Abstract 4182
In two different study populations with sibling (SIB) or unrelated (URD) HLA-identical donors we evaluated the role of 48 different genes (table1) reported to have influence on the ...outcome of allogeneic transplant and compared them between the transplant settings. 314 patients and their HLA identical URD and 285 patients and their HLA-identical SIB donors were analyzed after T cell repleted myeloablative transplantation and use of GVHD-prophylaxis with only MTX and CSA or CSA and MMF. Patients were transplanted for acute leukemia, CML, MDS, lymphoma and MM between Jan. 2000 and June 2011 at our center.
In the URD-cohort the occurrence of acute GVHD grade 2–4 was influenced adversely by gene variants on recipient side of LTA (40% vs 28%, P=0.013), MBL2 codon550 (47% vs 31%, P= 0.03), MCP1 (69% vs 42%, p=0.03) and NFKBIL1 (51% vs 34%, P=0.02). Further, the occurrence of severe aGVHD 3–4 was influenced adversely by gene variants of MBL codon 550 (10% vs 23%, P= 0.025), MBL2 codon 4 (10% vs 36% P=0.04), LCT13910 (9% vs 26%, P= 0.04) and CYP1B1 (8% vs 20%; P=0.05). Favorable effect was induced by a gene variant of IL6 on aGVHD 3–4 (4% vs 19%, P=0.04) in the URD setting, whereas NOD2 gene variants, but none of these gene variants had influence on aGVHD in the SIB cohort.
Further, we found that the rate of 5-year none-relapse mortality (NRM) was associated adversely with the detection of variants of IL16 (60% vs 34%, P=0.01) and MCP1 (58% vs 27%, P=0.02), which influenced the 5-year estimate for overall survival (OS) of patients (MCP1 40% vs 53%, P=0.01 and IL16 46% vs 28%, P=0.03) in the URD setting.
On donor side the occurrence of aGVHD grade 2–4 was influenced by MBL2 codon4 (69% vs 32%, P= 0.007), TLR2 (66% vs 41%, P=0.02), TLR5 (75% vs 42%, P=0.041). AGVHD 3–4 was influenced by IL23R favorably (0% vs 20%, p=0.01) and adversely by IL18 (10% vs 36%; p= 0.01) in the URD setting.
The 5-year NRM was associated with the detection of gene variants at donor side of CCR5 (53% vs 27%, p=0.01), CTLA4 (23% vs 44%, P=0.02), CYP1B1 (14% vs 26%, P=0.045), TLR2 (34% vs 66%, P=0.025). Also, IL10 gene variants at donor side influenced the 5-year OS significantly (23% vs 54%, p=0.03) as well as the gene variants TLR2 (28% vs 50%, P= 0.04), IL18 Rap (40% vs 72%, P= 0.03) and FAS (60% vs 36%, P=0.04).
In SIB cohort the 5-year TRM was influenced by MTHFR677 (30% vs 19%, p=0.05) at recipient side, and at donor side by the genes IL18 Rap (39% vs 19%, p=0.046) and CYP1B1 (29% vs 16%,p=0.07). IL10 gene variants at recipients side influenced the 5-year OS, too. At donor side the 5-year OS was influenced by IL23R (54% vs 72%, p=0.04) and MBL2CD55 49% vs 65% p=0.02).
