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Some allogeneic stem cell transplantation (allo-SCT) recipients develop therapy-related myeloid neoplasms (t-MNs) of recipient origin with features including karyotypically abnormal hematopoiesis without cell dysplasia and myeloblast increase. However, due to their rarity their clinical course remains unclear. We report six cases of t-MN in patients with chromosomal abnormalities (CAs) after autologous recovery following allo-SCT for acute leukemia. CAs were first detected at a median interval of 422 (range 30-1941) days from allo-SCT. The fraction of CA-bearing cells of recipient origin increased with time, and cytogenetic relapse of underlying disease was not observed. Continuous emergence of identical autologous CAs was observed in one patient who did not receive total body irradiation (TBI). The other five patients received TBI, and complex karyotypes with the appearance of different types of CAs were the most dominant feature. Despite the persistence of complex abnormalities in the irradiated patients, no patient developed therapy-related acute myeloid leukemia (t-AML). TBI appears to be the major cause of t-MN of recipient origin with different types of CAs. Although t-MNs in patients receiving TBI do not initially seem to evolve to overt t-AML, they were associated with higher risk of underlying disease and greater oncogenic potential of irradiation.

Primary graft failure (PGF) is a lethal complication that occurs early after allogeneic stem cell transplantation (allo-SCT). Cord blood transplantation (CBT) is a potential re-transplantation option. Total body irradiation (TBI) is often incorporated into the pre-salvage CBT conditioning regimen following PGF; however, patients experiencing PGF are not always amenable to TBI, and non-TBI regimens for salvage CBT should be established. Here, we report five patients with hematologic malignancies who received salvage CBT for PGF following a non-TBI regimen using fludarabine (Flu), melphalan (Mel), and low-dose anti-thymocyte globulin (ATG). The median intervals between the failed allo-SCT and salvage CBT, as well as between the diagnosis of PGF and salvage CBT, were 37 days and 8 days, respectively. The median neutrophil recovery period was 21 days (range 18-21 days). Four of five patients achieved neutrophil engraftment following salvage CBT; all four exhibited sustained engraftment with complete donor chimerism. Three of the five patients were alive after a median follow-up time of 907 days (range 315-909 days) post-salvage CBT; two patients died of causes unrelated to recurrence. These data suggest that CBT following the non-TBI regimen described here is feasible in patients with PGF.

Given the poor prognosis of patients with relapsed/refractory acute myeloid leukemia (AML), better therapy is needed. Fludarabine enhances the efficacy of Ara-C (cytarabine) by increasing intracellular Ara-C-triphosphate. The FLAG (fludarabine, high-dose Ara-C, supported with granulocyte colony-stimulating factor) regimen has been tested for use in AML patients by other investigators. In the phase II study reported here, we evaluated the efficacy and toxicity of FLAGM therapy (FLAG with mitoxantrone), further intensified by adding mitoxantrone, based on the results of a phase I study by our group. The major endpoints were complete remission (CR) rate and early death. From June 2004 to February 2008, 41 patients (median age 52 years; range 18-64 years) were enrolled. Thirty (73% 95% CI 58-84%) patients achieved CR, which met the primary endpoint; there was a single case of early death from pneumonia. Two-year overall survival was 39.4% (95% CI 25.2-55.6%). Of those who achieved CR, 27 underwent allogeneic stem cell transplantation (SCT), and 12 SCT recipients showed long-term survival. Grade 3/4 non-hematological adverse events included infection (59%), nausea/vomiting (15%), diarrhea (7%), and elevated liver enzymes (7%). In conclusion, FLAGM is an effective and safe salvage therapy for patients with relapsed/refractory AML, and facilitated SCT for a large proportion of patients.

Additional cytogenetic abnormality (ACA) acquisition at relapse has been recognized as clonal evolution at the cytogenetic level, and has a significant prognostic impact on relapsed acute myeloid leukemia (AML) patients. We retrospectively investigated 48 relapsed Philadelphia chromosome (Ph)-negative acute lymphoblastic leukemia (ALL) patients to clarify the clinical significance of ACA acquisition at the first relapse. Twenty-seven patients (56 %) acquired ACA at the first relapse. No significant predisposing factor for ACA acquisition was identified. Notably, patients with ACA acquisition showed a significantly lower second complete remission rate compared to those without ACA acquisition (14.8 % vs. 76.2 %, respectively; p < 0.01), and furthermore, the overall survival rates after the first relapse were significantly different between patients with and without ACA acquisition (25.9 % vs. 55.3 % at 1 year, respectively; p < 0.01). Multivariate analysis extracted ACA acquisition as the only negative prognostic factor (hazard ratio: 2.55, p < 0.01). All seven patients with ACA acquisition who underwent allogeneic transplant died within 2 years after relapse. These findings suggested that clonal evolution detected with conventional cytogenetic analysis at the first relapse triggers severe chemo-refractoriness in Ph-negative ALL cells, just like AML cells. Novel therapeutic strategies are warranted for this subset of patients.

Background: Additional cytogenetic abnormalities (ACA), the most frequent form of cytogenetic changes, are considered as a result of genetic instability and clonal evolution of leukemia cells. Recently, we described that ACA at the first relapse was associated with the significantly lower second complete remission (CR2) rate and poor survival in adult acute myeloid leukemia (AML) patients (Hematol Oncol. 2018;36:252-257). However, the prognostic impact of ACA after allogeneic stem cell transplant (allo-SCT) has not been elucidated in adult AML patients. Patients and methods: Of the 145 adult AML patients who underwent the first allo-SCT in CR2 between 1997 and 2019, 98 patients whose cytogenetic abnormality data both at diagnosis and at the first relapse were available were included in this study. Cytogenetic changes between at diagnosis and the first relapse were classified into four groups: (1) no change, (2) ACA was acquired at the first relapse, (3) cytogenetic abnormalities observed at diagnosis were reduced or had disappeared at the first relapse, and (4) cytogenetic abnormalities observed at diagnosis were reduced or had disappeared, and completely different ACA was acquired at the first relapse. In this study, groups 2 and 4 were defined as ACA acquisition. Overall survival (OS) was defined as the interval from the date of transplant to the date of death. Fisher's exact test was used to compare binary variables. The cumulative incidence (CI) of non-relapse mortality (NRM) and relapse were evaluated with Gray's test, considering relapse and NRM as a competing risk, respectively. OS was estimated with the Kaplan-Meier method and compared using the log-rank test. Factors associated with at least borderline significance (p < 0.20) in univariate analyses were subjected to multivariate analysis. The Cox and Fine-Gray proportional hazard model were used for multivariate analysis of prognostic and risk factors, respectively. Values of p < 0.05 were considered to indicate statistical significance. Results: Of the 98 patients included in this study, 57 were male, and 41 were female. The median age at transplant was 45 years (range, 17-71 years). The median duration of CR1 was 12.4 months (range, 1.3-70.3 months) and cytogenetic risk groups were good, intermediate, and poor in 26 (27%), 70 (71%), and two patients (2%), respectively. Donor types were related, unrelated, and cord blood in 23 (24%), 59 (60%), and 16 patients (16%), respectively, and 86 (87%) and 61 patients (62%) were conditioned with myeloablative and total body irradiation-containing regimens, respectively. According to the definition described above, 20 patients (20%) acquired ACA at the first relapse. There was no significant difference in baseline characteristics and transplant procedures between patients with and without ACA acquisition. The OS rates were not significantly different between two groups (55% vs. 72% at three years after transplant; p = 0.28). The CI of relapse was significantly higher in patients with ACA acquisition than those without ACA acquisition (59% vs. 15%; p < 0.01), while the CI of NRM were not significantly different between two groups (5% vs. 19%; p = 0.17). Multivariate analysis for OS revealed that age over 50 years (hazard ratio [HR] = 2.4; p < 0.01), but not ACA acquisition, was identified as an independent prognostic factor. ACA acquisition (HR = 4.7; p < 0.01) was extracted as an independent risk factor of relapse, while use of reduced intensity conditioning regimens (HR = 3.1; p = 0.03) and more than or equal to 1 of performance status at transplant (HR = 2.7; p = 0.04) showed independent risks of NRM. The similar OS rates between two groups might resulted from an offset of the lower relapse rate with the higher NRM rate in patients without ACA acquisition despite not reaching statistical significance. This increasing NRM rates in those without ACA acquisition was potentially associated with use of reduced intensity conditioning regimens in larger proportion (0% vs. 15%; p = 0.12). Conclusion: These findings suggested that ACA acquisition at the first relapse was associated with a higher risk of relapse even after allo-SCT in CR2 in adult AML patients. As AML cells with ACA acquisition was resistant to not only chemotherapy but also graft-versus-leukemia effect, innovative therapeutic strategy is warranted. Disclosures Handa: Janssen: Honoraria; Kyowa Kirin: Research Funding; Takeda: Honoraria, Research Funding; BMS: Honoraria; Chugai: Research Funding; Ono: Honoraria; Sanofi: Honoraria, Research Funding; Abbvie: Honoraria; MSD: Research Funding; Shionogi: Research Funding; Celgene: Honoraria, Research Funding; Daiichi Sankyo: Research Funding.

