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For patients requiring allogeneic stem cell transplant, in the absence of a HLA-matched sibling, an extended donor search within the family may yield a suitable donor especially in societies with a high prevalence of consanguinity. We describe outcomes in transplants with non-sibling family donors, and compare outcomes with controls having a sibling donor transplant. Retrospective analysis of all matched related (non-sibling) donor transplants between 1995 and 2015. For comparison, appropriate age, sex and disease-matched patients were chosen from the sibling transplants (MSD) performed during the same time period (± 2 years). Comparison between the fully matched non-sibling donor cohort and age, sex and disease-matched sibling donor transplants showed a significant increase in complications in the family donor group (viral infections, acute GVHD and rejection). Event-free survival and overall survival were significantly lower in the non-sibling donor cohort, and HLA disparity (1-2 antigen) further worsened the adverse impact. Though there was a significantly lower event-free and overall survival at 3 years in the family donor cohort, this did not retain significance in the multivariate analysis. This data on allogeneic transplants using family donors showed higher complication rates and poorer outcomes. However in situations where financial constraints prevent access to matched unrelated donor sources, extended family searches may be fruitful in yielding a donor, and modifications in conditioning regimens and improvement in supportive care may help in improving the outcomes in family donor transplants.

High-dose cyclophosphamide (PTCY) after allogeneic hematopoietic cell transplantation (HSCT) has been shown to be effective in preventing graft-versus-host disease (GVHD) after HLA-matched bone marrow transplantation. We performed a phase II study of PTCY given at 50 mg/kg i.v. on days 3 and 4 as the sole GVHD prophylaxis after HSCT for severe aplastic anemia (SAA) in patients receiving granulocyte colony-stimulating factor–mobilized peripheral blood stem cell (PBSC) grafts from HLA-matched related donors after conditioning with fludarabine, CY, and single-dose total body irradiation. Thirty patients with a median age of 29 years (range, 16 to 49) were enrolled in this study. Engraftment was seen in 27 patients (90%) at a median of 16 days (range, 12 to 21) post-HSCT. None of the patients developed veno-occlusive disease of the liver or hemorrhagic cystitis. Grades II to IV acute GVHD was seen in 22% of patients with grades III to IV GVHD in 11.1%. The 2-year cumulative incidence of chronic GVHD was 22.7%. Fourteen patients (46.6%) did not require any further immunosuppression after receiving PTCY. Comparing with 2 historical cohorts of 30 patients each who received cyclosporine and methotrexate (MTX; at 15 mg/m2 [MTX15] and 10 mg/m2 [MTX10]), the incidence of grades II to IV acute GVHD was lower, albeit not significantly, with the use of PTCY (PTCY, 22.2%, vs MTX15, 37.1%, vs MTX10, 53.8%; P = .056), whereas rates of chronic GVHD were significantly reduced (PTCY, 22.7%, vs MTX15, 63.6%, vs MTX10, 76.2%; P = .013). Viral infections including cytomegalovirus were significantly higher with the use of PTCY (60%) compared with cyclosporine and MTX (MTX15, 23.3%, vs MTX10, 33.3%; P = .008). Overall survival was similar between the 3 groups. We conclude that PTCY as the sole GVHD prophylaxis is associated with low rates of acute and chronic GVHD in patients undergoing PBSC transplant for SAA using HLA-matched donors. This trial is registered at CTRI/2010/091/001480.

There is paucity of data from developing countries on the clinical outcomes in myeloma post-autologous transplantation. In this retrospective study, we used hospital records to retrieve data of patients with multiple myeloma undergoing autologous stem cell transplantation (ASCT) from January 1995 to December 2014 at our centre. During the study period, 245 patients underwent ASCT for myeloma. Of these, 19%, 37% and 37% were in complete response, very good partial response and partial response respectively at the time of ASCT. Only in 14 (5.7%) patients, the stem cells were cryopreserved. The transplant related mortality was 2.86%. The median follow up was 40.7 months (range 0–237.4 months). The 5-year overall survival (OS) and progression-free survival (PFS) for the entire cohort was 61.6% ± 3.8% and 37.2% ± 3.9% respectively. Independent predictors of OS included mononuclear cell dose infused, pre- and post-transplant response; and the use of maintenance therapy. Independent predictors of PFS included age at diagnosis, pre- and post-transplant response; and the use of maintenance therapy. In a resource limited setting, ASCT for myeloma is associated with low transplant related mortality. Pre- and post-transplant response and maintenance therapy are predictors of survival.

