Relapse remains a major cause of mortality among patients receiving allogeneic hematopoietic cell transplantation (HCT). The impact of donor type on post-relapse survival (PRS) has not been widely examined. We compared the survival outcomes for patients relapsing after haploidentical donor transplantation (HIDT) using post-transplant cyclophosphamide with those relapsing after matched-related donor transplantation (MRDT) or matched-unrelated donor transplantation (MUDT) at our institution. Two hundred and thirty-seven consecutive HCT recipients with relapse occurring after HIDT (N=48), MUDT (N=87) and MRDT (N=102) were included in this analysis. Median age was 49 years (19-77 years) and the median time to relapse was 156 days (12-2465) after HCT. HIDT recipients had similar median time to relapse (5.8 vs 4.8 vs 5.5 months, P=0.638) compared with MUDT and MRDT, respectively. One-year PRS was worse among HIDT recipients compared with MRDT and MUDT (17% vs 46% vs 40%, P<0.05). In a multivariate analysis, time to relapse (<3 vs >3 months post transplant), no use of donor lymphocyte infusion (DLI) following relapse, higher Dana Farber disease risk index and HCT comorbidity index scores at the time of transplant and delayed platelet engraftment post transplant were all predictive of worse PRS. This analysis shows that 1-year PRS is inferior among HIDT when compared with MRDT or MUDT. Lower use of DLI after HIDT may have contributed to this inferior survival.

Inadequate T-cell chimerism following reduced-intensity conditioning transplantation may contribute to graft rejection and disease relapse. Anti-thymocyte globulin (ATG) enhances early donor T-cell chimerism, but may also deplete donor T cells, increasing risks of infection and relapse. We prospectively tested administration of rabbit ATG (rATG) ⩾14 days before the infusion of the graft, followed by in vivo decay of active rATG levels, to selectively deplete host T cells. Twenty-three patients received rATG total dose 4.5 mg/kg on days −16 and −15, fludarabine 30 mg/m2 per day on day −7 through −3, IV busulfan 130 mg/m2 per day on days −4 and −3 and cyclophosphamide 1500 mg/m2 on day −2. rATG levels were therapeutic in all patients on day −14, but were sub-therapeutic (<1 μg/mL) by day 0 in 82% of patients. Median donor T-cell chimerisms on days 30 and 180 were 100% (75–100%) and 100% (90–100%), respectively. Non-relapse mortality and relapse/progression at 48 months were 17 and 30%. Cumulative incidences of acute GvHD grades II–IV and III–IV were 39 and 9%. Median follow-up is 64 months (46–79 months). Survival and disease-free survival at 48 months were 70 and 52%. These data suggest that selective depletion of host T cells using this regimen is a feasible and effective strategy.

Although pretransplant alemtuzumab can reduce GVHD following allogeneic transplantation, it may also increase the risk of mixed donor T-cell chimerism and infections. We hypothesized that the early use of DLI without withdrawal of immunosuppressive drugs in patients with mixed T-cell chimerism would lower the risk of relapse without significantly increasing the risk of GVHD post DLI. Thirty-six patients (median age 59 years) were treated in this phase II trial using reduced-intensity conditioning including s.c. alemtuzumab (total dose 43 mg) and a PBSC graft from a matched unrelated donor (UD). DLI without withdrawal of immunosuppressive drugs was administered to all 25 patients with <50% donor T-cell chimerism on day +60. The cumulative risks of acute and chronic GVHD were 42% and 59%, respectively. Estimated probabilities of non-relapse mortality (NRM) at day 100 and 1 year were 3% and 14%, respectively. With a median follow up 2.4 years, estimated survivals at day 100, 1 and 2 years were 97%, 71% and 57%, respectively. In multivariate analysis, the occurrence of acute GVHD was associated with an increased risk of mortality, whereas the occurrence of chronic GVHD had a protective effect, associated with decreased relapse and improved disease-free survival. Low-dose alemtuzumab and preemptive DLI provides favorable transplant outcomes including low NRM in an older patient population with high-risk malignancies undergoing UD transplantation.

Availability of an HLA-identical sibling (MRD) or suitably matched unrelated donor (MUD) has historically been a limiting factor in the application of allogeneic hematopoietic transplantation. Although almost all patients have an HLA-haploidentical family donor, prior attempts at transplantation from such donors using T-cell replete grafts and conventional immunosuppression were associated with unacceptable rates of GVHD, and when stringent ex vivo T-cell depletion was used to control GVHD, rates of graft rejection and post-transplant infections were prohibitive. The recent approach to HLA-haploidentical donor transplantation developed in Baltimore that uses T-cell replete grafts and post-transplant CY (Haplo-post-HCT-CY) to control post-transplant allo-reactivity appears to have overcome many of the obstacles historically associated with haploidentical donor transplantation. In particular, TRM rates of <10% are usual and rapid reconstitution of immunity leads to a low rate of post-transplant infections and no post-tranplant lymphoproliferative disorders (PTLD), consistent with the hypothesis that post-transplant CY selectively depletes proliferating alloreactive T cells responsible for GVHD and graft rejection while preserving resting memory T cells essential for post-transplant immunologic recovery. In parallel trials using similar non-myeloablative conditioning regimens, Haplo-post-HCT-CY produced similar overall survival to double umbilical cord blood transplantation(DUCBT) in adult patients (62% vs 54%), with low rates of TRM (7% vs 24%), severe acute GVHD (0% vs 21%) and chronic GVHD (13% vs 25%). Furthermore, recent non-randomized comparisons adjusted for risk factors show that Haplo-post-HCT-CY achieve at least equivalent outcomes to conventional MRD and MUD transplants. Although most experience has been obtained using BM, emerging data suggest that a G-CSF mobilized PBSC graft can also safely be used for Haplo-post-HCT-CY. Haplo-post-HCT-CY also avoids the graft acquisition costs of DUCBT and MUDs and the cost of cell selection associated with T-depleted grafts. Although randomized comparisons will be forthcoming, Haplo-post-HCT-CY can already be considered a valid standard-of-care in patients who lack conventional donors thus extending the availability of allogeneic transplants to almost all patients. This donor source may also challenge the routine preference for a MUD in patients lacking an MRD.