In conclusion we report here that except IL23R and IL10 different panels of gene variants have influence on outcome of transplants from SIB donors compared to transplants from URD.CCL5 28 promotor G/Crs1800825MBL2 Codon220rs7096206CCR5 2086 A/Grs1800023MBL2 Codon4rs7095891CCR5 2554 G/Trs2734648MBL2 Codon550rs11003125CP2C19*2rs4244285MBL2G54Drs1800450CP2C19*3rs4986893MBL2G57Ers1800451CTLA4 A/G pos.49rs231775MBL2R55Crs5030737CYP1B1 432rs1056836MCP1 1543 C/Trs13900CYP2C9*2rs1799853mdr1 C3435Trs1045642CYP2C9*3rs1057910MTHFR1298rs1801131CYP2D6*3rs4986774MTHFR677rs1801133CYP2D6*4,rs1800716NFKBIL1rs2857605CYP2D6*6rs5030655NOD2 G908Rrs2066847CYP3A4*1BNOD2 L1007F insCrs2066847CYP3A5*3NOD2 R702Wrs2066844FAS 670 G/Ars4934436TLR2 R753Qrs5743708GSTA1 A567T, 69C 52Grs3957356TLR3rs3775291GSTP1 313A/Grs1695TLR4 D299Grs4986790IL10 -1082rs1800896TLR4 T399Irs4987233IL10 592 C/Ars1800872TLR5rs764535IL23RTLR6 745C>Trs5743810IL18 137 G/Crs187238TLR9 C-1237Trs5743836IL18 RAPrs917997TLR9 T-1486Crs187084IL6 G174Crs1800795TNF alpha 238 A/Grs361525LTArs2844484VEGF 405G/Crs833061
No relevant conflicts of interest to declare.
Patients (pts) with refractory acute myeloid leukaemia (AML) have a particularly dismal prognosis using conventional supportive therapy and chemotherapy. In this double-center retrospective ...observational study, sequential high-dose melphalan (HD-Mel) as part of the conditioning regimen for allogeneic hematopoietic stem cell transplantation (aSCT) was administered in 162 adult pts (median age 55, range 17 to 71 years) with overt refractory AML. For every patient pretransplant assessment of transplantation (PAM) score, European BMT (EBMT) score, and Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI) was calculated. Furthermore, by adjusting the threshold of 30 points PAM score was stratified into low and high risk group. 107 pts (66%) underwent a total body irradiation (TBI) based conditioning regimen and 55 pts (34%) a chemotherapy based regimen after a median interval of 5 days (range 1-18 days) following HD-Mel application. Dose of melphalan was 140 mg/m2 in 150 pts (93%), and 200 mg/m2 in 12 pts (7%). 48 pts (30%) were transplanted with an identical sibling donor (ISD), and 114 pts (70%) with matched unrelated donors (MUD). Pts had mostly intermediate (51%) or adverse (46%) cytogenetic risk subgroups.
In 150 pts (93%) a stable engraftment was observed and a complete chimerism could be detected in 124 pts (83%). Acute GvHD grades 0-I developed in 98 pts (60%), whereas higher grades II-IV occurred in 64 pts (40%). The median calculated PAM score was 31 (range 22-89). The corresponding median overall probability of death within 2 years after transplant was 70 % (range 44-95%). Median HCT-CI was calculated with 2 (range 0-9) characterizing a low risk comorbidity. Finally the European BMT (EBMT) score was calculated with more than 5 (range 3-7) in 166 pts (72%) transplanted in this cohort. The cumulative incidence of treatment failure estimate was 68% (95%-CL: 60-76%) after transplant resulting in a cumulative relapse estimate of 35% (95%-CL: 28-43%), and an overall non-relapse mortality (NRM) of 38% (95%-CL: 30-46%). After a median follow-up of 35 months after aSCT among surviving pts, the 3-year overall survival estimate (OS) was calculated 37% (95%-CL: 35-45%), and 5-year OS 30% (95%-CL: 25-40%). Time-dependent multivariate analysis on the primary endpoints OS, relapse-free survival (RFS), relapse incidence, and NRM demonstrated an influence of chronic GvHD on EFS (hazard ratio HR 0.443, p=0.0003), NRM (HR 0.369, p=0.0032), and relapse incidence (HR 0.554, p=0.0467). Furthermore, MUD donors tended to have a favourable impact on relapse risk (HR 0.590, p=0.0595) compared to sibling donors. PAM score demonstrated significant influence on OS (p=0.0381) and RFS (p=0.0121). For low and high risk groups stratified PAM score was shown to have significant influence on OS (HR 1.175, p=0.0056), RFS (HR 1.003, p=0.0160), and NRM (HR 1.283, p=0.0049), respectively. No influence could be observed for EMBT score and HCT-CI on none of the primary endpoints. In addition the factors age and cGvHD were found to have significant influence on relapse incidence (p=0.011, and p=0.0051) in multivariate analysis.
