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Bendamustine and rituximab (BR) is a preferred first-line therapy for indolent non-Hodgkin's lymphoma (iNHL) and mantle cell lymphoma (MCL); however, few reports on BR performance in elderly patients are available to date. We compared safety and efficacy of BR in patients ≥70 years (elderly) vs70 years (younger) treated at our institution. Among 201 patients, 113 were elderly (median age: 77 years), including 38 patients ≥80 years, and 88 were younger (median age: 62 years). Elderly patients had more bone marrow involvement by lymphoma, anemia, ECOG status 3, and high-risk disease follicular lymphoma (p0.05 for all). Fifty-four percent of elderly received full dose of bendamustine vs 79.5% of younger patients. More elderly patients (54%) vs younger (43.2%) experienced treatment delay. Less elderly proceeded to rituximab maintenance. Overall, the number of adverse events per patient and transformed B-Cell lymphoma/secondary malignancies were similar between groups. Elderly patients had less febrile neutropenia, rituximab-associated infusion reactions, but more herpes zoster reactivation. There were more deaths in the elderly (37.2%) vs younger (10.2%) groups (p0.001), mainly due to non-lymphoma-related causes. With median follow-up of 42 months [4.0-97.0] disease-free survival for the elderly was similar to younger patients. There was no difference between patients80 and ≥80 years (p=0.274). In conclusion, the real-world elderly patients have more advanced disease and higher ECOG status. BR is well-tolerated; elderly patients had lower incidence of febrile neutropenia. Dose reduction and treatment delays are common, but BR efficacy was not affected even in very old patients (≥80 years).

We present a case of synchronous dual hematological malignancies: multiple myeloma (MM) and masked essential Thrombocythemia (ET). Excessive thrombocytosis due to bone marrow recovery occurred during anti-myeloma therapy. Treatment for MM had no effect on ET; concomitant ET did not decrease the efficacy of anti-myeloma therapies in this frail patient.

Sporadic late-onset nemaline myopathy (SLONM) associated with monoclonal protein (MP) is a rare disease with an aggressive, and often fatal course. Whether SLONM + MP represents a malignancy or dysimmune disease remains unclear. Currently, two main approaches are used to treat SLONM + MP: nonchemotherapy-based treatment (immunosuppression, intravenous immunoglobulins, plasmapheresis and plasma exchange) or chemotherapy with or without autologous stem cell transplantation. Due to the rare occurrence of the disease, the best treatment modality is unknown. We analyzed treatment and outcomes in a large cohort of 53 patients with SLONM + MP: four our own patients and 49 cases from published literature. Neurological improvement in the nonchemotherapy group (N = 25) was observed in 52% of patients: 8% reached marked improvement, 8% moderate response, 36% mild response; none reached complete remission (CR). In the chemotherapy group (N = 28), neurological improvement was seen in 86% of patients: 46% reached CR, 25% marked response, 11% moderate response and 4% mild response. The best neurological improvement correlated with deep hematological remission. Mean time to best response in the chemotherapy group was 8 months versus 21 months in the nonchemotherapy group (P < .001). Overall survival was higher in patients in the chemotherapy group. A chemotherapy approach should be the preferred treatment for patients with SLOMN + MP with the goal to reach complete hematologic remission. Based on the clinical, morphological peculiarities, aggressive disease course and superior clinical benefits of chemotherapy over nonchemotherapy, SLONM + MP should be considered as a hematological malignancy with the presence of MP of clinical rather than undetermined significance.

Bone marrow (BM) biopsy is the most common diagnostic procedure in hematology. Bleeding is an expected complication, and its risk is assumed to be increased in patients on anticoagulants. However, the effect of anticoagulation on BM biopsy safety is unclear and guidelines are lacking robust data in this regard. As such, physicians use their clinical judgement to guide periprocedural management of anticoagulation.To provide the best available evidence regarding management of anticoagulation in patients who need BM biopsy.We reviewed and summarized available guidelines directing management of periprocedural anticoagulation for BM biopsy, and share our experience and practices with BM biopsy at our institution.The incidence of significant hemorrhage after BM biopsy is very low (0.007-1.1%). BM biopsy is classified as having a low to moderate bleeding risk. Interrupting anticoagulation is not consistently recommended. Strategies exist to minimize bleeding risk for anticoagulated patients. Patients with myeloproliferative neoplasms can develop an acquired von Willebrand syndrome which increases their risk for bleeding and therefore require extra vigilance to ensure appropriate hemostasis.Withholding anticoagulation prior to BM biopsy is not routinely recommended. Instead, assessment and optimization of bleeding risk factors should be done on a patient by patient basis.

A 74-year-old male with a history of chronic lymphocytic leukemia (CLL) previously treated with fludarabine/cyclophosphamide/rituximab (FCR) 5 years ago, presented with progressive fatigue, mucocutaneous bleeding, and cytopenias (hemoglobin 51 g/L, platelets 8.0 × 109/L, lymphocytes 0.4 × 109/L). He had normal respiratory findings, and no lymphadenopathy or hepatosplenomegaly. Further workup revealed a small spiculated lung nodule and multiple sclerotic bony lesions. Due to bleeding/profound thrombocytopenia, lung biopsy was not feasible. Peripheral smear revealed leukoerythroblastosis with few nucleated red blood cells and left shift of granulocytes. Bone marrow (BM) aspirate yielded a dry tap with clusters of extrinsic atypical cells on touch preparations. BM core biopsy showed infiltration and near complete replacement by a population of highly atypical cells with surrounding fibrosis. Cells were positive for cytokeratins CK7 and CK8/18, Napsin A, and thyroid transcription factor-1, specific for a primary poorly differentiated lung adenocarcinoma. Leukoerythroblastosis in association with cytopenia often indicates a BM infiltration and warrants an early BM biopsy to rule out hematological and solid malignancies, particularly in CLL patients treated with FCR. In our case, a diagnosis of a lung adenocarcinoma was established by BM examination, the only clinically feasible diagnostic modality.

Patients with a single hematological malignancy may be unexpectedly diagnosed with a clonally unrelated synchronous dual hematological malignancy (SDHM). The presence of a secondary hematological malignancy may be overlooked and only identified in situations presenting with discordant clinical or laboratory findings. Clinical management of these patients can be challenging, in part due to the relatively unknown etiopathology of SDHM and the impact of therapy on the secondary malignancy.To assess, characterize patients with synchronous double hematological malignancies and share our experience with this challenging group of patients.We performed a retrospective chart review of 3036 patients with hematological malignancy at our cancer center between February 2013 and July 2017.We identified 46 patients with SDHM, a prevalence of 1.51% among patients diagnosed with any hematological malignancy. We identify several heterogeneous combinations of SDHM comprised of myeloid and/or lymphoid lineages and provide our experience with managing patients with these underreported conditions.SDHMs are not uncommon and should be suspected in situations presenting with unusual or unexpected findings.