The translocation t(8;16)(p11;p13), which results in fusion of the MOZ/MYST3/KAT6A gene (8p11) and CBP/CREBBP gene (16p13), is characterized by unique morphologic and clinical findings in acute mye...

Background: Extramedullary (EM) relapses were sometimes observed in acute leukemia patients both after chemotherapy and allo-SCT. Our recent study described that the rate of EM relapses after allo-SCT was significantly higher when comparing with that after chemotherapy in acute myeloid leukemia (AML) patients. Since more potent graft-versus-leukemia (GVL) effect in EM lesion than bone marrow (BM) is proposed as potential biological basis of this phenomenon, it is expected that EM relapses after allo-SCT more frequently occurred than after chemotherapy also in ALL patients. However, this hypothesis has not been examined, and risk factors of EM relapses after allo-SCT have not been elucidated. So, we conducted this retrospective study to address this unsolved issue. Patients and methods: The study population included in this study was 215 adult patients who were diagnosed as ALL between 1990 and 2017 and received intensive chemotherapy. In the first part of this study, to compare the rates of EM relapses between after chemotherapy and allo-SCT, the initial relapses of the 88 patients were analyzed. In the second part, to investigate risk factors for EM relapses after allo-SCT, 110 patients who underwent allo-SCT against ALL were analyzed. EM relapses included both one only in EM lesions and in concurrent EM and BM lesions. Fisher's exact test was used to compare binary variables. Cumulative incidences (CIs) of EM relapse were compared using the stratified Gray test, considering relapse without EM lesions and death without the event as a competing risk. The logistic regression model and the Fine-Gray proportional hazard model were used for multivariate analysis of risk factors of EM relapses among the initial relapses and after allo-SCT, respectively. Values of p < 0.05 were considered significant. Results: Of the 88 relapsed patients included in the first part of this study, the median age at diagnosis was 47 years (range, 15-79 years), and the median duration of the first complete remission (CR1) was 7.1 months (range, 0.7-105.7 months). Philadelphia chromosome (Ph) and EM lesions at diagnosis were observed in 21 and 21 patients, respectively. Allo-SCT in CR1 was undergone in 12 patients. EM relapses occurred in 21 patients, and the sites of EM relapses were central nervous system (CNS) in 13, mediastinum in two, and bone in two. The median durations of CR1 were not significantly different between relapses with and without EM lesions (16.8 vs. 6.7 months, respectively; p = 0.295). In univariate analysis for risk factors of EM relapses, there was no significant difference in EM relapse rates between relapses after allo-SCT and chemotherapy (8.3% vs. 26.3%, respectively; p = 0.279), and in multivariate analysis, only EM lesion at diagnosis was identified as independent risk factor (odds ratio 4.21; p = 0.008). Of the 110 allo-SCT recipients included in the second part, the median age at diagnosis was 43 years (range, 16-66 years). Ph and EM lesions at diagnosis were observed in 43 and 21 patients, respectively. Disease status at the time of transplant was CR1 in 67, advanced CR in 17, and non-CR in 26. Stem cell sources were related, unrelated, and cord blood in 30, 50, and 25 patients, respectively, and almost all patients were conditioned with total body irradiation-containing myeloablative regimens. EM relapse after allo-SCT occurred in nine patients, and the 2-year CI of EM relapses was 6.5%. The sites of EM relapses after allo-SCT were CNS in three, lymph node in two, and skin in two. In univariate analysis for EM relapses after allo-SCT, the significantly higher CI of EM relapses after allo-SCT was observed in patients with EM lesion at diagnosis when comparing with those without EM lesion (28.6% vs. 1.1%, respectively; p = 0.279). Multivariate analysis extracted only EM lesion at diagnosis as an independent risk factor for EM relapses after allo-SCT (hazard ratio 24.09; p = 0.004). Conclusion: As a higher frequency of EM relapse after allo-SCT in ALL patients was not confirmed in this study, the hypothesis, more potent GVL effect in EM lesion than BM, was not able to apply to these patients. To determine whether this hypothesis is correct or not, further investigation in patients with other hematologic malignancy such as chronic myeloid leukemia is warranted. The vigilance is required regarding EM relapses in adult ALL patients with EM lesion at diagnosis both after chemotherapy and allo-SCT. Disclosures Handa: Ono: Research Funding.

Although the introduction of imatinib dramatically improved the outcomes for patients with Philadelphia chromosome-positive B-cell precursor acute lymphoblastic leukemia (Ph + BCP-ALL), the survival benefit of imatinib has not been assessed in the context of Ph + mixed phenotype acute leukemia (Ph + MPAL). To clarify this important issue, we studied 42 Ph+ acute leukemia (Ph + AL) patients who received intensive chemotherapy and concurrent administration of imatinib. Of the 42 Ph + AL patients, 13 (31%) patients were categorized as Ph + MPAL (positive for both myeloid and B-cell lineage), 27 (64%) were categorized as Ph + BCP-ALL, and two (5%) were categorized as Ph + acute myeloid leukemia. The complete remission rates after the initial induction therapy were not significantly different when comparing Ph + MPAL and Ph + BCP-ALL patients (100% vs. 85%, respectively, P = 0.14). Likewise, there were no significant differences in the 5-yr overall survival (OS) or disease-free survival (DFS) rates when comparing the MPAL and BCP-ALL groups (OS: 55% vs. 53%, respectively, P = 0.87, DFS: 46% vs. 42%, respectively, P = 0.94). These findings suggest that concurrent imatinib administration with chemotherapy improved the outcomes of Ph + MPAL patients to the level seen in Ph+BCP-ALL patients and should, therefore, be considered as the standard therapy for these patients.