The results of this large study confirm an association between PAM score risk stratification and outcome after aSCT following sequential conditioning regimen with HD-Mel in patients with refractory AML. We could show, that by using a stratified PAM score with the threshold of 30 points a separation between prognostic risk groups is possible. We can summarize that this protocol is a feasible therapy option for patients with refractory AML.
No relevant conflicts of interest to declare.
Abstract 5503
Early detection of inapparent replicative human cytomegalovirus (HCMV) infection together with its preemptive antiviral treatment has led to a marked reduction of life-threatening HCMV ...disease after allogeneic hematopoietic stem cell transplants (alloSCT). A new aspect of HCMV reactivation and pretransplant HCMV serostatus has recently emerged by an earlier retrospectively performed report from us showing that the occurrence of a HCMV-reactivation after transplant reduces the risk for relapse in patients with AML and NHL. This idea was supported by a study by Scheper and co-worker (Leukemia, 2013) reporting recently, that gamma-delta T cells elicited by HCMV reactivation after alloSCT cross-recognize HCMV and leukemia. Here we evaluate the potential impact of early HCMV replication in a prospectively performed observational study about the occurrence of a HCMV- reactivation after T cell repleted alloSCT on the risk for leukemic relapse in patients with AML (Registration Trial DRKS00004300).
Between January 2012 and March 2013 we enrolled in this trial 83 patients with AML who were consecutively transplanted at the University Hospital of Essen. 48 of 83 patients received a myeloablative (TBI based conditioning n=27, chemotherapy based conditioning n=23) and 35 patients a RIC regimen. Patients were transplanted in 1.CR (n=40), 2.CR (n=23) or more progressive disease stages (n=20) from HLA-identical sibling donor (n=17) or HLA-identical unrelated donor (URD) (n=42) or mismatched unrelated donor (n=24). The median age of patients was 53 years (range 18-72) and that of the donors 38 years (range 12-61). GVHD prophylaxis was performed with MTX and CSA, or CSA and MMF with or without ATG (n=64) (30-60mg total dose). The incidence of acute GVHD grade 2-4 was statistically not different in both groups (78% versus 85%).
HCMV status of recipient (R) or donors (D) were in 29% R-/D-, 8% R-/ D+; 34% D+/R- and 29% R+/D+. Patients with a documented HCMV-reactivation (HCMV-R) had an estimated relapse incidence (CIR) at 1-year after transplant of only 8% compared to 43% in patients without a HCMV-R (p=0.03). Patients in more progressive disease phase of AML (N=43) benefit more from a HCMV-R in regard of CIR than patients in 1.CR of AML (0% versus 55% estimate for relapse at 1-year after transplant for patients with HCMV-R compared to patients without HCMV –R, p=0.028). One-year overall survival was statistically not different in both groups. Non relapse mortality was greater in patients with HCMV reactivation 37.8% versus 12.5%, p=0.1)
Conclusion
The first result of this prospective study confirms an independent advantageous effect of early HCMV replication on the leukemic relapse risk in patients with AML after transplant, which was more pronounced in patients in progressive disease phase of AML than patients in 1.CR of AML.
Off Label Use: The off-label use of HCG will be presented here for the first tiem for treatment of chronic GVHD and will clearly marked as off-label use.
