (vs. 2-3/8) HLA mismatches have a higher incidence of chronic GVHD (all grades) without adversely affecting acute grade 2-4 GVHD, RI, LFS, OS and GRFS. Disclosures Labopin: Jazz Pharmaceuticals: Honoraria. Bazarbachi: Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Abbvie: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Hikma: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Astra Zeneca: Membership on an entity's Board of Directors or advisory committees. Blaise: Jazz Pharmaceuticals: Honoraria. McDonald: BioCryst Pharmaceuticals: Honoraria, Membership on an entity's Board of Directors or advisory committees. Forcade: Novartis: Other: travel grant. Ciceri: IRCCS Ospedale San Raffaele: Current Employment. Mohty: Takeda: Honoraria; Astellas: Honoraria; Adaptive Biotechnologies: Honoraria; Novartis: Honoraria; Celgene: Honoraria, Research Funding; Bristol Myers Squibb: Honoraria; Sanofi: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Gilead: Honoraria; Jazz: Honoraria, Research Funding; Pfizer: Honoraria; Amgen: Honoraria.

This work summarizes our experience with WT1 monitoring before and after allogeneic hematopoietic stem cell transplantation (allo-HSCT).The expression of WT1 gene was measured by real-time polymerase chain reaction in peripheral blood according to the European Leukemia Net recommendations. Between May 2005 and August 2019, we analyzed 147 consecutive patients with acute myeloid leukemia with high WT1 expression at diagnosis, transplanted in first (CR1) or second (CR2) complete remission.At the time of allo-HSCT, 107 patients had WT1-normal expression (WT1 ≤ 50 copies), and 40 patients had WT1-high expression. The median follow-up was 21 months. The estimated 5-year overall survival and event-free survival was significantly better in the WT1-normal cohort (65% and 57% vs. 37% and 25%; P = .0003 and P .0001, respectively) and 5-year cumulative incidence of relapse was significantly lower in the WT1-normal group (19% vs. 53%; P .0001). Five-year non-relapse mortality was not significantly different (20% and 23%). Multivariate analysis revealed WT1-high expression and acute graft-versus-host disease grade 3/4 as significantly negative prognostic factors for OS. Overall, 49 patients developed WT1 molecular relapse in the post-transplant period; in 14 cases, the therapeutic intervention was done. In all but 1 relapsed patient where WT1 minimal residual disease (MRD) was monitored (38 patients), we detected WT1-high levels (sensitivity of 97%).The results of the analysis confirmed our previous experience that WT1 status before allo-HSCT is a strong prognostic factor for both OS and relapse risk. In addition, we confirmed the usefulness of this marker for MRD monitoring after allo-HSCT. The main advantage is the possibility of frequent MRD monitoring in peripheral blood and early bone marrow examination based on WT1-high expression.

Background We retrospectively analyzed data from 310 patients with acute myeloid leukemia with intermediate-risk cytogenetics in first complete remission (CR1) to evaluate the usage and efficacy of various types of postremission therapy. Patients and Methods Cox regression with time-dependent covariates, landmark analysis, and competing risk models were used to estimate the outcomes and effects of treatment and patient- and disease-related risk factors. Results The early relapse rate and early nonrelapse mortality (NRM) were 12.8% and 4.4%, respectively. In our study, 77.2% of patients completed postremission therapy: 44% received allogeneic hematopoietic cell transplantation (HCT), 20% completed treatment with high-dose cytarabine (HIDAC), and 13% completed treatment with intermediate-dose cytarabine. The 3-year overall survival rate was 67.5% for patients treated with HIDAC and 63.4% after HCT (P = .5876). The NRM and relapse rate at 3 years were 0% and 58.9% after HIDAC and 21.9% and 29.3% after HCT, respectively. HCT reduced the risk of relapse (hazard ratio, 0.6; 95% confidence interval, 0.36-0.98). Total body irradiation-based myeloablative conditioning increased NRM compared with busulfan-based conditioning (hazard ratio, 8.33; 95% confidence interval, 2.52-27.45). Conclusion Most patients with acute myeloid leukemia with intermediate-risk cytogenetics received allogeneic HCT, which decreased the risk of relapse but increased NRM, leading to a similar overall survival for patients who received HCT and HIDAC. Our data support the use of allogeneic transplantation for patients in CR1 from a human leukocyte antigen-matched related or unrelated donor after a busulfan-based myeloablative conditioning regimen as a primary strategy of postremission therapy for eligible younger patients.