Background:Although cytogenetic abnormalities at diagnosis are recognized as one of the most potent prognostic factors in acute leukemia patients, CCH acquisition at diagnosis, which are considered as a result of clonal evolution of leukemia cells, is not taken into account in prognostic classifications. Recent studies reported that CCH acquisition was observed in 24 - 32% of adult AML patients with abnormal karyotype, was more likely to occur in patients with older age and complex karyotype, and showed adverse prognostic impact. However, the clinical significance of CCH acquisition has not been investigated in adult ALL patients to date. Patients and methods: Of the 238 adult ALL patients diagnosed between 1990 and 2016, 120 patients with abnormal karyotype at diagnosis, who underwent intensive chemotherapy, were included in this study. CCH was defined as presence of two or more cytogenetically abnormal clones. A defined ancestral clonal evolution included either mother-daughter and/or branched patterns. In the mother-daughter pattern, a daughter clone showed all cytogenetic abnormalities of a mother clone plus additional abnormality(s), which define a distinct subclone. In a branch pattern, all subclones possessed common cytogenetic abnormalities suggesting presence of a common ancestry, but each subclone acquires unique additional abnormality(s), which define them as distinctive subclones. Both patterns of cytogenetic clonal evolution were sometimes seen in a patient. Composite karyotypes were applied to patients where a common ancestry could not be clearly determined because of too complicated cytogenetic findings. Fisher's exact test was used to compare binary variables. The logistic regression model was used for multivariate analysis of predisposing factors. Overall survival (OS) was estimated with the Kaplan-Meier method and compared using the log-rank test. The Cox proportional hazard model was used for multivariate analysis of prognostic factors. Values of p < 0.05 were considered to indicate statistical significance. Results:Of the 120 patients included in this study, 64 patients were male, and 56 were female. The median age was 50 years (range, 16-79 years). Karyotypes at diagnosis were Philadelphia chromosome (Ph) in 56 patients, complex in 15, and t(8;14) in seven. According to the definition described above, 47 patients (39%) showed CCH at diagnosis, and two (4%) among them were categorized as composite karyotype. Of the 45 patients harboring a defined ancestral clonal evolution, numbers of subclones were two, three, and four in 32 patients (68%), 11 (24%), and 2 (4%), respectively. Mother-daughter pattern, branched pattern, and both were seen in 34 patients (76%), 5 (11%), and 6 (13%). In univariate analysis for predisposing factors of CCH acquisition, only younger age was significantly associated with CCH acquisition (48% in age 50; p = 0.04), but not karyotype. This statistical significance was confirmed with multivariate analysis (odds ratio = 0.44; p = 0.03). When investigating the prognostic impact of CCH acquisition, patients were divided into Ph-negative or Ph-positive ALL groups. In the 64 Ph-negative ALL patients, the CR rates were not significantly different between patients with or without CCH (78% vs. 78%, respectively; p = 1.00). The OS rates were similar between two groups (26% vs. 39% at five years, respectively; p = 0.56). Multivariate analysis for OS revealed that complex karyotype and t(8;14) were independent prognostic factors, but not CCH acquisition. Likewise, in the 56 Ph-positive ALL patients, CCH acquisition was not significantly associated with the CR rates (92% vs. 78%, respectively; p = 0.27), and the OS rates did not significantly differ between the two groups (34% vs. 40% at five years, respectively; p = 0.90). In multivariate analysis for OS, no independent prognostic factor was identified. Conclusion: Adult ALL patients with abnormal karyotype acquired CCH at diagnosis with a frequency comparable to that of AML patients. However, unlike AML patients, CCH acquisition was more frequently observed in younger population and did not show any prognostic impact in ALL patients. These findings suggested that biological backgrounds of CCH acquisition at diagnosis were possibly different between in patients with ALL and AML. So, to confirm these important findings, clinical studies with larger study subjects are warranted. Disclosures Handa: Celgene: Honoraria, Research Funding, Speakers Bureau; Takeda: Consultancy, Honoraria, Research Funding, Speakers Bureau.

We retrospectively investigated 144 patients with relapsed acute myeloid leukemia (AML) to clarify predisposing factors and the prognostic impact of acquisition of additional cytogenetic abnormalities (ACA) at the first relapse. Additional cytogenetic abnormalities are recognized as clonal evolution at the cytogenetic level. Fifty-nine patients (41%) acquired ACA at the first relapse. The incidences of ACA acquisition varied depending on cytogenetic abnormalities at initial diagnosis. Multivariate analysis identified t(8;21), complex karyotype, and a duration of fewer than 12 months of complete remission as independent predisposing factors for ACA acquisition. Notably, patients with ACA acquisition showed a significantly lower second complete remission rate compared with those without ACA acquisition (20.0% vs 72.5%, respectively, P

Summary We conducted a multi-center phase I/II trial of nonmyeloablative stem cell transplantation for patients with hematologic malignancies. The aim of this trial was to assess the safety and feasibility of this treatment modality for older or younger patients with significant organ dysfunction, who could not be treated with conventional high dose chemoradiotherapy. Twelve patients were treated with a conditioning regimen consisting of fludarabine and cyclophosphamide, followed by peripheral blood stem cell transplantation from human leukocyte antigen (HLA) identical siblings. Nonhematologic toxicities were mild. Median time to absolute neutrophils above 0.5 × 109/l, 1.0 × 109/l and platelets above 50 × 109/l were 8, 10 and 12 days, respectively. Donor dominant hematopoiesis was achieved in all patients, with or without donor leukocyte infusion. The cumulative incidence of acute and chronic graft-versus-host disease (GVHD) was 75 and 56%, respectively. Only one patient experienced early death within 100 days, caused by acute GVHD complicated by fungal infection. All patients except one achieved complete remission. With a median follow-up of 330 days, expected progression-free survival is 75%. Overall survival is 76%. Our study confirms that nonmyeloablative stem cell transplantation with cyclophosphamide and fludarabine conditioning is a safe and promising treatment for elderly patients with hematologic malignancies. A further study in large-scale setting is warranted.

De novo acute basophilic leukemia (ABL) is a rare form of myeloid leukemia. The low prevalence of ABL makes it difficult to define its clinical characteristics and to establish an effective therapeutic protocol. We present here a case of de novo ABL in a 64-year-old Japanese man. The diagnosis of ABL depended on the following: (1) metachromasia with toluidine blue stain, (2) intracytoplasmic theta granules identified by electron microscopy, and (3) findings obtained from extensive immunophenotypic analysis. Although blast cells lacked basophil-specific antigens such as CDw17, CD88, and FcepsilonRI, an expression profile of cytokine receptors including CD116 (GM-CSF receptor), CD117 (c-kit), and CD123 (IL-3 receptor alpha) helped to define the cellular lineage in our case. The patient achieved complete remission with intensive chemotherapy composed of idarubicin and cytosine arabinoside and was disease free during the following 30 months. We propose that immunophenotyping, especially focusing on cytokine receptors, is useful in diagnosing ABL.

OBJECTIVES Hepatitis C virus infection has often been suggested as a possible cause of various kinds of autoimmune diseases. The aim of this study was to determine the relationship between chronic idiopathic thrombocytopenic purpura (ITP) and hepatitis C virus infection and to characterize the clinical features of anti-HCV antibody (HCVab) positive chronic ITP patients. SUBJECTS AND METHODS We studied HCVab in 79 patients with chronic ITP (25 males, 54 females, mean age 42.3 yr, range 11-86 yr) using the third-generation ELISA method. RESULTS HCVab was detected in 11 of the 79 patients (13.9%). Quantitative HCV-RNA studies showed a high serum concentration of HCV-RNA in these patients. The platelet counts in these 11 HCVab-positive patients (Group 1) were lower than in the 68 HCVab-negative patients (Group 2) [(2.6 +/- 0.9) versus (4.9 +/- 3.0) x 10(10)/L, respectively; p

Successful engraftment of a second transplant from unrelated cord blood identifying acceptable HLA Ag mismatches as treatment for primary graft failure possibly mediated by anti-HLA Abs after ‘mega-dose’ haploidentical PBSC transplantation

We report three acute myelogenous leukemia (AML) patients who developed intracerebral granulocytic sarcomas (GS) and were successfully treated with allogeneic BMT (allo-BMT). The diagnosis of one patient was AML M2 with myelofibrosis, and the other two patients were AML M4 with eosinophilia (AML M4 Eo), according to the FAB classification. Two patients first experienced a relapse in the brain that resulted in the formation of GS, followed by a relapse in the bone marrow. The remaining patient developed an optic nerve GS after suffering a bone marrow relapse. All three patients received irradiation for the GS and systemic chemotherapy before the allo-BMT. TBI was used for conditioning, and GVHD prophylaxis was with cyclosporine (CsA) and short-term MTX in all three cases. These patients are currently 9 to 37 months post-BMT without relapse. Thus, our experience suggests that allo-BMT is an effective treatment for AML patients with existing or pre-existing intracerebral GS.

We report a case of haemophagocytic syndrome (HPS) occurring after allogeneic bone marrow transplantation (BMT) for acute promyelocytic leukaemia (APL) in a patient in fourth complete remission (CR). Anti- cytomegalovirus (CMV) antibody (Ab) was negative in this patient before BMT. BMT was performed from an HLA-identical unrelated donor who was positive for CMV Ab. After bone marrow engraftment and haematological recovery, severe acute graft-versus-host disease (GVHD) developed. This patient was treated with methylprednisolone in addition to cyclosporin A (CsA). Acute GVHD showed partial improvement, but CMV antigenaemia was observed. Despite administration of gancyclovir and immunoglobulin, CMV antigenaemia showed no improvement and HPS developed. As no other infections or malignancies were observed, we suspect that CMV infection was the trigger for development of HPS.

