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THE BRAZILIAN SOCIETY FOR BLOOD AND MARROW TRANSPLANTATION (SBTMO) PRESENTS THE BRAZILIAN GUIDELINES ON HEMATOPOIETIC STEM CELL TRANSPLANTATION

Severe aplastic anemia (SAA) is a life-threatening disease that can be cured with allogeneic cell transplantation (HCT). Haploidentical donor transplantation with post-transplantation cyclophosphamide (haplo-PTCy) is an option for patients lacking an HLA-matched donor. We analyzed 87 patients who underwent haplo-PTCy between 2010 and 2019. The median patient age was 14 years (range, 1 to 69 years), most were heavily transfused, and all received previous immunosuppression (25% without antithymocyte globulin). Almost two-thirds (63%) received standard fludarabine (Flu)/cyclophosphamide (Cy) 29/total body irradiation (TBI) 200 cGy conditioning, and the remaining patients received an augmented conditioning: Flu/Cy29/TBI 300-400 (16%), Flu/Cy50/TBI 200 (10%), or Flu/Cy50/TBI 400 (10%). All patients received PTCy-based graft-versus-host disease (GVHD) prophylaxis. Most grafts (93%) were bone marrow (BM). The median duration of follow-up was 2 years and 2 months. The median time to neutrophil recovery was 17 days. Primary graft failure occurred in 15% of the patients, and secondary or poor graft function occurred in 5%. The incidences of grade II-IV acute GVHD was 14%, and that of chronic GVHD was 9%. Two-year overall survival and event-free survival (EFS) were 79% and 70%, respectively. EFS was higher for patients who received augmented Flu/Cy/TBI (hazard ratio [HR], .28; P = .02), and those who received higher BM CD34 cell doses (3.2 × 10E6/kg) (HR, .29; P = .004). The presence of donor-specific antibodies before HSCT was associated with lower EFS (HR, 3.92; P = .01). Graft failure (HR, 7.20; P.0001) was associated with an elevated risk of death. Cytomegalovirus reactivation was frequent (62%). Haploidentical HCT for SAA is a feasible procedure; outcomes are improved with augmented conditioning regimens and BM grafts with higher CD34 cell doses.

Mielodysplastic syndrome and hematopoietic stem cell transplantation based on genetic status.

To better understand the outcomes of HSCT in Brazil, we conducted a multicenter study using the CIBMTR database. Seven participating centers extracted their own data through the Data Back to Center tool. Main indications for HSCT-auto were MM(51%), NHL(18%) and HL(17%); Allogeneic, AML(24%), ALL(23%) and SAA(15%). For acute leukemias, risk of death was higher in the 18-40 years group (HR=1.18,p=0.022), 40-60(HR=1.19,p

To increase the report of Brazilian hematopoietic stem cell transplantation (HSCT) data to the Center for International Blood and Marrow Transplant Research (CIBMTR), the Data Managers Working Group (GTGD) of the Brazilian Society of Bone Marrow Transplants (SBTMO), and the Sao Paulo State Bone Marrow Association (AMEO) developed several strategies since 2016: training data managers (GDs) in national and international HSCT meetings, the development of a free online teaching course (EAD) in Portuguese on Transplant Essential Data (TED), on­line and presential training course for new data managers offered by AMEO, the approval by the National Committee of Ethics in Research (CONEP) of a national multicenter protocol to formalize sharing data of Brazilian transplants with the CIBMTR, and the first multicenter eval­uation our HSCT results using the CIBMTR Data Back to Center. The contract between SBTMO and CIBMTR was signed in 2019 and GTGD of the SBTMO was officially created. These actions resulted in an increase from 24 to 41 transplant centers registered at the CIBMTR from 2016 to 2019. The process of increasing adherence and continuity of HSCT reports to the CIBMTR is complex and requires commitment of all professionals involved HSCT. The success of this process depends on education of the GD and the involvement of all HSCT directors.

Objectives The aim of this study was to analyze the outcomes of children with Diamond-Blackfan anemia (DBA) treated in Brazil with hematopoietic cell transplantation (HCT). Methods We performed a retrospective analysis of 44 pediatrics patients transplanted between 1990 and 2018. The median age of patients was 5 years, and 57% were male. Twenty-five received their first HCT from an HLA-matched sibling donor (MSD), 12 from a HLA matched unrelated bone marrow donor (MUD 10/10, n = 12) and 7 other HLA mismatched donors (MMD). Results After a median follow-up of 4 years, estimate 5-year overall survival (OS) for the entire cohort was 70%, 80% for MSD group, 73% for MUD, and 29% for MMD. Thirty-eight out of the 44 evaluable patients engrafted successfully. Primary and secondary graft failure was observed in five and three patients, respectively. Rates of grade II-IV and III-IV acute graft-versus-host disease (aGVHD) were 25% and 18%, respectively. Nine patients developed chronic GVHD (cGVHD). Conclusion Overall survival rates observed after HLA matched donors transplant for DBA were comparable to those reported from higher-income countries and international registries.

Background Immunological life-threatening complications frequently occur in post-hematopoietic stem cell transplantation (HSCT), despite matching recipient and donor (R/D) pairs for classical human leukocyte antigens (HLA). Studies have shown that R/D non-HLA disparities within the major histocompatibility complex (MHC) are associated with adverse effects post-HSCT. Methods We investigated the impact of mismatches of single-nucleotide polymorphisms (SNPs) in C4A/C4B genes, for showing the highest diversity in the MHC gamma block, on 238 patients who underwent HLA 10/10 unrelated donor (URD) HSCT. The endpoints were acute graft-versus-host disease (aGVHD), chronic graft-versus-host disease (cGVHD) and mortality. One hundred and twenty-nine R/D pairs had 23 C4-SNPs typed by PCR-SSP (Gamma-Type™v.1.0), and 109 R/D pairs had these 23 SNPs identified by next-generation sequencing (NGS) using the Illumina platform. Results The percentage of patients who received HSC from HLA 10/10 donors with 1–7 mismatches was 42.9%. The R/D pairs were considered C4 mismatched when bearing at least one disparity. These mismatches were not found to be risk factors for aGVHD, cGVHD or mortality after unrelated HSCT when SNPs were analyzed together (matched or mm ≥ 1), independently or according to the percentage of incompatibilities (full match for 23 SNPs; 1–3 mm and >3 mm). An exception was the association between 1–3 mismatches at the composite of SNPs C13193/T14952/T19588 with the development of aGVHD (P = 0.012) and with grades III-IV of this disease (P = 0.004). Conclusion Our data are not consistent with the hypothesis that disparities in C4A/C4B SNPs increase the risks of post-HSCT adverse effects for the endpoints investigated in this study.

The results of hematopoietic stem cell transplant (HSCT) for primary immunodeficiency diseases (PID) have been improving over time. Unfortunately, developing countries do not experience the same results. This first report of Brazilian experience of HSCT for PID describes the development and results in the field. We included data from transplants in 221 patients, performed at 11 centers which participated in the Brazilian collaborative group, from July 1990 to December 2015. The majority of transplants were concentrated in one center (n = 123). The median age at HSCT was 22 months, and the most common diseases were severe combined immunodeficiency (SCID) (n = 67) and Wiskott-Aldrich syndrome (WAS) (n = 67). Only 15 patients received unconditioned transplants. Cumulative incidence of GVHD grades II to IV was 23%, and GVHD grades III to IV was 10%. The 5-year overall survival was 71.6%. WAS patients had better survival compared to other diseases. Most deaths (n = 53) occurred in the first year after transplantation mainly due to infection (55%) and GVHD (13%). Although transplant for PID patients in Brazil has evolved since its beginning, we still face some challenges like delayed diagnosis and referral, severe infections before transplant, a limited number of transplant centers with expertise, and resources for more advanced techniques. Measures like newborn screening for SCID may hasten the diagnosis and ameliorate patients' conditions at the moment of transplant.