Background: Post-transplant cyclophosphamide (PTCy) has been shown to significantly reduce transplant related mortality (TRM) post hematopoietic stem cell transplantation (HSCT) and is being increasingly used for acute myelogenous leukemia (AML) patients (pts) undergoing HSCT including from unrelated donors (UD). These publications mainly include pts transplanted in first complete remission (CR1). We recently reported outcome in 1879 AML pts transplanted in second CR (CR2) with conventional graft-versus-host disease (GVHD) prophylaxis (Leukemia 2020). Results may differ in transplantation with PTCy as GVHD prophylaxis, eliminating proliferating alloreactive T cells, and upregulating T regulatory cells while suppressing host natural killer (NK) cells immediately after transplantation, changing the biology and characteristics of the transplantation. Methods: The study aim was to assess outcome of adult AML pts, aged ≥18 years in CR2 undergoing HSCT from a 9-10/10 UD with PTCy, in 2010-2019.Statistics included multivariate analysis (MVA) adjusting for potential confounding factors was performed using a Cox's proportional-hazards regression model for main outcomes. Results: In total, 127 pts were included. Median follow-up was 19.2 (95% CI, 14.7-28) months (mos). Median age was 45.5 (range, 18.2-71.3) years. 54.3% were male. Cytogenetic risk (MRC classification) was favorable, intermediate, and adverse in 15.7%, 55.9%, and 5.5% of pts, respectively (missing data-22.8percentage) Median year of transplantation was 2017. Time from diagnosis to transplantation was 20.4 (range, 4.1-182.4) months. All pts were at CR2 at time of transplantation. Donors were 10/10 and 9/10 UD in 60.6% and 39.4% of pts, respectively. 77.8% and 47.2% of the pts and donors, respectively, were cytomegalovirus (CMV) seropositive. Conditioning was myeloablative in 50.4% and reduced intensity in 49.6%. The most frequent (61.4%) conditioning consisted of busulfan and fludarabine. All pts received PTCy as anti GVHD prophylaxis in combination with immunosuppression, which was cyclosporine A /mycophenolate mofetil (MMF) in 21.3% and MMF/tacrolimus in 23.6%. 33.9% of the pts received In vivo T-cell depletion. Grafts were peripheral blood in 93.7% and bone marrow in 6.3% of transplants. Karnofsky performance score (KPS) was > 90 in 71.2% and the hematopoietic cell transplantation-specific comorbidity index (HCT-CI) was zero in 61.5% of the pts. Engraftment was achieved by 97.6% with day (d) 60 absolute neutrophil count (ANC) > 0.5 x 10 9/L in 96.8%, and d 180 incidence of acute (a) GVHD II-IV and III-IV was 26.2% and 9.2%, respectively. The 2-year total and extensive chronic (c) GVHD was 34.3% and 13.8 %, respectively. The 2-year non-relapse mortality (NRM) was 17.2%. The 2-year relapse incidence (RI) was 21.1%. RI was the main cause of death in 41% of pts who died, followed by infections (23.1%) and GVHD (20.5%). The 2-year leukemia-free survival (LFS), overall survival (OS) and GVHD-free, relapse-free survival (GRFS) was 61.7%, 65.2% and 49.3%, respectively (Figure). In MVA time from diagnosis to transplant was significant prognostic factor for RI, LFS, OS and GRFS hazard ratio (HR) =0.19 (95% CI 0.07-0.48, p Conclusions: Outcome of AML pts undergoing HSCT from a 9-10/10 MUD in CR with PTCy as GVHD prophylaxis, are similar to previous reports using conventional GVHD prophylaxis with 26% of pts developing aGVHD ,34% cGVHD and NRM of 17%. These results are also similar to those we previously observed in pts undergoing HSCT from UD with PTCy while in CR1. Figure 1 Figure 1. Disclosures Labopin: Jazz Pharmaceuticals: Honoraria. Kulagin: X4 Pharmaceuticals, Alexion, Apellis, Biocad: Research Funding; Novartis, Generium, Sanofi, Roche, Johnson & Johnson, Pfizer: Speakers Bureau. Blaise: Jazz Pharmaceuticals: Honoraria. Yakoub-Agha: Jazz Pharmaceuticals: Honoraria. Ciceri: IRCCS Ospedale San Raffaele: Current Employment. Mohty: Sanofi: Honoraria, Research Funding; Pfizer: Honoraria; Novartis: Honoraria; Takeda: Honoraria; Jazz: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Gilead: Honoraria; Celgene: Honoraria, Research Funding; Bristol Myers Squibb: Honoraria; Astellas: Honoraria; Amgen: Honoraria; Adaptive Biotechnologies: Honoraria.