The FDA recommends voriconazole (VOR) levels ≥0.5mg/L, however current literature recommends trough concentrations of ≥1-2mg/L and <5.5mg/L. We implemented a VOR therapeutic monitoring program based on our current algorithm which strives for a level of ≥0.5 for prophylaxis and ≥2 for empiric/treatment therapy. Our primary objective was to determine the likelihood of achieving therapeutic levels, and if dose modification can be helpful in optimizing attainment of therapeutic levels. We prospectively studied steady state VOR levels in 89 consecutive patients (pts) between 02/2010 and 07/2011. Pts in the prophylaxis group received 200mg BID. Pts in the empiric group received 6 mg/kg BID for two doses, followed by 4 mg/kg BID. Fifty of the pts had undergone allogeneic HSCT (56%), 38 were undergoing leukemia therapy (43%), and 1 was an autologous transplant pt. GVHD was documented in 20/50 HSCT pts (40%), and 5 of those had gut GVHD. VOR was being used as prophylaxis in 49/89 pts (55%). A target level of ≥0.5 mg/L was achieved in 86% (42/49) of pts. The level was ≥1, ≥2, and ≥5.5 mg/L in 61%, 43%, and 0%, respectively. Of the 7 pts not reaching ≥0.5, five doses were increased with subsequent level ≥0.5 mg/L. VOR was being used for empiric therapy in 40/89 pts (45%). Levels achieved target of ≥2 mg/L in 30 (75%) of 40 pts. Levels were ≥0.5, ≥1, and ≥5.5 mg/L in 85%, 82%, and 40%, respectively. Of the 10 pts with levels <2 mg/L, VOR was discontinued in 3 pts and dose was increased in 6 pts. Of the 6 increased doses, 3 follow-up levels were obtained and 2 were ≥2. The dose of VOR was decreased in 9 pts with level ≥5.5. Patients receiving prophylactic VOR were statistically more likely to achieve targeted levels (≥0.5) than pts receiving empiric VOR (≥2) (96% vs 80%, p = 0.038). The presence of gut GVHD was associated with a statistically significant decrease in achievement of therapeutic VOR levels compared with GVHD pts without gut involvement (60% vs 100%, p = 0.034). However, all GVHD pts achieved therapeutic levels after dose modification. Utilizing a prospective VOR monitoring program, we were able to demonstrate that the majority of unselected leukemia and HSCT pts achieve therapeutic VOR levels. VOR level monitoring allowed for documentation of compliance, gave opportunity for dose modification to ensure achievement of therapeutic levels, and reduced toxicity by identifying super-therapeutic levels.

Posaconazole (POS) is an extended-spectrum triazole with proven efficacy for antifungal prophylaxis in patients (pts) undergoing HSCT or treatment of acute leukemia. The FDA recommends a goal POS average serum drug concentration of >700 ng/ml. We implemented a pharmacy-driven POS therapeutic monitoring program. Our primary objective was to see if pharmacy intervention can be helpful in optimizing attainment of therapeutic POS levels. Forty-eight steady-state plasma trough POS levels (33 in HSCT pts, 15 in pts undergoing acute leukemia therapy) performed after at least 7 days of administration were analyzed. POS levels were >700 ng/ml in 19/48 (40%) pts. Mean POS level was 790 ng/ml (range 53- 2960), and median was 602 ng/ml. Of the 29 levels <700ng/ml, there were 26 dose modifications. POS was changed to another antifungal in 13 pts, POS was discontinued in 2 pts, and dose was increased in 11 pts. Of the 11 increased doses, 8 follow up levels were drawn with 4 pts achieving a documented therapeutic level. POS was being used as prophylaxis (starting dose 200mg TID) in 31 pts (65%) and empirically (starting dose 400mg BID) in 17 pts (35%). The highest dose used was 400mg QID in one pt with documented fungal infection. GVHD was present in 16 of 33 HSCT pts (48%), and ten of the pts had gut GVHD at the time of level. POS levels were >700ng/mL in 6/16 (38%) and 2/10 (20%) of all GVHD and gut GVHD pts, respectively, although this was not statistically signficant. Proton-pump inhibitor or H2 antagonist therapy (PPI/H2) was administered concurrently with 42/48 (88%) of levels, although the use of these drugs had no apparent effect on therapeutic levels. Leukemia pts were significantly less likely to achieve therapeutic POS levels when compared to HSCT pts (27% vs 61%, p = 0.029). Other than treatment group, we found no other factors that correlated with achieving therapeutic levels. The pharmacy based implementation of POS therapeutic monitoring revealed that achievement of recommended POS levels remains a challenge in an unselected HSCT and leukemic population. This program enabled documentation of compliance and allowed an attempt at improvement of POS levels by dose adjustment. Pharmacists counseled pts on ways to increase absorption by taking with a high fat meal, nutritional supplement, or acidic carbonated beverage, and by stopping their PPI/H2.