Background: Bendamustine plus rituximab (B+R) was established as a preferred first-line therapy for indolent non-Hodgkin's lymphoma (iNHL) and mantle cell lymphoma (MCL); however, few reports on the performance of this combination in the real-world setting in elderly patients are available to date. Methods: A retrospective review of adult patients over 70 years (elderly) vs younger ( Results: Among 201 assessed patients, 133 were elderly (mean age 77.9 years) and 88 younger (mean age 61.1 years) at time of B+R initiation. Baseline patient characteristics are presented in Table 1. There were more MCL in the elderly group: 20.3% vs 3.2% in the younger group. Significantly more patients in the elderly group had history of second malignancy. Prostate, breast, colon, and bladder cancer were more common in elderly, and lymphoid and thyroid in younger groups. Bulky lymphadenopathy, cytopenia, and constitutional symptoms were the most common indications for B+R initiation both in elderly (74.4%) and younger (79.26%) patients. Median number of B+R cycles was 6 for both groups. Mean dose of bendamustine received was 83.6 mg/m 2 in the elderly vs 88 mg/m 2 in the younger groups (p=0.0001). Full doses of bendamustine were given in 54% of elderly patients as compared to 79.5% younger patients. Treatment was delayed in 54% of the elderly and 43.2% of the younger patients. The mean delay time was similar in both groups: 20.1 [7-147] vs 17.1 [7-35 days]. The number of adverse events (AE) per patient was similar between the groups across each cycle (Table 2). Rituximab-associated infusion reactions were the most common adverse events in both groups. One patient in younger group developed prolonged neutropenia, lasting over 15 months. G-CSF support received 12.4% elderly and 22.7% younger patients. Nine patients (8%) in elderly and six patients (6.8%) in younger group (p=0.7604) developed transformed aggressive B-Cell lymphoma. Thirteen patients (11.5%) in elderly and five patients (5.7%) in younger group (p=0.1530) had secondary malignancies. Melanoma, metastatic squamous cell and renal carcinoma were more common in elderly group. Younger patients had metastatic squamous cell carcinoma and renal carcinoma, Kaposi sarcoma, MDS and thyroid cancer. Overall response rate was 91.2% in elderly group vs 98.9% in younger group, including complete remission in 71.7% vs 84.1%. Median follow-up was 42 months [4.0-97.0]. Although median overall survival (OS) was not reached in both groups, it was shorter in elderly compared to younger group (HR 0.24, CI 0.14-0.42, p Conclusion: In the real-world setting elderly patients had more advanced and high-risk disease, as well as higher ECOG status. B+R was associated with greater dose reduction and treatment delays. Adverse events profile and incidence did not differ significantly from the younger group. Response rates were lower, but relapse rate was higher in elderly patients. OS was inferior in elderly patients as compared to the younger group, due to higher rate of relapse and secondary malignancies. Figure 1 Figure 1. Disclosures Prica: Astra-Zeneca: Honoraria; Kite Gilead: Honoraria.

Background: Myeloproliferative neoplasms (MPNs) are a heterogenous group of chronic hematologic malignancies that lead to morbidity and early mortality primarily due to thrombotic complications and progression to acute leukemia. Clinical and mutational risk factors have been demonstrated to predict outcomes in patients with MPNs, and are used commonly to guide therapeutic decisions (including allogenic stem cell transplant) in myelofibrosis. Adolescents and young adults (AYA, age ≤45 years) comprise less than 10% of all MPN patients, and have unique clinical and therapeutic considerations. The prevalence and clinical impact of somatic mutations implicated in myeloid disease has not been extensively reported in this population. Methods: We conducted a retrospective review of patients evaluated at the Princess Margaret Cancer Centre (PMCC) between 1/1/2000 and 30/6/2021 for an MPN diagnosed at ≤45 years of age. Diagnoses were defined per 2016 WHO criteria using available information on chart review. Targeted mutational profiling of clinically relevant myeloid genes (49- or 54-gene panel) was previously performed on peripheral blood or bone marrow samples. Pathologic variants in ASXL1, EZH2, IDH1/2, SRSF2, and U2AF1 Q157 were categorized as high-molecular risk (HMR). Categorical variables were compared using the χ2 test. Kaplan-Meier method was used for overall survival (OS) and time-to-event analysis; and were compared using the log-rank test. Results: A total of 237 patients with initial MPN diagnosis ≤45 years were included in the study, with median age of diagnosis 35 (range 12-45) years. MPN diagnosis included: essential thrombocythemia (ET, n=100), polycythemia vera (PV, n=75), prefibrotic primary myelofibrosis (Pre-PMF, N=29), overt PMF (n=24), and MPN-unclassifiable (MPN-u, n=9). Driver mutation data, available for 230 (97%) patients, were: JAK2 in 134 (56%), CALR in 70 (30%), MPL in 6 (2.5%), and triple-negative in 20 (8.4%) patients. Median follow-up was 10.2 (range 0.3-45.3) years, and median OS was the shortest for those with overt PMF (21.4 years, P=0.001) compared with PV (33.0 years), ET (31.4 years), and Pre-PMF (median OS not reached). No difference in OS based on driver mutation was observed. Progression to a secondary MF (SMF) was observed in 84 patients (47% of ET, 48% of PV) after median time of 19.7 years; with no difference in time to progression due to diagnosis or driver mutation. Progression to an accelerated/blast phase (AP/BP) was observed in 26 patients and was associated with diagnosis of overt PMF (P=0.04) and triple-negative for driver mutation (P=0.04). Thrombosis was observed in 61 (26%) patients: 34 (14%) patients with thrombosis prior to/concurrent with MPN diagnosis, and 34 (14%) patients with thrombosis after diagnosis. Splanchnic circulation thrombosis was found in 29 (12%) patients and 12 (5%) patients had Budd-Chiari syndrome. Portal hypertension was reported in 37 (16%) patients. CALR type-2 mutations were associated with the lowest frequency of total thrombosis (4%, P=0.02); while JAK2 had the greatest frequency of splanchnic circulation clot (17%, P=0.03). Targeted mutational profile was obtained for 202 (85%) of patients: 135 samples obtained during the initial disease phase, 51 samples during a secondary MF phase, and 16 during an AP/BP. For the patients with mutation analysis in the initial phase, 24 pathogenic mutations were observed in 16 (12%) patients including 3 patients with HMR mutations. The most frequent mutations observed were in TET2 (n=12, 9%), and ASXL1 (n=3, 2%). Presence of additional mutations did not predict OS, AP/BP progression, or thrombosis; though TET2 mutation was associated with shorter time to SMF progression in patients with PV/ET (P=0.002). Additional mutations were found in 34/51 (67%) patients in whom mutational analysis was first performed during a SMF disease phase. Conclusions: A long-term follow-up study of a large molecularly annotated cohort of AYA patients with MPN demonstrated excellent long-term survival for these patients. Overt PMF is associated with the lower OS and higher risk of AP/BP transformation. Thrombotic complications including splanchnic circulation thrombosis are frequent complications. Mutations aside from JAK2/MPL/CALR are uncommon and HMR mutations rare in the initial phase of MPN in the AYA population. Figure 1 Figure 1. Disclosures Gupta: Roche: Consultancy; Pfizer: Consultancy; AbbVie: Consultancy, Honoraria; BMS-Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Sierra Oncology: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Incyte: Honoraria, Research Funding; Constellation Pharma: Consultancy, Honoraria. Maze: Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene-BMS: Honoraria; Takeda: Research Funding; PharmaEssentia: Research Funding; Kronos Bio: Research Funding.

To review the emergence of secondary malignancies (SMs) in recipients of allogeneic hematopoietic cell transplantation (HCT), we documented the occurrence of SMs in 2415 allogeneic HCT recipients, ages 18 to 71, in a single center over 4 decades. SMs were seen in 209 patients, including 58 with nonmetastatic squamous cell (SCC) and basal cell carcinoma (BCC) of the skin. Cumulative incidence of SM was 6.3% at 10 years, 13.5% at 20 years, and 17.6% at 30 years post-HCT. Median age at diagnosis of SMs was 61 years (range, 21 to 85). By multivariable analysis, older age at HCT was the only independent prognostic factor for SM (HR, 1.39 for ages 41 to 55 and HR, 1.92 for age55 compared with age ≤ 40; P = .001). The rate of SM (excluding nonmetastatic SCC/BCC of skin) after HCT was 2.07 times higher (P = .01) compared with the general population. Overall survival (OS) after diagnosis of SM (excluding nonmetastatic SCC/BCC of skin) was 58% at 5 years and 50% at 10 years postdiagnosis. Eastern Cooperative Oncology Group (ECOG) score was the only independent predictor of OS on multivariable analysis, with over 2-fold increased risk of death for patients with an ECOG score of 1 and over 6-fold for ECOG scores of 2 to 4, compared with ECOG score 0 (P .0001). Forty of 209 patients (19%) diagnosed with SMs subsequently developed another new malignancy. OS was 68% and 51% at 5 and 10 years, respectively. The survival of SM patients post-HCT is favorable, thus warranting diligent long-term cancer screening and standard of care treatment. ECOG status of these patients is a predominant prognostic factor.