Acute graft-versus-host disease (GVHD) remains a major limitation of allogeneic stem-cell transplantation; not all patients have a response to standard glucocorticoid treatment. In a phase 2 trial, ruxolitinib, a selective Janus kinase (JAK1 and JAK2) inhibitor, showed potential efficacy in patients with glucocorticoid-refractory acute GVHD.We conducted a multicenter, randomized, open-label, phase 3 trial comparing the efficacy and safety of oral ruxolitinib (10 mg twice daily) with the investigator's choice of therapy from a list of nine commonly used options (control) in patients 12 years of age or older who had glucocorticoid-refractory acute GVHD after allogeneic stem-cell transplantation. The primary end point was overall response (complete response or partial response) at day 28. The key secondary end point was durable overall response at day 56.A total of 309 patients underwent randomization; 154 patients were assigned to the ruxolitinib group and 155 to the control group. Overall response at day 28 was higher in the ruxolitinib group than in the control group (62% [96 patients] vs. 39% [61]; odds ratio, 2.64; 95% confidence interval [CI], 1.65 to 4.22; P0.001). Durable overall response at day 56 was higher in the ruxolitinib group than in the control group (40% [61 patients] vs. 22% [34]; odds ratio, 2.38; 95% CI, 1.43 to 3.94; P0.001). The estimated cumulative incidence of loss of response at 6 months was 10% in the ruxolitinib group and 39% in the control group. The median failure-free survival was considerably longer with ruxolitinib than with control (5.0 months vs. 1.0 month; hazard ratio for relapse or progression of hematologic disease, non-relapse-related death, or addition of new systemic therapy for acute GVHD, 0.46; 95% CI, 0.35 to 0.60). The median overall survival was 11.1 months in the ruxolitinib group and 6.5 months in the control group (hazard ratio for death, 0.83; 95% CI, 0.60 to 1.15). The most common adverse events up to day 28 were thrombocytopenia (in 50 of 152 patients [33%] in the ruxolitinib group and 27 of 150 [18%] in the control group), anemia (in 46 [30%] and 42 [28%], respectively), and cytomegalovirus infection (in 39 [26%] and 31 [21%]).Ruxolitinib therapy led to significant improvements in efficacy outcomes, with a higher incidence of thrombocytopenia, the most frequent toxic effect, than that observed with control therapy. (Funded by Novartis; REACH2 ClinicalTrials.gov number, NCT02913261.).

In this multi-centre study, we analysed the prognostic impact of mutations in 19 genes associated with myeloid malignancies in 258 newly diagnosed acute myeloid leukaemia patients (aged 19-70 years) undergoing intensive therapy. We identified five patient groups with different prognostic risks and different benefits from allogeneic hematopoietic stem cell transplantation (alloHSCT) within the intermediate cytogenetic risk group patients (n = 184). The most adverse prognosis was observed in patients with DNMT3A and FLT3-ITD co-mutation, whose survival could be significantly improved with alloHSCT. In contrast, the most favourable prognosis without any further benefit from alloHSCT was identified in patients with mutations in NPM1 or CEBPA, after exclusion of the unfavourable prognostic groups defined by mutations in DNMT3A, RUNX1 or genes from chromatin/spliceosome group. An additional analysis of 113 diagnosis-remission paired samples revealed that persistence of non-DNMT3A mutations (above 2% VAF) represented a further negative prognostic factor. The proposed model offers a possible molecular stratification and treatment guidance for intermediate cytogenetic risk group patients.