A retrospective study was performed to collect information regarding efficacy and toxicity of cidofovir (CDV) in allogeneic stem cell transplant patients. Data were available on 82 patients. The ...indications for therapy were cytomegalovirus (CMV) disease in 20 patients, primary preemptive therapy in 24 patients, and secondary preemptive therapy in 38 patients. Of the patients, 47 had received previous antiviral therapy with ganciclovir, foscarnet, or both drugs. The dosage of CDV was 1 to 5 mg/kg per week followed by maintenance every other week in some patients. The duration of therapy ranged from 1 to 134 days (median, 22 days). All patients received probenecid and prehydration. Ten of 20 (50%) patients who were treated for CMV disease (9 of 16 with pneumonia) responded to CDV therapy, as did 25 of 38 (66%) patients who had failed or relapsed after previous preemptive therapy and 15 of 24 (62%) patients in whom CDV was used as the primary preemptive therapy. Of the patients, 21 (25.6%) developed renal toxicity that remained after cessation of therapy in 12 patients. Fifteen patients developed other toxicities that were potentially due to CDV or the concomitantly given probenecid. No toxicity was seen in 45 (61.6%) patients. Cidofovir can be considered as second-line therapy in patients with CMV disease failing previous antiviral therapy. However, additional studies are needed before CDV can be recommended for preemptive therapy.
Abstract 3101
Natural killer (NK) cell alloreactivity, after allogeneic hematopoietic cell transplantation (HCT) is influenced by the interaction of killer-cell immunoglobulin-like receptors (KIRs) ...on donor NK cells and human leukocyte antigen (HLA) class I ligands on recipient cells. Recently, a positive influence of KIR haplotype B versus haplotype A donors on the outcome of HLA-matched allogeneic HCT was demonstrated (Cooley et al., Blood 2010). Previously, Ruggeri et al. (Science 2002) reported the positive influence of KIR-ligand mismatch (MM) on outcome of haploidentical HCT (HHCT). Here we investigated the influence of the donor KIR haplotype and KIR-ligand MM on relapse of 57 patients with hematologic malignancies receiving HHCT after reduced intensity conditioning and graft CD3/CD19 depletion. 36 patients with AML, eight with ALL, four with multiple myeloma, four with NHL and one with MCL, CML, CMML, MDS, CLL, respectively (median age 45 years, range 19–61 years) were evaluated. Patients were “high risk” because of relapse (n=8), prior HCT (n=23), refractory disease (n=20) or cytogenetic risk (n=6). At HHCT, 29 patients were in complete remission (CR) and 28 in partial remission (PR). 15 KIR genes were determined by real-time PCR as described (Vilches et al., Tissue Antigens 2007, Alves et al., Tissue Antigens 2009), and donors were assigned the A/A or B/x haplotype. Patients and donors were HLA-typed by high-resolution molecular methods. Of the 57 donors, 17 had KIR haplotype A (29.8%) and 40 KIR haplotype B (70.2%). A KIR-ligand MM was found in 34 of 57 patients (59.6%). Cumulative incidence adjusted for competing risk showed no difference between KIR haplotype A or B patients regarding non-relapse mortality (NRM) (Gray’s test: p=0.200), but a significantly reduced incidence of relapse for patients with a haplotype B donor (p=0.001). In particular, patients in PR benefited more from a haplotype B graft (p=0.008) than patients in CR (p=0.297). This resulted in a trend in the Kaplan-Meier estimated event free (EFS) at 3 years of 26.8 % for KIR haplotype B and 11.7 % for KIR haplotype A (HR=1.33 CI=0.66–2.70, log rank test: p=0.422). In detail, all patients in PR died within 1.2 years when haplotype A donor cells were transplanted whereas 25% of haplotype B recipients were