e19540 Background: Bendamustine plus rituximab (B+R) was established as a preferred first line therapy for patients with previously untreated indolent non-Hodgkin’s lymphoma based on the BRIGHT and STIL trials. However, only few reports on efficacy and safety data of this combination in the real-world setting are available to-date. Methods: We conducted a retrospective review of patients who received therapy with standard doses of B+R in our cancer center from June 2013 to January 2021. Patients with indolent non-Hodgkin’s lymphoma (iNHL) and mantle cell lymphoma (MCL) who received more than one cycle of B+R were evaluated. Results: Amongst a total of 201 patients 56% were males and 44% females. Median age at B+R initiation was 72 years (range 34-94). Follicular lymphoma (FL) (50.3%), marginal zone lymphoma (MZL) (19.4%), and lymphoplasmacytic lymphoma (LPL) (14.5%) were the most common iNHL. Stage 3 and 4 diseases represented 19.9% and 68.6% of patients. Extranodal disease was found in 35.8%. The proportion of patients with high risk disease was 48.5% for FL (FLIPI ≥3), 86.6% for LPL (WMISS score ≥2), and 80.5% for MCL (MIPI score ≥6.2). Prior history of secondary malignancy had 23.4% of patients; 11.4% patients had ECOG 3. Most common indications for B+R initiation were bulky symptomatic lymphadenopathy (69.1%), cytopenia (36.8%) and constitutional symptoms (36.8%). Fifty-eight percent of patients had more than one indication for therapy. Median number of B+R cycles delivered was 6 (range: 1-6), median dose of bendamustine was 90 mg/m2 (range 45-90). Full doses of treatment were given in 66.7% of patients, reduced in 33.3% with mean dose 78.3 mg/m2. A total of 50.8% completed 6 cycles with no delays, in 49.2% treatment was delayed (mean delay time 1.8 weeks). Overall response was 94.5%, with 77.6% complete and 16.9% partial remission. Median duration of follow-up was 35 months (range: 4-91). At the end of follow-up, event free survival (EFS) was 77.1% and overall survival (OS) was 79.6%. Six percent of patients relapsed, 8% developed secondary hematological malignancies, including 14 cases of aggressive B-cell lymphoma and 2 cases of MDS. 16.9% of patients required support with G-CSF. Grade 3-4 neutropenia was recorded in 22.4%, febrile neutropenia in 7.5%, grade 3-4 anemia in 7.9%, and grade 3-4 thrombocytopenia in 3.9% of patients. Rituximab-associated infusion reactions, skin rash, thrombophlebitis, and infection were the most common non-hematological adverse events. A total of 80.6% of patients proceeded to rituximab maintenance. Conclusions: B+R chemoimmunotherapy is feasible to administer in non-clinical trial setting. Despite more dose reduction as compared to STIL trial, B+R retained its efficacy with comparable EFS and OS. No new adverse events or increase in secondary malignancies were found.

Lenalidomide in combination with dexamethasone (Len‐dex) represents a highly effective treatment in relapsed/refractory multiple myeloma (RRMM) patients. However, an increased risk of secondary primary malignancies (SPMs), including myelodysplastic syndrome (MDS) and acute myelogenous leukemia (AML) has been described in patients receiving lenalidomide. In order to assess the incidence and features of this complication, we reviewed 195 patients with RRMM treated with Len‐dex at our institution. The median follow‐up time from diagnosis of MM was 73 months (10–234 months) and from initiation of Len‐dex was 19 months (1–104 months). The median duration of Len‐dex for all patients was 7.8 months (range 1–90 months). The incidence rate (IR) for all SPMs from start of Len‐dex was 2.37 per 100 patient‐years, which reflected an IR of 1.29 for MDS/AML and 1.08 for nonhematologic malignancies (NHM). MDS was the most common SPM noted. The cumulative IR of SPM at 5 years was 1.54% from the time of MM diagnosis and 5.24% from starting Len‐dex. Multivariable cumulative incidence of SPM analysis identified older age (P = 0.005) and prior number of regimens (P = 0.026) as adverse risk factors. We found more concomitant G‐CSF use (P = 0.029) in patients with MDS/AML, however, causal association is not clear. The progression‐free survival after Len‐dex was the longest for patients in MDS/AML group, and the 5‐year overall survival did not differ among groups. Although the rate of SPM was relatively low with Len‐dex, concomitant G‐CSF should be used judiciously and patients receiving this regimen should be observed for the development of this complication.

8545 Background: A subset of sporadic late-onset nemaline myopathy (SLONM) associated with monoclonal gammopathy of undetermined significance (MGUS) has more aggressive course, often fatal. Whether SLONM+MGUS is a malignancy or dysimmunity is unclear. Two approaches are used to treat SLONM+MGUS: 1) immunosuppression (IS) ± plasmapheresis/exchange; 2) chemotherapy (ChT) ± autologous stem cell transplantation (ASCT). Due to the rare occurrence of the disease the best treatment modality is not known. Methods: We conducted a literature search to identify previous treatment for patients with SLONM+MGUS using PubMed, Elsevier, Medline, and CINAHL databases from 1975 to 2019. All publications were carefully reviewed to remove “duplicate” patients. Overall, 28 reports were included for the final analysis. Results: 38 unique patients with SLONM+MGUS received either IS (n = 19) or ChT ± ASCT (n = 19). The median age was 48 years [24-75]. In the IT group 74% (n = 14) were males vs 53% (n = 10) in the ChT group. All patients had IgG monoclonal protein (MP): kappa in 57% (n = 11) in the IT, 42% (n = 8) in the ChT group. In the IT group MP values were 0.42 & 0.2 g/L (n = 2); in the ChT group median MP was 2.7 g/L [0.1-14, n = 14]. In the IT group 84% (n = 16) received steroids, 26% (n = 5) plasmapheresis, 53% (n = 10) non-steroid immunosuppressants, 11% (n = 2) rituximab, and 53% (n = 10) IVIG. Six patients (32%) had one IT modality; 13 (68%) had 2 or 3. In the ChT group 10 patients (53%) had ASCT; 6 patients (31%) had CyBorD or Lenalidomide+Dexamethasone + ASCT; 3 patients (16%) had chemotherapy without ASCT. 10 patients in IT group had neurological improvement (NI): 53% overall response (OR) with 16% (n = 3) complete remission (CR), and 37% (n = 7) partial response (PR). No improvement/progression had 9 patients (47%). In 2 patients (10%), neurological CR was associated with resolution of MP. Mean time to best response was 19 months. In ChT group 18 patients achieved NI: 94.7% OR with CR in 73.7% (n = 14) and PR in 21.0% (n = 4). Only one patient had no response to therapy. The best NI correlated with resolution of MP. Mean time to best response was 10 months. Conclusions: Our study with the most extensive cohort of patients with SLOMN+MGUS supports ChT ± consolidative ASCT aimed at complete elimination of the malignant plasma cell clone as the preferred treatment. Superior clinical benefits of ChT suggest that the presence of MP has clinical rather than undetermined significance, and SLOAN + MP should be considered as a malignancy rather than dysimmunity.