Breast ultrasonography (US) presents an alternative to mammography in young asymptomatic individuals and a complementary examination in screening of women with dense breasts. Handheld US is the standard-of-care, yet when used in whole-breast examination, no effort has been devoted to monitoring breast coverage and missed regions, which is the purpose of this study. We introduce a computer-aided system assisting radiologists and US technologists in covering the whole breast with minimum alteration to the standard workflow. The proposed system comprises a standard US device, proprietary electromagnetic 3D tracking technology and software that combines US visual and tracking data to estimate a probe trajectory, total time spent in different breast segments, and a map of missed regions. A case study, which involved four radiologists (two junior and two senior) performing whole-breast ultrasound in 75 asymptomatic patients, was conducted to test the importance and relevance of the system. The mean process time per breast was $$74\pm 22\,{\mathrm {s}}$$ , with no statistically significant difference between the left and the right sides, and slightly longer examination time of junior radiologists. The process time density shows that central parts of the breast have better coverage compared to the periphery. Within the central part, missed regions of minimum detectable size of $$0.09\,{\mathrm {cm}}^2$$ occur in $$8\%$$ of examinations, and non-negligible $$1\,{\mathrm {cm}}^2$$ regions occur in $$3\%$$ of cases. The results of the case study indicate that missed regions are present in handheld whole-breast US, which renders the proposed system for tracking the probe position during examination a valuable tool for monitoring coverage.

Liposarcomas are malignant tumors of the soft tissue. Myxoid liposarcoma is the second most common subtype of these tumors in adults. It accounts for approximately 20% of all malignant soft tissue tumors [1] , [2] . Peak of its incidence occurs between 40 to 60 years of age with relatively indolent clinical course Matsumoto et al. (2007) [3] , Cho et al. (2010) [4] , Faiman et al. (2005) [5] . Typical localizations of myxoid liposarcoma comprise limbs, particularly thighs with a tendency to metastasize into extrapulmonary sites such as retroperitoneum, mediastinum, bones. Cardiac metastases are extremely rare. We present a case of a 36-year-old man with a history of recurrent myxoid liposarcoma. Primary location was in the left popliteal area. After extirpation of the tumor, metastatic tumor was subsequently revealed in the right axilla. Each surgical extirpation was followed by radiation therapy and brachytherapy. Cardiac metastasis was accidentally diagnosed with PET/CT during the staging process. The patient was asymptomatic and was admitted to our institution for further diagnostics and treatment. After confirmation of its location, the tumor was excised. Histological examination revealed myxoid liposarcoma.