Introduction: Allogeneic stem-cell transplantation (HSCT) remains a potentially curative approach for acute lymphoblastic leukemia (ALL), especially for high-risk patients and those with relapsed/refractory disease, although its efficacy is offset by a not negligible toxicity. Adult patients with ALL fare worse in developing countries with low data about the HSCT in this setting. In this study, we aim to describe outcomes and examine risk factors for overall survival (OS), disease-free survival (DFS), cumulative incidence of relapse (CIR), non-relapse mortality (NRM) and graft-versus-host disease (GVHD) after HSCT for ALL in Brazilian centers. Methods: This is a retrospective registry study. Patients with ALL or ambiguous lineage leukemia above 16 years who underwent a first HSCT in 5 Brazilian centers between January 2007 and December 2017 were included. Kaplan-Meier method and competing risk analysis were used. Multivariable analysis (MVA) was performed using Cox regression and the Akaike's information criteria was used for model selection. Cut-offs for continuous variables were calculated through "findcut" R function. Center effect was evaluated by using frailty model. Results: Overall, 275 patients were included with a median age of 31y (range, 16-65). Philadelphia chromosome was found in 35%. Baseline characteristics are summarized in Table 1. Matched sibling donor (MSD), matched unrelated donor (MUD), mismatched unrelated donor (MMUD), haploidentical donor and umbilical cord were reported in 53%, 19%, 9%, 19%, and 5%, respectively. Total body irradiation (TBI) was used in 67% of myeloablative HSCT. Median time to HSCT in CR1 was 7.8 months. Engraftment failure rate was 1.5%. Median follow-up time was 6.4 y. Cumulative incidence of acute grade II-IV and chronic GVHD were 54.2% and 26.2%, respectively. In MVA, the use of MUD (HR=2.3) and increased donor age (HR=1.02) were associated with GVHD. Five-year CIR was 28.1% (95% CI 22.9-33.6) and 5-y NRM was 34.1% (95% CI 28.4-39.8). At D+100, NRM incidence was 22.6%. Central nervous system involvement at the diagnosis (HR=2.2), and disease status (HR 1.8 for CR2+, and HR 7.9 for refractory) increased relapse incidence, whereas the use of peripheral blood graft (HR=0.51) and haploidentical donor (HR=0.4) significantly decreased relapse incidence. In MVA, NRM was increased by patient's age (HR=1.04), refractory status (HR=4.2), MUD (HR=3.8) and donor age (HR=1.02). Center effect was significantly associated with relapse and NRM. Five-year OS and DFS were 40.7% (95% CI 35.1-47.1) and 37.8% (95% CI-32.3-44.1), respectively (Figure 1). Patient's age, donor age and disease status were independently associated with OS and DFS (Table 2). When GVHD (as a time-dependent variable) was introduced in the MVA for OS and DFS, it was associated with decreased OS (HR 4.2, p0.01%) was associated with worse DFS in univariate analysis (HR=1.47) in available cases. Conclusions: This is the largest series of ALL adults receiving HSCT from Brazil. While OS and DFS were similar to published data, NRM was higher. Patient's age and donor age outweighed donor type or graft source in our analysis. Interestingly, haploidentical HSCT related to lower CIR, whereas the use of MUD was associated with higher NRM and GVHD rates. These results impact on donor selection strategy in our country, aiming to timely offer HSCT for high-risk ALL patients in our setting. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

The number of hematopoietic stem cell transplantation (HSCT) in Brazil is growing rapidly. To better understand the outcomes of HSCT in Brazil, strategies have been developed with the Center for International Blood and Marrow Transplant Research (CIBMTR), using its standardized registry structure and data sharing application. The methods adopted to establish the registry were through efforts to increase the Brazilian centers that report to CIBMTR included training courses for HSCT data managers, the officialization of a multicenter HSCT study using the CIBMTR structure and the partnership between Brazilian Society of Bone Marrow Transplantation (SBTMO) and the CIBMTR. Here we describe the history for establishing the HSCT Brazilian database using the CIBMTR back to center data and present the aggregated results since 2016. We found a significant increase in the numbers of active centers reporting to CIBMTR from 11 in 2016 to 21 in 2020 corresponding to higher numbers of transplants reported to the CIBMTR from 574 to 921 in that period. The model used to generate this national database was effective as it leverages existing infrastructure to assess the activity and outcomes of HSCT in Brazil.

Understanding the HSCT scenario in Brazil is challenging due to the lack of a national registry that allows the analysis of results. The partnership between the Brazilian Cellular Therapy and Bone Marrow Transplant Society (SBTMO) and the Center for International Blood and Marrow Research (CIBMTR) allowed the return of Brazilian data registered in the CIBMTR, through the Data Back to Center (DBtC), in a standardized and organized way. With this database it was possible to know the demographic data and the outcomes of transplants performed in Brazil. The spreadsheet was imported into the Power BI desktop, and functions and charts were created. Between 2008 and 2019, 7,264 transplants were reported to the CIBMTR from 24 Brazilian transplant centers. The partnership between SBTMO and CIBMTR, made the Brazilian registry possible and allowed the development of the first Brazilian Summary slides. Despite the difference in the number of cases and of follow-up time, the results in this study were similar to those presented in the US Summary Slides.

Background Hepatitis A virus (HAV) infection is highly prevalent in developing countries. In countries experiencing a shift from intermediate/high endemicity to low endemicity, the World Health Organization recommends the incorporation of HAV vaccine into the national vaccination calendar for children aged ≥1 year. Since HAV antibodies wane over time, most HSCT revaccination guidelines advise vaccination as optional, following the country recommendation. However, no study has evaluated the serological response to HAV vaccine in allogeneic HSCT recipients. Methods We conducted a prospective study in 46 HSCT recipients who received two doses of inactivated HAV vaccine. Blood samples were taken before vaccination to determine HAV prevalence rates, and before and 4-6 weeks after the second dose. Specific anti-HAV antibodies were detected by a competitive commercial enzyme immune assay. Results Patients received the first dose of vaccine at a median of 332.5 (120-4134) days after HSCT. Median absolute lymphocyte count at vaccination was 1947 (696-12 500)/mm3 . The seroprevalence rate was 93.5% at inclusion. Although safe and well tolerated, the serological response to HAV vaccine in susceptible patients was poor (33%), and no boost effect was observed in seropositive patients. Conclusions In areas with intermediate/high seroprevalence of HAV, serology should be recommended prior to referral to vaccination. The mechanisms of antibody interference and how to overcome T-cell function deficiency need to be better understood in transplant populations receiving HAV vaccine. Alternative schedules of HAV vaccination should be evaluated in prospective trials.

In this study, we report on major MRD or URD BMT outcomes in pediatric patients with SAA in Brazil. This was a retrospective study, which included 106 patients ≤18 years old who received a first BMT for SAA. All patients received bone marrow as graft source from an MRD (n = 69) or a URD (n = 37). Conditioning regimen was non-myeloablative in 73.6% of cases, and GVHD prophylaxis comprised a calcineurin inhibitor plus methotrexate in 89.6% of patients. After a median follow-up of 4.5 years after BMT, 81 patients are alive, with a 4-year OS of 77% and no statistically significant difference between the MRD and URD groups (82% vs. 69%, respectively; P = .08). Grade III-IV aGVHD at 6 months and cGVHD at 2 years were observed in 8% and 14% of cases, respectively, and were not statistically different between the groups. Twenty-five (23%) patients died at a median of 2.9 months after BMT. Our study showed that 4-year OS after BMT was not statistically different between MRD and URD recipients. This study shows that the outcomes of pediatric patients transplanted for SAA with a URD in Brazil are approaching those of MRD transplants. In contrast, OS after MRD BMT was lower than we would expect based on previous reports. The wide range of preparatory regimens used by the study centers highlights the need for standardized protocols for these children. Our findings provide a benchmark for future studies focused on improving BMT outcomes in this setting in Brazil.