Cyclophosphamide (Cy) has been shown to be an effective regimen for HSC mobilization in NHL patients undergoing autologous stem cell transplantation (ASCT). However, the optimal dose to be used, which maximizes HSC collection yields while minimizing febrile neutropenia and other toxicities, remains controversial. Three successive cohorts of NHL patients who received G-CSF and Cy at doses of either 4g/m2 (Cy4), 2g/m2 (Cy2) or 3g/m2 (Cy3) were compared. 31 pts undergoing Cy3 mobilization between October 2009 and August 2011 were retrospectively analyzed and compared to our historical Cy2 (n = 28) and Cy4 (n = 28) data. Minimal and optimal yield was defined as collection of ≥2 x 106 and ≥5 x 106 CD34+ cells/kg, respectively. Apheresis was initiated utilizing WBC and CD34+ cell count to guide start of collection and preemptive plerixafor use, whereas in historical Cy4 and Cy2 cohorts, plerixafor was only used following mobilization failure. Minimal cell dose required for ASCT was achieved in the majority of patients in all groups (89%, 100% and 100% of Cy2, 3, and 4 pts, respectively). However, the collection efficiency clearly favored Cy3 and Cy4, with the proportion of patients collecting ≥2 x 106 CD34+ cells/kg in 2 days being 87% and 82%, respectively vs. 39% for Cy2 (p<0.001). In contrast, toxicity, as measured by % febrile neutropenia and median hospitalization days, favored Cy2 (0%, 0d) compared with Cy4 (32%, 4d, p = 0.002), with Cy3 falling intermediate between these groups (16%, 3d). Requirement for Plerixafor was significantly higher for both Cy2 (32%) and Cy3 (42%), compared with Cy4 (4%, p = 0.003). Relative cost clearly favored Cy4, when accounting for the combined costs of Cy, G-CSF, plerixafor, hospitalization, and apheresis, with Cy3 and Cy2 costing approximately 37% and 47% more, respectively, per patient mobilization. Although Cy2, 3, and 4 are all effective mobilizing regimens, collection efficiency, toxicity, and cost vary greatly. Both Cy3 and Cy4 improve collection efficiency, at the expense of increased hospitalization, particularly with Cy4. Cy4 appears to maximize collection efficiency while minimizing plerixafor use and overall cost. Further improvements in supportive care strategies to reduce the incidence of febrile neutropenia and associated hospitalization are clearly needed.TableCy2 (n = 28)Cy3 (n = 31)Cy4 (n = 28)P-valuePairwise Comparison (significant if p-value<0.017 based on Bonferroni adjustment)Cy2 vs Cy3Cy2 vs Cy4Cy3 vs Cy4Collect ≥2x106 in ≤2 days39%87%82%<0.001<0.0010.0010.597Collect≥5x106 in ≤2 days14%42%46%0.0220.0190.0090.729Collect≥5x106 in all days18%45%64%0.0020.025<0.0010.141Collect≥2x106 in all days89%100%100%n.sN/AN/AN/AMedian # of collections322<0.001<0.0010.0110.830% Patients hospitalized for FN0%16%32%0.0020.0620.0020.127Hospitalization Days (median)0340.0040.0330.0020.113Days of G-CSF (median)11.512.510.5n.sN/AN/AN/A% Pts receiving plerixafor32%42%4%0.0030.4370.005<0.001Relative Mobilization Cost (normalized to Cy4)1.471.371.00 Open table in a new tab