Although studies have demonstrated a high prevalence of extramedullary (EM) relapse after allogeneic stem cell transplantation (allo-SCT) in patients with acute myeloid leukemia (AML), the prevalence of EM relapse has not been compared with that after chemotherapy. This study investigated the prevalence of EM relapse among 498 adult AML patients (median age, 57 years; range, 15-82 years) who underwent intensive chemotherapy. A total of 281 relapses occurred in 210 patients (36 after allo-SCT; 245 after chemotherapy), and 33 relapses (11.7%) were accompanied by EM disease. Among these relapses, EM disease was more frequently observed at relapse after allo-SCT than after chemotherapy (25% vs. 9%, respectively; p=0.008). Eight of 33 relapses after the first allo-SCT had EM disease, and only presence of extensive chronic graft-versus-host disease (GVHD) was identified as a predisposing factor for EM relapse. Additionally, the 1-year overall survival rate after relapse was not significantly different when comparing those with EM relapse and those with BM relapse (38% vs. 16%, respectively; p=0.279). These data suggest that AML patients undergoing allo-SCT should be closely followed for signs of EM relapse, especially those with extensive chronic GVHD.

The presence of pre-transplant anti-HLA antibodies in recipients of cord blood transplantation (CBT) is associated with failed engraftment. However, only a small number of studies have reported that recipient-derived anti-HLA antibodies persist after CBT and have potential impact on the outcome. Of 61 patients who underwent HLA-mismatched CBT at Saiseikai Maebashi Hospital, three patients were identified as having anti-HLA antibodies not corresponding to HLA antigens in the transplanted CB. All patients achieved successful engraftment. However, the three patients with the pre-transplant anti-HLA antibodies not corresponding to HLA antigens in the transplanted CB continued to produce these antibodies even after engraftment; the persistence of these antibodies served as a sensitive minimal residual disease (MRD) marker. In contrast, donor HLA-specific and newly produced third party antibodies were not detectable even after relapse. The persistence of anti-HLA antibodies even after engraftment may be a potential marker for MRD, but is not a significant factor in secondary humoral engraftment failure.

To investigate the clinical significance of granulocytic sarcoma (GS) in adults with acute myeloid leukemia (AML), 434 consecutive patients with AML were analyzed retrospectively. Forty‐five patients (10.4%) with GS at diagnosis were younger (P

Post-transplant lymphoproliferative disorder (PTLD) is a fatal complication of allogeneic hematopoietic stem cell transplantation (HSCT) that is caused by reactivation of Epstein–Barr virus (EBV). A successful approach, monitoring EBV-DNA load in peripheral blood (PB) accompanied by preemptive rituximab therapy, has recently been reported. Here, we describe a 29-year-old woman who developed isolated central nervous system (CNS) PTLD. She received HSCT against acute myelogenous leukemia from a related human leukocyte antigen-haploidentical donor, following a conditioning regimen that included antithymocyte globulin. Tacrolimus and methylprednisolone were given as prophylaxis for graft-versus-host disease. On day +172, the patient’s consciousness deteriorated. Magnetic resonance imaging showed six ring-enhanced lesions in the cerebral hemispheres. These tumors were diagnosed, via a craniotomy and tumorectomy, as PTLD. EBV-DNA load was elevated in the cerebrospinal fluid (CSF) but not detected in PB. She was treated with whole-brain irradiation and rituximab, and achieved partial remission of the tumors. This case serves as a reminder that vigilance is required regarding the development of isolated CNS PTLD; it is worth examining EBV-DNA replication in CSF for diagnosis even when the EBV-DNA load is negative in PB.

We retrospectively analyzed the potential of Wilms' tumor gene 1 (WT1) mRNA levels in peripheral blood for predicting the prognosis of 50 patients with AML. After achieving complete remission (CR), 34 patients (69.4%) were determined to be positive and 15 (30.6%) were negative for WT1. The relapse rate of the positive and negative patients was 73.5% and 40.0% (p#x2009;=#x2009;0.02), respectively. After consolidation therapy, only 15 patients (32.6%) were positive and 31 (67.4%) were negative for WT1. Although the relapse rate of the positive and negative patients was 80.0% and 54.8% (p#x2009;=#x2009;0.10), respectively, the rate of relapse within 1 year was 73.3% in positive patients and only 33.3% in negative patients (p#x2009;=#x2009;0.01), respectively. The disease-free survival (DFS) rate at 3 years was 20.0% for positive patients and 50.0% for negative patients (p#x2009;=#x2009;0.01). The overall survival (OS) rate at 3 years was 42.8% in positive patients and 69.8% in negative patients (p#x2009;=#x2009;0.04), respectively. WT1 mRNA levels in the peripheral blood can predict relapse after CR, and its levels after consolidation therapy are closely correlated with DFS, OS, and early relapse.

We retrospectively analyzed the clinical outcome of dasatinib in 7 patients with chronic myelogenous leukemia (CML) or Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL) resistant or intolerant to imatinib. Three patients with chronic phase CML and two patients with Ph+ALL achieved major molecular response, however, two CML patients in accelerated phase (AP)/blast crisis (BC), did not. Gradeor =3 pancytopenia was seen in four patients. Among these, two AP/BC-CML patients required interruption/or dose reduction of dasatinib. As for nonhematologic adverse events, pleural effusion was seen in one patient and cytomegalovirus (CMV) colitis was observed in two patients. No patients who had been intolerant to imatinib experienced the same nonhematologic toxicity following treatment with dasatinib. We identified three patients who developed peripheral lymphocytosis, identified as natural killer cells or cytotoxic T-cells based on their large granular lymphocyte (LGL) morphologies and immunophenotypic profiles, out of six patients receiving dasatinib therapy. All three cases that developed LGL lymphocytosis achieved optimal molecular response, two of the patients, however, had pleural effusion and CMV colitis, respectively. Dasatinib inhibits off-target kinases, which may result in unexpected drug responses.

A 54-year-old woman had an episode of sudden oral bleeding and generalized petechiae 1 week after a sore throat and diarrhea. On admission, the platelet count was 0.1 x 10(4)/microl, and the platelet-associated IgG level was elevated. Hyperplasia of megakaryocytes in a bone marrow specimen and aberrant Epstein-Barr virus (EBV) antibody patterns led to a diagnosis of EBV-associated idiopathic thrombocytopenic purpura (ITP). Prednisolone (PSL) promptly restored her platelet count; however, she developed disorientation and affective lability soon after PSL was tapered. Subsequently, she ran a high fever and developed convulsive seizures. T2-weighted MRI demonstrated a high signal area in the subcortical white matter, and no abnormal findings were found on examination of the cerebrospinal fluid. The diagnosis of acute disseminated encephalomyelitis (ADEM) was made and steroid pulse therapy was started, which resulted in remission of the symptoms without recurrence in the following months. This is the first reported case of ADEM following EBV infection during treatment for ITP. Administration of PSL for ITP might mask the presenting clinical picture of ADEM. The possibility of ADEM should be investigated in patients of ITP following viral infection who develop acute encephalopathy.

We retrospectively analyzed the clinical course and prognosis of 11 patients with angioimmunoblastic T-cell Lymphoma (AILT). Median patient age was 62 years old (range 39 to 85). All patients were in clinical stage III or IV. Clinical features included B symptoms, hepatosplenomegaly, skin rushes, pleural effusion, ascites and polyclonal hypergammaglobulinemia. The disease can be classified into three categories based on histological findings: 3 cases of AILT with hyperplastic germinal centers, 4 cases of typical AILT, and 4 cases of AILT with numerous clear cells. As the initial therapy, 10 patients received combination chemotherapy and only 1 patient received autologous peripheral blood stem cell transplantation. Seven patients achieved CR and 4 showed PD. The response rate was 63% and the median survival time was 20 months. One patient survived in CR for 122 months. Patients with AILT demonstrating hyperplastic germinal centers and no bone marrow infiltration were able to achieve long-term survival. The survival time of AILT demonstrated a wide range. It was thought that further consideration of the prognostic factors and stratification was required.

Lymphoproliferative disease of granular lymphocytes (LDGL) is a disorder characterized by the clonal expansion of granular lymphocytes. It has recently been shown that the clonal expansion of granular lymphocytes occurs in patients with paroxysmal nocturnal hemoglobinuria (PNH) in a subclinical fashion. To test the possibility that LDGL patients share a PNH phenotype, we obtained peripheral blood cells from 20 patients with LDGL and examined the expression of the glycosylphosphatidyl inositol (GPI)-anchored proteins, CD55 and CD59. Compared with normal controls, however, a defective expression of CD55/59 was not observed on either granulocytes or erythrocytes from LDGL patients. An unexpected finding was the significantly lower CD55/59 expression on granular lymphocytes from patients with CD16(+)CD56(-) phenotype LDGL than from patients with CD16(+)CD56(+) phenotype LDGL, or natural killer (NK) and NK/T lymphocytes from healthy individuals. The positive correlation between the expression of CD56 and CD55/59 might have some relevance to the functional properties of the CD56(+) subset of large granular lymphocytes.