Introduction. COVID-19 pandemic has spread worldwide and reached HSCT centers in many countries. The first proven case of COVID-19 in Brazil was diagnosed in São Paulo by the end of February 2020. The Brazilian Society of Marrow Transplantation (SBTMO) promptly published local recommendations for the diagnosis and management of COVID-19 in HSCT centers. We describe the main clinical findings and outcomes of SARS CoV-2 infection and COVID-19 in 22 HSCT recipients from two Brazilian HSCT centers, followed up for at least 14 days. Methods. The detection of SARS CoV-2 infection was performed by RT-PCR in all transplant candidates before admission, and in all HSCT recipients with respiratory symptoms. Other respiratory viruses were also investigated by direct fluorescent assay (DFA) or RT-PCR. COVID-19 was managed according to the SBTMO recommendations. Results. From March to June 2020, SARS CoV-2 infection was detected in 5 asymptomatic patients (29.4%) and COVID-19 was diagnosed in 17 HSCT recipients with respiratory symptoms (7 AUTO, 6 MRD, 5 MUD and 4 HAPLO) at a median of 94 days after HSCT (range -6 to +1,850). The asymptomatic cases at diagnosis remained so during follow-up. Two asymptomatic patients were receiving the conditioning regimen when SARS CoV-2 was diagnosed. The median age at diagnosis was 39,2 (1-72) years. Five patients were children (1-12 years) and 17 were adults (19-72 years). Eleven patients (50%) had comorbidities, the most frequent being diabetes and hypertension. Fever, cough and diarrhea were the symptoms more frequently observed and occurred in 13 (76.4%), 7 (41.2%), and 5 (29.4%) of the 17 symptomatic patients, respectively. Symptoms such as anosmia and dysgeusia, which have been frequently associated with COVID-19 were not observed in this series. Eleven of the symptomatic patients (64.7%) showed altered CT or X-ray at diagnosis. Glass ground opacities were the images more frequently seen (63.6%). The median lymphocyte count was 619.5 (0-2,604) /mL. C-reactive protein and d-dimer ranged from 0.65 to 339 ng/mL and from 0.39 to 4,530 mg/L, respectively. Four (18%) HSCT recipients died (1 AUTO, 2 HAPLO, 1 MRD). COVID-19 was the cause of death in two of them. In the remaining two HAPLO HSCT recipients, KPC co-infection followed by septic shock had a major role in patients' death. Median age of patients who died was 39 (11-59) years, and two of them had comorbidities (hypertension and chronic lung disease). Conclusions. Symptoms of COVID-19 mimic other respiratory virus infections and specific diagnosis is mandatory. Interstitial pneumonia was frequent (around 65%). Clinical outcome of SARS Cov-2 infection or COVID-19 was moderate in the majority of the patients in the present series. However, the mortality rates observed in HSCT recipients (14.3% in AUTO; 20% in ALLO) were higher than in general population. Asymptomatic cases were seen in almost 30% of the patients, suggesting that frequent screening is necessary to control transmission in HSCT centers. Disclosures No relevant conflicts of interest to declare.

Introduction Many developing countries do not have a consolidated registry to report hematopoietic stem cell transplant outcomes (HSCT), what poses a great challenge to understand the HSCT results. The CIBMTR is an excellent strategy for these countries to report, validate, and to have their own nationwide data. Objective To report strategies and tools developed in Brazil to increase the number of active centers reporting data to the CIBMTR. Methods The Brazilian Society of Bone Marrow Transplant (SBTMO) and Sao Paulo State Bone Marrow Association (AMEO), in partnership with the CIBMTR and support from the Brazilian government (PRONON-SUS), have outlined strategies and developed tools to improve data reporting: data managers visited the CIBMTR for specific training, online-based learning tools were developed in Portuguese; the SBTMO has constituted a formal data manager working group and has worked on a formal agreement with the CIBMTR to have organized nationwide data back to the country. The data managers group organized an online real time communication tool (WhatsApp) with the senior data managers and with an outstanding Portuguese-speaking staff of the CIBMTR (Figure 1). Results and Discussion Since the beginning of the project in 2016, the number of centers registered at the CIBMTR has increased from 24 to 33 and among them, the number of centers with current reports increased from 9 to 16 (Figure 2). With the expected delay in starting this process complete CIBMTR affiliation, inclusion of new centers in the study for reporting data in the nationwide Platform, submission to the local ethics committee, and training of data managers, we expect this number to further increase in the next months. There was a 50% increase in the number of participants at the SBTMO meeting organized for Brazilian data managers, 23 participants in 2017, and 52 in 2019. The participation of data managers at the Tandem Meetings increased from 3 in 2016 to 10 in 2019. The SBTMO data managers working group has their mission, vision and values published in the society's webpage. A multicenter study was approved in 2017 to send national data to the CIBMTR and in 2019 it gained Central Brazilian IRB (CONEP) approval, currently with 19 participating centers. AMEO has started training of new data managers with governmental support (Pronon), currently with 144 students from 36 centers. Conclusion The actions developed in our country have reached a large number of centers and professionals being prepared to report high quality data to the CIBMTR. The SBTMO recognition may help to establish data managers as an official activity in the country. We hope the Brazilian example may encourage other centers and countries, ultimately aiming at improving the quality of care for patients who need HSCT.

Severe aplastic anemia is a life-threatening disease usually treated with immunosuppression or HSCT. This is a multicenter retrospective study that included 78 patients who have undergone haploidentical HSCT with PTCy for severe aplastic anemia in Brazil between 2010 and 2019. Median age was 14 y/o (range: 1-69), and most patients had been heavily transfused. Conditioning regimen was FluCyTBI-based, and GVHD prophylaxis consisted of PTCy, MMF, and tacrolimus (13%) or cyclosporine (87%). Most grafts (92%) were bone marrow. One-year OS was 81%, and it was lower in females (HR=4.6; P=0.007) and in those who had graft failure or poor graft function (HR=10.3; P 30 y/o and lower TNC dose. In conclusion, we have shown that haploidentical transplantation for SAA is feasible. The incidence of graft failure/poor graft function was high, and increasing the TBI dose to 300-400 cGy or Cy to 50 mg/kg in the conditioning regimen may overcome graft failure, but not the addition of ATG. Patients who had not been previously exposed to ATG or alemtuzumab might be at high risk of graft failure. High cellular bone marrow grafts should be pursued.

Hematopoietic stem cell transplant (HSCT) recipients should be routinely revaccinated after transplantation. We evaluated the difficulties met in the revaccination program and how a prospective and tailored follow-up could help to overcome these obstacles. HSCT recipients (n=122) were prospectively followed up and categorized into Group 1 (n=72), recipients who had already started the revaccination program, and Group 2 (n=50), recipients starting their vaccines. Whenever a difficulty was reported, interventions and subsequent evaluations were performed. Reported problems were related to patient compliance, HSCT center and/or vaccination center. Problems related to patient compliance were less frequent than those related to HSCT center modifications of previous recommendations, or to errors made by the vaccination center. The main gap found was vaccination delays (81.9%). Advisory intervention was needed in 64% and 46% of Group 1 and Group 2, respectively (p=0.05), and was partially successful in around 70% of the cases. Total resolution was achieved in more than 35% in both groups. Improvements are needed in the Brazilian vaccination program for HSCT recipients to assure a complete and updated revaccination schedule. HSCT centers should assign nurses and transplant infectious disease specialist physicians to organize the revaccination schedule and to monitor the program development.

Aedes mosquitoes are well adapted in domestic environments and widespread in tropical regions. Since 2015, Brazil has been experiencing a triple epidemic of dengue (DENV), chikungunya (CHKV), and Zika (ZIKV) viruses. The last 2 viruses are likely following the path of DENV, which has been endemic in most parts of the country since the 1980s. Given this triple epidemic, we proposed a prospective and collaborative study to assess the prevalence, morbidity, and mortality of DENV, CHKV, and ZIKV infections in hematopoietic stem cell transplant (HSCT) recipients and oncohematological patients. A case definition strategy (fever and rash) was used to prompt diagnostic investigation of DENV, ZIKV, and CHKV, which was accomplished by real-time polymerase chain reaction with plasma and urine samples. Clinical follow-up was performed 7 and 30 days after symptom onset. We report here the first cases of ZIKV and CHKV infections diagnosed in this ongoing study. From February to May 2016, 9 of the 26 patients (34.6%) fulfilling case definition criteria were diagnosed with DENV (3 cases), ZIKV (4 cases), or CHKV (2 cases) infections. Prolonged viremia and viruria were observed in dengue and Zika fever cases, respectively. Thrombocytopenia was the most frequent complication. Delayed engraftment was noted in 1 patient who acquired ZIKV 25 days before HSCT. All patients survived without sequelae. With the geographic expansion of arboviruses, donor and recipient screening may become mandatory. Patients living in areas where these viruses are not endemic are also at risk, since these viruses can be transmitted by blood as well as organ or tissue transplantation.