Abstract Abstract 4389 Background: Autologous hematopoietic stem cell transplantation (ASCT) has become an integral part of the treatment for multiple myeloma (MM). In addition, it is standard practice to collect enough stem cells for more than one transplant. Therefore, it is critical to have an effective mobilization strategy in order to efficiently collect sufficient numbers of CD34+ cells. Administering granulocyte-colony stimulating factor (G-CSF) alone to MM patients can produce sufficient CD34+ yields in the majority of patients. However, some patients may require > 4 apheresis days to achieve those yields. In addition, some patients may fail to collect enough CD34+ cells for ASCT. Plerixafor was approved in 2008 to be used in combination with G-CSF to mobilize hematopoietic stem cells to the peripheral blood. Plerixafor can increase the average daily CD34+ yields by 3-fold. However, since the majority of patients can collect with G-CSF alone, a plerixafor algorithm was developed in 2009 to judiciously administer plerixafor only to those patients at higher perceived risk for mobilization failure. Administration of plerixafor is based on a peripheral blood CD34+ count drawn after 3 days of G-CSF and subsequent CD34+ collection yields. Methods: G-CSF 10mcg/kg/day (given daily or divided into twice daily) was administered subcutaneously from day 1 to 4. On day 4, a peripheral absolute CD34+ cell count was drawn. If the absolute CD34+ cell count was ≥ 12 cells/mm3 then apheresis started on day 5. If the absolute CD34+ cell count on day 4 was < 12 cells/mm3 plerixafor 240mcg/kg was administered subcutaneously the evening prior to apheresis beginning on day 5. During apheresis, if the CD34+ yield was < 1.0×106 CD34+/kg or 50% less than the previous collection, plerixafor was initiated. The minimum collection yield for all patients was 4.0×106 CD34+/kg. The maximum number of apheresis days was 5. Previous therapy was also examined. Results: From October 2009 to May 2011, 68 multiple myeloma patients were mobilized with G-CSF +/− plerixafor. Ninety-three percent (63/68) of patients achieved the minimum collection yield of 4.0×106 CD34+/kg. Ninety-nine percent (67/68) of patients achieved a yield of at least 2.0×106 CD34+/kg. Forty-four percent (30/68) of the patients required at least 1 dose of plerixafor with the majority requiring it prior to the first apheresis (83%). The median days of apheresis was 2 (range 1–5). The overall average yield on the first apheresis day was 4.35×106 CD34+/kg (95% CI +/− 0.64). The overall average total yield was 8.71×106 CD34+/kg (95% CI +/− 0.93). Sixty percent (41/68) and 76% (52/68) of patients collected ≥ 6.0×106 CD34+/kg in ≤ 2 days and ≤ 4 days of apheresis, respectively. The average daily yield (ACD34) for G-CSF alone can be predicted by ACD34 = 0.0377+ 0.07456xCD34 (see figure). ACD34 after plerixafor + G-CSF can be predicted by the equation 3(0.0377 + 0.07456xCD34) = ACD34. Of the patients that received previous radiation therapy (9) or cyclophosphamide (2), plerixafor was utilized in 78% and 100%, respectively. Previous lenalidomide therapy was present in 50% of the patients and it did not correlate to any increase in plerixafor usage. Conclusion: Adding plerixafor to G-CSF based upon a day 4 CD34+ count and collection yields is an effective strategy to mobilize CD34+ cells. Ninety-three percent of the of the patients were able to collect a minimum of 4.0×106 CD34+/kg cells and 99% collected > 2.0×106 CD34+/kg, in a median of two collections. Limitations to the study include a small sample size and an arbitrarily determined threshold to administer plerixafor. Also, the length of lenalidomide could not be retrospectively determined. A cost-based analysis is currently being performed to help determine the best day 4 CD34 cutoff for future studies. Disclosures: No relevant conflicts of interest to declare.

6110 Background: The NCCCP has engaged in special programs to enhance clinical trial accrual among underserved populations. These include cultural awareness webinars, nurse/lay navigators with translated consent forms and interpreters, expansion of trials in outreach sites, community site pairing, and utilization of a web-based tracking tool to monitor clinical trial screening and accrual barriers. Methods: Screening and accrual data of 19 NCI Cooperative Group trials encompassing 9 disease categories from the geographically diverse NCCCP sites was collected between March 2009 and December 2010. The data included patient demographics, trial eligibility, trial enrollment, and reasons for non-enrollment. We used Fisher’s exact test for determination of P values. This abstract addresses patient demographics. Results: Of the 1,589 patients screened during this period, 359 were enrolled, for an overall accrual rate of 23%. The accrual rates among the various demographic subsets are shown in the table. No disparity based on gender, ethnicity, or race between Whites and African Americans (P value for the latter comparison 0.59) was found and the disparity gap between the young and elderly appears narrowed when compared to historical data (3-fold difference; Murthy VH, et al JAMA 2004). Conclusions: NCCCP has captured clinical trial screening and accrual outcome among several underserved populations coming from diverse geographic locations. Data suggests that through barrier identification and a concerted program of network strategies involving community cancer centers, disparities in clinical trial accrual have been reduced. This project funded in whole or part with federal funds from NCI, NIH under Contract No. HHSN261200800001E. # Screened # Enrolled Accrual rate (%) P Overall 1,589 359 23 -- Female 1,078 246 23 0.80 Male 511 113 22 Age > 65 689 143 21 0.09 < 65 883 216 25 Hispanic 93 20 22 0.80 Non-Hispanic 1,465 339 23 White 1,309 306 23 0.59 African American 205 44 22