Background: Cytogenetic changes between the time of diagnosis and the first relapse are found in 30 to 60% of relapsed AML cases. ACA, the most frequent form of cytogenetic changes, are considered as a result of genetic instability and clonal evolution of AML cells. However, because the clinical significance of ACA has not been elucidated in adult AML patients, we conducted a large-scale retrospective study to address this unsolved issue. Patients and methods: Of the 375 adult patients diagnosed with AML between 1990 and 2010, 144 relapsed patients whose cytogenetic abnormality data both at diagnosis and at the first relapse were available were included in this study. All these patients underwent intensive chemotherapy. Patients with acute promyelocytic leukemia were excluded. Cytogenetic changes between the time of diagnosis and the first relapse were classified into four groups: (1) no change, (2) ACA was acquired at time of the first relapse, (3) cytogenetic abnormalities observed at diagnosis were reduced or had disappeared at the time of the first relapse, and (4) cytogenetic abnormalities observed at diagnosis were reduced or had disappeared, and completely different ACA was acquired at the time of the first relapse. In this study, groups 2 and 4 were defined as those with ACA acquisition. Overall survival (OS) was defined as the interval from the date of the first relapse to the date of death. Fisher’s exact test was used to compare binary variables. OS was estimated with the Kaplan-Meier method and compared using the log-rank test. Multiple logistic regression analysis and the Cox proportional hazard model were used for multivariate analysis of predisposing factors and prognostic factors, respectively. Values of p < 0.05 were considered to indicate statistical significance. Results: Of the 144 patients included in this study, 81 patients were male, and 63 were female. The median age was 53 years (range, 15–79 years). According to the definition described above regarding cytogenetic changes between the time of diagnosis and the first relapse, 83 (58%), 55 (38%), 2 (1%), and 4 (3%) patients were categorized into group 1, 2, 3, and 4, respectively; thus, 59 patients (41%) acquired ACA at the first relapse. With univariate analysis, t(8;21), complex karyotype, fewer than 12 months duration of the first remission, and relapse after allogeneic stem cell transplantation (allo-SCT) were extracted as statistically significant predisposing factors for ACA acquisition at the first relapse. Of these four factors, the first three were confirmed with multivariate analysis to be independent predisposing factors. Excluding four patients that directly proceeded to allo-SCT without re-induction chemotherapy, the 140 patients with ACA acquisition showed a significantly lower second remission rate compared with those without ACA acquisition (20.0% vs. 72.5%, respectively; p < 0.001). Furthermore, among all 144 patients, the 3-year OS rate after the first relapse in patients with ACA acquisition was significantly poorer than that in those without ACA acquisition (8.5% vs. 36.8%, respectively; p < 0.001). Multivariate analysis revealed that ACA acquisition was the strongest negative prognostic factor compared to all other reported factors (hazard ratio: 2.13, p < 0.001). Of the 59 patients with ACA acquisition (median age: 51, range; 15–79 years), 27 underwent allo-SCT after the first relapse. Eight patients were in remission at the time of transplant, and one directly proceeded to allo-SCT without re-induction chemotherapy. The 3-year OS rates after the first relapse were significantly different between patients undergoing allo-SCT after the first relapse and those treated only with chemotherapy (17.8% vs. 0%; p = 0.007). With multivariate analysis, undergoing allo-SCT after the first relapse was identified as an independent prognostic factor, in addition to the cytogenetic risk group at diagnosis. Conclusion: These findings suggested that ACA acquisition at the time of the first relapse was associated with chemo-refractive disease and poor prognosis. As ACA acquisition showed the most potent prognostic impact, treatment approaches for relapsed AML patients should be determined with consideration of this phenomenon. Clarification of the biological background of ACA acquisition may contribute to the development of novel therapeutic strategies and improved treatment outcomes in adult AML patients. Disclosures No relevant conflicts of interest to declare.

A 51-year-old female with acute myeloid leukemia was admitted to our hospital in December 2001. Though she had undergone two courses of induction chemotherapy (idarubicin hydrochloride + cytarabine), she failed to achieve a complete remission. In April 2002, while in non-complete remission, she subsequently underwent total body irradiation (TBI) and treatment with cyclophosphamide (CY) and etoposide (VP-16) before receiving an allogeneic peripheral blood stem cell transplant from her HLA-identical brother. For graft-versus-host disease (GVHD) prophylaxis, she was given tacrolimus and methotrexate. The infused CD34 positive cells provided 8.1 x 10(6) cells per kg. Engraftment was obtained on post-transplant day 14, and there was no evidence of clinical acute GVHD. The use of tacrolimus was discontinued on post-transplant day 60. As there was no occurrence of clinical acute GVHD, the patient received a donor lymphocyte infusion (CD3 cells 0.57 X 10(7) cells per kg) on post-transplant day 105. On day 132, however, she complained of coughing and fever, and on day 135, she was admitted to our hospital again for dyspnea. A CT scan demonstrated ground-glass opacity in the right pulmonary lobe. After considering her clinical course, symptoms, blood gas, CT scans, etc., we suspected interstitial pneumonia. The dyspnea progressively worsened, however, and despite the use of mechanical ventilation from day 143, the patient died on day 149. From the day she was admitted till the day she was intubated, she was unable to produce sputum. Autopsy findings revealed yellow-white tracheal pseudomembranes, as well as Aspergillus hyphae in the trachea, bronchus, and bilateral lungs. These findings are characteristic of Aspergillus tracheobronchitis. The clinical course of Aspergillus tracheobronchitis in allogeneic stem cell transplant recipients is, however, different from that of the usual invasive Aspergillus infection, and although Aspergillus tracheobronchitis is a very rare disease, attention should be paid to the possibility of its occurrence.

A-36-year-old male diagnosed with acute myelogenous leukemia (AML, M2) failed to achieve a complete remission after having undergone two courses of induction chemotherapy (idarubicin hydrochloride + cytarabine, high-dose cytarabine), and moreover, his cerebrospinal fluid (CSF) then revealed abnormal blasts. Dosages of 30 mg of methotrexate, 80 mg of cytarabine, and 40 mg of prednisolone acetate were given via lumbar puncture, and following this treatment, the leukemic cells were no longer detectable in his CSF. As a prophylaxis for meningeal leukemia relapse, he continued to receive intrathecal chemotherapy (methotrexate, prednisolone acetate) twice a week, and later he underwent reinduction therapy (second high-dose cytarabine). He displayed mental disorientation on the thirty-seventh day after he had been given a high-dose of cytarabine (araC). Up to the thirty-seventh day, he had also been given a total of 135 mg of intrathecal methotrexate. On the thirty-ninth day he fell into a coma, and his brain computed tomography (CT) demonstrated low density areas in the white matter, in addition to edema. These findings were compatible with leukoencephalopathy. With the administration of glycerin and methylprednisolone, his condition, however, began to reverse, and by the fifty-third day his brain edema had subsided and his mental condition had improved. On the ninetieth day he began to walk without assistance, and after the third course of re-induction chemotherapy, he achieved complete remission. He is currently doing well.

A 36-year-old male was admitted to the hospital with anemia and leukopenia. A bone marrow specimen revealed the proliferation of leukemic cells with flower-like nuclei observed in adult T-cell leukemia. The leukemic cells were positive for HLA-DR, CD2, CD7, and CD56. A diagnosis of aggressive NK cell leukemia was made, the patient was treated with induction chemotherapy and cord blood stem cell transplantation, and he is well now. Seen with electron microscopy, some leukemic cells had ribosome-lamella complexes (RLC). This is the first reported case of leukemic cells with flower-like nuclei seen with light microscopy and RLC seen with electron microscopy.