Background:Natural Killer Cells are innate immune system cells important in host defenses against viruses and tumor cells. Two subpopulations are well described: NK CD56bright CD16neg (NK56++16-) which is less frequent in peripheral blood (PB) and associated with high cytokine production, and NK56dim16pos (NK56+16+), more frequent in PB and associated with high cytotoxic activity. In allogeneic hematopoietic stem cell transplantation (allo-HSCT), NK cells are important for infection control, and also for the disease control. The mismatch between donor NK cell receptors and host HLA may lead to a stronger graft versus leukemia (GVL), possibly modulating graft versus host disease (GVHD). However, only a few studies evaluated NK subpopulations recovery after HSCT and the impact on transplant outcomes. Objectives: The aim of the study was to analyze NK cells subpopulations reconstitution after HSCT and their possible impact on HSCT endpoints: relapse, GVHD (acute and chronic), transplantation related mortality and overall survival. Patients and Methods: Overall, 77 patients from 4 HSCT centers (60 % male, median age 17 years, range 1-74), receiving bone marrow (BM, 47%), umbilical cord (UCB, 30%) or peripheral blood (PB, 23%) from unrelated (80%) or related donors (20%) were studied. The most common diagnosis was acute leukemia (AML 38%, ALL 34%). Most patients received myeloablative conditioning (MAC) regimens (61%). Antithymocyte globulin (ATG) was used in 27 patients (35%) and total body irradiation (TBI) in 40 (52%). Median follow up time was 82 months (22-107). NK subpopulations were quantified by multiparametric flow cytometry at engraftment and days 3, 7, 14, 21 and 60 after engraftment. We have then elaborated graphs plotting cells counts over time (until 60 days) and calculated the area over the curve (AOC) for each subpopulation [NK56++16- (NK56-index) and NK56+16+ cells (NK16-index)], considering 0.5x10e9/L as cut-off value for both subpopulations. A higher AOC represents a more profound NK deficiency. Using receiver operating characteristic (ROC) curves we determined cut offs for the AOC that could provide the best correlation with survival. Results:The overall survival (OS) in 80 months was significantly worse in patients with NK56 deficiency, defined by a NK56-index > 14592.31 cells/mm3.days (29% x 73% for non- deficient, p=0.0001, Figure 1). NK56 deficient patients also had a higher cumulative incidence (CI) of non-relapse related mortality (NRM: 35% x 15%, p=0.03, Figure 2). GVHD (acute or chronic) was similar between low NK56-index and high NK-56 index patients. In multivariate analysis, high NK56index remained significantly associated with worse OS [hazard ratio (HR) 3.5; 95% confidence interval (95%CI) 1.6-7.6], and higher NRM (HR 2.9; 95%CI 1.0-8.0). There were no significant correlations between NK16-index with any of the analyzed HSCT outcomes. Conclusion: A higher NK56-index is significantly associated with worse outcome in long term survival and non relapse related mortality in patients submitted to allogeneic hematopoietic stem cell transplantation. This strategy might be helpful in identifying risk groups and possible earlier therapeutic interventions. Disclosures No relevant conflicts of interest to declare.

Background: Most studies in immune reconstitution after allogeneic hematologic stem cell transplantation (alloHSCT) focus on adaptive immunity, particularly in lymphocyte recovery. Classical monocytes (cMo) are part of the innate immunity, playing an important role in the defense against fungal and bacterial infections. The innate and adaptive immunity are closely related, and non-classical monocytes (ncMo) participate in this connection, regulating T cell response. However, the role of these cells in the graft versus tumor effect and graft versus host disease (GVHD) is still unclear. Objectives: The aim of the study was to investigate cMo and ncMo reconstitution after alloHSCT and a possible impact of these cells subsets on acute and chronic GVHD, relapse, non-relapse related mortality (NRM) and overall survival (OS). Patients and Methods: This is a retrospective analysis of 77 patients who underwent alloHSCT in 4 different transplant centers in Brazil. Peripheral blood samples were collected from patients at neutrophil engraftment (NE) and 3, 7, 14, 21, and 42 days after NE. The cMo (DR+, CD11c+, CD14+, CD16-) and ncMo (DR+, CD11c+, CD14-, CD16+) were classified and analyzed by 8-color multiparametric flow cytometry (FACSCanto II). In order to analyze the possible impact of duration and severity of monocytopenia after transplant, we calculated then the 'mono-index' and the 'ncMo-index', based on the area over the curve (AOC) of absolute cMO counts (AMC) and absolute ncMo counts, respectively, considering a horizontal line of AMC 0.5x10e9/L as cut-off value for both subpopulations. Results: The medium follow up was 82 months. Out of 77 patients, 46 (60%) were male, and the median age was 17 years (range: 1-74). The stem cell source was bone marrow in 36 (47%), cord blood in 23 (30%), and peripheral blood in 18 (23%); and donors were matched unrelated in 61 (79%), and matched related in 16 (21%) cases. Most patients received myeloablative conditioning (n=47, 61%); and acute leukemia was the most common diagnosis (72%). A total of 40 (52%) patients received total body irradiation (TBI), and 27 (35%) patients received antithymocyte globulin (ATG). We calculated the possible impact of cMo at all timepoints and found no differences in the main outcomes between patients with lower or higher counts. We then analyzed the AOC of all cMo counts (the mono-index). A higher index represents a more severe deficiency of cMo. We then used the receiver operating characteristic (ROC) curve to define the cut-off value of 14234.4 cells/days x mm3 to discriminate patients as cMo deficient (n=31, 40%) or non-deficient (n=46, 60%). Non relapse mortality (NRM) at 6 years was higher in cMo deficient patients calculated by the mono-index (40% vs. 16% for non-deficient, p=0.02, Figure 1). Deficient patients also had worse OS at 6 years (58% vs. 37% for non-deficient, p=0.03, Figure 2). In multivariate analyses, cMo deficiency calculated by the mono-index remained significantly associated with NRM (hazard ratio 3.07, 95% confidence interval) and OS (HR 2.05, 95%CI 1.20-7.85). We observed no impact of mono-index on acute or chronic GVHD or relapse. We observed no impact of the ncMo counts at all timepoints or the ncMo-index in any of the analyzed outcomes. Conclusion: cMo deficiency calculated by the mono-index can predict mortality in alloHSCT. Mono-Index is an inexpensive, accessible and easy to perform tool that might help clinicians in predicting unfavorable outcomes. Further studies are needed to confirm these findings and to test how different transplant strategies or therapeutic changes might interfere with monocytes recovery in alloHSCT. Disclosures No relevant conflicts of interest to declare.

Introduction The Hematopoietic Stem Cell Transplantation Service (HSCT) of the Amaral Carvalho Hospital began its activities in August 1996. At first, an Excell® spreadsheet was applied, in which all the information concerning the HSCT performed in our service were included. The use of this tool had the purpose of organizing the HSCT service information. In 2009, we started to send data to the Center for International Blood and Marrow Transplant Research (CIBMTR). Due to the beginning of this new activity and the large amount of information requested by CIBMTR, an improvement in the previously used platform was felt necessary. Today there are 12 Brazilian active centers in the CIBMTR. According to a recent CIBMTR report (info request #1807-14), our center has reported an average of 43% of all first transplants performed in Brazil and reported to the CIBMTR in the last 4 years. Objective Due the lack of resources for large investments in the technology information area as a public center, and the need to improve the tool in use, another software was proposed to speed up the data collection, to organize the internal database and to report the data to the CIBMTR. Materials and Methods In 2013 a database was developed in Access® (Microsoft® Office), containing all the information requested in the CIBMTR forms and necessary for the analysis and control of the Service results. After entering all the data, the program is able to generate a report containing all information necessary to complete the pre-HSCT forms (Forms 2804, 2814, 2400 and 2402). Within the program there are links to carry out the risk calculation of VOD (hepatic veno-occlusive disease)/SOS (hepatic sinus obstructive syndrome) and DRI (disaster risk index). There is also a calculator for the HCT-CI (Hematopoietic cell transplant specific comorbidity index), using as a template the site http://www.hctci.org/Home. The post-HSCT data can also be inserted, making it possible to use the database to fill up all the CIBMTR follow-up forms. Results and Discussion With the development of this database program a great improvement was achieved in the quality of organization of internal data and in the timely report to the CIBMTR. Between 2011 and 2014 the average percentage of forms submitted within the proposed deadline was 25.5%, while between 2015 and July 2018 this average increased to 80.5%. Currently, approximately 200 HSCT are reported annually and around 900 post-transplant follow-up forms are sent. Conclusion As the new tool was developed by the data manager, we have the possibility to edit the program according to our needs and with the information requested by CIBMTR. Idealized for routine use, this tool allowed the organization of the information, in a large HSCT center with few resources, helping us to report 100% of the HSCT performed to the CIBMTR since 2009.