Abstract 889 [][1] Introduction: Haploidentical hematopoietic stem cell transplantation (HSCT) provides an opportunity for nearly all patients to benefit from HSCT when a human leukocyte antigen (HLA) genotypically matched donor is not available. Initial approaches to mismatched allografting using ex-vivo T-cell depletion and intense preparative regimens were associated with high rates of graft rejection, severe graft-versus-host disease (GVHD) and infectious complications, resulting in an unacceptable treatment-related morbidity and mortality. More promising outcomes have been recently demonstrated by a new approach to haploidentical transplantation, utilizing a nonmyeloablative preparative regimen, followed by a T cell-replete bone marrow infusion and post-transplantation immunosuppression with high dose Cyclophosphamide (Cy), tacrolimus, and mycophenolate mofetil (MMF). However, relapse represents the major cause of treatment failure in these patients, particularly with high-risk myeloid malignancies.Methods: In order to decrease relapse risk in patients with high-risk malignancies, we initiated a trial between January 2009 and March 2011, of haploidentical allografting using a myeloablative preparative regimen and peripheral blood stem cells (PBSC) instead of bone marrow as the graft source. Eligibility was limited to patients perceived to be at prohibitively high risk of relapse following nonmyeloablative haploidentical BMT. Initial conditioning (n=5) consisted of Fludarabine 30 mg/m2 on days −7 to −2, IV Busulfan 130 mg/m2 on days −7 to −4, and Cy 14.5 mg/kg on days −3 and −2 followed by an unmanipulated PBSC infusion in all patients. In response to increased rates of mucositis, fludarabine and busulfan doses were decreased by 30% and 15%, respectively, in subsequent patients. Post-grafting immunosuppression consisted of Cy 50mg/kg/day on days 3 and 4, MMF, and tacrolimus.Results: A total of twenty patients were enrolled in the study: median age 44 years (25–56); diagnoses AML=12, ALL= 2, HD=1, CML=3, CLL=1, NHL=1; allograft from 5/10 locus matched (n=14), 6/10 locus matched (n=2), 7/10 locus matched (n=3), or 8/10 locus matched (n=1). CIBMTR disease risk-high risk =7 (35%), intermediate risk = 4 (20%) or low risk = 9 (45%). Of the 9 low risk patients, seven were cytogenetically poor-risk AML and/or required ≥2 induction cycles to induce complete response. Donor engraftment occurred in all 20 patients, with a median time to neutrophil and platelet recovery of 16 and 27 days, respectively. All evaluable patients achieved complete donor T cell and myeloid chimerism by Day +30. The cumulative incidence of grades II–IV and grades III–IV aGVHD was 30% and 20%, respectively. The cumulative incidence of cGVHD at one year was 42%. Non-relapse mortality (NRM) at 100 days and 1 yr was 10% for all patients and 0% for low-risk patients. Non-infectious fever (median tmax 103.9; 101.2–106.8), possibly related to cytokine release from proliferating alloreactive cells, developed in 90% of patients within a median of 2.5 days (1–5) of transplant and resolved by day 6 (5-7) following post-transplant Cy. BK virus-associated cystitis occurred in 75% of patients, and was severe (requiring hospital admission for bladder irrigation and/or pain management) in 35%. Other severe infections were not seen at increased frequency compared to conventional donor myeloablative transplants at our center. With a median follow-up of 14 months, the estimated 1 year overall and disease-free survival was 74% and 51%, respectively for all patients; 100% and 76%, respectively for low-risk patients.Conclusion: HLA haploidentical HSCT using this myeloablative regimen with T-cell replete PBSC and post-transplant Cy is associated with excellent rates of engraftment, GVHD, NRM and DFS, it is therefore a valid option in patients with high-risk malignancies who lack timely access to a conventional donor.Disclosures: Sizemore: Otsuka America Pharmaceuticals, Inc.: Research Funding. Bashey: Otsuka America Pharmaceuticals, Inc.: Research Funding. Sanacore: Otsuka America Pharmaceuticals, Inc.: Research Funding. Manion: Otsuka America Pharmaceuticals, Inc.: Research Funding. Holland: Otsuka America Pharmaceuticals, Inc.: Research Funding. Morris: Otsuka America Pharmaceuticals, Inc.: Research Funding. Brown: Otsuka America Pharmaceuticals, Inc.: Research Funding. Solomon: Otsuka America Pharmaceuticals, Inc.: Research Funding. [1]: #fn-2

