BackgroundRecently, maintaining higher relative dose intensity (RDI) of chemotherapeutic drugs has become a widespread practice in an attempt to achieve better outcomes in the treatment of aggressive lymphoma. The addition of rituximab to chemotherapy regimens has significantly improved outcome in diffuse large B-cell lymphoma (DLBL). However, it is unknown if higher RDI in chemotherapy when combined with rituximab leads to a better outcome in aggressive B-cell lymphoma.MethodsWe retrospectively evaluated the impact of the RDI of initial chemotherapy (consisting of cyclophosphamide, doxorubicin, vincristine and prednisolone with rituximab (R-CHOP) on outcome in 100 newly diagnosed DLBL patients.ResultsA multivariate Cox regression model showed that RDI trended towards a significant association with mortality [hazard ratio per 0.1 of RDI = 0.8; 95% confidence interval 0.6–1.0; P = 0.08]. Additionally, on multivariate logistic analysis, advanced age was a significant factor for reduced RDI.ConclusionOur data suggest that in DLBL patients, mortality was affected by RDI of R-CHOP as the initial treatment, and the retention of a high RDI could therefore be crucial.

A 59-year-old man with lymphoma-type adult T-cell leukemia/lymphoma was admitted to hospital for treatment of a skin relapse on day 398 after allogeneic hematopoietic stem cell transplantation (allo-HSCT). To induce a graft-versus-adult T-cell leukemia/lymphoma effect, we discontinued methylprednisolone and tacrolimus. About a month after the discontinuation, he developed grade II acute graft-versus-host disease (GVHD) with a high fever. Soon after the development of GVHD, all the skin lesions regressed in size and finally vanished. However, he developed diffuse alveolar hemorrhage (DAH), which was resistant to high-dose corticosteroid therapy. He was intubated for respiratory insufficiency on day 451. Cyclophosphamide pulse therapy was administered at a dose of 1 g per day for 2 days and his oxygen saturation then improved, and ventilatory support was released on day 465. On analysis of cytokine profiles at the onset of DAH, we found elevated serum levels of T-helper 2 cytokines as well as T-helper 1 cytokines, suggesting that both T-helper 1 and T-helper 2 cytokines might play a role in the occurrence of DAH following allo-HSCT. Pulse cyclophosphamide treatment might be very effective in suppressing the exaggerated allogeneic immune response in DAH.

In reduced intensity, allogeneic stem cell transplantation from unrelated donors (u-RIST), graft-versus-host disease (GVHD), graft failure, and non-relapse mortality (NRM) are persistent problems. Although anti-thymocyte globulin, alemtuzumab, and total body irradiation (TBI) have been explored as conditioning modalities for u-RIST, the necessity for T-cell depletion or TBI to prevent GVHD or facilitate engraftment in u-RIST has not been determined. We here report the use of u-RIST with bone marrow grafting, following a simple conditioning regimen of 180 mg/m(2) fludarabine and 8 mg/kg of oral or intravenous busulfan without TBI or T-cell depletion. The study population was exclusively Japanese patients with a history of prior chemotherapy. We retrospectively analyzed 31 consecutive patients (median age 53 years). Twenty-five patients (81%) were transplanted from HLA-A, -B, and -DRB1 allele-matched donors. In all patients, neutrophil engraftment was achieved. The cumulative incidence of grade II-IV acute GVHD was 42%. However, 77% of patients with acute GVHD improved with, and could be managed by, initial, systemic, high-dose steroid treatment alone. Two-year overall and event-free survival was 62 and 53%, respectively. The NRM of 10% at 2 years was relatively low. Our results suggest that u-RIST without TBI or T-cell depletion may improve the prognosis after u-RIST in certain patient populations.