Hepatitis C virus infection has often been suggested as a possible cause of various kinds of autoimmune diseases. The aim of this study was to determine the relationship between chronic idiopathic thrombocytopenic purpura (ITP) and hepatitis C virus infection and to characterize the clinical features of anti-HCV antibody (HCVab) positive chronic ITP patients.We studied HCVab in 79 patients with chronic ITP (25 males, 54 females, mean age 42.3 yr, range 11-86 yr) using the third-generation ELISA method.HCVab was detected in 11 of the 79 patients (13.9%). Quantitative HCV-RNA studies showed a high serum concentration of HCV-RNA in these patients. The platelet counts in these 11 HCVab-positive patients (Group 1) were lower than in the 68 HCVab-negative patients (Group 2) [(2.6 +/- 0.9) versus (4.9 +/- 3.0) x 10(10)/L, respectively; p0.02]. Significantly more patients in Group 1 required prednisolone therapy (10/11, 90.9%) than in Group 2 (31/68, 45.6%) (P0.005). The response rate to prednisolone treatment was significantly higher in Group 2 (19/31, 61.3%) than in Group 1(0/10, 0%) (P0.001). There was no difference in the response to splenectomy between Groups 1 (4/7, 57.1%) and 2 (3/5, 60%).Given these findings, we recommend that HCVab is measured upon diagnosis of chronic ITP, and that splenectomy is planned in patients with HCVab in the event that prednisolone treatment is ineffective.

Background Base excision repair (BER) systems have important role for repairing oxidative DNA damage, and known to influence the carcinogenesis and the response to anti-cancer treatments. Although few studies have shown that several DNA repair genes are associated with an increased risk of leukemia, the clinical significance of BER polymorphisms in acute myeloid leukemia (AML) patients remains unclassified. The aim of this study was to evaluate the impact of polymorphisms in genes encoding four main proteins of BER system: OGG1 Ser326Cys, MUTYH Gln324His, APE1 Asp148Glu, and XRCC1 Arg399Gln, and on the risk of AML. Methods Between December 1991 and May 2013, 99 patients (male/female 55/44, median age 58 years, range 15-86 years) diagnosed as AML and 192 healthy controls were included in this study. Cytogenetic subgroups were classified as good, intermediate, and adverse risk according to NCCN guidelines. Genomic DNA was isolated from peripheral blood using the DNA extraction kit. Genotyping was determined by the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. Genotype and allele frequencies were compared between patients group and control group by using χ2-test. Probability values Results The APE1 Asp/Asp genotype increases the risk of AML (OR 2.30, 95% CI 1.41-3.77, p Conclusions According to our data, BER gene polymorphisms may affect the carcinogenesis and the cytogenetic risk of AML. Disclosures: No relevant conflicts of interest to declare.

Two myeloma patients presented high fever with no signs or data indicating infection at diagnosis or relapse. Both patients had plasmablastic myeloma, and serum levels of lactic dehydrogenase (LDH) and CRP were extremely high. Plasmablastic morphology, high LDH, and CRP were recognized as poor prognostic factors, indicating a fulminant phase of multiple myeloma. Interleukin-6 (IL-6) was only high in measured cytokines. We proposed that IL-6 caused high fever and induced the fulminant phase in these 2 cases.

It has recently been shown that the Fas-Fas ligand (FasL) system may be one of the pathogeneses for acute graft-versus-host disease (GVHD), and it has been reported that serum soluble Fas ligand (sFasL) increases with the presence of acute GVHD. However, there is no report on a correlation between the Fas-FasL system and chronic GVHD. We present two cases of chronic GVHD with elevated levels of serum sFasL. Its level in each case was high at the onset of chronic GVHD, but it decreased with steroid therapy. Liver dysfunction also improved as the level of serum sFasL decreased. It appears in these cases that the Fas-FasL system was related to the pathogenesis of liver damage.

Apoptosis is essential to many physiological processes, including maturation of cells and the immune system. Deficient regulation of apoptosis may play an important role in many pathological conditions, such as autoimmunity, AIDS, and myelodysplastic syndrome. Several methods have been described to identify apoptotic cells. DNA strand breaks can be identified by labeling free 3'-OH termini with modified nucleotides by enzymatic reaction (TUNEL method). In this study, apoptosis was introduced in cultured HL-60 cells treated with VP-16, and the TUNEL method was adapted for electromicroscopy, called the EM TUNEL method. The results of the EM TUNEL method were compared with those of light microscopy and flow cytometry. Apoptotic cells following VP-16 (10 micrograms/mL) treatment were detected after 3 h by all methods (light microscopy, Erythrocin B, electron microscopy, flow cytometry, TUNEL, and EM TUNEL). EM TUNEL was the most sensitive method of detection, with a detection rate of 32%. Furthermore, EM TUNEL was more suitable for distinguishing cell lineage than light microscopy TUNEL. The results indicate that EM TUNEL can be used to detect apoptosis in bone marrow species in vivo.

The standard therapy for patients affected by acute promyelocytic leukemia (APL) is the administration of all-trans-retinoic acid (ATRA). ATRA therapy is usually well-tolerated, but it also has the potential to induce toxicity. The most severe side effect of ATRA is retinoic acid syndrome; the next is acute pancreatitis, which is a rare but serious adverse event mostly due to hypertriglyceridemia. We herein report a patient who developed ATRA-induced acute pancreatitis without hypertriglyceridemia. A 17-year-old female presented to our hospital complaining of a 3-week history of dyspnea. Her peripheral blood counts were: Hb: 4.5 g/dL, WBC: 0.96 9 10/L with 9% blasts, and platelets: 48 9 10/L. The biochemistry findings were significant only regarding the serum lactate dehydrogenase level of 276 IU/L. A bone marrow examination revealed an abnormal cellularity, thus indicating APL, while a cytogenetic study showed the presence of t(15;17) (q22;q21). The patient was treated with ATRA for the purpose of remission induction. On the second day of ATRA treatment, she suffered acute epigastric and upper left quadrant pain, and laboratory tests showed an elevation of amylase to 7,600 IU/L (normal range: 49–136 IU/L) and lipase to 1,680 IU/L (normal range: 11–53 IU/L), with no marked increases in triglyceride (TG). Computed tomography of the abdomen revealed no abnormal findings in either the biliary ducts or pancreas. With the cessation of ATRA, the symptoms rapidly disappeared and the pancreas-derived enzyme level thereafter decreased to the normal range. The peak level of TG was only 145 mg/dL (normal range: 30–149 mg/dL) throughout the entire course. The patient was then treated with arsenic trioxide therapy without experiencing any subsequent complications, and she has since remained in complete remission for 8 months after starting the induction treatment. Four cases of acute pancreatitis associated with the use of ATRA have been described [1–4], but only one of these presented without hypertriglyceridemia, which is one of the common side effects of ATRA [4, 5]. Our case is the second such case. The pathogenesis of ATRA-induced acute pancreatitis without hypertriglyceridemia is not clear. Cytokines, such as IL-8, IL-1beta, and TNF-alpha, have been shown to be intimately involved in the inflammatory response to acute pancreatitis in general [6]. Teng et al. suggested that the increased expression of these cytokines in APL cells induced by ATRA may also play a role in the pathogenesis of ATRA-induced acute pancreatitis [4, 7]. As far as the case of Teng et al. is concerned, however, this suggestion remains controversial because of the recurrence of an elevated lipase level with a second ATRA treatment even after achieving complete remission in his case. His case rather suggests that either allergic or autoimmune mechanisms might play critical roles in the development of ATRA-induced acute pancreatitis. On the other hand, the activation of pancreatic stellate cells (PSCs) is known to be implicated in the production of pancreatic fibrosis and associated with the loss of retinol-containing fat droplets, which are stored in quiescent PSCs. Recent studies have demonstrated that retinol and its ATRA metabolites induce quiescence in activated PSCs and decreased collagen synthesis [8]. Pancreatic fibrosis, which is the process of repair after pancreatic injury, is prevented by ATRA, and then proinflammatory cytokines might be upregulated and lead to ATRA-induced acute pancreatitis. T. Hoshino (&) N. Hatsumi S. Takada T. Sakura S. Miyawaki Leukemia Research Center, Saiseikai Maebashi Hospital, Kamishinden-machi, 564-1, Maebashi, Gunma 371-0821, Japan e-mail: takumihoshino4249@yahoo.co.jp