Celiac disease (CD) is a common systemic disease, affecting about 1.0% of the population. Classical presentation includes malabsorption syndrome and deficiencies of macro-/micronutrients. Patients with undiagnosed CD may be referred to hematologists with different hematologic issues, including anemia, thrombocytosis, thrombocytopenia, leukopenia, venous thromboembolism, hyposplenism, and IgA deficiency. CD imposes an increased risk of various lymphomas, especially intestinal T- and B-cell lymphomas. Enteropathy-associated T-cell lymphoma (EATL) is a rare and aggressive disease with poor prognosis and often fatal complications. Here we present a case of EATL associated with cavitating mesenteric lymph node syndrome as a first manifestation of undiagnosed CD.

Introduction A rare subset of sporadic late-onset nemaline myopathy (SLONM) is associated with monoclonal gammopathy of unknown significance (MGUS). The role of monoclonal protein (M-protein) in SLONM is unknown, but SLONM with MGUS (SLONM+MGUS) demonstrates an aggressive disease course with severe muscular weakness, early development of respiratory failure, and is often fatal. Whether SLONM+MGUS represents a malignant or dysimmune disease remains unclear. Currently, two approaches are used to treat SLONM+MGUS: 1) immunosuppression ± plasmapheresis/exchange; or 2) chemotherapy (ChT) ± autologous stem cell transplantation (ASCT). Unfortunately, due to the rare occurrence of the disease, the best treatment modality is unknown. Methods We conducted a literature search to identify previous treatment modalities for patients diagnosed with SLONM+MGUS using PubMed, Elsevier, Medline, and CINAHL databases from 1975 to 2019. All publications were carefully reviewed to remove "duplicate" patients. Overall, 28 reports were included for the final analysis. Results We identified 38 unique patients diagnosed with SLONM+MGUS treated either with immunotherapy (IT) (n=19) or ChT ± ASCT (n=19). The median age was 49 years [range: 26-75] in the IT group and 47 years [range: 24-64] in the ChT group. There was a slight male preponderance in the IT group [n=14 (74%)] than in the ChT group [n=10 (53%)]. Similarly, more cases with kappa light chain restricted M-protein were observed in the IT group [n=12 (67%)] than in the ChT group [n=8 (42%)]. In the IT group, M-protein values were only reported in two patients (mean: 0.42 g/L), while M-protein values were reported for 14 patients in the ChT group (mean: 6.54 g/L). In the IT group 16 patients (84%) received steroids, 5 (26%) plasmapheresis, 10 (53%) steroid-sparing immunosuppressants (low dose cyclophosphamide, azathioprine, cytarabine, and mycophenolate mofetil), 2 (11%) rituximab, and 10 (53%) IVIG. Twelve (63%) patients received oral prednisone (mean dose: 67 mg) and 3 (16%) received pulse methylprednisolone (1 g). Patients received IT modalities sequentially or in parallel. Six patients (32%) received 1 and 13 patients (68%) received 2 or 3 (median = 2) IT types. Neurological improvement was observed in 10 patients, a 53% overall response rate (ORR) with 3 (16%) patients in complete remission (CR), and 7 (37%) patients in partial response (PR). No improvement or progression was observed in 9 (47%) patients (Figure 1). In 2 patients, neurological CR was associated with complete disappearance of M-protein. Mean time to best response was 19 months in a follow-up duration of 23 months. The ChT group included three categories: 1) 10 (53%) patients received ASCT with high dose melphalan (mean: 164 mg/m2); 2) 3 patients (16%) were treated with Cyclophosphamide/Bortezomib/Dexamethasone (CyBorD), cyclophosphamide/Thalidomide/Dexamethasone and Lenalidomide and Dexamethasone (Ld) chemotherapy without ASCT; and 3) 6 (31%) patients underwent induction chemotherapy with CyBorD (n=2) and Ld (n=4), followed by consolidative ASCT. Neurological improvement was achieved in 18 patients, a 94.7% ORR with CR in 14 (73.7%) and PR in 3 (21.0%) patients. Only one patient did not respond to therapy. The best neurological improvement correlated with disappearance of M-protein [complete hematological remission (CHR)]. Mean time to best response was 10 months, which was shorter than the IT group. Follow-up duration was 31 months. Conclusion Based on a comprehensive evaluation of existing treatment modalities for patients with SLOMN+MGUS we conclude that the best course of treatment is through consideration of the disease as a malignancy rather than a dysimmune disease. Our review supports that the best method of treatment entails ChT with or without of consolidative ASCT in the pursuit of eliminating the malignant plasma cell clone. In conjunction with nemaline myopathy presence of M-protein has clinical significance and it may be worth considering reclassifying SLONM+MGUS as SLONM with Monoclonal Gammopathy of Clinical (Neurological) Significance (SLONM+MGCS). Disclosures No relevant conflicts of interest to declare.

The efficacy of Onconase on the growth of a panel of chemosensitive and chemoresistant neuroblastoma cell lines was investigated. Onconase decreased cell viability of chemosensitive (IMR-32, UKF-NB-3) and chemoresistant neuroblastoma cell lines characterised by high expression of P-glycoprotein (P-gp) (UKF-NB-3(r)DOX(20)) or by high P-gp expression in combination with mutated p53 (UKF-NB-3(r)VCR(10), Be(2)-C), in a similar manner. Moreover, Onconase caused cell cycle block in G1 phase and induced caspase-independent cell death. Transmission electron microscope investigations suggested that Onconase-induced autophagy contributes to Onconase-induced cell death. Antitumour activity of Onconase against naïve and drug-resistant neuroblastoma xenografts was confirmed in animals.

A high frequency of human cytomegalovirus (HCMV) genome and antigens in tumor samples of patients with different malignancies is now well documented, although the causative role for HCMV in the development of the neoplasias remains to be established. HCMV infection can modulate multiple cellular regulatory and signalling pathways in a manner similar to that of oncoproteins of small DNA tumor viruses such as human papilloma virus or adenoviruses. However, in contrast to these DNA tumor viruses, HCMV infection fails to transform susceptible normal human cells. There is now growing evidence that tumor cells with disrupted regulatory and signalling pathways enable HCMV to modulate their properties including stimulation of cell proliferation, survival, invasion, production of angiogenic factors, and immunogenic properties. In contrast to previously suggested "hit and run" transformation we suggest that persistence in tumor cells is essential for HCMV to fully express its oncomodulatory effects. These effects are observed particularly in persistent HCMV infection and are mediated mainly by activity of HCMV regulatory proteins. In persistently HCMV-infected tumor cell lines - a selection of novel, slowly growing virus variants with changes in coding sequences for virus regulatory proteins takes place. As a result, oncomodulatory effects of HCMV infection may lead to a shift to more malignant phenotype of tumor cells contributing to tumor progression.

Recently, the term oncomodulation has been proposed to express the ability of human cytomegalovirus (HCMV) to modify tumor cell biology, a phenomenon that is independent from transformation. Because past studies have failed to show that HCMV can transform normal human cells, HCMV has not been regarded as an oncogenic tumor virus. However, recent investigations have revealed a high frequency of HCMV in tumor cells of malignancies such as colon cancer, malignant glioma, prostatic intraepithelial neoplasia, and carcinoma. Data from experiments with HCMV-infected tumor cell lines have highlighted the oncomodulatory potential of HCMV and provided important insights into the patho-mechanisms associated with aberrant signaling pathways and transcription factor and/or tumor suppressor function of the host cell.