Graft rejection (GR) after allogeneic stem cell transplantation (allo-SCT) occurs in 10% to 20% of patients with β-thalassemia major (TM). There are limited data on the clinical profile and long-term outcome of patients who have had a GR. We undertook a retrospective analysis of patients who had a graft failure after allo-SCT for TM at our center. From October 1991 to June 2016, 55 of 506 patients (11%) transplanted for TM had a graft failure. An additional 7 patients with graft failure after allo-SCT done at other centers were referred to us for a second transplant. The median age was 8 years (range, 1 to 19), and there were 38 males (61.2%). Thirty-two patients (52.4%) were primary graft failures (15 with aplasia and 17 with autologous recovery) and 30 (47.6%) were secondary graft failures (5 with aplasia and 25 with autologous recovery). On conventional risk stratification 40 patients (64.5%) were class III. Seventeen patients (53.12%) with primary graft failure and 16 (53.3%) with secondary graft failure did not receive a second transplant. Twenty-nine patients (46%) with GR underwent a second allo-SCT. With the exception of 1 patient (first allo-SCT with an unrelated cord blood product), the donor for the second transplant was the same as the first transplant. Conditioning regimen for the second SCT was busulfan-based myeloablative (MAC) in 7 patients (24%), treosulfan-based MAC in 12 patients (41.3%), and the remaining received non-MAC regimens in view of pancytopenia and perceived inability to tolerate MAC. None of the patients conditioned with a treosulfan-based regimen had a GR, although 1 patient died with complications secondary to chronic graft-versus-host disease. Of the remaining 17 patients, 10 died after the second GR and 3 of regimen-related toxicity. Four are alive, of which 1 has recurrent TM and the rest are well and transfusion independent at 55, 80, and 204 months, respectively, from second transplant (all busulfan-based MAC). On a univariate analysis a nontreosulfan-based conditioning regimen and time from GR to second transplant of1 year was significantly associated with an adverse impact. However, on a multivariate analysis only a nontreosulfan-based regimen was associated with a significant adverse impact on event-free survival (HR, 11.5; 95% CI, 1.13 to 116.4; P = .039). In conclusion, there has been a significant improvement in clinical outcomes in our experience with the use of a treosulfan-based reduced-toxicity MAC regimen for second allo-SCT for TM. It would be reasonable, where feasible, to defer the second transplant by a year after the first GR.