Abstract Abstract 4229 Background Cyclophosphamide (Cy) (2-7 g/m2) has been shown to be an effective regimen for hematopoietic stem cell (HSC) mobilization in multiple myeloma (MM) patients undergoing autologous stem cell transplantation (ASCT). However, the optimal dose to be used, which maximizes HSC collection yields while minimizing febrile neutropenia and other toxicities, remains controversial. Two historical cohorts of MM patients who received G-CSF and Cy at dose of either 4g/m2 (Cy4) or 2g/m2 (Cy2) were compared. Methods A total of 72 patients undergoing first mobilization with Cy and G-CSF at a single institution between June 2006 and December 2008 were retrospectively analyzed. The initial Cy4 patient cohort (n=35) was mobilized with Cy 4gm/m2 starting on Day 1 followed by G-CSF 10ug/kg/day starting on Day 7 and continuing until completion of apheresis. Beginning in Feb 2008, the Cy dose was reduced to 2gm/m2 and the G-CSF start date was moved to day 4 (Cy2 n=37). Apheresis was initiated at physician discretion based on patient specific factors. Minimal and optimal yield was defined as collection of ≥2 × 106 and ≥6-10 × 106 CD34+ cells/kg respectively. Prophylactic antibiotics were given for ANC <500 to reduce risk of febrile neutropenia. Results Minimal cell dose required for ASCT (≥2 × 106 CD34+ cells/kg) was achieved in 97% vs. 86.5% of Cy4 and Cy2 patients, respectively. Of the 5 patients failing to mobilize on Cy2, four of these subsequently mobilized adequately following G-CSF and plerixafor. Median number of apheresis collections required was significantly lower in the Cy4 patients (1 vs.3, p=0.0065). The proportion of patients collecting the minimal and optimal cell dose in 2 or fewer days of apheresis was 94% vs. 86.5% (p= 0.4304) and 77% vs. 35% (p=0.0004), in the Cy4 and Cy2 patients respectively. However, mobilization with Cy4 was associated with a significantly higher incidence of hospital admissions due to febrile neutropenia (40% vs. 5%, p=0.0005), which is what prompted the change from Cy4 to Cy2. Conclusions Although Cy4 and Cy2 are both effective HSC mobilizing regimens, mobilization efficacy and toxicity vary greatly. Cy4 results in higher HSC yields requiring fewer apheresis procedures, but this benefit is offset by increased morbidity and hospital utilization. Based on the suboptimal results with Cy 4g/m2 and Cy 2g/m2 mobilization, newer mobilization strategies are clearly needed for MM patients. We are currently exploring a chemotherapy-free approach utilizing G-CSF +/- plerixafor, with the aim of optimizing HSC yields while minimizing toxicity and costs (apheresis collections, hospital utilization, etc.). In our current algorithm, all MM patients receive G-CSF at a dose of 10ug/kg/day, with a day 4 peripheral CD34+ cell count determining requirement for plerixafor on the evening prior to apheresis collection(s). Disclosures: Off Label Use: Cyclophosphamide is being used as off label use for hematopoietic stem cell mobilization.

The international staging system (ISS) for multiple myeloma (MM) is a validated alternative to the Durie–Salmon staging system (DSS) for predicting survival at diagnosis. We compared these staging systems for predicting outcomes after upfront autologous stem cell transplantation by analyzing the outcomes of 729 patients between 1995 and 2002. With a median follow-up of 56 months, the univariate probabilities (95% CI) of non-relapse mortality (NRM), relapse, progression-free survival (PFS) and overall survival (OS) at 5 years were 7, 68, 25 and 52%, respectively. The median OS for stages I, II, III by DSS and ISS were 82, 68, 50 and 64, 68, 45 months, respectively. The concordance between the two staging systems was only 36%. Staging systems were formally compared using Cox models fit with DSS and ISS stages. The relative risks of PFS and OS were significantly different for stages I vs II and II vs III for DSS, but only for stages II vs III for ISS. Although both systems were predictive of PFS and OS, the DSS was superior in formal statistical comparison using Brier score. However, neither system was strongly predictive of outcomes, indicating the need for newer schemes incorporating other prognostic markers.

Historically, myeloablative allogeneic hematopoietic SCT (HSCT) has required prolonged in-patient hospitalization due to the effects of mucosal toxicity and prolonged cytopenias. We explored the safety and feasibility of outpatient management of these patients. A total of 100 consecutive patients underwent a matched-related donor myeloablative allogeneic HSCT for a hematologic malignancy at a single institution. Patients were hospitalized briefly for stem-cell infusion and thereafter only for complications more safely managed in the in-patient setting. The median hospital length of stay from the start of the preparative regimen to day +30 and day +100 post-transplant was 12 and 15 days, respectively. Planned hospital discharge occurred in 79 patients after stem cell infusion. Patients were readmitted to hospital at median of day +7 post transplant, with neutropenic fever being the primary cause for readmission. In total, 18 patients required no in-patient care in the first 100 days. Non-relapse mortality at day 100 and 6 months was 10 and 15%, respectively, for all patients, and 0 and 5%, respectively, for standard risk patients. In summary, outpatient myeloablative allogeneic HSCT with expectant in-patient management can be accomplished safely with low treatment-related morbidity and mortality. Clinical outcomes seem comparable to those reported for traditional in-patient management.

The prognosis is poor and the options are limited for patients with metastatic breast cancer (MBC), especially for those patients who have previously received taxanes and anthracyclines; treatment strategies are primarily palliative. Murine models have demonstrated that allogeneic T cells are capable of eliciting graft-versus-tumor (GVT) effects against breast cancer, inhibiting growth of breast cancer cell lines in vivo, providing the rationale to pursue allogeneic adoptive cellular therapy as a strategy to treat MBC. However, the clinical application of allogeneic hematopoietic stem cell transplantation (alloHSCT) was limited by concerns over toxicity and unproven efficacy. The development of non-myeloablative (a.k.a. reduced-intensity) conditioning regimens, which have less treatment-related mortality but preserve the T-cell mediated GVT effects, led to increased investigation of alloHSCT in MBC. Early reports of non-myeloablative alloHSCT indicate that a clinical GVT effect against breast cancer does exist. The responses, observed in 20-40% of patients, appear to be associated with the development of complete donor lymphoid chimerism and may be delayed. In its current form, alloHSCT by itself is unlikely to result in complete eradication of MBC; however, it may serve as a therapeutic platform to complement and enhance the effects of existing cytotoxic therapies and immunotherapies (e.g. trastuzumab), as well as therapies under development (e.g. vaccines). Current data on alloHSCT for MBC should be interpreted cautiously and carefully used for the design of future studies to fully determine the clinical efficacy of this form of adoptive cellular therapy in MBC.