3551 Background: Allogeneic hematopoietic cell transplantation (HCT) may even cure leukemia following relapse or primary induction failure. Several pre-transplant variables including age, duration of remission, poor-risk cytogenetics, tumor burden at HCT, type of donor, and performance status reportedly affected the post-HCT prognosis of leukemia that is not in remission. However, there has been insufficient examination of the factors required to achieve long-term survival or cure of leukemia that is not in remission at HCT. We might consider long-term survival without relapse, particularly for more than 5 years, as ‘likely cure' of leukemia. Therefore, we evaluated the factors that contribute to long-term survival (for more than 5 years) in patients with active leukemia at HCT. Method: We retrospectively performed an analysis of leukemia not in remission at HCT performed at our single institute between January 1999 and July 2009. Forty-two patients aged from 15 to 67 years (median age: 39 years) received intensified myeloablative (n=9), myeloablative (n=11) or reduced-intensity conditioning (n=22) for HCT. Twelve patients received individual chemotherapy for cytoreduction within the three weeks before reduced-intensity conditioning for HCT. Diagnoses included de novo AML (n=17), ALL (n=12), CML-AP (n=2), MDS/AML (n=10) and plasma cell leukemia (n=1). In those with acute leukemia, cytogenetic abnormalities were intermediate (n=17, 44%)or poor (n=22, 56%). Seven patients were primarily refractory to induction chemotherapy. The other patients relapsed after conventional chemotherapy or the first HCT. The median number of blast cells in bone marrow (BM) was 26.0% (range; 0.2–100) before the start of chemotherapy for HCT. Six patients had leukemic involvement of the central nerve system. Stem cell sources were related BM (n=3, 7%), related peripheral blood (n=13, 31%) unrelated BM (n=20, 48%) and unrelated cord blood (CB) (n=6, 14%). Thirty-one pairs were matched for HLA-A, B and DRB1 antigens. Three patients were mismatched for one HLA antigen (two at HLA-A, one at HLA-B), and seven were mismatched for two (two at HLA-A and B, five (all CB) at HLA-B and DRB1). The remaining patient was mismatched for all three antigens. Prophylaxis for acute GVHD consisted of calcineurin alone (n=5), calcineurin combined with short-term methotrexate (n=32), calcineurin combined with mycophenolate mofetil (n=2) or none (n=3). In this study, we defined long-term survival as survival without relapse for more than 5 years. Results: Engraftment was achieved in 33 (79%) of 42 patients. Median time to engraftment was 17 days (range: 9–32). Five patients died early after HCT (range 4–20 days). Twenty four (65%) of 37 evaluable patients developed acute GVHD (eight grade I, nine grade II, five grade III, two grade IV), and 12 (50%) of 24 evaluable patients developed chronic GVHD (1 limited, 11 extensive). With a median follow up of 85 months for surviving patients, the five-year Kaplan-Meier estimates of leukemia-free survival rate and overall survival (OS) were 17% and 19%, respectively. At five years, the cumulative probability of non-relapse mortality was 38%. In the univariate analyses of impact of pre-transplant variables on OS, poor-risk cytogenetics, number of BM blasts (>26%), MDS/AML and CB as stem cell source were significantly associated with worse prognosis (p=.03, p=.01, p=.02 and p<.001, respectively). In addition, the five-year Kaplan-Meier estimates of OS in patients with and without cGVHD were 66.7% and 0% (p<.001) respectively. Conclusion: Graft-versus-leukemia effects mediated by cGVHD may have played a crucial role in long-term survival in, or cure of active leukemia. We speculate that effective cytoreduction by individual chemotherapy and/or conditioning for HCT to control disease until cGVHD subsequently occurred might be also important, particularly in leukemia with rapid proliferation. However, intensive conditioning for HCT did not appear to be indispensable in relatively indolent leukemia, even with non-remission status at HCT. In addition, based on our results, CB might be unsuitable as a source of stem cells for leukemia that is active at the time of HCT. Disclosures: No relevant conflicts of interest to declare.

BackgroundThere has been insufficient examination of the factors affecting long-term survival of more than 5 years in patients with leukemia that is not in remission at transplantation.MethodWe retrospectively analyzed leukemia not in remission at allogeneic hematopoietic cell transplantation (allo-HCT) performed at our institution between January 1999 and July 2009. Forty-two patients with a median age of 39 years received intensified conditioning (n = 9), standard (n = 12) or reduced-intensity conditioning (n = 21) for allo-HCT. Fourteen patients received individual chemotherapy for cytoreduction during the three weeks prior to reduced-intensity conditioning. Diagnoses comprised acute leukemia (n = 29), chronic myeloid leukemia-accelerated phase (n = 2), myelodysplastic syndrome/acute myeloid leukemia (MDS/AML) (n = 10) and plasma cell leukemia (n = 1). In those with acute leukemia, cytogenetic abnormalities were intermediate (44%) or poor (56%). The median number of blast cells in bone marrow (BM) was 26.0% (range; 0.2-100) before the start of chemotherapy for allo-HCT. Six patients had leukemic involvement of the central nervous system. Stem cell sources were related BM (7%), related peripheral blood (31%), unrelated BM (48%) and unrelated cord blood (CB) (14%).ResultsEngraftment was achieved in 33 (79%) of 42 patients. Median time to engraftment was 17 days (range: 9-32). At five years, the cumulative probabilities of acute graft-versus-host disease (GVHD) and chronic GVHD were 63% and 37%, respectively. With a median follow-up of 85 months for surviving patients, the five-year Kaplan-Meier estimates of leukemia-free survival rate and overall survival (OS) were 17% and 19%, respectively. At five years, the cumulative probability of non-relapse mortality was 38%. In the univariable analyses of the influence of pre-transplant variables on OS, poor-risk cytogenetics, number of BM blasts (>26%), MDS overt AML and CB as stem cell source were significantly associated with worse prognosis (p = .03, p = .01, p = .02 and p < .001, respectively). In addition, based on a landmark analysis at 6 months post-transplant, the five-year Kaplan-Meier estimates of OS in patients with and without prior history of chronic GVHD were 64% and 17% (p = .022), respectively.ConclusionGraft-versus-leukemia effects possibly mediated by chronic GVHD may have played a crucial role in long-term survival in, or cure of active leukemia.