Introduction The Center for International Blood & Marrow Transplant Research (CIBMTR) presents a system that makes it easier to register standardized transplantation data, as well as a business intelligence tool for the devolution of data to the transplant centers, the Qlikview app, which allows data extraction. The software might be useful for the conduction of clinical trials. Objective To evaluate overall survival (OS) and clinical characteristics of patients (pts) undergoing hematopoietic stem cell transplantation (HSCT) in Brazil while testing the usefulness and efficacy of the Qlikview app. Methods Seven Brazilian transplantation centers were asked to enter the in the CIBMTR database using their passcodes and retrieve data from all the pts undergoing HSCT between 2008 (when the Data Back to Centers, DBtC, began) and 2018 using the Qlikview. The seven spreadsheets with the whole set of clinical and demographical data were unified and analyzed using the SPSS software. OS was calculated using Kaplan Meier curves and log rank test. Results In the study period, 3994 pts received transplants in the seven centers (1546 autologous and 2448 allogeneic transplants). The set of data analyzed represented approximately 21% of the transplants performed in Brazil in the period. Among the autologous HSCTs, 1346 (87%) pts were adults and 1514 (98%) had malignant diseases (750 multiple myelomas, 292 non-Hodgkin lymphomas and 262 Hodgkin lymphomas). Among allogeneic HSCTs, 1514 (62%) were adults, 1739 (71%) had malignant diseases (603 AML, 574 ALL and 263 pts with MDS/MPN). The allogeneic source of cells was the bone marrow in 1611 (66%), 685 (28%) peripheral blood and 152 (6%) umbilical cord blood. The two-year OS for the pts with malignant diseases undergoing autologous HSCT (1202) was 79% for adult pts (1055) and 68% for children (147), while for allogeneic transplants for malignant cases (1138) it was 55%, 45% and 38% respectively for pts receiving transplants from HLA matched related (777), unrelated (287) and related donors (74) but with some HLA incompatibility (p Conclusion The Qlikview app allowed the standardized collection and analysis of data from the selected transplant centers, which may be useful for countries, such as Brazil, where a national database is not available. However, some variables were lacking in the app and should be added to improve the analyses. The data analysis has shown that pts characteristics and survival in the seven Brazilian centers are similar to the international literature.

The Lee Chronic Graft-versus-Host Disease (GVHD) Symptom Scale is a patient-reported instrument developed and validated in English to measure the symptoms and functional impact of cGVHD. This tool has not yet been validated in a Latin American population, however. The Brazil-Seattle Chronic GVHD Consortium conducted a multicenter study at 5 Brazilian institutions to validate the Lee cGVHD Symptom Scale in adults with cGVHD. Study objectives included the translation and validation of the instrument in Brazilian Portuguese and evaluation of the correlation with other quality of life (QoL) tools, including the Medical Outcomes Study Short Form 36 (SF-36) and Functional Assessment of Chronic Illness Therapy with Bone Marrow Transplant subscale (FACT-BMT). Translation and validation were done according to the American Association of Orthopedic Surgeons Outcome Committee guidelines. Spearman's correlation coefficient was used to measure construct validity. Reliability was assessed using Cronbach's α and intraclass correlation coefficients. Between April 2011 and August 2012, 47 patients with cGVHD based on the 2005 National Institutes of Health criteria (29 males [62%], 18 females [38%]; median age, 48 years; range, 23 to 69 years) were enrolled in this study. The reliability of the Lee cGVHD Symptom Scale was adequate (Cronbach's α = 0.62 to 0.83). The correlations between similar domains of the Lee cGVHD Symptom Scale, SF-36, and FACT-BMT were moderate to high. Our data indicate that the Brazilian Portuguese version of the Lee cGVHD Symptom Scale is valid and reliable and can be used in clinical trials of cGVHD in Brazil.

Malaria is an unusual complication after hematopoietic stem cell transplantation in non-endemic countries. However, transplant candidates, recipients and donors living in endemic regions frequently report previous episodes of malaria. This fact could represent an important risk for immunosuppressed recipients that could develop severe malaria cases. We report a case of hematopoietic stem cell transplant (HSCT) in which the donor had a history of previous malaria, and close monitoring was performed before and after procedure by parasitological and molecular tests. The donor presented Plasmodium vivax in thick blood smears one month after transplant and was treated according to Brazilian Health Ministry guidelines. The polymerase chain reaction (PCR) was able to detect malaria infection in the donor one week earlier than thick blood film. Even without positive results, the recipient was pre-emptively treated with chloroquine in order to prevent the disease. We highlight the importance of monitoring recipients and donors in transplant procedures with the aim of reducing the risk of malaria transmission.

Na leucemia linfoide aguda (LLA), a proliferação, acúmulo e infiltração de células imaturas caracterizam uma entidade heterogênea, apresentando ampla diversidade de aspectos clínicos e biológicos. Na LLA do adulto, a concentração de fatores prognósticos de alto risco, como o imunofenótipo B, alterações cromossômicas e, principalmente, a presença do cromossomo Ph positivo. Considerações a respeito da alta morbidade e mortalidade relacionadas ao transplante de células-tronco hematopoéticas (TCTH) têm gerado controvérsias quanto à indicação desta modalidade terapêutica, nos pacientes adultos com LLA em primeira remissão (1ª RC). Os resultados da terapia convencional com quimioterapia, diante dos diferentes grupos de risco em pacientes com LLA, têm sido utilizados para a indicação de TCTH. Apresentamos o algoritmo de indicações do transplante de células-tronco hematopoéticas em pacientes adultos com LLA.

Under a Creative Commons license.-- et al., Dendritic cells (DCs) are antigen-presenting cells that drive immune responses and tolerance and are divided in different subsets: myeloid DCs (mDCs: lineage-; HLA-DR+, 11c+), plasmacytoid dendritic cells (pDCs: HLA-DR+, CD123+), and monocyte-derived DCs (moDC: lineage-, 11c+, 16+). After hematopoietic stem cell transplantation (HSCT), low DC counts in the recipients' peripheral blood (PB) have been associated with worse outcomes, but the relevance of DC graft content remains unclear, and there are few data in the setting of unrelated donor HSCT. We evaluated the DC graft content and monitored DC recovery in PB from 111 HSCT recipients (median age, 17 years; range 1 to 74), who received bone marrow (46%), umbilical cord blood (32%), or PB (22%) from unrelated (81%) or related donors (19%). In 86 patients with sustained allogeneic recovery, patients with higher counts of all DC subsets (pDC, mDC, and moDC) 3 weeks after engraftment had lower incidence of nonrelapse mortality (NMR) and acute graft-versus-host disease (aGVHD) and better survival. pDC counts were associated with more striking results: patients with higher pDC counts had much lower incidences of NRM (3% versus 47%, P < .0001), lower incidence of aGVHD (24% versus 67%, P < .0001), and better overall survival (92% versus 45%, P < .0001). In contrast, higher pDC counts in the graft was associated with an increased risk of aGVHD (55% versus 26%, P= .02). Our results indicate that DC counts are closely correlated with HSCT outcomes and warrant further prospective evaluation and possible early therapeutic interventions to ameliorate severe aGVHD and decrease mortality., The research reported in this publication was supported by grants from Fundação de Amparo a Pesquisa do Estado de Sao Paulo (FAPESP process no. 2012/11730-7). M.V.G. was supported by Conselho Nacional de Desenvolvimento Cientifico e Tecnológico (CNPq process no. 142026/2009-3). V.R. was supported in part by the National Institute for Health Research, Oxford Biomedical Research Centre at the Oxford University Hospitals NHS Trust, and the University of Oxford.

Pretransplant influenza vaccination of the donor or allogeneic hematopoietic SCT (HSCT) candidate was evaluated in a randomized study. One hundred and twenty-two HSCT recipients and their donors were assigned to three randomization groups: no pretransplant vaccination (n=38), donor pretransplant vaccination (n=44) or recipient pretransplant vaccination (n=40). Specific IgG was assessed by both hemagglutinin inhibition (HI) and, in 57 patients, by an indirect influenza-specific ELISA at specified times after HSCT. Vaccinated donors had seroprotective HI titers for Ags H1 and H3 (P

A compatibilidade HLA é o fator mais valorizado na escolha do doador de medula óssea voluntário, preconizando-se a realização de HLA de alta resolução nos locos HLA-A,B,C, DRB1 e DQB1. Tem sido dado preferência para o doador com consanguinidade alélica 8x8 (A,B,C, DRB1). Na presença de incompatibilidade na classe-I sugere-se a busca de doador com compatibilidade DQB1 (9x10). Já as incompatibilidades dos locos DPB1 não constituem critério de exclusão de doador, exceto quando existir presença de anticorpo contra o loco HLA-DP do doador.