Cytotoxic drug treatment of neuroblastoma often leads to the development of drug resistance and may be associated with increased malignancy. To study the effects of long-term cytotoxic treatment on malignant properties of tumor cells, we established 2 neuroblastoma cell sublines resistant to vincristine (VCR) and doxorubicin (DOX). Both established cell lines (UKF-NB-2(r)VCR(20) and UKF-NB-2(r)DOX(100)) were highly resistant to VCR, DOX and vice-versa but retained their sensitivity to cisplatin. UKF-NB-2(r)VCR(20) and UKF-NB-2(r)DOX(100) expressed significant amounts of P-glycoprotein, while parental cells were P-glycoprotein negative. GD2 expression was upregulated, whereas NCAM expression was decreased in both resistant cells. Spectral karyotype (SKY) analysis revealed complex aberrant karyotypes in all cell lines and additional acquired karyotype changes in both resistant cells. All cell lines harbored high levels of N-myc amplification. Compared to parental cells, UKF-NB-2(r)VCR(20) and UKF-NB-2(r)DOX(100) exhibited more than 2-fold increase in clonal growth in vitro, accelerated adhesion and transendothelial penetration and higher tumorigenicity in vivo. We conclude that development of drug resistance and acquisition of certain karyotypic alterations is associated with an increase of additional malignant properties that may contribute to the poor prognosis in advanced forms of NB. The 2 novel neuroblastoma cell sublines also provide useful models for the study of drug resistance in aggressive forms of neuroblastoma.

Mechanisms linking mitogenic and growth inhibitory cytokine signaling and the cell cycle have not been fully elucidated in either cancer or in normal cells. Here we show that activation of protein kinase B (PKB)/Akt, contributes to resistance to antiproliferative signals and breast cancer progression in part by impairing the nuclear import and action of p27. Akt transfection caused cytoplasmic p27 accumulation and resistance to cytokine-mediated G1 arrest. The nuclear localization signal of p27 contains an Akt consensus site at threonine 157, and p27 phosphorylation by Akt impaired its nuclear import in vitro. Akt phosphorylated wild-type p27 but not p27T157A. In cells transfected with constitutively active AktT308DS473D (PKBDD), p27WT mislocalized to the cytoplasm, but p27T157A was nuclear. In cells with activated Akt, p27WT failed to cause G1 arrest, while the antiproliferative effect of p27T157A was not impaired. Cytoplasmic p27 was seen in 41% (52 of 128) of primary human breast cancers in conjunction with Akt activation and was correlated with a poor patient prognosis. Thus, we show a novel mechanism whereby Akt impairs p27 function that is associated with an aggressive phenotype in human breast cancer. NOTE: In the version of the article initially published online, the abstract contained one extraneous sentence. This error has been corrected in the HTML and PDF versions. The abstract will appear correctly in the forthcoming print issue.

p27(Kip1) is an important effector of G(1) arrest by transforming growth factor beta (TGF-beta). Investigations in a human mammary epithelial cell (HMEC) model, including cells that are sensitive (184(S)) and resistant (184A1L5(R)) to G(1) arrest by TGF-beta, revealed aberrant p27 regulation in the resistant cells. Cyclin E1-cyclin-dependent kinase 2 (cdk2) and cyclin A-cdk2 activities were increased, and p27-associated kinase activity was detected in 184A1L5(R) cells. p27 from 184A1L5(R) cells was localized to both nucleus and cytoplasm, showed an altered profile of phosphoisoforms, and had a reduced ability to bind and inhibit cyclin E1-cdk2 in vitro when compared to p27 from the sensitive 184(S) cells. In proliferating 184A1L5(R) cells, more p27 was associated with cyclin D1-cdk4 complexes than in 184(S). While TGF-beta inhibited the formation of cyclin D1-cdk4-p27 complexes in 184(S) cells, it did not inhibit the assembly of cyclin D1-cdk4-p27 complexes in the resistant 184A1L5(R) cells. p27 phosphorylation changed during cell cycle progression, with cyclin E1-bound p27 in G(0) showing a different phosphorylation pattern from that of cyclin D1-bound p27 in mid-G(1). These data suggest a model in which TGF-beta modulates p27 phosphorylation from its cyclin D1-bound assembly phosphoform to an alternate form that binds tightly to inhibit cyclin E1-cdk2. Altered phosphorylation of p27 in the resistant 184A1L5(R) cells may favor the binding of p27 to cyclin D1-cdk4 and prevent its accumulation in cyclin E1-cdk2 in response to TGF-beta.

[Figure][1] A 74-year-old woman presented with fatigue and normocytic anemia (hemoglobin 64 g/L and mean corpuscular volume 82 fL). Erythrocyte sedimentation rate was 131 mm/h; creatinine, 150 g/L; and ferritin, 1608 g/L. Protein electrophoresis showed no monoclonal protein, but κ free

[Figure][1] A 59-year-old female was diagnosed 13 years earlier with JAK2 617-positive polycythemia vera (PV) and treated with phlebotomies. Recently she developed progressive splenomegaly and decreased needs for phlebotomy. A diagnosis of post–PV-myelofibrosis was considered, but not

Background: Patients with a single hematological malignancy (SHM) may be unexpectedly diagnosed with a synchronous dual hematological malignancy (SDHM). Management of such patients is challenging and the impact of therapy on the secondary malignancy is often unknown. Methods: We reviewed 3036 patients followed in our center from February 2013 to July 2016. Using WHO 2008 criteria we excluded closely-related diseases (e.g. transformed lymphoma, myeloma arising from monoclonal gammopathy of unknown significance (MGUS), lymphoproliferative disorders with associated paraproteins) and included only clonally unrelated SDHMs. Results: We identified 41 patients with SDHM, a prevalence of 1.35%. Median age was 75 years (range 23-90), with male predominance (26 male, 15 female). All patients were Caucasians except 1 African, and 38/41 were diagnosed locally. Thirteen patients (31.7%) had concomitant solid cancers. Referrals from family practitioners/hospitalists were of two types: 65% with a general diagnosis and 35% with non-specific symptoms requiring work-up. Referrals from specialists (internal medicine or hematology) were more accurate; only asymptomatic secondary diagnoses were missed. SDHMs were diagnosed either incidentally during routine work-up, or because discordant clinical/laboratory findings did not fit a single diagnosis. Three combinations of SDHMs were identified (Table 1). In the Myeloid+Lymphoid group, concomitant MGUS was most frequent. Within the Lymphoid+Lymphoid group, SDHM combinations were random. There were only 3 Myeloid+Myeloid SDHMs. Twenty-nine patients (70.7%) required initiation of therapy for primary malignancy and 12 (29.3%) were on active surveillance. For secondary diagnosis, 29 (70.7%) patients were actively monitored, and 12 (29.3%) needed treatment (9 simultaneously, 3 delayed). At the completion of treatment for primary malignancy, 37 (90.2%) were either in remission or have non-progressing disease, 4 patients progressed. At the time of data cut-off, 34 patients (82.9%) were alive, compared to 87.2% of patients with SHM. Seven patients died, 3 from disease progression, and 4 from unrelated health issues. Our management experience of SDHM is following: - Have low threshold for intensive investigations if there are discordant data - Patients with low-grade/low-acuity SDHM can be managed safely by active surveillance, with early re-evaluation of both diseases if conditions change - If two malignancies require treatment, therapy should be aimed at the more aggressive one - ABVD chemotherapy completely resolved cutaneous T-cell lymphoma lesions - Cladribine, 6 cycles, had no effect on concomitant chronic myelomonocytic leukemia (CMML) - Ruxolitinib either precipitated chronic lymphocytic leukemia from B-cell lymphocytosis or accelerated progression - Hydroxyurea decreased M-spikes in MGUS, regardless of type - Azacitidine given for CMML positively affected mast cell leukemia and was associated with reduction of bone marrow fibrosis, but had no effect on follicular lymphoma - Phlebotomized patients with polycythemia vera may develop profound anemia on chemotherapy. We recommend holding phlebotomies and replacing iron stores intravenously. Temporary therapy with erythropoietin-stimulating agents or red cell transfusions may be needed. Conclusions: SDHMs are not uncommon and require careful investigation if the primary diagnosis is not clear. Myeloid+Lymphoid and Lymphoid+Lymphoid combinations are most common. The high frequency of concomitant solid tumors suggests increased susceptibility to SDHM or impaired immunity. Many second hematological malignancies can be managed by regular monitoring. Active treatment of SDHM requires special considerations. Our recommendations are limited by small patient numbers and a single center. Further studies of SDHM, exploring different cohorts and ethnicities, are needed. Disclosures Nay: Gilead Sciences, Inc.: Honoraria; Janssen: Honoraria, Other: Advisory board; Celgene: Honoraria, Other: Advisory board; Amgen: Other: Advisory board; Lyndbeck: Honoraria; BMS: Honoraria.