still alive after 3 years (HR=1.27 CI=0.49–3.30, p=0.631). In comparison, 16.6% of haplotype A and 28.1% of haplotype B recipients in CR survived for more than 3 years (HR=1.46 CI=0.54–3.94, p=0681). Surprisingly, KIR-ligand MM cumulative incidence curves were not statistically different for relapse (p=0680) or NRM (p=0.579). In addition, KIR-ligand MM resulted in a trend for decreased EFS rate for MM patients (17.6%) in contrast to matched patients (33.7%; HR=1.47 CI=0.89–2.75, p=0.230). These effects were even more pronounced when analyzing the patient cohort with AML. Of the 36 donors, 10 showed KIR haplotype A (27.8%), 26 KIR haplotype B (72.2%) and KIR-ligand MM was present in 25 patients (69.4%). EFS at 3 years was prolonged for KIR haplotype B graft recipients (EFS: HR=2.29 CI=0.88–5.96, p=0.087). In addition, cumulative incidence adjusted for competing risk analysis revealed a reduced incidence of relapse for patients with a haplotype B donor (all AML patients: p=0.079, AML in PR: p=0.049), but not for NRM (all AML patients: p=0.806, AML in PR: p=0.674). Again, KIR-ligand MM cumulative incidence curves were not significantly different for both relapse (p=0.126) and NRM (p=0.535). In line, KIR-ligand MM led to decreased EFS rate for MM patients (16.0%) in contrast to matched patients (53.0%; HR=2.27 CI=1.08–5.06, p=0.045). Taken together, in the setting of RIC and CD3/CD19 depleted HHCT we could not confirm the positive data with KIR-ligand MM but observed a significant lower risk of relapse with a KIR haplotype B donor. We therefore conclude from our results that a donor KIR B haplotype should be favored as donor for HHCT using RIC and CD3/CD19 depletion in patients with hematological malignancies, particularly if no complete remission has been achieved prior to HHCT.
Off Label Use: off lable use of drugs for conditioning.
Abstract 1049
Elevated pretransplant serum ferritin levels have been associated with an increased susceptibility for opportunistic infections and increased incidence of morbidity and mortality after ...allogeneic haematopoietic stem cell transplantation (HCT). We studied in 81 patients who underwent myeloablative allogeneic HCT for acute myeloid leukemia pre- and posttransplant serum ferritin levels and correlated the serum ferritin levels with the TLR9 expression and the cellular immune reconstitution 3 and 12 months post transplant. Further, we studied in vitro-experiments in Kasumi-1 cells the TLR1, TLR2, TLR3, TLR5, TLR7, TLR9 and TLR10 expression after overwhelming iron and ferritin exposure. The average pretransplant serum ferritin level was 1245 μg/ml (mean) in all AML-patients (mean 1100μg/l for patients with AML in 1.CR and mean 1820μg/l for patients with AML > 1.CR). Post transplant serum ferritin level increased up to 2080 μg/ml (mean) for all AML patients (mean 1290mg/l for AML in 1.CR and mean 2350 μg/l for patients with AML > 1.CR). The application of 300ng iron to acute leukaemia cell lines SD1, and Kasumi-1 cells increased significantly TLR1, TLR2, TLR3, TLR5, TLR7 and TLR9 expression in relation to the housekeeping gene abl measured by real-time RT-PCR. In Kasumi-1 cells TLR1 increased up to 50,6% (p=0.014) TLR2 up to 35.5% (p=0.046), TLR3 up to 57,8% (p=0.006), TLR5 up to 62.9% (p=0.005), TLR7 up to 46.2% (p=0.02), TLR9 up to 44.2%(p=0.026) and TLR10 up to 54,7% (p=0.07) compared to untreated Kasumi-1 cells. The application of 2000μg/L ferritin increased TLR9 expression even more extensively in Kasumi-1 cells: TLR1 increased up to 332% (p<0.001), TLR2 up to 150% (p=0.016), TLR3 up to 293% (p<0.0001), TLR5 up to 349% (p<0.0001), TLR7 up to 287% (p<0.0001), TLR9 up to 229% (p=0.028). Elevated TLR-expression was also seen in CD34+ progenitor cells derived from volunteers.
