Conditioning regimens used in reduced intensity transplants are designed to optimize immune suppression to allowing for prompt engraftment and robust graft versus tumor effect. The Tufts regimen (Miller KB, et al. Bone Marrow Transplant 2004;34:881) has a reduced incidence of GVHD while demonstrating disease response using extracorporeal photopheresis (ECP), pentostatin 4 mg/m2/day × 2 and a reduced dose of total body irradiation (TBI: 600 cGy given in 3 fractions). We treated 45 patients with a minimum of 6 months follow up, median age of 55 years (27-67); 33 patients were 50 years or older; 25 received sibling and 20 an unrelated donor (UD) transplant. All but one sibling transplant was a 6/6 match, whereas 8/20 UD transplants involved mismatched loci. GVHD prophylaxis consisted of tacrolimus and short course methotrexate in 43, tacrolimus/MMF in 1 and tacrolimus/sirolimus in 1. Seventeen patients had AML, 3 MDS, 2 ALL, 2 CML, 11 CLL, 8 NHL, 1 HD and 1 lymphoplasmacytic lymphoma. Eight of the 45 had prior stem cell transplantation. The median number of CD34+ cells infused was 4.54 million/kg. Nine patients were transplanted in CR or early disease phase. Five patients died before anticipated neutrophil recovery, 2 had no neutrophil nadir and median time to neutrophil engraftment was 14.5 days, and platelets recovered in 18.7 days. Donor chimerism at 30 days by VNTRs was 94% (range 34%-100%). The overall day 100 survival was 69% (31/45), with 80% (20/25) of sibling graft recipients alive and 55% (11/20) of UD recipients still living. Twelve patients developed regimen related toxicity. In five this manifested as ARDS or multiorgan failure with capillary leak syndrome, and 2 had renal failure. Ten patients had disease resistance or relapse after transplant, and all have expired. Overall survival to date is 42% (48% for sibling transplants and 35% for UD) with a range of follow-up from 283 to 1366 days (median 535 days). Acute GVHD grade III or IV was seen in only 3 patients. After day 100, 27% had extensive GVHD. The best results were seen in AML or CLL in CR or early relapse with chemosensitive disease, no AML patient in full blown relapse survived. This regimen is well tolerated and offers a suitable platform for reduced intensity allogeneic stem cell transplantation. The benefit(s) of ECP require further testing in the context of improved radiation therapy, TBI versus TLI (total lymphoid irradiation).
2552 Background: Myelomatous plasma cells have a variable surface phenotype which depends on the stage of differentiation arrest. Polyclonal anti-thymocyte globululin (rATG) is generally thought of as an anti-T cell lineage reagent, although it has potent activity against many cell surface antigens expressed on B cells. We describe the use of rATG to induce in vitro apoptosis of CD19+ plasmablasts, CD138+ cell lines and freshly isolated myeloma cells. Methods: We tested the ability of rATG (Thymoglobulin; Sangstat), anti-CD20 (rituximab), and anti-CD52 (Campath-1H) to induce apoptosis in human plasmablasts, myeloma cell lines (RPMI 8226, NCI-H929, U266) and freshly isolated myeloma cells from bone marrow aspirates of 5 untreated patients isolated by CD138 magnetic bead affinity columns. Surface marker phenotyping was performed for all cells. Cells were incubated with rATG (0.01 - 1000 mcg/ml), anti-CD20 (0.01–10 mcg/ml) anti-CD52 (0.01–100 mcg/ml), and pooled rabbit immunoglobulin in media containing heat inactivated sera. Apoptosis was assessed at 18 hours post-exposure by annexin-V plus TOPRO-3 staining, nuclear fragmentation, caspase 3/8/9 staining, mitochondiral membrane potential, and sub-diploid DNA quantitation. Results: All myeloma cells and cell lines were phenotyped by FACS and found to express surface at least 3 antigens known to have reactivity with rATG (MHC class I, CD80, CD38, CD40, CD45). No myeloma cells, cell lines, or pre-plasmablasts expressed significant expression of the target antigens for rituximab (CD20) or campath-1H (CD52). Compared with controls, rATG at 100 mcg/ml induced significant apoptosis of naive B cells (94±11%, p<0.001), CD40L stimulated plasmablasts (99±12%, p<0.001), all myeloma cell lines (93±7%, p<0.001), and myeloma cell isolates (91±24%, p<0.001). Neither CD40L stimulated pre-plasmablasts, myeloma cells or cell lines had apoptotic levels statistically different from controls. Conclusions: These results indicate that rATG, but not campath-1H or rituximab, is an active agent against multiple myeloma tumor cells. Further testing in a rigorous clinical trial to determine in vivo efficacy is warranted. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Sangstat
With the eventual goal of reducing relapse and thus improving overall survival in selected lymphoma patients, a Phase I study was performed using the cytoprotectant amifostine to permit safe dose-augmentation of melphalan in the carmustine (BCNU), etoposide, cytarabine (arabinosylcytosine), and melphalan (BEAM) regimen before autologous hematopoietic stem cell transplantation. Between 30 July 2003 and 25 November 2008, a total of 32 lymphoma patients were entered, of which 28 were evaluable. We found the melphalan dose in BEAM could be safely escalated to at least 260 mg/m², a substantial increase from the usual dose of 140 mg/m² in BEAM while the trial was terminated early due to poor accrual, no maximal tolerated dose or dose-limiting toxicity was found. A Phase II trial is planned.