Introduction: There is limited data on the best treatment strategy for patients who relapse after upfront arsenic trioxide (ATO) based therapy for acute promyelocytic leukemia (APL). We had recently reported that there was significant micro-environment mediated drug resistance (EM-DR) to ATO which we noted was predominantly mediated by upregulation of the NF-ⱪB pathway. We also noted that this upregulation was more prominent in relapsed APL and that EMDR to ATO could be overcome by the use of proteasome inhibitors (Leukemia 2016 - In Press). Pre-clinical mouse model and preliminary clinical data validated these observations. There has also been a recent concern of mutations in the oncogenic PML-RARA gene following treatment with ATO, with reports suggesting a third of relapsed APL patients having such mutations and that the clinical outcomes in this subset with conventional therapy is poor [NEJM. 2014;370(19): 1864-6]. Methods: In this prospective, open-label, non-randomized, phase 2, single center study, we enrolled APL patients in first hematological relapse. Inclusion criteria included presence of t(15; 17) and exposure to ATO as part of up front therapy. Enrolled patients received conventional therapy for relapse, included ATO and ATRA in induction, consolidation. Anthracycline (mitoxantrone) was used only in induction. Additionally, patients received two doses of bortezomib (1.4mg / m2 / dose) in induction and consolidation on days 2 and 5 and one dose in maintenance (10 days/month x 6 months) on day 2. Primary end point was safety (graded according to the NCI Common Terminology Criteria for Adverse Events version 4.0) and the key secondary end points were proportion in complete molecular remission at the end of induction and event free survival (EFS). The study is ongoing and continues to recruit patients. This trial is registered with ClinicalTrials.gov, number NCT01950611. Results: Between Sep 2013 and Mar 2016, 18 patients met eligibility criteria and were enrolled in this study. All 18 patients achieved CHR at a median of 45 days (range: 42-63). Seventeen patients (94.4%) were RT-PCR negative at the end of induction. The median time complete molecular remission was 35 days (range: 21-56 days). None of the patients had any major bleeding or thrombotic events in induction. With the exception of one patient who had Grade IV neurotoxicity which required treatment and recovered after temporarily discontinuing treatment during induction none of the other patients had any Grade III/IV non-hematological toxicity. Other non-hematological events were ≤ Grade II, usually transient and judged to be unrelated to the interventional agent. These included mild headache in 8 (33.3%) and one case (5.5%) each with diarrhea, mild rash, redness of eyes, oral ulcers, vertigo and paresthesia. Auto-SCT was offered to all patients in molecular remission post consolidation. Eight patients (44.4%) underwent an autologous SCT post consolidation while the rest opted to receive maintenance therapy. One patient who opted for maintenance therapy relapsed 6 months after completing maintenance. At an actuarial median follow up of 24 months (range: 4-35) the 3 year KM estimate of EFS was 92.3±7.4% and the cohort had 100% survival at last follow up. This clinical profile and outcome data was compared with a historical cohort that was treated with the same protocol with the exception of bortezomib and the comparative data is summarized in table 1 and figures 1A and 1B. Conclusion: Addition of proteasome inhibitors with ATO is well tolerated. In combination with conventional agents, proteasome inhibitors can potentially improve the clinical outcome of patients with relapsed APL treated with upfront ATO. Our preliminary data also suggests that this combination can obviate the need for an auto-SCT in this setting. Disclosures No relevant conflicts of interest to declare.

Allogeneic hematopoietic stem cell transplantation (Allo-SCT) with fludarabine based reduced intensity or toxicity reduced conditioning regimen with Busulfan or Melphalan (Flu/Bu; Flu/Mel) has improved HSCT outcome in patients with AML. Limited reports on the PK of Flu in patients with malignant hematological diseases undergoing Allo-SCT suggest that Flu AUC is associated with transplant related mortality (TRM) (Long-Boyle et al, 2011). We prospectively analyzed the PK and pharmacogenetics (PG) of Flu and Bu on Allo-SCT outcome in patients with AML receiving Flu/Bu or Flu/Mel based regimen. Forty-eight adult AML patients receiving Flu/Bu(targeted) (Flu 40mg/m2 /day intravenously from day-5 to -2 and intravenous Bu 130mg/m2 /day from day-5 to-2; n=27) or Flu/Mel (Flu 30mg/m2 /day intravenously from day -6 to -2 and Mel 140mg/m2 intravenously on day -1; n=21) regimen prior to Allo-SCT between January 2012 and 2015 were enrolled in this study. Peripheral blood was collected for PK analysis at serial time points and plasma was separated and analyzed the same day (for Bu TDM). Bu dose was adjusted based on the first dose PK to achieve target cumulative total AUC (22000mmoles*min). Flu plasma levels was analyzed using LC-MS/MS and the concentration was