A frequente utilização de sangue de cordão umbilical - SCU como fonte de células- tronco hematopoéticas - CTH, tanto em crianças, como em adultos, que não dispõem de doador na família, tem levado ao estabelecimento da padronização de critérios em sua seleção, objetivando a obtenção de melhores resultados. A escolha da unidade de SCU deve basear-se no número total de células nucleadas e no número de diferenças de antígenos leucocitários humanos (HLA). Diante de uma unidade com celularidade mínima, deve-se considerar a possibilidade da utilização de duplo cordão. Frente a mais de uma unidade com características semelhantes, a realização da contagem de células CD34 e da compatibilidade ABO, assim como a qualidade e a rapidez para obtenção da unidade, podem definir a escolha. The frequent use of umbilical cord blood as the source of hematopoietic stem cells, both in children and adults who do not have related donors, has led to the establishment of a better standardization of selection criteria aiming at improving the results. The choice of the umbilical cord blood unit should be based on the total number of nucleated cells and the number of differences in the human leukocyte antigen (HLA) system. When a unit has minimal cellularity, the use of a double cord blood transplant should be considered. When two or more units have similar characteristics, the choice may be determined by the CD34 count, ABO compatibility and the quality and speed to obtain the unit.

Apesar da presença de anticorpos anti-HLA em transplantes de órgãos sólidos estar associada à rejeição, essa correlação não havia sido pesquisada em transplante alogênico de células progenitoras hematopoéticas (TCPH). Estudos mais recentes na literatura têm demonstrado que a falência da enxertia no TCPH pode ser mediada por aloanticorpos anti-HLA doador especifico (DSA). A especificidade desses anticorpos pode ser evidenciada pelas técnicas de fase sólida, onde os antígenos HLA únicos são aderidos a pérolas de poliestireno, que permite a realização da prova cruzada virtual. Na presença de DSA, é recomendável selecionar outro doador ou realizar as estratégias de remoção dos anticorpos. In spite of Anti-HLA antibodies being associated to rejection in solid organs transplantation, this correlation has not been well established yet in allogenic bone marrow transplantation.Recent studies in the literature have demonstrated that engraftment failure in hematopoietic cell transplantation (HCT) can be mediated by donor specific anti-HLA antibodies (DSA). These antibodies specificity can be detected by solid-phase techniques, where single HLA antigens are adhered to microbeads, which allows the interpretation of host reactivity by "virtual crossmatch". In the presence of DSA, it is advisable to either search for another donor or remove the antibodies prior to transplantation.

Hematopoietic Stem Cell transplantation (HSCT) is the treatment of choice for patients with high-risk leukemia. In spite of this, relapse remains a major cause of death of these patients. Our objective was to analyze the outcomes of patients with acute leukemia submitted to hematopoietic stem cell transplantation in two Brazilian institutions. A retrospective study of 208 patients transplanted between 1990 and 2007 with a median age of 9 years (range: 1-18 years) was made. One hundred and nineteen patients had acute lymphocytic leukemia (ALL) and 89 had acute myeloid leukemia (AML). Early disease was considered for CR1 and CR2 cases and advanced disease >CR3 and refractory and relapse disease. Ninety patients are alive between 258 and 6068 days after hematopoietic stem cell transplantation (M: 1438 days). The overall survival (OS) was 45% (3 years) and event free survival (EFS) was 39% (3 years). Primary graft failure occurred in 14/195 patients (8%). There were no differences in the overall survival and event free survival between patients with acute lymphocytic leukemia and acute myeloid leukemia, between sources of cells used or between those who developed acute or chronic graft-versus-host disease (GVHD). When comparing transplants from related and unrelated donors, there was no difference in the overall survival. Patients with acute lymphocytic leukemia receiving the total body irradiation (TBI) conditioning regimen had better overall survival and event free survival (p

The rising success rate of solid organ (SOT) and haematopoietic stem cell transplantation (HSCT) and modern immunosuppression make transplants the first therapeutic option for many diseases affecting a considerable number of people worldwide. Consequently, developing countries have also grown their transplant programs and have started to face the impact of neglected tropical diseases (NTDs) in transplant recipients. We reviewed the literature data on the epidemiology of NTDs with greatest disease burden, which have affected transplant recipients in developing countries or may represent a threat to transplant recipients living in other regions. Tuberculosis, Leprosy, Chagas disease, Malaria, Leishmaniasis, Dengue, Yellow fever and Measles are the topics included in this review. In addition, we retrospectively revised the experience concerning the management of NTDs at the HSCT program of Amaral Carvalho Foundation, a public transplant program of the state of São Paulo, Brazil.

Submitted by Guilherme Lemeszenski (guilherme@nead.unesp.br) on 2013-08-22T18:40:39Z No. of bitstreams: 1 S1516-84842008000300004.pdf: 224795 bytes, checksum: 5603e7f154858adf790a1b4206a83183 (MD5) Made available in DSpace on 2013-08-22T18:40:39Z (GMT). No. of bitstreams: 1 S1516-84842008000300004.pdf: 224795 bytes, checksum: 5603e7f154858adf790a1b4206a83183 (MD5) Previous issue date: 2008-01-01 Made available in DSpace on 2013-09-30T19:26:32Z (GMT). No. of bitstreams: 2 S1516-84842008000300004.pdf: 224795 bytes, checksum: 5603e7f154858adf790a1b4206a83183 (MD5) S1516-84842008000300004.pdf.txt: 16581 bytes, checksum: 026e3525fe8d4e03c35be3b3e7d16790 (MD5) Previous issue date: 2008-01-01 Submitted by Vitor Silverio Rodrigues (vitorsrodrigues@reitoria.unesp.br) on 2014-05-20T15:07:26Z No. of bitstreams: 2 S1516-84842008000300004.pdf: 224795 bytes, checksum: 5603e7f154858adf790a1b4206a83183 (MD5) S1516-84842008000300004.pdf.txt: 16581 bytes, checksum: 026e3525fe8d4e03c35be3b3e7d16790 (MD5) Made available in DSpace on 2014-05-20T15:07:26Z (GMT). No. of bitstreams: 2 S1516-84842008000300004.pdf: 224795 bytes, checksum: 5603e7f154858adf790a1b4206a83183 (MD5) S1516-84842008000300004.pdf.txt: 16581 bytes, checksum: 026e3525fe8d4e03c35be3b3e7d16790 (MD5) Previous issue date: 2008-01-01 Este trabalho teve por objetivo correlacionar o status quimérico de pacientes pós -TCPH alogênico com parâmetros clínicos, para avaliar o valor preditivo dos achados laboratorias de quimerismo. Amostras de sangue de 98 pacientes (67 em seguimento e 31 novos casos) foram submetidas à análise do status quimérico pós-TCPH. Os locianalisados por biologia molecular foram CS1PO, TPOX, F13A1, FESFPS, HUMTH01, VWA, SE33, HUMARA, HUMD21S11 e Amelogenina. Precocidade da evidência laboratorial de quimerismo misto (QM), em relação ao aparecimento dos sintomas clínicos de recaída, foi observada em 9 dos 12 pacientes nas LA, ou seja, nesses casos, a primeira manifestação de QM foi detectada pelo exame laboratorial antes de qualquer evidência citológica ou clínica de recaída. em todos eles, houve uma mudança terapêutica relacionada com esse momento do aparecimento do QM. em 100% dos pacientes com QM na LMC, a detecção do quimerismo pelo exame laboratorial foi anterior a qualquer evidência citológica ou clínica de recaída. de uma maneira geral, o exame laboratorial da avaliação do status quimérico pós-TCPH alogênico pela análise dos locihipervariáveis do genoma, mostrou ser um exame sensível, com detecção de até 1% de QM e precoce, visto que, muitas vezes, foi a primeira manifestação de doença residual antes de qualquer evidência citológica ou clínica da mesma. A associação da existência de QM e a recaída clínica e/ou óbito fica mais evidente nos casos de LA do que nos casos de LMC e AAS. This study aimed to correlate the chimerical status in post-allogeneic hematopoietic stem cell transplantation (HSCT) patients to clinical patterns in order to evaluate the predictive value of chimerism laboratorial findings. Blood samples from 98 patients (67 current and 31 new cases) were submitted to post-HSCT chimerical status analysis. The CS1PO, TPOX, F13A1, FESFPS, HUMTH01, VWA, SE33, HUMARA, HUMD21S11 and Amelogenian loci were analyzed. Precocity of Mixed Chimerism (MC) laboratorial evidence in relation to recurrent clinical symptom manifestations was observed in 9 out of 12 patients in AL, i.e., in these cases the first MC manifestation was detected in laboratory tests before any cytological or clinical evidence. In all cases, there was a therapeutic change due to MC onset. Chimerism detection through laboratorial examinations was prior to any cytological or clinical evidence in 100% of patients presenting MC in CML. Considering that it was the first manifestation of residual disease, before any cytological or clinical manifestation, laboratorial examination to evaluate chimerical status in post-allogeneic hematopoietic stem cell transplantation through analysis of genome hyper-variable loci, turned out to be a more sensitive examination and presented a detection rate of up to 1% for early MC. The association of MC to clinical recurrence and/death is more evident in AL cases than in CML and SAA. Unesp Faculdade de Medicina Hemocentro Unesp Instituto de Biociências Programa de Pós-Graduação em Ciências Biológicas, Biologia Celular e Molecular Hospital Dr. Amaral Carvalho de Jaú para o TMO Hemocentro de Botucatu Serviço Cooperativo Unesp Faculdade de Medicina Hemocentro Unesp Instituto de Biociências Programa de Pós-Graduação em Ciências Biológicas, Biologia Celular e Molecular