DLI are frequently employed after nonmyeloablative (mini) allogeneic marrow transplant (allo-BMT) to enhance chimerism. To ensure the ready availability of cells for DLI we cryopreserved CD3+ cells from mobilized allo-BMT donors. We report here the safety and efficacy of infusing cryopreserved CD3+ T cells for DLI (c-DLI) from G-CSF mobilized allo-PBSC donors and the overall clinical utility of c-DLI. Methods: Graded doses of CD3+ donor T cells from allo-PBSC (2 bags of 10 × 106 & 2 of 50 × 106/kg pt wgt) were cryopreserved in 10% DMSO using a controlled rate freezer and stored in vapor-phase liquid nitrogen until use. We reviewed patients (pts) who received allo-BMT for hematologic malignancy from 1/03 to 12/05 to assess the number of c-DLI administered and the effect of c-DLI on chimerism. Results: Of 135 allo-BMT, 29 DLI were administered to 21 pts (median 1 DLI/pt, maximum, 3), 19 of which were c-DLI and 13 of which were for mini-allo-BMT. A median of 10.5 × 106 CD3+ T cells /kg pt weight (range 5 - 108 × 106) was administered. No unexpected infusion-related toxicities or adverse events were encountered. Eight pts were unevaluable for response, due to full donor chimerism at DLI (4) or insufficient data after DLI (4). Ten pts received 11 c-DLI after min-allo-BMT to improve chimerism (4 NHL; 3 CLL; 2 Acute Leukemia; 1 MM). There were 6 responses in T cell chimerism (> 5% increase) among 5 pts (4 NHL; 1 CLL), 2 to full donor chimerism (2 NHL). The mean increase in chimerism after all c-DLIs was 16% (0 - 50) and among responders the mean increase in T cell chimerism was 24.5% and required a mean 64 days (range 14 – 130 days). Four of 5 responders were in CR before c-DLI and remained in CR, while 4 of 5 non-responders had evidence of disease before and/or after c-DLI (NS by Chi square). Fifteen pts received 21 c-DLI due to persistent or recurrent disease (5 AML, 3 CLL, 3 lymphoma, 1 each CML, MM, MDS, Breast). Two pts were not evaluable for response due to death within 30 days. Three pts had CRs attributable, at least in part, to DLI (1 each AML, CML, MM). Conclusions: Prospectively cryopreserved CD3+ donor T cells from mobilized PBSC are frequently employed for DLI after mini-allo-BMT. Thawed c-DLI are readily available when needed and are not associated with unexpected infusion toxicity. C-DLI are frequently effective in improving donor chimerism post BMT, however a prospective comparison of fresh vs c-DLI will be required to assess comparative efficacy.

Controversy exists over whether pretransplantation consolidation chemotherapy affects the outcome of subsequent autotransplantation for acute myelogenous leukemia (AML). The current study was undertaken to determine the association between previous consolidation and outcome of autotransplantation for AML in first remission. Posttransplantation outcomes of 146 patients receiving no consolidation were compared with those of 244 patients receiving standard-dose (<1 gm/m2) and 249 patients receiving high-dose (1-3 gm/m2) cytarabine, using proportional hazards regression to adjust for differences in prognostic variables. One-year transplantation-related mortality was similar among the cohorts. Five-year relapse rates were 49% (95% confidence interval CI} = 39%-58%) with no consolidation, 35% (95% CI = 29%-42%) with standard-dose cytarabine, and 40% (95% CI = 33%-48%) with high-dose cytarabine (P = .07). Five-year leukemia-free survival rates were 39% (95% CI = 30%-47%) with no consolidation, 53% (95% CI = 46%-60%) with standard-dose cytarabine, and 48% (95% CI = 40%-56%) with high-dose cytarabine (P = .03). Similarly, 5-year overall survival was better in those patients receiving consolidation: 42% (95% CI = 34%-51%) with no consolidation, 59% (95% CI = 52%-65%) with standard-dose cytarabine, and 54% (95% CI = 46%-61%) with high-dose cytarabine (P = .01). Although most patients received 1 or 2 cycles of consolidation, the number of courses had no detectable effect on transplantation outcome. In multivariate analysis, risks of relapse and treatment failure were lower in the patients receiving consolidation, especially among those patients receiving blood cell grafts. Outcomes with standard-dose and high-dose cytarabine were similar. Based on our findings, we recommend that patients with AML in first remission receive consolidation before undergoing autotransplantation.