expressed as mmol/ml. Genetic polymorphisms that influence Flu and Bu PK (NT5E 5'-UTR variant rs2295890 and GSTA1*B polymorphism) were screened using pre- HSCT genomic DNA. The influence of Flu/Bu PK and PG on clinical outcome endpoints such as overall survival (OS) and event-free survival (EFS) was evaluated using cox regression analysis. The demographics of the patients is listed in the Table. There was a significant inter-individual variation in the flu clearance (1.2mL/h/m2(0.5-4.3); 8.6 fold) and AUC (46mmol*h/ml (24-101); 4.2 fold). Fludarabine AUC trended higher in Flu/Bu group when compared to Flu/Mel group (median AUC 52 vs. 43 mmol*h/ml respectively; p=0.08). Neither of the polymorphisms significantly explained the variation in Bu or Flu PK in this cohort and none of the PK parameters was associated with EFS/OS. However, patients carrying variant genotype of the NT5E 5'UTR polymorphism (rs2295890) showed significantly better OS (p=0.016) and EFS (p=0.007) (Figure) compared to those carrying wild type genotype. We have previously reported that this variant is associated with decreased Flu Clearance in patients with aplastic anemia and thalassemia receiving Flu based conditioning regimen (Mohanan et al, December 06, 2014; 124 (21): 3884; Mohanan et al, December 03, 2015; 126 (23): 3120). Although not significant, the Flu clearance was lower in the NT5E variants in this cohort as well. It can be extrapolated that patients carrying the variant genotype of the NT5E polymorphism, have decreased relapse incidence (Wild type-8; Variants-1) and hence better EFS and OS post HSCT, due to decreased clearance and increased systemic exposure to Flu. This finding need to be validated in a larger number and in patients with other disease conditions undergoing HSCT with Flu based regimen, in order to achieve the goal of personalizing conditioning regimen. Table Table. Disclosures No relevant conflicts of interest to declare.

Graft rejection (GR) following an allo-SCT occurs in 10-20% of patients with β thalassemia major (TM). The reported clinical outcome following second transplants have been associated with a high incidence of graft rejection, treatment related mortality, and graft versus host disease [Haematologica 2009; 94(9)]. There is limited data on the clinical profile and long term outcome of patients who have had a graft rejection. We undertook a retrospective analysis of patients who had a graft failure post allogeneic SCT for TM at our center. From October, 1991 to June 2016, 506 HLA matched related transplants for TM were done at our center. Of these 55 (11%) patients had a graft failure. An additional 7 patients with graft failure following an allo-SCT done at other centers were referred to us for a second transplant. Of the 62 patients with graft failure 32 (52.4%) were primary graft failures (PGF; 15 with aplasia and 17 with autologous recovery) while 30 (47.6%) were secondary graft failures (SGF; 5 with aplasia and 25 with autologous recovery). The median age of the patients who had graft failure was 8 years (range:1-19) and there were 38 (60.3%) males. On conventional risk stratification 40 (63.5%) were Class III. Eighteen (54.5%) cases with PGF and 16 (53.3%) with SGF did not receive a second transplant. From Oct 2009, at our center, a reduced toxicity myeloablative (MAC) treosulfan based conditioning regimen with a PBSC graft was offered to all high risk patients and for second transplants at the treating physician's discretion. Twenty nine (46%) of the patients with GR underwent a second allo-SCT. With the exception of one patient (first allo-SCT with an unrelated cord blood product) the donor for the second transplant was the same as the first transplant. Conditioning regimen for second SCT was busulfan based MAC in 7 (24%), treosulfan based MAC in 12 (41.3%) and the remaining received non-myeloablative conditioning regimens (fludarabine based, low dose TBI, OKT3, Cy-OKT3) often in view of pancytopenia and perceived inability to tolerate a MAC. All patients receiving a treosulfan based regimen had a PBSC graft. A BM graft was used in 7 (41%) of the remaining cases. None of the patients conditioned with a treosulfan based regimen had a graft rejection though one patient died of Grade IV acute GVHD. Of the remaining 17 patients 10 died following a second GR, 3 died of regimen related toxicity. Four are alive of which one has recurrent TM and the rest are well and transfusion independent at 55, 80 and 204 months from second transplant (all busulfan based MAC). The baseline characteristics and clinical outcomes of patients who received a treosulfan based MAC regimen versus the rest is summarized in table 1 and figure 1. On a univariate analysis a non-treosulfan based conditioning regimen and time from GR to second transplant of In conclusion there has been a significant improvement in clinical outcomes in our experience with the use of a treosulfan based reduced toxicity MAC regimen for second allo-SCT for TM. It would be reasonable, where feasible, to defer the second transplant by a year following the first graft rejection. Disclosures No relevant conflicts of interest to declare.