Dados do Registro Internacional de Transplante de Medula Óssea, International Bone Marrow Transplant Registry (IBMTR) contribuem para o progresso do transplante de medula óssea (TMO) em todo o mundo. Neste artigo relatamos a experiência brasileira em leucemia mielóide aguda e comparamos os resultados do TMO com os dados internacionais. Foi realizado um estudo retrospectivo com dados de tratamento de LMA com o TMO de 16 instituições brasileiras. A análise estatística dos transplantes da modalidade autogênica (TMO auto) e alogênica (TMO alo) foi realizada com o método de Kaplan-Meier e log-rank. Todos os valores de p foram bicaudados. Foram avaliados os dados de 731 pacientes (205 TMO auto e 526 TMO alo). A mediana de sobrevida global dos pacientes submetidos ao TMO auto foi superior à dos submetidos ao TMO alo (1.035 vs 466 dias, p=0,0012). A origem das células-tronco (OCT) no TMO alo em 73% dos pacientes foi de medula óssea (CTMO), em 23% de sangue periférico (CTSP) e em 4% de cordão umbilical. No TMO auto, a OCT foi 63% de CTSP, 22% CTMO e 15% de ambas as fontes. A OCT não teve impacto na sobrevida global (SG). Não houve diferença na SG também entre os pacientes segundo a classificação FAB no TMO alo, mas os pacientes com LMA M3 com o TMO auto tiveram SG longa. Como esperado, a principal causa de óbito entre os pacientes do TMO auto foi relacionada à recidiva de doença (60%), enquanto no TMO alo as principais causas foram a doença enxerto versus hospedeiro e infecções (38%). Em ambos os grupos foi observada SG mais longa nos pacientes tratados em primeira remissão completa (1RC) quando comparados aos de segunda remissão (2RC) e outras fases (p

s / Biol Blood Marrow Transplant 19 (2013) S313eS341 S323 throughout the monitoring period. The other 40 cytokines did not show significant trend between responders and non responders. Thus, sCD25 and TNFb can be potentially used as biomarkers to predict response of cGvHD to ECP. Studies with larger number of patients on ECP will be required to confirm these findings.

Abstract 4541 Background: The heterogeneous status of host immune defenses may influence the risk of infection and graft-versus-host disease (GVHD) after hematopoietic stem cell transplantation (HSCT). In such defense, dendritic cells (DC) which act as specialized antigen-presenting cells that bridge the innate and adaptive immune systems, and NK-cells, responsible for the innate defense against infections and residual tumor cells, are essential cell components. Objectives: To monitor the recovery of different subsets of DC and NK cells after unrelated umbilical cord blood (UCB), bone marrow (BM), and peripheral blood (PBSC) HSCT and to evaluate the impact of the distribution of these cell subsets on the outcome of the transplant. Methods: Overall, 34 patients (median age 13y; range 1–63y) receiving a UCB (n=15), BM (n=14) or PBSC (n=5) unrelated HSCT were studied. The most common diagnosis was acute leukemia (ALL, 12 cases; AML, 10; CML, 5; aplastic anemia, 4; MDS, 2; Hodgkin lymphoma, 1; SCID, 1), a majority of patients were males (56%), and received myeloablative conditioning (MAC) regimens (73%). Antithymocyte globulin (ATG) was used in 38% and total body irraditation (TBI) in 41% of cases. Median time to neutrophil engraftment was 18 days (range: 12–45). T-cell (CD4+, CD8+, CD4−8−, CD4+8+), DC [CD123+ plasmacytoid(p)DC, CD11c+ myeloid(m)DC, and CD16+ monocytoid(mo)DC] and NK cell subsets (CD3−/CD19− 56++16− and 56+16++) were quantified by multiparametric flow cytometry at 7 sequential time points (pre-transplant, at engraftment, and at days 3, 7, 14, 21 and 60 after engraftment). Results: As compared to BM/PBSC, UCB was associated with a delayed neutrophil recovery (28 days vs. 17 days; p=0.01), and a trend to lower counts of all T-, NK- and pDC subsets, particularly for the CD4+ and CD4−/CD8− T-cells during the first 3 weeks after recovery. Conversely, no significant differences were observed between both groups as regards the distribution of mDC and moDC. The use of TBI, MAC or ATG were not associated with the reconstitution of the studied cell subsets. In contrast, patients who died from transplantation-related causes (TRM) had significantly lower counts of pDC and mDC during the first 3 weeks after HSCT. At day 21 after engraftment, the median number of pDC and mDC was 0.9 and 2.0/uL among patients who died from TRM vs. 7.1 (p=.006) and 8.4/uL (p=.01) in the remainder, respectively). Patients presenting grade II-IV acute GVHD also had significantly lower pDC counts at days 14 and 21. There was no significant association of both the hematopoietic stem cell source and the conditioning regimen on the risk of TRM or acute GVHD. Conclusion: Low pDC counts in the first weeks after unrelated HSCT are associated with an increased incidence of GVHD and mortality. The precise mechanisms that might explain the role of pDC on immunity early after HSCT deserve further investigations. Disclosures: No relevant conflicts of interest to declare.