Further, patients with elevated post transplant ferritin level > 2000 μg/l had an increased TLR9 expression in mononuclear cells (TLR9/ABL quotient 6485 versus 4543; p<0.05) 3 months post transplant. The numbers of T helper cells (mean 412 versus 231 cells/μl 3 months post transplant, p=0.014), and cytotoxic T cells CD4+CD8+ in patients with elevated serum ferritin level were significantly elevated after transplant (mean 285 versus 164 cells/μl 3 months post transplant, p=0.027), whereas no differences were found in the number of B19+ cells and Nk cells.
These results indicate that elevated ferritin levels might activate the innate immune system by increasing TLR expression. This might be of importance since we recently showed that increased TLR9 expression was associated with adverse impact on non-relapse mortality in the transplant setting. Further exaggerated TLR9 expression has been discussed to induce overwhelming immune responses as SIRS or ARDS. More studies are definitely necessary to evaluate the role of elevated iron overload on the innate immune system.
No relevant conflicts of interest to declare.
Abstract 4912
Cytomegalovirus reactivation (HCMV) occurs frequently after hematopoetic stem cell transplantation and is often associated with an increased treatment-related mortality. Recently we ...have demonstrated that a HCMV-reactivation is associated with a reduced relapse risk and improved overall survival rate for patients with acute myeloid leukemia, but not for patients with chronic myeloid leukemia after allogeneic transplant. Now, we aimed to evaluate the effects of a HCMV-reactivation in patients transplanted for lymphoma.
We performed a retrospective study in a cohort of 67 patients (44 male/23 female) with lymphoma, who were transplanted with an unmanipulated graft from an unrelated donor (URD) after conditioning with a reduced-intensity regimen (n=9) or myeloablative regimen (n=58) in our centre. 48 patients were transplanted from HLA-matched donors, whereas 19 patients received a transplant from an URD with a HLA-mismatch. ATG was given to 19 of 67 patients. The median age of patients was 42 years (range 18–67). 25 patients were diagnosed with diffuse large B-cell lymphoma, 14 pts with follicular lymphoma, 13 pts with T-cell lymphoma, 10 pts with mantle cell lymphoma, 2 ptswith transformed B-cell lymphoma, 3 pts with Hodgkin's lymphoma. The median IPI score was 2 (n=50) prior to transplant, the median score for FLIPI was 2 (n= 14).
A HCMV-reactivation occurred in 27 of 67 transplanted patients (40%) and was documented by CMV-related matrix protein pp65 antigenemia test and routinely accompanied by a CMV preemptive therapy with valganciclovir or ganciclovir.
In in-vitro experiments we exposed the human T cell lymphoma cell line Karpas 299 to HCMV and measured the apoptosis rate by FACS and HCMV copy numbers by real-time RT-PCR 14 days after exposure.
We found an improved 4-year progression-free-survival rate (PFS) in patients with a HMC reactivation. The cumulative incidence of 4-year PFS was 55.9% in patients with HCMV-reactivation versus 38.7% in patients without a HCMV reactivation after transplant (p=0.049). The 4-year overall survival was 64.9% versus 46% without a HCMV reactivation (p=0.16). The incidence of acute GVHD grade 2–4 and chronic GVHD was not different in both groups (42 and 43% for acute GVHD and 46% and 45% for chronic GVHD). In in-vitro experiments we could not detect the induction of apoptosis by HCMV in the T cell lymphoma cell line Karpas 299 nor an increase of HCMV DNA after HCMV exposure demonstrating that the lymphoma cellline was not infected by HCMV.
The pathway how HCMV induces an anti-lymphoma effect is not clear yet and seems to be different from that in AML, in which HCMV infects AML cells directly as shown earlier. Nevertheless, a HCMV reactivation seems to improve the outcome for patients with lymphoma after transplant, which is of clinical interest.
No relevant conflicts of interest to declare.