An allogeneic stem cell transplant (SCT) remains the only curative option for patients with β thalassemia major (TM). Conventional pre-transplant risk stratification is limited by its subjective nature of definition of hepatomegaly, adequacy of chelation therapy and also the need for an invasive liver biopsy. We have previously reported on the significant limitations in applying this risk stratification in our population (developing country) where the majority will fall into the high risk Class III group and further there is significant heterogeneity within this Class III subset that is not recognized by the conventional risk stratification (BBMT 2007;13:889). The major determinant of pre-transplant risk in patients with TM is related to iron overload, in organs such as the liver and heart. T2* magnetic resonance imaging (T2*MRI) has been widely utilized as a non-invasive measure of iron overload in these organs and has been reported to predict organ dysfunction and to guide adequacy of therapy. There is however no data available on the role of T2*MRI in pre-transplant risk assessment of patients with TM. From Jan 2014 to June 2016, in 69 patients with TM undergoing an allo-SCT a pre-transplant a T2*MRI cardiac and hepatic value was generated using standard techniques and validated software. The median age of this cohort was 7 years (range: 2-20) and there were 43 (62.3%) males. Twenty four (34.8%) were Lucarelli Class I/II while 45 (65.2%) were Class III. Of the Class III patients 15 (33.3%) were Class III high risk (Class III-HR) as previously defined by us. All Class III patients received a treosulfan based reduced toxicity myelo-ablative conditioning regimen. In this cohort 5 (7.2%) had graft failure, 12 (17.4%) had acute GVHD, 10 (14.5%) had sinusoidal obstruction syndrome (SOS) and 5 (7.2%) patients died. The cause of death was related to GVHD in 4 and in one it was due to uncontrolled sepsis. The 3 year KM estimate of OS and TFS for this cohort was 91.4±4.0% and 84.7±4.9% respectively. The median T2*MRI cardiac and hepatic value was 17.3 msec (range: 0.06-65) and 3 msec (range: 0.44-27) respectively. The correlation coefficient between T2*MRI cardiac and liver values was 0.169; P-value=0.164 (Fig 1A). It was of biological interest to note that there were patients in whom there was preferential hepatic or cardiac iron overloading as seen in Figure 1A. There was a trend to correlation with age and T2*MRI cardiac values (Fig 1C) similarly there was a significant though weak correlation between T2*MRI cardiac values and conventional risk stratification (Fig 1B). There was no significant correlation between either T2*MRI cardiac or hepatic values on graft rejection, SOS, GVHD or death nor did either of this parameters stand out as significant on linear regression analysis. In conclusion, with currently used reduced toxicity regimens, in the absence of organ dysfunction there is limited prognostic values of T2*MRI cardiac and hepatic readings on immediate peri-transplant events. Its impact on long term follow up post-transplantation on organ function and its role in directing post-transplant chelation therapy remains to be analyzed. Further evaluation is also required to understand the genetic and environmental factors that favor iron over load in one over the other organ as clearly seen in a proportion of cases. Disclosures No relevant conflicts of interest to declare.