Side effects of varying severity are frequent in peripheral blood stem cell harvest (PBSCH). Life-threatening complications associated with PBSCH have also been reported. Heart rate variability (HRV), which reflects sympathovagal balance and autonomic cardiovascular control, has been a subject of intense interest in various diseases precipitating sudden death. Here, we prospectively assessed the impact of leukapheresis on HRV among autologous hematopoietic cell transplant patients and healthy donors. We found that HRV indicators, the standard deviation of normal-to-normal intervals (SDNN) value, the square root of the mean of the sum of squared differences between the adjacent normal-to-normal interval (r-MSSD) value, total frequency (TF), high frequency (HF) and low frequency (LF) powers decreased significantly to morbid levels during leukapheresis (all P < 0.01). Morbid changes in SDNN value, TF and LF powers were significantly sustained for 6-9 h after leukapheresis (all P < 0.05). Furthermore, TF and LF powers prior to leukapheresis were significantly lower in subjects with symptomatic hypotension than in the other subjects [3282 (3121-4427) vs. 6018 (4983-9816) ms(2), P = 0.03; 93 (42-144) vs. 237 (142-360) ms(2), P = 0.03, respectively]. Our results suggest that HRV analysis might be of use in evaluating and predicting the adverse effects of cardiovascular complications in PBSCH.

4347 Optimal graft-vs.-host disease (GVHD) prophylaxis in T-cell-replete, reduced-intensity allogeneic stem cell transplantation from an unrelated donor (u-RIST) has not been established yet. Tacrolimus-based acute GVHD prophylaxis has been widely used in allogeneic stem cell transplantation from unrelated donors. In addition, T-cell-depletion conditioning regimen containing anti-thymocyte globulin (ATG), or alemtuzumab with/without 2-4 Gy total body irradiation (TBI) has been reportedly applied in u-RIST. However, in-vivo T cell depletion using ATG or alemtuzumab may cause increased risk of infection or relapse after transplantation. TBI may also possibly cause increased incidence of GVHD via tissue damage. Here we report the feasibility of using cyclosporine and short-term methotrexate for GVHD prophylaxis in u-RIST. The conditioning regimen consisted of fludarabine and busulfan (Flu+Bu) without T-cell depletion, such as ATG or alemtuzumab, and without TBI for u-RIST in patients who received prior chemotherapy. In this study, we retrospectively analyzed 30 consecutive patients with hematologic malignancies (median age: 53; range: 22 to 69 years; AML: 11; ALL: 9; MDS: 2; NHL: 5; ATL/L: 3) who received unrelated-donor bone marrow transplantation from HLA 6/6 (A, B, DRB1), either allele-matched (n = 24 patients), one DRB1 allele-mismatched (n = 5 patients), or one A allele-mismatched (n=1) donor at our institution between September 2002 and June 2009. All patients received at least one cycle of prior chemotherapy (median cycle: 6; range: 1 to 19). Of these, 15 patients (50%) were at high risk of relapse. For all, acute GVHD prophylaxis consisted of cyclosporine and short-term methotrexate (day 1: 10mg/m2; day 3 and 5: 7 mg/m2). The reduced intensity conditioning consisted of fludarabine 180mg/m2 and oral busulfan 8 mg/kg for 12 patients; the other 18 patients' conditioning consisted of fludarabine 180 mg/m2 and intravenous busulfan 8mg/kg. Neutrophil and platelet engraftments were achieved in 100% (30/30) and 93% (28/30) of patients, respectively. The median times for neutrophil and platelet engraftments were 16 days (range: 12 to 26 days) and 24.5 days (range: 18 to 291 days), respectively. In patients receiving oral and intravenous busulfan for conditioning, the achievement rates of complete T-cell chimerism by day 100 were 75% (9/12) and 100% (18/18), respectively (p = 0.03). The median period of follow-up was 280 days (range: 34∼1987). During the follow-up our observational periods, 19 patients were alive and 11 patients died of relapse (n = 8) or transplant-related mortality (n = 3). The cumulative incidences of acute GVHD of grade II to IV and III to IV at day 100 were 40% and 17%, respectively. Extensive type of chronic GVHD was 30% in 23 evaluable patients. The 2-year overall survival (OS) and event-free survival rates were 58% (low/standard risk group: 78%; high risk group: 43%; p = 0.04) and 52% (low/standard risk group: 72%; high risk group: 33%; p = 0.01), respectively. In multivariate analysis, grade III to IV acute GVHD and disease status at high relapse were significantly associated with worse OS (p = 0.03 and 0.008, respectively). Day 100 and 2-year TRM were 3% and 10%, respectively. Cyclosporine and short-term methotrexate for GVHD prophylaxis without T-cell deplete-conditioning allowed acceptable incidence of GVHD even in u-RIST. Additionally, only Flu+Bu conditioning for uRIST ensured high rate of complete T-cell chimerism especially in patients receiving intravenous busulfan. Our results suggested that we might be required to determine optimal conditioning and GVHD prophylaxis regimens based on patient characteristics, including a history of prior chemotherapy. Disclosures: Hino: Kyowa Hakko Kirin Co., Ltd. : Research Funding.