Abstract 2574 Background: Mixed phenotype acute leukemia (MPAL) has historically been known as biphenotypic acute leukemia (BAL), and novel diagnostic criteria for this disease entity are described in the World Health Organization (WHO) classification 4th edition. As the most common recurrent genetic abnormality observed in MPAL is the bcr-abl fusion gene, Philadelphia chromosome-positive MPAL (Ph+MPAL) has been recognized as one distinctive disease entity. The prognosis of Ph+B-cell acute lymphoblastic leukemia (Ph+B-ALL) has been dramatically improved with the introduction of imatinib, and the goal of this study was to determine whether imatinib results in a survival benefit in the context of Ph+MPAL. Patients and Methods: We retrospectively analyzed 42 consecutive adult patients who were diagnosed with Ph+AL between January 2001 and March 2012 at Gunma University Hospital and Saiseikai Maebashi Hospital in Gunma, Japan. Ph+AL was diagnosed based on detection of the bcr-abl fusion gene with the polymerase chain reaction method and the presence of more than 20% of blasts in the peripheral blood and/or bone marrow. Patients with a previous history of chronic myelogenous leukemia were excluded. The lineage of leukemia cells was defined according to the WHO classification 4th edition. All patients received intensive chemotherapy and concurrent administration of imatinib. The c2-test was used for comparison of binary variables. The Mann-Whitney U test was used for comparison of continuous variables. Overall survival (OS) rate was estimated by the Kaplan-Meier method and were compared using the log-rank test. P < 0.05 was considered as statistically significant. Results: According to the WHO classification 4th edition, 13 (31%) patients were categorized as Ph+MPAL (positive for both myeloid and B-cell lineage), 27 (64%) patients were categorized as B-cell lineage acute lymphoblastic leukemia (Ph+B-ALL), and two (5%) patients were categorized as acute myeloid leukemia (Ph+AML). Patients with Ph+AML were excluded from this study, as the number of patients was relatively small. Of the 40 Ph+AL patients, 23 patients were men, and 17 were women, and the median age was 53 years (range, 16–75 years). Age, sex, white blood cell counts, lactate dehydrogenase levels, and the prevalence of additional cytogenetic abnormalities at diagnosis were not significantly different when comparing the groups, although patients with Ph+MPAL showed significantly higher frequency of major bcr-abl gene than those with Ph+B-ALL (69% and 19%, respectively; p < 0.01). Immunophenotypic analysis revealed that Ph+MPAL patients expressed CD10 and CD34 with significantly lower frequency than Ph+B-ALL patients. Notably, positivity of myeloid antigens (CD13 and 33) was similar between both groups. The complete response (CR) rates after the initial induction therapy were not significantly different when comparing Ph+MPAL and Ph+B-ALL (100% vs. 85%, respectively, p = 0.14). Likewise, the 5-year-OS rate was similar when comparing patients with Ph+MPAL and Ph+B-ALL (55% vs. 53%, respectively, p = 0.87). Of the 13 patients with Ph+MPAL, six patients received AML-type chemotherapy, and seven patients received ALL-type chemotherapy as the initial induction therapy. All patients achieved CR after the initial induction therapy, and there was no significant difference in 5-year OS according to the therapeutic strategy (AML-type vs. ALL-type), (50% vs. 63%, respectively, p = 0.71). Among 12 patients younger than 65 years old who were alive at >3 months after the diagnosis, eight patients underwent allogeneic hematopoietic stem cell transplantation (allo SCT). The 5-year OS was significantly better for patients who underwent allo-SCT than for those who received chemotherapy alone (58% vs. 20%, respectively, p = 0.05). Conclusion: Among adult Ph+AL patients, mixed phenotype was more frequently observed than expected, and Ph+MPAL patients showed unique clinical features, including immunophenotype and the type of bcr-abl fusion gene. Although BAL has been considered as a negative prognostic factor, Ph+MPAL patients showed comparable prognosis to those with Ph+B-ALL who received imatinib-containing intensive chemotherapy. Therefore, the established theory that mixed phenotype is associated with poor outcomes should be revisited among these patients. Disclosures: No relevant conflicts of interest to declare.

Abstract 4338 Background and aim: Gemtuzumab ozogamicinamicyn (GO) is an anti-cancer drug for acute myelogenous leukemia (AML), which targets CD33 positive leukemic cells. It has been approved by basis of effectiveness for refractory and relapse AML as single agent. However, the optimal method of administration is also currently under investigation. We evaluated the efficacy of time-sequential administration of GO after conventional chemotherapy as consolidation therapy for AML. Subjects and methods: AML patients in second complete remission (CR), who received time-sequentially GO after conventional chemotherapy as consolidation, were included. The duration of second CR (+CRi), overall survival, and toxicity were examined retrospectively. To evaluate the efficacy, the duration of first CR and second CR (+CRi) was compared. Result: Ten patients received time-sequentially GO followed by conventional chemotherapy. Six patients were male, and four were female. Median age was 69 (62–79) years old. At the onset of AML, 7 patients had normal karyotype, 2 patients inv (16), and one patient trisomy 8, respectively. All patients were treated in lamina airflow room at the beginning of chemotherapy. All but one patient received GO 3mg/‡uat day 10 after short MEC therapy (MIT 7mg/‡u day1–3, VP16 80mg/‡u day1–5, AraC 100mg/‡u day1–5). One patient received 6 mg/‡uat day 7 after short MEC therapy. Hydrocortisone was administered before and after GO administration to prevent infusion reaction. Prevention for veno-occulusive disease was not performed. Six patients received 3 courses of treatment, one patient 2 courses, and 3 patients one course, respectively. The median duration of second CR (+CRi) and overall survival from second CR was 376 (56–2100) days and 576 (123–2099) days, respectively. In eight of ten patients, the duration of second CR was longer than first CR. All patients experienced Grade 4 toxicities of neutropenia and thrombopenia. Median period when neutrophils were less than 500/μl was 16 (9–35) days. Non-hematologic toxicities of grade 3 or more were sepsis for7 patients, febrile neutorpenia for2 patients, loss of appetite for one patient, liver dysfunction for one patients, and cardiac dysfunction for one patient. Veno-occulusive disease and infusion reaction was not experienced. Treatment-related death was not observed. Conclusion: Although our experience has been limited, time-sequential administration of GO after conventional chemotherapy as consolidation therapy in second CR was very effective. Non-hematological toxicities except infections were limited. As bone marrow suppression caused by this treatment is very strong, it is very necessary to pay enough attention to infectious disease. Disclosures: No relevant conflicts of interest to declare.

Abstract 4339 Background and aim: Refractoriness to platelet transfusion is one of complications during the treatment of acute leukemia. The major reason is destruction of transfused platelets by anti-human leukocyte antigen (HLA) antibodies to HLA on donor’s platelets. We investigated retrospectively the incidence and characteristics of patients with refractoriness to platelet transfusion due to anti-HLA antibodies during the treatment of acute leukemia. Method: From 2000 to 2010, 348 acute leukemia patients underwent chemotherapy at our hospital. Among them, we surveyed 325 patients who received platelet transfusions more than five times. Examination of anti-HLA antibodies was performed when clinically an attending physician suspected that platelet transfusion was not effective. The existence of anti-HLA antibodies were tested both lymphocyte cytotoxicity test (LCT) and anti human immunoglobulin-LCT (AHG-LCT). Result: Of the 325 patients, males were 186, and female were 139. Two hundred sixty-three patients and 62 patients suffered from acute myeloid leukemia (AML) and acute lymphocytic leukemia (ALL), respectively. The median age of all patients was 57 (15–86) years. All patients had received red blood cell and platelet products from which leukocytes were removed by filtration. Of all patients, 23 (7.1%) were positive for anti-HLA antibodies. The median age of patients with anti-HLA antibodies was 57(24–76) years. The number of male and female were 2(8.7%) and 21 (91.3 %), respectively. All female patients with anti-HLA antibody had a history of delivery. 8.3 % of AML patients and 1.6% of ALL patients were positive for anti-HAL antibodies.The median number of platelet transfusions until the presence of anti-HLA antibodies was 11 (4–48). The median date of anti-HLA antibodies detection was 27(8–263) days after first platelet transfusion. After detection of anti-HLA antibodies, all patients with anti-HLA antibodies received HLA-matched platelets, and fatal bleeding was not seen. History of delivery (p Conclusion: During chemotherapy for the treatment of acute leukemia, 7% of patients suffered from refractoriness to platelet transfusion due to ant-HLA antibodies. The frequency was low compared with other blood disorders. Elderly AML patients with a history of delivery tended to produce anti-HLA antibodies. Patients with anti-HLA antibodies could obtain similar outcomes by using HLA-matched platelets, comparing with patients without anti-HLA antibodies. Disclosures: No relevant conflicts of interest to declare.