Background Drug resistance to chemotherapy is often associated with increased malignancy in neuroblastoma (NB). One explanation for the link between resistance and malignancy might be that resistance facilitates cancer progression and invasion. To investigate this hypothesis, adhesion, transendothelial penetration and NCAM (CD56) adhesion receptor expression of drug-resistant versus drug-sensitive NB tumor cells were evaluated. Methods Acquired drug resistance was mimicked by exposing parental UKF-NB-2, UKF-NB-3 or IMR-32 tumor cells to increasing concentrations of vincristine- (VCR) or doxorubicin (DOX) to establish the resistant tumor cell sublines UKF-NB-2VCR, UKF-NB-2DOX, UKF-NB-3VCR, UKF-NB-3DOX, IMR-32VCR and IMR-32DOX. Additionally, the malignant behaviour of UKF-NB-4, which already possessed the intrinsic multidrug resistance (MDR) phenotype, was analyzed. UKF-NB-4 exposed to VCR or DOX were designated UKF-NB-4VCR or UKF-NB-4DOX. Combined phase contrast – reflection interference contrast microscopy was used to separately evaluate NB cell adhesion and penetration. NCAM was analyzed by flow cytometry, western blot and RT-PCR. Results VCR and DOX resistant tumor sublines showed enhanced adhesion and penetration capacity, compared to their drug naïve controls. Strongest effects were seen with UKF-NB-2VCR, UKF-NB-3VCR and IMR-32DOX. DOX or VCR treatment also evoked increased invasive behaviour of UKF-NB-4. The process of accelerated tumor invasion was accompanied by decreased NCAM surface and protein expression, and down-regulation of NCAM coding mRNA. Transfection of UKF-NB-4VCR cells with NCAM cDNA led to a significant receptor up-regulation, paralleled by diminished adhesion to an endothelial cell monolayer. Conclusion It is concluded that NB cells resistant to anticancer drugs acquire increased invasive capacity relative to non-resistant parental cells, and that enhanced invasion is caused by strong down-regulation of NCAM adhesion receptors.

Recent pathological findings reveal a higher frequency of human cytomegalovirus (HCMV) in tumor cells from different tumors compared with surrounding tissues. Experimental investigations suggest possible supportive effects of HCMV for tumor development and progression. One HCMV effect on tumor cells is the inhibition of apoptosis, leading to the promotion of tumor cell survival. Decreased sensitivity to treatment-induced tumor cell death is a major reason for failure of anticancer chemotherapy. HCMV infection interferes with both the intrinsic and extrinsic cellular apoptosis pathways. HCMV promotes cell survival signaling influencing the tumor suppressor p53 and its relative p73, and stimulates the antiapoptotic Ras/Raf/MEK/Erk- and PI-3K-signaling pathways. Antiapoptotic effects mediated by HCMV are inhibited by antiviral treatment in cell culture. Therefore, a better understanding of the influence of HCMV infection on tumor cell apoptosis might translate into improved anti-cancer therapy.

Valproic acid (VPA) is a widely used antiepileptic agent that is undergoing clinical evaluation for anticancer therapy. We assessed the effects of VPA on angiogenesis in vitro and in vivo. In human umbilical vein endothelial cells, therapeutically relevant concentrations of VPA (0.25 to 1 mM) inhibited proliferation, migration, and tube formation. VPA 1 mM inhibited endothelial cell proliferation by 51 +/- 5%, migration by 86 +/- 11%, and tube formation by 82 +/- 3%. These changes were preceded by the hyperacetylation of histone H4, indicating the inhibition of histone deacetylase (HDAC), and a decreased expression of the endothelial nitric-oxide synthase (eNOS). The inhibition of endothelial cell tube formation by VPA was prevented by addition of the nitric oxide donor (Z)-1-[2-(2-aminoethyl)-N-(2-ammonioethyl)amino]diazen-1-ium-1,2-diolate (DETA NONOate). The anticonvulsive active VPA derivative 2-ethyl-4-methylpentanoic acid, which does not inhibit HDAC, did not affect endothelial cell proliferation, tube formation, or eNOS expression. VPA was also found to inhibit angiogenesis in vivo in the chicken chorioallantoic membrane assay and in a Matrigel plug assay in mice. Embryos from VPA-treated mice showed disturbed vessel formation. These results indicate that therapeutic plasma levels of VPA inhibit angiogenesis by a mechanism involving a decrease in eNOS expression preceded by HDAC inhibition.

Replication restricted oncolytic viruses such as multimutated herpes simplex virus type 1 (HSV-1) G207 represent a novel and attractive approach for cancer therapy, including pediatric solid tumors. Rhabdomyosarcoma is the most common soft-tissue sarcoma of childhood and is often diagnosed already as an advanced disseminated disease. Despite aggressive therapeutic approaches, the prognosis for patients with metastatic rhabdomyosarcoma remains grim. Therefore, there is a need for novel effective drugs with superior safety and efficacy profile. In this study, we showed marked in vitro activity of HSV-1 G207 against embryonal and alveolar rhabdomyosarcoma cells. All human embryonal (KF-RMS-1, RD, and CCA) and alveolar RMS (KFR, Rh28, Rh30, and Rh41) cell lines were highly sensitive to cytotoxic and replicative effects of G207 even at a multiplicity of infection of 0.01, except embryonal Rh1 rhabdomyosarcoma cells, which were efficiently killed only upon multiplicity of infection of 1.0. i.v. G207 treatment of xenotransplanted KFR and KF-RMS-1 tumors in mice led to significant tumor growth inhibition of both tumor entities, whereas intraneoplastic G207 treatment additionally resulted in complete tumor disappearance in 25% of animals. No difference has been found between alveolar and embryonal types of rhabdomyosarcoma. Combination treatment of both cell lines with G207 and vincristine led to strongly enhanced in vitro cytotoxicity without affecting infection efficiency and replication of G207 in KFR as well as in KF-RMS-1 cells. In vivo combination treatment using i.v. G207 and vincristine resulted in complete regression of alveolar rhabdomyosarcoma in five of eight animals and significant growth inhibition of embryonal rhabdomyosarcoma. Taking into consideration the proven safety of G207 in humans, we suggest that G207 alone and in combination with vincristine should be additionally evaluated as a potential agent against human rhabdomyosarcoma.

Cytotoxic drug treatment of neuroblastoma often leads to the development of drug resistance and may be associated with increased malignancy. To study the effects of long-term cytotoxic treatment on malignant properties of tumor cells, we established 2 neuroblastoma cell sublines resistant to vincristine (VCR) and doxorubicin (DOX). Both established cell lines (UKF-NB-2(r)VCR(20) and UKF-NB-2(r)DOX(100)) were highly resistant to VCR, DOX and vice-versa but retained their sensitivity to cisplatin. UKF-NB-2(r)VCR(20) and UKF-NB-2(r)DOX(100) expressed significant amounts of P-glycoprotein, while parental cells were P-glycoprotein negative. GD2 expression was upregulated, whereas NCAM expression was decreased in both resistant cells. Spectral karyotype (SKY) analysis revealed complex aberrant karyotypes in all cell lines and additional acquired karyotype changes in both resistant cells. All cell lines harbored high levels of N-myc amplification. Compared to parental cells, UKF-NB-2(r)VCR(20) and UKF-NB-2(r)DOX(100) exhibited more than 2-fold increase in clonal growth in vitro, accelerated adhesion and transendothelial penetration and higher tumorigenicity in vivo. We conclude that development of drug resistance and acquisition of certain karyotypic alterations is associated with an increase of additional malignant properties that may contribute to the poor prognosis in advanced forms of NB. The 2 novel neuroblastoma cell sublines also provide useful models for the study of drug resistance in aggressive forms of neuroblastoma.