Introduction Oxidative stress as a disruption of redox homeostasis is a state where reactive oxygen species (ROS) concentration is transiently/chronically increased or ROS-scavening capacity is declined. ROS have an important role in intracellular signaling process. On the other side increased ROS production could lead to oxidative damage of biomolecules as lipids, DNA and proteins. Many types of cancer cells have elevated levels of ROS for promoting cell proliferation and differentiation [1,2]. In the context of hematopoietic malignancy, in acute myeloid leukemia (AML) there is evidence of elevated ROS and/or accompanying oxidative stress [3], however little is known about the changes of oxidative status during AML treatment. The aim of this study was to estimate oxidative stress using the malondialdehyde (MDA) concentration as a marker of lipid peroxidation. The MDA concentrations were measured during treatment of AML patients in the initial stage (AML patients in diagnosis), after chemotherapy treatment (AML patients in remission), and after pretransplantation conditioning (AML patients before transplantation) in comparison with healthy controls. Methods Serum MDA concentration was analyzed in samples obtained at diagnosis, in remission, and before transplantation from patients (n=20) treated in the Institute of Hematology and Blood Transfusion, Prague, Czech Republic. As a control we used serum of healthy donors (n=13). Briefly, serum samples were prepared by alkaline hydrolysis, deproteinized and total MDA was derivatized by 2,4-dinitrophenylhydrazine (DNPH). MDA-DNPH derivates were separated by HPLC and determined using positive ion multiple reaction monitoring (MRM) mode by MS/MS. Results Using analysis of variance (ANOVA) we found significant differences in MDA concentrations in serum of AML patients and healthy controls (P < 0.0001). Moreover, Tukey post-hoc test applied to comparison of all treatment periods of AML patients with healthy controls revealed significantly increased MDA levels in the period before transplantation (P < 0.001) with respect to healthy controls. The MDA levels in the initial stage was also elevated as compared with healthy controls, but non significantly (P = 0.062). Comparing only AML patients in the individual treatment periods, we found significantly increased concentrations of MDA in samples of AML patients before transplantation with respect to AML patients in diagnosis (P = 0.023) and also to the patients in remission (P = 0.012). Conclusion Overall, throughout treatment periods for AML patients compared to healthy controls significant changes in MDA concentrations were identified. It is in agreement with previous findings stated that cancer cells have elevated levels of ROS possibly playing an important role in the initiation and progression of cancer. The highest MDA concentration was detected in samples of AML patients before transplantation which could be related to conditioning regimens [4]. The monitoring of AML patients at different times of disease treatment revealed that oxidative stress is changing not only as a result of disease progression but also as a result of treatment. Acknowledgement This work was supported by the European Regional Development Fund and the state budget of the Czech Republic (project AIIHHP: CZ.02.1.01/0.0/0.0/16_025/0007428, OP RDE, Ministry of Education, Youth and Sports), by the project of the Ministry of Health, Czech Republic, 00023736, by Grant from the Czech Science Foundation, Czech Republic, 19-02739S, and by ERDF OPPK CZ.2.16/3.1.00/24001. [1] Boonstra J, Post JA. Gene 2004;337, 1-13. [2] Schafer FQ, Buettner GR. Free Radic Biol. Med. 2001;30, 1191-1212. [3] Hole PS, Zabkiewicz J, Munje C, Newton Z, Pearn L, White P, Marquez N, Hills RK, Burnett AK, Tonks A, Darley RL. Blood. 2013;122(19):3322-3330. [4] Trachootham D, Alexandre J, Huang P. Nat Rev Drug Discov. 2009;8(7):579-591. Disclosures No relevant conflicts of interest to declare.

Chromosome 11 abnormalities are found in many hematological malignancies. In acute myeloid leukemia (AML), a proto-oncogene MLL (11q23.3) is frequently altered. However, rearrangements involving other regions of chromosome 11 have been reported. Therefore, we have characterized the chromosome 11 breakpoints and common deleted and amplified areas in the bone marrow or peripheral blood cells of newly diagnosed patients with AML. Using molecular-cytogenetic methods (multicolor fluorescence in situ hybridization (mFISH), multicolor banding (mBAND), microarrays, and FISH with bacterial artificial chromosome (BAC) probes, chromosome 11 abnormalities were delineated in 54 out of 300 (18%) newly diagnosed AML patients. At least 36 different chromosome 11 breakpoints were identified; two were recurrent (11p15.4 in the NUP98 gene and 11q23.3 in the MLL gene), and three were possibly nonrandom: 11p13 (ch11:29.31-31.80 Mb), 11p12 (ch11:36.75-37.49 Mb) and 11q13.2 (68.31-68.52 Mb). One new MLL gene rearrangement is also described. No commonly deleted region of chromosome 11 was identified. However, some regions were affected more often: 11pter-11p15.5 (n = 4; ch11:0-3.52 Mb), 11p14.1-11p13 (n = 4; ch11:28.00-31.00 Mb) and 11p13 (n = 4; ch11:31.00-31.50 Mb). One commonly duplicated (3 copies) region was identified in chromosomal band 11q23.3-11q24 (n = 9; ch11:118.35-125.00 Mb). In all eight cases of 11q amplification (>3 copies), only the 5' part of the MLL gene was affected. This study highlights several chromosome 11 loci that might be important for the leukemogeneic process in AML.