In patients with acute promyelocytic leukemia (APL), in spite of recent advances, early treatment related mortality (TRM) still remains a challenge and is largely related to the associated coagulopathy. It is well recognized that conventional coagulation parameters used in the clinic do not accurately predict the risk of adverse outcomes like major bleeding or thrombosis. There is limited data on the clinical utility of whole blood viscoelastic assays and extended coagulation parameters for evaluation of coagulopathy in patients with APL. Consecutive patients with PML-RARA positive APL were enrolled. Blood samples were collected prior to infusion of blood products on day 1 and again on day 4 for thromboelastometry done on whole blood and activated with recombinant tissue factor at a final dilution of 1:50,000 (ROTEM analyzer, Tem Innovations GmbH, Basel) and an extended panel of coagulation parameters done by immunoassays (TAT complex, protein C, ATIII, PIC complex, tPAIC, d-dimer and thrombomodulin). Platelet count and conventional coagulation parameters, which were prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and thrombin time (TT), were measured daily for the first 14 days (more frequently as clinically indicated). Patients received platelet transfusions to target a platelet count of 30x109/L (in the absence of bleeding). Fresh frozen plasma and cryoprecipitate transfusions were done to target a normal PT and aPTT and maintain a fibrinogen level above 140 mg%. Major bleeding, thrombosis and death during induction therapy were the outcome variables. Of the 61 patients enrolled, 11 were excluded (3 did not continue treatment at our hospital, 2 died within 48 hours of admission, and 6 took discharge against medical advice before completing induction). Of the remaining 50 cases that were evaluated, 40 were newly diagnosed and 10 were relapsed. The median age was 34.5 years (range 9-68). 25 were males (50 %). The WBC count was above 10 x 109/L in 20 patients (40%). The median platelet count was 28 x 109/L (range 4-339). There were 13 (26%) deaths in induction. Six patients had a major bleeding event. Five patients had a thrombotic event. Of the evaluated conventional coagulation parameters, extended coagulation parameters, platelet counts and ROTEM parameters at diagnosis (ROTEM data not available at diagnosis in 2 cases) only the ROTEM parameter of maximum clot firmness (MCF) as a continuous variable was significantly associated with death (p=0.012). On univariate cox regression analysis with death as the outcome, MCF≤ 30mm was a poor prognostic marker (hazard ratio of 13.24, 95%CI 1.71-102.19; p =0.013). On multivariate cox regression analysis including high WBC count (>10 x 109/L), low platelet count (< 40 x 109/L) and history of relapse, MCF ≤30mm was an independent poor prognostic variable (HR: 11.89; 95% CI 1.43 - 98.75; p 0.022). Four of the 6 major bleeding events, four of five thrombotic events and all deaths related to coagulopathy occurred in patients with MCF ≤30mm. The descriptive statistics of patients with MCF >30mm (n=21) vs those with MCF ≤ 30mm (n=27) are shown in table 1. Figure 1 illustrates the type of discordance one can see between conventional coagulation parameters and ROTEM values. This study suggests that the MCF value from a ROTEM assay at diagnosis is probably a better measure of the hemostatic defect at diagnosis in APL. Patients with APL with low MCF on ROTEM at diagnosis are at an increased risk of death during induction therapy despite an adequate blood product replacement strategy which was based on conventional coagulation parameters. In these patients, there is a need to develop novel and possibly a more intensive replacement strategy. Table 1. Comparison of baseline characteristics and clinical outcomes. Variables MCF ≤30 (n = 27)N (%) /Median (range) / Mean±SD MCF > 30 (n=21)N (%) /Median (range) / Mean±SD p value Age (years) 40(12-68) 27(9-48) 0.006 WBC >10 x x109/L 17(62.96) 2(9.52) 0.003 Platelet count (x109/L) 17(4-89) 45(10-339) 0.001 PT in seconds 14.5(11-87.5) 11.8(10.1-14.8) 0.004 aPTT in seconds 28(23.2-77.9) 30.2(22-53.6) 0.104 Fibrinogen in mg% 134.8(24.7-393) 172.2(14.7-549.5) 0.066 Major bleeding 4(14.8) 1(4.8) 0.368 Thrombosis 4(14.8) 1(4.8) 0.369 Death 12(44.4) 1(4.8) 0.003 Disclosures No relevant conflicts of interest to declare.