We show that p27 localization is cell cycle regulated and we suggest that active CRM1/RanGTP-mediated nuclear export of p27 may be linked to cytoplasmic p27 proteolysis in early G1. p27 is nuclear in G0 and early G1 and appears transiently in the cytoplasm at the G1/S transition. Association of p27 with the exportin CRM1 was minimal in G0 and increased markedly during G1-to-S phase progression. Proteasome inhibition in mid-G1 did not impair nuclear import of p27, but led to accumulation of p27 in the cytoplasm, suggesting that export precedes degradation for at least part of the cellular p27 pool. p27-CRM1 binding and nuclear export were inhibited by S10A mutation but not by T187A mutation. A putative nuclear export sequence in p27 is identified whose mutation reduced p27-CRM1 interaction, nuclear export, and p27 degradation. Leptomycin B (LMB) did not inhibit p27-CRM1 binding, nor did it prevent p27 export in vitro or in heterokaryon assays. Prebinding of CRM1 to the HIV-1 Rev nuclear export sequence did not inhibit p27-CRM1 interaction, suggesting that p27 binds CRM1 at a non-LMB-sensitive motif. LMB increased total cellular p27 and may do so indirectly, through effects on other p27 regulatory proteins. These data suggest a model in which p27 undergoes active, CRM1-dependent nuclear export and cytoplasmic degradation in early G1. This would permit the incremental activation of cyclin E-Cdk2 leading to cyclin E-Cdk2-mediated T187 phosphorylation and p27 proteolysis in late G1 and S phase.

Valproic acid (VPA) has been shown to induce growth-arrest and differentiation of human neuroectodermal tumors similarly to several other fatty acids. In the present study, we show that continuous VPA treatment together with Interferon-alpha (INF-alpha) synergistically inhibited cell growth of a well-established model of neuroblastoma (NB) differentiation using the human N-myc amplified cell line BE(2)-C. Suppression of tumor growth was accompanied by morphological features of neuronal differentiation and inhibition of histone deacetylase activity. Furthermore, induction of differentiation was concomitant with altered expression of genes related to malignant phenotype such as down-regulation of N-myc, induction of bcl-2 and neural cell adhesion molecule. Production of inhibitors of angiogenesis like thrombospondin-1 and activin A was up-regulated in differentiated NB cells. Treatment with VPA alone decreased the ability of BE(2)-C cells to adhere to and penetrate human endothelium. All these effects of VPA were significantly enhanced when combined with INF-alpha which on its own had little or no effect. These results suggest that combination of VPA and INF-alpha may provide a novel therapeutic strategy for NB due to enhanced inhibition of tumor cell growth, induction of tumor differentiation and suppression of malignant biology by reduced angiogenic and decreased metastatic potentials.

Allogeneic hematopoietic cell transplantation (HCT) is a curative treatment option for acute myeloid leukemia (AML) when indicated. Numerous pre-transplant risk scores have been developed to predict post-transplant outcome, utilizing a variety of parameters. The purpose of this single-center study was to retrospectively develop and validate a prognostic score based on known significant pre-transplant variables for outcomes of 747 patients that underwent HCT for AML between 1978 and 2013. Median age of all patients at transplant was 44 years (range 17-71 years), 391 patients (52%) were female. HCT was performed in first complete remission (CR1) for 497 patients (67%) and in second complete remission (CR2) or advanced disease for 250 patients (33%). Donors were related for 538 patients (72%) and unrelated for 209 patients (28%). Peripheral blood stem cells (PBSC) were used as a graft source in 367 patients (49%). Myeloablative conditioning (MAC) was administered to 615 (82%) patients, 132 (18%) received reduced-intensity conditioning (RIC) regimens. HCT was performed over the time periods 1978-1990 (n=139), 1991-1999 (n=192), 2000-2006 (n=183) and 2007-2013 (n=233). Median follow-up of survivors was 90 months. Patients were assigned a combined score based on patient age, disease status and donor status. For disease status CR1, age Univariate analysis for the test cohort demonstrated a favorable risk group with score 0 (n=92), an intermediate risk group of score 1-2 (n=255) and an unfavorable risk group with score 3 (n=26) with a 5-year overall survival (OS) of 61%, 35% and 20% respectively (p=0.0001)(Figure). Cumulative incidence of relapse (CIR) demonstrated a marginally significant difference between groups (p=0.05) with 5-year CIR 14%, 28% and 23% respectively. Non-relapse mortality (NRM) was marginally different (p=0.07) with 5-year NRM 27%, 39% and 54% respectively. Multivariable analysis of the test cohort for OS demonstrated that the presented scoring system remained significantly prognostic (p Analysis of the validation cohort confirmed significant stratification for OS on univariate (p In the presented study we developed and validated this readily calculable pre-transplant scoring system involving age, CR status and donor type which is highly prognostic for OS and NRM of patients undergoing allogeneic HCT for AML. We also demonstrated that the year transplant was performed over the last three decades had no influence on the prognostic significance of the scoring system. Figure 1 Figure 1. Disclosures Messner: Otsuka Pharmaceuticals Inc: Research Funding.

Late effects occurring post allogeneic hematopoietic cell transplantation (HCT) include the development of secondary malignancies (SM). The purpose of this single-center study was to retrospectively assess the incidence of SM in 2200 patients that consecutively underwent HCT for a variety of hematological conditions between 1970 and 2013, and to investigate parameters associated with occurrence of SM and survival post diagnosis. Median patient age at transplant was 42 years (range 17-71). Graft was bone marrow in 1310 patients (60%), peripheral blood stem cells (PBSC) in 890 patients (40%). Related donors were used in 1624 patients (74%), unrelated in 576 patients (26%). Transplants were performed for acute myeloid leukemia (AML, n=756, 34%), chronic myeloid leukemia (CML, n=486, 22%), acute lymphoblastic leukemia (ALL, n=275, 13%), non-Hodgkin lymphoma (n=174, 8%), myelodysplastic syndrome (n=159, 7%), aplastic anemia (n=128, 6%) and other conditions (n=222, 10%). Conditioning regimen was myeloablative in 1903 patients (87%) and reduced intensity in 297 patients (13%). Concerning total body irradiation (TBI) dose, 556 patients (25%) did not receive TBI, 1060 patients (48%) received 200-500 cGy and 584 patients (27%) received >500 cGy. Median follow-up of survivors was 120 months (range 1-398). SM was observed in 155 patients (7% of total). Of the patients that developed SM, 39 (25% of SM) were with skin malignancy (30 with non-metastatic squamous and basal cell carcinoma), 25 (16%) with gynecological malignancies, 18 (12%) with gastrointestinal, 19 (12%) with hematological, 20 (13%) with oral squamous carcinoma, 14 (9%) with prostate, 6 (4%) with lung, 4 (3%) with thyroid and 10 (6%) with other forms of SM. Excluding patients with non-metastatic squamous and basal cell carcinoma of skin, the remaining 125 patients demonstrated a median time to SM of 99 months (range 1-393). Median time to development of SM was 4, 7 and 12 years for the age groups >55, 41-55 and Concerning the survival of the 125 patients following diagnosis of SM (excluding non-metastatic squamous and basal cell carcinoma of skin), median follow-up of survivors was 37 months (range 1-344 months), survival at 10 years post-SM was 49% (SE ±6.6%). 25% of patients died of causes related to SM. Univariate analysis demonstrated a significant influence of ECOG score at diagnosis of SM (p In conclusion, incidence of SM post-HCT does not seem to be related to dose of TBI or conditioning intensity. Younger patients develop SM significantly later post-HCT, while a higher ECOG score at diagnosis of SM is independently prognostic of poor survival. Disclosures Messner: Otsuka Pharmaceuticals Inc: Research Funding.