Since August 1996, we have perfomed 206 hematopoietic stem cell transplantations (HSCT) in patients with Chronic Myeloid Leukemia (CML). The number of procedures has been progressively lower since 2006, consequence of the results of ÍRIS Study (Imatinib in 1a line for patients with CML–1a CP). In 2007, we did 15 transplants. Among them, 26% didn’t have access to Imatinib, against 70% of 31 patients who were transplanted in 2004. During the last twelve years, we transplanted 163 patients in 1a CP that have presented survival probability curve of 80% and median follow up of 1.204 days. The patients ≤ 30 years old (n=29), that were already submitted to transplant, more than five years ago, presented survival rate of 93%, just a little bit superior to the 89% observed in the ÍRIS Study. In this group of patients, we observed two obits (1–acute Graft versus Host Disease, a-GVHD; 1–chronic Graft versus Host Disease, c-GVHD;), three relapses, all of them are alives and in complete cytogenetic remission, 15 patients developed c–GVHD, most of them were extensive, three of them remain in lengthened immunossuppression. On December, 2003, the patients with CML–1a CP, with age > 30 years old, presented survival rate statistically inferior, than the patients with age ≤ 30 years old, using as myeloablative conditioning oral Busulfan without serum monitoring, BU (16 mg/kg), and Cyclosphophamide, CY, (120 mg/m2), due to higher transplanted related mortality (TRM = 29,2%) verified in the first group, against 6% verified in the second group. Since this date, the introduction of the association oral BU, without serum monitoring (16 mg/kg) and Fludarabine, FLU, (120 mg/m2) BU-FLU, n = 49, determined that the patients with higher age, median = 43 years old, showed similar survival rate with the group with lower age, n = 56 and median = 29 years old, that used BUCY, in the same period, 83% versus 85%, respectively, with median follow up of 877 days, consequence of lower TRM = 6,1%, observed in the BU-FLU group, after migration from historical BUCY group. Since 1996, the monitoring of BCR-ABL transcript, by molecular biology techniques, has provided the induction of cytogenetic evaluation realization, allowing that 72% from the 23 patients that relapsed in CP, from the 163 transplanted in CP, were detected in cytogenetics relapse. The 23 patients are alives: 14 already completed one year of relapse, among them, 13 are in complete cytogenetic remission (CCR). One patient, 16 years old, was submitted to a 2° HSCT and is in hematological remission. At this, in our service, the patients with CML in 1a CP, have indication to use Imatinib in 1a first line, even those < 30 years old, due to the toxicity related to HSCT, mostly due to the high incidence of c-GVHD, with the exception of children below 18 years old, who don’t have access to Imatinib at Brazil. The older patients, conditioned with BLU-FLU, median age of 43 years old, have today a similar survival rate probability to the younger patients submitted to BUCY. Besides that, the monitoring by molecular biology techniques of BCR-ABL transcript, has provided us to diagnose a high rate of cytogenetic relapse, which has contributed for a good therapeutic result. This way, the HSCT with identical sibling donor remains being an adequate alternative, for the obtainment of a prolonged survival rate in patients with CML in 1 a CP, and should be considered, mainly in young patients, in case of unsuccess in using Imatinib, as long as adjustments on the conditioning of patients with higher age be done as well as the monitoring by molecular biology techniques of BCR-ABL transcript.

Hematopoietic stem cell transplantation is a valid alternative as post-remission therapy in ALL. Our aim was analyzed retrospectively the clinical outcomes of 97 ALL patients with HLA identical sibling donors who underwent an allo PBSCT. Median age was 24 ys (2–45), advanced disease was present in 74%, conditioning without irradiation was 56%; GVHD prophylaxis with MTX/CsA was 91%; CD34+ median was 4.6X106/kg (1.2–24); the median follow-up for surviving patients was 22 months (1.6–93). Median day for neutrophils and platelets engraftment was 15 and 13, respectively; no TBI conditioning, no MTX/CsA, were associated significantly with faster neutrophils engraftment; no MTX/CsA with platelets. Cumulative incidence (CI) for ≥ 2 aGVHD was 45%, extensive cGVHD 50%; aGVHD in patients who received TBI conditioning was 34% (P=0.04). The estimates of OS and DFS at 92 months was 21% and 31%, respectively; OS for patients >36ys was 16% (P=0.04), for patients with aGVHD 11% (P=0.03); there was a trend towards better OS and DFS in patients with cGVHD (54%, 63%; P=0.07, P=0.06). CI for relapses was 60%; relapses for cGVHD patients were 36% (P= 0.05), and there was a trend towards higher relapses in advanced disease (66%, P=0.06). TRM was 64%; in those patients with aGVHD, 73% (P=0.008). In multivariate analyses no MTX/CsA was related with the speed of platelets engraftment (P=0.007); TBI conditioning was associated with less aGVHD and TRM (P=0.05, P=0.01); aGVHD had a negative impact on OS with higher TRM (P=0.02, P=0.02). Although not confirmed in the multivariate analyses, fewer relapses, and a trend towards better OS, and DFS were found in patients with extensive cGVHD. However, further follow up will be necessary to confirm these results.

Fludarabine in combination with intravenous Busulfan has been used to reduce treatment related mortality (TRM) in allogeneic stem cell transplantation (SCT). Considering that busulfan has erratic bioavailability and unpredictable intestinal absorption, previous investigations have used intravenous busulfan with plasma-targeted levels dosing. In Brazil neither intravenous Busulfan nor routine plasma level measurement of Busulfan are available. In this report we retrospectively analyze 74 patients (median age 32 y.o.) submitted to SCT using a Fludarabine and oral Busulfan based conditioning regimen. Forty three patients had acute myeloid leukaemia (AML, age range 5 to 58) and 31 patients chronic myeloid leukemia (CML, age range 19 to 58). Among the AML patients, 44% were in first remission (CR1), 23% in second remission (CR2) and 33% patients had active disease (AD) at the time of transplant. Among CML patients, 65% were in chronic phase (CML-CP), 29% in accelerated phase (CML-AP) and 6% in blast crisis (CML-BC). Fludarabine 30 mg/m2 and oral Busulfan 4 mg/kg was given for 4 days with Cyclosporine A and Methotrexate GVHD prophylaxis. For patients with unrelated donors, ATG were added. All patients engrafted (median 14 days). At a median follow up time of 180 days non-relapse mortality was 5%. Seventeen patients (23%) died (12 AML and 5 CML patients). Among survivors (57 patients), 56 remain in complete remission. One patient with a refractory AML and a complex karyotype relapsed on day +90. One patient died of severe sinusoidal obstruction syndrome (SOS). Acute GVHD occurred in 14 (19%) patients (10 AML and 4 CML) none of them grade III or IV. Chronic GVHD occurred in 11 patients so far, being the cause of death in 2 patients. Major cause of death was relapse of disease in patients transplanted with active disease. Only three AML patients in CR1 died (chronic GVHD, sepsis and fulminant hepatic failure) in contrast to 60% of patients with active disease (88% relapsed). One patient with CML-CP died with a relapse in CML-BC, the remaining 19 (92%) patients are alive in complete remission. One patient transplanted in CML-AP died (cGVHD and zygomykosis) and all patients transplanted in BC died of their disease. Actuarial 1-year overall survival for CML is 92% and 54% (CP and AP/BC respectively, p=0,04) and for AML 72% and 23% (CR1/CR2 and AD, respectively, p=0,005). These preliminary data show that oral Busulfan and Fludarabine can safely be used without plasma level monitoring. The follow up time is short and the effect on the control of CML cannot be concluded. However AML has been effectively controlled as far as patients were transplanted in remission (AML-CR1 and CR2). For patients in more advanced disease stages this regimen is not optimal. However, this regimen is safe and may improve the results in early stages of AML and CML even in countries with limited resources in health care.

Purpose: Imatinib Mesilate is currently considered the most advanced therapy for CML due to its innovative molecular targeting mechanism of action, resulting in a high level of efficacy with a favorable toxicity profile which results in health-related quality of life (HRQL) benefits. We therefore decided to evaluate 230 patients with chronic myeloid leukemia (CML) treated with Imatinib Mesilate (Gleevec) as second line therapy, along 12 months, after failing Interferon (IFN) based therapy, due to lack of efficacy or toxicity, in an a Quality of Life (QoL) Study in Brazil, here presented as an interim analysis. Patients and Methods: From July 2002 until December 2003, 230 Patients from 21 Brazilian Medical Institutions, were enrolled in a Quality of Life (QoL) Study, where patients completed FACT-BRM questionnaire at baseline and during treatment. FACT-BRM includes 4 subscales appropriate for any chronic illness or treatment [physical (PWB), social/family (SFWB), emotional (EWB), functional (FWB)] and 2 treatment-specific subscales [BRM-physical (BRMP). The primary endpoint was the composite Trial Outcomes Index (TOI=PWB + FWB +BRMP + BRMCE). The questionnaire was applied at baseline (visit 0),monthly thereafter during the first 6 months on imatinib therapy (visits 1 through 7) and finally after 12 months on treatment (visit 8). Study population was distributed as following: gender 55,9% male and 44,1% female, mean age 46 years (range 18 to 76), Karnofsky status 100% in 56.7% and 80–90% in 29.9%. Initial Imatinib Mesilate dose was 400mg for 81,3% and 600mg for 18,7%. All patients were evaluated at baseline and at visits 7 (six months) and 8 (12 months) 147 (63.9%) and 45 (19.5%) patients were evaluated, respectively. Results: An increase of 5 or more from baseline was defined as a clinically relevant improvement 6. Patients had clinically relevant mean estimated improvement in TOI along treatment. After 1 treatment month TOI had an estimated mean increase of 5.4 (p Conclusion: Imatinib offers remarkable QoL improvement even as a second line treatment in CML as reported previously on IRIS Study, where patients were allowed to cross over to the Imatinib treatment arm, after receiving Interferon based therapy.