Background: The treatment for acute myeloid leukemia patients with relapse after stem cell transplantation is limited to dose reduction of immunosuppressive agents, donor leukocyte infusion (DLI), and a second transplantation. The prognosis of such patient is very poor if these therapies cannot be tolerated or are unsuccessful. Gentuzumab ozogamicin(GO) is an antibody targeted chemotherapy consisting of a humanized anti-CD33 monoclonal antibody linked to calicheamycin. The CD33 antigen is expressed on most AML cells and myeloid progenitor cells, but is not expressed on lymphocytes which play an important role in GVL effect. Therefore, GO can potentially eradicate AML cells without harming these lymphocytes. Patients: We retrospectively studied 9 patients with AML, who relapsed following allogeneic stem cell transplantation (SCT) and had difficulty tolerating DLI. Their donor sources included one 6/6 HLA-matched sibling bone marrow cells, four 6/6 HLA-matched unrelated bone marrow stem cells, and four 4/6 HLA-matched unrelated cord blood. The status of leukemia at SCT was 1st complete remission (CR) in one patient, 2nd CR in one patient, and active disease in seven patients. Treatment protocol: GO was administered at 6 mg/m2 for 2 doses separated by 2 weeks. Treatment was initially performed at morphological relapse but after April 2006 patients received treatment at molecular relapse. The molecular relapse was diagnosed by the quantitative expression of WT1 (Wilms tumor gene). (Blood.2003;101:1698–1704) Results: Five patients were treated at morphological relapse (group A) and four patients were treated at molecular relapse (group B). Eight received both doses of GO. The period from SCT to relapse ranged from 36 days to 193 days (median: 85 days). The period from SCT to GO administration ranged from 54 days to 229 days (median: 98 days). Seven of 9 patients achieved a remission (3/5 in group A, 4/4 in group B). Three CR patients in group A relapsed (day 48, 95, and 106, respectively). All of the patients in group A died within 447 days. (at 42 days, 131 days, 158 days, 173 days and 447 days, respectively, after GO). Two of the 4 patients in group B relapsed, one on day 300 and one on day 350. One patient died in CR from multiple organ failure following CMV infection; the fourth patient is still in CR. Three patients in group B are alive at 276 days, 410 days, and 443 days. Three patients developed infusion-related fever, one patients nausea. All patients developed grade 4 neutropenia and thrombocytopenia. Febrile neutropenia was observed in four patients. Five patients developed elevation of ALT, grade 3 in 1 patient and grade 1 in 4 patients. Three patients developed grade 1 hyperbilirubinemia. Only one patient developed reversible VOD. VOD occurred on thirteenth day after the administration of GO. The period between SCT and GO administration was 77 days. Conclusion: The administration of GO is effective in inducing remission in relapsed AML patients after SCT. The ability of GO therapy to induce durable response may possibly be enhanced by early therapeutic intervention before the onset of hematologic relapse. This approach is feasible and well tolerated with minimal toxicity. Additional studies in a large group of patients will be required to adequately assess the safety and efficacy of this approach.

Background: Approximately 70–80% of all newly diagnosed patients with adult AML achieve a complete remission (CR). However, only about one third of those pts remain free of disease for more than 5 years. It is therefore important to predict which pts are most likely to suffer a relapse and thus perform alternative treatments such as stem cell transplantation in order to improve the prognosis of AML. We evaluated the impact of the detection of Wilms’ tumor gene1 (WT1) mRNA in the peripheral blood on the prognosis of AML pts. Patients and Methods: From June 1, 2001 to October 30, 2003 a study was performed on 191 pts with AML which evaluated the clinical usefulness of a WT1 mRNA assay kit for the early detection of relapse in AML pts (submitted in Rinsho Ketsueki). From these 191 pts, we selected the subjects for this study. All selected subjects achieved a complete remission, and also had their WT1 expression analyzed after consolidation therapy. The pts were excluded if they had received a stem cell transplantation before relapse. The WT1 mRNA levels were determined using the WT1 mRNA assay kit (Otsuka Pharmaceutical Co. Ltd) in accordance with the standard operating procedures using peripheral blood. The lower limit of detection was 50 copy/μgRNA. Therefore, less than 50 copy/μgRNA was judged as negative. All induction, consolidation and maintenance therapies were performed according to institutional standards. Results: Of 118 pts who achieved a complete remission, 50 pts (median age: 56 yrs 22–86) were evaluable. Their median WT1 mRNA levels before induction therapy was 48327 copy/μgRNA (137–329185). The WT1 mRNA levels at diagnosis did not correlate with either the relapse rate, DFS or OS, respectively. After CR, the WT1 mRNA level ranged from Conclusion: This study shows that the detection of the WT1 mRNA in the peripheral blood after treatment closely correlated with the prognosis in AML.

Background: Translocation (8;21) is one of the most common structural aberrations found in AMLand good response rates and a better DFS have been described in pts possessing it. Especially, the DFS rate may exceed 60–70% in younger pts given repetitive courses of HDAra-C. However, it was recently reported that a subtype of AML with t(8;21) showed a poor prognosis and this case also had the KIT mutation. As a result, we retrospectively analyzed the prognosis of AML pts with t(8;21) prospectively enrolled in the JALSG AML97 study. Patients and Methods: Between 1997 and 2001, JALSG AML97 enrolled 809 pts previously untreated for AML and pts with M3 were excluded. From the 789 eligible pts, we selected the subjects with t(8;21) for this study. Induction therapy consisted of cytarabine and idarubicin. All CR pts were randomized to receive either four courses of standard dose consolidation therapy without maintenance therapy or three courses of standard dose consolidation with 6 courses of maintenance therapy. HDAra-C was not administered in the JALSG AML97 study. Peripheral blood and bone marrow smears and karyotypes were reevaluated by the central review committees. Any patients who underwent SCT were censored at the date of SCT. The Kaplan-Meier method was used to estimate OS and DFS. For comparisons of OS or DFS, the log rank test was used. Result: Cytogenetic studies were performed in 783 patients (99.2%) and only 15 studies resulted in failure. One hundred forty-two (18.5%) of those pts showed t(8;21). The median age was 43 yrs (15–64). The male: female ratio was 95: 47. The distribution of FAB types was as follows: AMLM2, 130; M4, 6; M1, 5; and M5, 1. A total of 69 (48.6%) pts had a sole t(8;21), 46 (32.4%) had a loss of a sex chromosome, and 27 (19.0%) had other cytogenetic abnormalities. The CR rate was 90.0%. Thirty-two pts underwent two courses of induction therapy. The early death (< one month) rate was 1.4% (2/142). Only a high WBC count (>=10x109/L) was found to be a marginally significant prognostic factor (p=0.0517). The estimated OS rate at 5yrs was 53.6%, and the DFS of the CR pts was 41.2%. We found no relationship between OS or DFS and the following factors: age, gender, karyotypic abnormality, performance status, the percentage of MPO positive blasts, the presence or absence of Auer rods, the platelet count, the number of induction therapies for CR and the type of postremisson therapy. However, two factors, the WBC count and the percentage of blasts in bone marrow were found to be strongly predictive factors for the outcome. For the pts with a WBC count >=10x109/L, the DFS rate at 5yrs was 30.8%, while for the pts with less than 10x109/L, it was 48.8% (p=0.0215). For the pts with blast >=50% and less than 50%, the DFS rates at 5yrs were 32.2% and 56.7% (p=0.0087), respectively. According to these two factors, a poor risk group (N=30, 21.0%) was thus identified. They had a WBC count >=10x109/L and blast >=50%. The DFS rate at 5yrs was only 22.3 % in the poor risk group while that of the other pts was 48.9% (P=0.0003). Conclusion: This study confirmed that all AML pts with t(8;21) shows a high response rate and a good prognosis, thus indicating that this favorable AML group includes a poor risk group which can be identified based on the WBC count and the blast percent in the bone marrow.