Summary Objectives To evaluate risk factors, diagnostic procedures, and treatment outcomes of invasive aspergillosis (IA) in patients with hematological malignancies. Methods A retrospective analysis of data from proven/probable IA cases that occurred from 2005 to 2009 at 10 hematology centers was performed. Results We identified 176 IA cases that mainly occurred in patients with acute leukemias (58.5%), mostly those on induction/re-induction treatments (39.8%). Prolonged neutropenia was the most frequent risk factor for IA (61.4%). The lungs were the most frequently affected site (93.8%) and computed tomography detected abnormalities in all episodes; however, only 53.7% of patients had findings suggestive of IA. Galactomannan (GM) detection in serum or bronchoalveolar lavage fluid (positive in 79.1% and 78.8% of episodes, respectively) played a crucial role in IA diagnosis. Neutrophil count and antifungal prophylaxis did not influence the GM positivity rate, but empirical therapy decreased this rate (in serum). Of the IA cases, 53.2% responded to initial antifungal therapy. The combination of voriconazole and echinocandin, even as initial or salvage therapy, did not perform better than voriconazole monotherapy ( p =0.924 for initial therapy and p =0.205 for salvage therapy). Neutrophil recovery had a significant role in the response to initial (but not salvage) antifungal therapy. Conclusions Our retrospective analysis identified key diagnostic and treatment characteristics, and this understanding could improve the management of hematological malignancy patients with IA.

Enterococci are an important cause of healthcare-associated infections. We retrospectively analyzed risk factors and outcome of vancomycin-resistant enterococci (VRE) and vancomycin-sensitive enterococci (VSE) infections.Seven hundred fifty-two patients who received hematopoietic stem cell transplants from 2004 through 2008 at the University of Minnesota were included.Ninety-three patients had enterococcal bloodstream infection (BSI) during the first year after transplant. Vancomycin resistance was observed in 66% and 31% of isolates in adults and children, respectively. Cumulative incidence of VRE and VSE bacteremia was 6.6% (95% confidence interval [CI], 4.8%-8.4%) and 5.7% (95% CI, 4.0%-7.4%), respectively. Colonization with VRE before or after transplant was a risk factor for VRE bacteremia (odds ratio [OR], 3.3 [95% CI, 1.3-8.3] and 7.0 [95% CI, 4.0-14.8], respectively). Delay in engraftment increased the incidence of VRE bacteremia from 4.5% (95% CI, 2.9-6.6) if engrafted before day 21 and to 15% (95% CI, 3.2%-38%) if engrafted between days 36 and 42. In adults, mortality 30 days after infection was 38% for both VRE (95% CI, 25%-54%) and VSE cases (95% CI, 21%-62%). The hazard ratio for all-cause mortality up to 1 year after transplant was 4.2 (95% CI, 3.1-6.9) and 2.7 (95% CI, 1.4-5.1) for patients with VRE and VSE BSIs, respectively, compared to patients without enterococcal BSI. In pediatric patients, mortality 30 days after VRE and VSE bacteremia was 20% (95% CI, 5.4%-59%) and 4.5% (95% CI, .6%-28%), respectively.High rates of vancomycin resistance and association of enterococcal infections with significant mortality warrant further efforts to optimize prevention and management of these infections.

Hematooncologic patients often host rare or fastidious pathogens. Using 16S rDNA sequencing and transmission electron microscopy, we have identified 2 lymphoma patients infected with Candidatus Neoehrlichia mikurensis. In both individuals, the clinical presentation suggested ehrlichiosis-like syndrome. We believe that molecular techniques open new vistas in the field of pathogen detection.