Background: Factor XIII (FXIII) catalyzes the formation of covalent bonds between fibrin monomers, stabilizes fibrin clot, and protects it from premature fibrinolysis.FXIII deficiency, which is extremely rare, impairs clot stability and increases bleeding tendency.Aims: Case Report.Methods: A 76-year-old male with Grave's Disease, asthma, and hypertension presented to ED with exertional fatigue, pain across his left flank, and ecchymosis.No new medical conditions or medications were recognized.Work-up revealed extensive left flank hematoma on CT chest and abdomen, acute anemia, normal basic coagulation studies with unexplained markedly reduced FXIII levels (Table ).
2552 Background: Myelomatous plasma cells have a variable surface phenotype which depends on the stage of differentiation arrest. Polyclonal anti-thymocyte globululin (rATG) is generally thought of as an anti-T cell lineage reagent, although it has potent activity against many cell surface antigens expressed on B cells. We describe the use of rATG to induce in vitro apoptosis of CD19+ plasmablasts, CD138+ cell lines and freshly isolated myeloma cells. Methods: We tested the ability of rATG (Thymoglobulin; Sangstat), anti-CD20 (rituximab), and anti-CD52 (Campath-1H) to induce apoptosis in human plasmablasts, myeloma cell lines (RPMI 8226, NCI-H929, U266) and freshly isolated myeloma cells from bone marrow aspirates of 5 untreated patients isolated by CD138 magnetic bead affinity columns. Surface marker phenotyping was performed for all cells. Cells were incubated with rATG (0.01 - 1000 mcg/ml), anti-CD20 (0.01–10 mcg/ml) anti-CD52 (0.01–100 mcg/ml), and pooled rabbit immunoglobulin in media containing heat inactivated sera. Apoptosis was assessed at 18 hours post-exposure by annexin-V plus TOPRO-3 staining, nuclear fragmentation, caspase 3/8/9 staining, mitochondiral membrane potential, and sub-diploid DNA quantitation. Results: All myeloma cells and cell lines were phenotyped by FACS and found to express surface at least 3 antigens known to have reactivity with rATG (MHC class I, CD80, CD38, CD40, CD45). No myeloma cells, cell lines, or pre-plasmablasts expressed significant expression of the target antigens for rituximab (CD20) or campath-1H (CD52). Compared with controls, rATG at 100 mcg/ml induced significant apoptosis of naive B cells (94±11%, p<0.001), CD40L stimulated plasmablasts (99±12%, p<0.001), all myeloma cell lines (93±7%, p<0.001), and myeloma cell isolates (91±24%, p<0.001). Neither CD40L stimulated pre-plasmablasts, myeloma cells or cell lines had apoptotic levels statistically different from controls. Conclusions: These results indicate that rATG, but not campath-1H or rituximab, is an active agent against multiple myeloma tumor cells. Further testing in a rigorous clinical trial to determine in vivo efficacy is warranted. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Sangstat
Patients who are seropositive for herpes simplex virus (HSV) and are undergoing autologous marrow or peripheral blood stem cell transplantation require prophylaxis for HSV infection. Most prophylaxis regimens have used intravenous acyclovir (ACY). Oral valacyclovir (VAL), the L-valyl ester of ACY, can be used to achieve plasma concentrations equivalent to levels achieved with intravenous ACY. In this study, adults undergoing autologous stem cell transplantation were randomized to receive ACY, 250 mg/m2 intravenously (IV) every 12 hours from day 0 to engraftment, or VAL, 1 g orally every 12 hours from day 0 to engraftment. The primary study objective was to compare cost of HSV prophylaxis between study groups. Thirty patients were randomized to receive either oral VAL (n = 14) or IV ACY (n = 16) prophylaxis. Mean pharmacy cost of HSV prophylaxis in the patient group randomized to IV ACY was $l080 versus $320 for the group randomized initially to VAL. This study demonstrates the feasibility and significant cost savings of using oral VAL for HSV prophylaxis.Biol Blood Marrow Transplant 2002;8(12):662-5.