Valproic acid (VPA) has been shown to induce growth-arrest and differentiation of human neuroectodermal tumors similarly to several other fatty acids. In the present study, we show that continuous VPA treatment together with Interferon-alpha (INF-alpha) synergistically inhibited cell growth of a well-established model of neuroblastoma (NB) differentiation using the human N-myc amplified cell line BE(2)-C. Suppression of tumor growth was accompanied by morphological features of neuronal differentiation and inhibition of histone deacetylase activity. Furthermore, induction of differentiation was concomitant with altered expression of genes related to malignant phenotype such as down-regulation of N-myc, induction of bcl-2 and neural cell adhesion molecule. Production of inhibitors of angiogenesis like thrombospondin-1 and activin A was up-regulated in differentiated NB cells. Treatment with VPA alone decreased the ability of BE(2)-C cells to adhere to and penetrate human endothelium. All these effects of VPA were significantly enhanced when combined with INF-alpha which on its own had little or no effect. These results suggest that combination of VPA and INF-alpha may provide a novel therapeutic strategy for NB due to enhanced inhibition of tumor cell growth, induction of tumor differentiation and suppression of malignant biology by reduced angiogenic and decreased metastatic potentials.

Abstract 1867 Secondary myelodysplastic syndrome and acute myelogenous leukemia (2° MDS/AML) are well-known complications that can occur after alkylating agent therapy for multiple myeloma (MM) or other cancers. However, until recently, the survival of MM pts was relatively short, a feature which may have contributed to a relatively low reported incidence of this complication in MM. The introduction of novel agents has improved survival rates of MM pts; lenalidomide (len) + dexamethasone–currently approved for MM after one prior therapy– is one of the main regimens that has contributed to this finding. Since alkylating agents, either given orally or as part of high-dose melphalan + ASCT, still remain an important component of MM therapy, more pts may survive to be at risk for 2° MDS/AML. Using the MM database at PMH, we retrospectively reviewed the charts of patients with relapsed/refractory (rel/ref) MM treated with len-based regimens (>1 cycle) to determine the incidence and characteristics of 2° MDS/AML that developed during this therapy. Between 06/2006 and 08/2012 we identified 230 patients having received len-based therapy: len + corticosteroids 222 patients, len alone 8 patients, cyclophosphamide + len + prednisone (CPR) 32 patients. 2° MDS/AML developed in 9 patients (3.9%) at a median of 89.6 months (range 30–188) from the time of diagnosis of MM and 22.4 (2–56.6) months from the time of initiation of len regimens. The median follow-up from start of len was 1.6 years, and from the start of diagnosis 7.5 years. The median duration of len treatment was 9.4 months. The MDS/AML cytogenetic changes were variable, but four patients had deletions of all or part of chromosome 5. None of the 2° MDS/AML had translocation t(4;14), as compared to 5.9% in (−) MDS/AML subgroup. The characteristics of patients at the time of starting len, in those who later developed (+) or did not develop (−) 2° MDS/AML during therapy, are shown in Table 1. Cumulative incidence of 2° AML/MDS from time of diagnosis to time of 2° AML/MDS is 4.5% [95% CI 2.2–9.2%] at 15 years. Cumulative incidence of 2° AML/MDS from starting time of len to time of AML/MDS is 5% [95% CI 2.4–10.4%] at 5 years. The incidence of 2° MDS/AML among those who had prior oral alkylators (OA) and/or concomitant OA was 10.5% (2/19 patients), concomitant cyclophosphamide only 7.6% (1/13), prior OA only 1.9% (3/152), and 6.5% for those who did not receive prior/concomitant OA (3/46). Grade 3–4 neutropenia occurred during len in 44% versus 58% in those with and without 2° MDS/AML, respectively. G-CSF was used in 56% of pts who developed MDS compared with 53% who did not. We conclude: 1) The cumulative incidence of MDS/AML from starting len to time of 2° AML/MDS was 5% at 5 years; 2) patients who developed 2° MDS/AML while on len regimens were slightly older, had slight male predominance, higher beta-2-microglobulin, creatinine and platelet count, less often received prior ASCT, thalidomide, and bortezomib, but had longer exposure to len; 3) the relationship with OA is not entirely certain, but it appears that those with prior and concomitant exposure to OA have the highest incidence of this complication, which is most often seen in prolonged len treatment. Table 1. Patient characteristics (n=230) Feature ALL patients (+) MDS/AML (–) MDS/AML Number of patients 230 9 221 Median age, years 61 (31–80) 68 (53–76) 61 (3–80) Male 134 (58%) 6 (67%) 128 (56%) Median baseline ANC, × 109/L 2.8 (0.9–61.4) 3.0 (1.5–5.1) 2.8 (0.9–61.4) Median baseline β-2 microglobulin (nmol/L) 222 (43–1695) 300 (133–481) 222 (43–1695) Median baseline pl count, × 109/L 156 (5–479) 200 (43–277) 156 (5–479) Median baseline creatinine, μmol/L 87 (39–515) 97 (56–117) 86 (39–515) Median # prior regimens 2 (0–6) 2 (1–5) 2 (0–6) Prior alkylating agents (all) 218 (95%) 9 (100%) 209 (95%) Prior oral alkylators 167 (73%) 6 (67%) 162 (73%) Prior ASCT 187 (81%) 2 (78%) 180 (81%) Prior thalidomide 132 (57%) 3 (33%) 129 (58%) Prior bortezomib 109 (47%) 3 (33%) 106 (48%) Concomitant cyclophosphamide 32 (13.9%) 3 (33%) 29 (13%) G-CSF use 123 (53%) 5 (56%) 118 (53.39%) Median duration of Len (mo, range) 9.4 (0.1–67.2) 22.8 (6.6–56.6) 6.8 (0.1–67.2) Disclosures: Chen: Johnson & Johnson, Lundbeck, Celgene: Consultancy; Roche: Honoraria; Johnson & Johnson, Celgene, GlaxoSmithKline: Research Funding. Kukreti:Roche: Consultancy, Honoraria; Celgene: Honoraria; Janssen: Honoraria. Reece:Janssen: Consultancy, Honoraria, Research Funding; Merck: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Bristol Myers Squibb: Honoraria, Research Funding; Otsuka: Honoraria, Research Funding; Millennium Pharmaceuticals: Research Funding.

Acquisition of P-gp-mediated multidrug-resistance does not always correlate with observed malignant behavior of NB. To characterize alterations accompanying development of multidrug-resistance in NB we established two neuroblastoma cell sublines resistant to vincristine (UKF-NB-3rVCR10) and doxorubicin (UKF-NB-3rDOX20). UKF-NB-3rVCR10 and UKF-NB-3rDOX20 overexpressed functional P-gp and developed an increased malignant phenotype: presented constitutive phosphorylation of AKT, resistance to gamma-irradiation, and had increased survival in serum-free medium. Inhibition of P-gp restored chemosensitivity but did not affect increased survival in serum-free medium and sensitivity to gamma-irradiation. Inhibition of AKT had no influence on chemoresistance but restored sensitivity to serum starvation. Both resistant cell lines acquired additional chromosomal changes. UKF-NB-3rVCR10 cells acquired a missense P53 mutation in exon 5, an increased MYCN amplification, an enhanced adhesion to endothelium, a decreased NCAM expression, a distinctly higher clonogenicity, and an increased in vivo tumorigenicity. We conclude that acquisition of increased malignant behavior in neuroblastoma occurs concomitantly with multidrug-resistance and is P-gp-independent.