Introduction Acute myeloid leukemia (AML) represents an aggressive bone marrow malignancy with diverse genetic abnormalities. The tumor cells, to support their own growth and proliferation, may alter metabolism 1) to accelerated glycolysis to provide energy/biosynthetic precursors and 2) to produce intermediates by active TCA cycle for synthesis of essential biomolecules [1]. Mutations of isocitrate dehydrogenase (IDH1/2) as frequent mutations (affecting approximately 20% of AML patients) cause the reduction of α-ketoglutarate to D-2-hydroxyglutarate instead of oxidative decarboxylation of isocitrate to α-ketoglutarate. IDH2 mutations occur almost exclusively in hematopoietic tumors. Whereas IDH2R140 mutation is frequently accompanied by normal cytogenetics and NPM1 mutations, IDH2R172 is frequently the only mutation detected in AML. In addition, IDH2R172 confers a poor prognosis in patients with AML [2, 3]. The aim of this study was to characterize and uncover the differences in metabolism of AML patients with or without IDH2 mutations in diagnosis (the initial stage), in remission (after chemotherapy treatment), and before transplantation (after conditioning). Methods Serum metabolomics profiles were generated with samples obtained at diagnosis, in remission, and before transplantation from patients (n=20) treated in the Institute of Hematology and Blood Transfusion, Prague, Czech Republic. Patients were assigned in IDH2WT (n=7) and IDH2R140/ IDH2R172 (n=7/6) groups. Targeted metabolomic profiling of 19 metabolites related mainly to TCA cycle and glycolysis was performed by LC-MS/MS. Results Using non-parametric randomized block analysis of variance (Friedman test) we found significant differences in levels of 13 metabolites among treatment periods for all AML patients. Moreover, when comparing each treatment periods for all patients, we found significantly decreasing levels of 12 metabolites between the initial stage and the period before transplantation. If we considered the division of patients into groups according to IDH2 mutations, we found significantly different levels of 4 metabolites among treatment periods for samples of patients with IDH2R140,namely 2 metabolites of TCA cycle: isocitrate, succinate; and 3-hydroxybutyrate and urate. We obtained significantly different levels in the same number of other metabolites for IDH2WT. In samples of patients with IDH2R172 we found significantly different levels of 8 metabolites among treatment periods, namely 5 metabolites of TCA cycle: citrate, 2-hydroxyglutarate, succinate, fumarate, malate; 2 metabolites of glycolysis: 3-phosphoglycerate, phosphoenolpyruvate; and pyroglutamate of glutathione metabolism. Furthermore, using Nemenyi post-hoc test we ascertained significantly decreasing levels of named metabolites in IDH2R140 and IDH2R172 samples before transplantation with respect to the initial stages of AML (diagnosis). Conclusion Overall, this study identified significant changes in several metabolites of TCA cycle and glycolysis between initial and final treatment periods and also between remission and period before transplantation in AML patients. With respect to IDH2 mutations we found more significant changes in metabolites specifically in TCA cycle for IDH2R172 patients relative to IDH2R140. The results of our preliminary targeted metabolomic profiling of AML patients with IDH2 mutations are corresponding with the already described differences in morphological and genetic patterns in the patients and, moreover, support the classification of IDH2R172 as separate AML subtype. Metabolomic profiling thus seems to be a new valuable tool providing additional important information. Acknowledgment This work was supported by the European Regional Development Fund and the state budget of the Czech Republic (project AIIHHP: CZ.02.1.01/0.0/0.0/16_025/0007428, OP RDE, Ministry of Education, Youth and Sports), by the project of the Ministry of Health, Czech Republic, 00023736, by Grant from the Academy of Sciences, Czech Republic, P205/12/G118, and by ERDF OPPK CZ.2.16/3.1.00/24001. [1] DeBerardinis RJ, Lum JJ, Hatzivassiliou G, Thompson CB. Cell Metab. 2008;7(1):11-20. [2] Rakheja D, Konoplev S, Medeiros LJ, Chen W. Hum Pathol. 2012;43(10):1541-51. [3] Meggendorfer M, Cappelli LV, Walter W, Haferlach C, Kern W, Falini B, Haferlach T. Leukemia. 2018;32(5):1249-1253. Disclosures No relevant conflicts of interest to declare.

We demonstrate spontaneous desorption time of flight mass spectrometry investigations on chemical reactions within thin solid films with a thickness of a few monolayers deposited by the Langmuir–Blodgett–Kuhn (LBK) technique and in the μm regime by spincoating. The photo induced decomposition of the polymeric system of a dye, disperse red 1, covalently bound to polymethylmethacrylate is one of the systems under investigation. Films of a thickness, which are typical for channel waveguides, were illuminated with UV and annealed subsequently. The decomposition of the dye after the illumination could be proven by the decrease of the mass peaks of intact dye and the increase of dye fragments. The annealing process leads to an evaporation of the loosened dye, its fragments and fragments of the polymer backbone. The results are compared with in situ bleaching experiments observed by time dependent photo thermal beam deflection. The second system consists of a poly[(tert-butylacrylate)-co-CN(3-methacroylpropyl)-3,4-dimethylmaleicacidanhydride)] multilayer LBK sample that is cross-linked via UV irradiation and saponified by wet HCl treatment to achieve a thin film poly(methacrylic acid) network. The time development of the saponification is observed by the mass spectrometry and Fourier Transform Infrared Spectroscopy.