Relapse of malignancy is an important cause of treatment failure after allogeneic hematopoietic stem cell transplantation (allo-HCT). Malignant cells may evade adoptive immunotherapy post allo-HCT by mechanisms including lack of co-stimulation and direct or indirect inhibition of T-cell activation. CTLA-4 is a homologue of CD28 which functions as a negative regulator of T-cell activation. Blockade of CTLA-4 using neutralizing antibodies has demonstrated potent anti-cancer effects in animal models. Phase I/II clinical trials of CTLA-4 blockade in advanced tumors have demonstrated durable tumor regressions as well as immune breakthrough phenomena. Although CTLA-4 blockade may augment graft-versus-malignancy following allo-HCT, GVHD and other immune complications may also be increased. We report the results of a phase I dose-escalation trial of a neutralizing human monoclonal anti-CTLA-4 antibody (MDX-010) in patients with relapse of malignancy following allo-HCT. Eligibility criteria included allo-HCT ≥90 days previously, > 50% donor T-cell chimerism, no prior grade 3/4 GVHD, no prophylaxis/therapy for GVHD for ≥ 6 weeks. Patients received a single dose of MDX-010 over 90 min. DLI at a dose of 5 x 10e6 CD3 cells/kg was allowed 8 weeks following MDX-010 if no GVHD occurred and progression of malignancy (PD) was present. Twelve patients (8M, 4F; median age 45; CML=2, CLL=1, AML=1, Hodgkins disease [HD] =3 Myeloma [MM]=3, Renal Ca =1, Breast Ca=1) have been treated (4 at dose-level 0.1 mg/kg, 3 at 0.33 mg/kg, 4 at 0.66 mg/kg and 1 at 1.0 mg/kg). Median time between BMT and MDX-010 infusion was 10.3 months (4–79). Four patients received additional DLI. MDX-010 was well tolerated in this setting. No infusional toxicity was seen. No patient has developed clinically significant GVHD following MDX-010 alone. One patient developed grade II acute GVHD of the skin 12 weeks following DLI. Two possible immune breakthrough events were documented: grade 3 polyarthropathy 14 weeks following MDX-010, but also 6 weeks post DLI, which resolved with corticosteroid therapy, (AML, dose 0.1mg/kg, RhF+ pre-MDX-010); grade 1 chemical hyperthyroidism with thyroid-stimulating antibody 6 weeks post MDX-010 (CLL, 0.66 mg/kg). Three patients have demonstrated possible anti-cancer responses following MDX-010 alone (partial remission of AML refractory to prior therapies at 0.1 mg/kg dose, molecular remission of CML maintained off imatinib at 0.1 mg/kg dose, stabilization of previously progressive MM (0.33mg/kg) and one patient developed regression of malignancy (HD) following additional DLI (0.66mg/kg). With a median follow-up of 195d (lead f/u 570d) from MDX-010 infusion three patients have died (PD), 8 are alive and 1 is in CR and 1 is in PR. Pharmacokinetic and correlative science data will be presented. This study shows tolerability with possible anti-tumor effects at the dose levels

Collection of an optimal dose of peripheral blood progenitor cells (PBPC), eg, >5x106 CD34+ cells/kg, speeds engraftment after autologous bone marrow transplantation (ABMT). PBPC mobilization using high dose cyclophosphamide (Cy), eg 3–7gm/m2 and G-CSF typically produces a higher yield of PBPC than Cy or G-CSF alone, but WBC rebound following such regimens is often unpredictable, necessitating multiple assessments of blood WBC and CD34+ cell count, may require weekend leukapheresis (LP), and is associated with a high risk of febrile neutropenia. To minimize these problems while producing an adequate PBPC yield, we mobilized 230 unselected patients (pts) for ABMT using moderate dose Cy (1.5g/m2, day 1), followed by sequential administration of GM-CSF (500mcg/d, days 3–7) and G-CSF (5mcg/kg/d, day 8 until completion of LPs). This “CyGMG” regimen was based upon reports suggesting a synergy between GM-CSF and G-CSF. LP was initiated on day 11 irrespective of WBC or blood CD34+ cell count. Cy was administered on Friday (day 1) with LP starting on Monday (day 11 = LP day 1) and 20L LPs were performed for up to six days, thus avoiding weekend LP in most pts (median #LP = 3, range 1–6). Pt median age was 53 (range 19–78); 134 male, 96 female; diagnosis; myeloma (77), NHL (94), breast cancer (17), Hodgkin's disease (28), Testicular cancer (4), other (10). Median prior chemotherapy (CT) regimens = 2 (range 0–6). The estimated (Kaplan-Meier) cumulative probability of achieving a target collection of >2, or 5x106/CD34+ cells/kg on LP days 1–5 was 0.5, 0.77, 0.87, 0.91, 0.93, 0.87 and 0.25, 0.5, 0.65, 0.72, and 0.74 respectively. In addition, since 12/2003 when the collection target for pts with myeloma was increased to 10x106 CD34+ cells/kg, 76% of myeloma pts achieved this goal. Based on multivariate cox regression, diagnosis (myeloma vs other) and day 1 platelet (plt) count were significantly associated with achieving 2 or 5 x 106/CD34+ cells/kg and the above factors plus the # of prior CT regimens were associated with achieving 10x106/CD34+ cells/kg. However, (in contrast with a previous report) the day 1 plt count was not correlated with CD34+ cells/kg in the subgroup of myeloma pts (r=0.07, p=0.62). For non-myeloma pts a plt count >75,000 predicted achievement of 5x106 CD34+ cells/kg (2/17 pts with <75K plt vs 91/136 pts with >75K plt; p<.0001 by X2). Toxicities consisted mostly of mild bone pain and fevers, and 12 patients required hospital care during mobilization (not necessarily regimen related).