Introduction: Myelofibrosis is a chronic myeloproliferative neoplasm characterized by bone marrow fibrosis, splenomegaly, and debilitating constitutional symptoms, often resulting in significant morbidity and mortality. Allogeneic hematopoietic stem-cell transplantation (SCT) remains the only potentially curative treatment but is associated with considerable risks. Ruxolitinib, a JAK1/2 inhibitor, improves splenomegaly and symptoms but does not offer a cure. The primary objective of this study was to compare event-free survival (EFS) between patients who underwent SCT after 3 months of ruxolitinib induction therapy and those who continued ruxolitinib due to lack of a suitable donor (HLA-identical sibling or 10/10 matched unrelated donor). Methods: This prospective, multicenter clinical trial (RuxoAllo study, NCT03333187) enrolled 87 myelofibrosis patients, all of whom began with ruxolitinib induction. Major inclusion criteria comprised primary or secondary myelofibrosis with intermediate-2 or high-risk disease, or intermediate-1 risk with high-risk cytogenetics, transfusion dependency, or thrombocytopenia; all patients were ruxolitinib-naïve and aged ≥18 years. After screening, 73 were assigned to either transplantation (SCT group, n=57) or continued ruxolitinib therapy (ContRuxo group, n=16). Efficacy endpoints included EFS and overall survival (OS). Safety endpoints included incidence of acute and chronic graft-versus-host disease, disease-related mortality, and non-relapse mortality. EFS was defined as survival without relapse, disease progression, death, or change in therapy. Safety was evaluated through adverse events, laboratory parameters, and ECOG performance status. Quality of life (QoL) was assessed before, during, and after treatment. Results: At baseline, the median patient age was 58 years, with 71% having primary myelofibrosis and 63% being male. In the Full Analysis Population, SCT showed significantly improved EFS, with a median EFS not reach for the SCT group vs. 18 months for the ContRuxo group (P<0.001). SCT was associated with 84% reduced risk of death or progression, with a hazard ratio of 0.16 (95% CI: 0.06–0.46). Multivariable adjustment with patient- and disease-specific variables confirmed the independent benefit of SCT, with a hazard ratio of 0.18 (P<0.001). Subgroup analyses confirmed consistent benefits of SCT across age and DIPSS risk groups. Three-year OS was 84% for the SCT group vs. ContRuxo 83%. Spleen responses were notable after ruxolitinib induction but did not differ significantly between arms thereafter. The cumulative incidence of grade II–IV acute graft-versus-host disease by day 100 was 7% (95% CI: 2–15), while chronic graft-versus-host disease occurred in 63% (95% CI: 49–75%) at 3 years, with 32% classified as moderate or severe. Disease-related mortality was lower in the SCT group (9% vs. 17%). Relapse/progression rates at 3 years were significantly higher in the ContRuxo group (56% vs. 18%, p=0.02), whereas non-relapse mortality was higher in the SCT group (0% vs. 7%, p=0.04). Severe adverse events were more frequent with SCT (50%) compared to ContRuxo (31%), including infections, cytopenias, and graft-versus-host disease. Ruxolitinib was mainly associated with hematological toxicities. QoL initially declined following SCT but improved substantially over time, with a 45% reduction in symptom burden and an 8% increase in overall well-being by 24 months. In contrast, QoL in the ContRuxo group remained more stable, with only modest symptom relief (22% reduction) and a 5% decline in functional QoL. Conclusion: The RuxoAllo prospective study demonstrates that SCT following ruxolitinib induction significantly improves EFS and disease control compared to continued ruxolitinib in patients with myelofibrosis, particularly in those with intermediate- or high-risk disease. Despite a relatively low non-relapse mortality of 7%, SCT remains associated with substantial risks, including graft-versus-host disease and other toxicities, underscoring the need for careful patient selection. Ruxolitinib remains valuable for symptom management and can serve as an effective bridge to transplant. These findings support SCT as the preferred curative approach for eligible myelofibrosis patients and highlight the importance of strategies to mitigate transplant-related morbidity.

The role of autologous-allogeneic tandem stem cell transplantation (alloTSCT) followed by maintenance as upfront treatment for multiple myeloma is controversial. Between 2008 and 2014 a total of 217 multiple myeloma patients with a median age of 51 years were included by 20 German centers within an open-label, parallel-group, multicenter clinical trial to compare alloTSCT to autologous tandem transplantation (autoTSCT) followed by 2 years of maintenance therapy with thalidomide (100 mg/day) in both arms with respect to relapse/progression-free survival (PFS) and other relevant outcomes. A total of 178 patients underwent a second transplant (132 allogeneic, 46 autologous). PFS at 4 years after the second transplant was 47% (95% CI: 38-55%) for alloTSCT and 35% (95% CI: 21-49%) for autoTSCT (P=0.26). This difference increased to 22% at 8 years (P=0.10). The cumulative incidences of non-relapse mortality and of relapse at 4 years were 13% (95% CI: 8-20%) and 2% (95% CI: 0.3-2%) (P=0.044) and 40% (95% CI: 33-50%) and 63% (95% CI: 50-79%) (P=0.04) for alloTSCT and autoTSCT, respectively. The difference for relapse/progression increased to 33% (alloTSCT: 44%, autoTSCT: 77%) at a median follow-up of 82 months (P=0.002). Four-year overall survival was 66% (95% CI: 57-73%) for alloTSCT and 66% (95% CI: 50-78%) for autoTSCT (P=0.91) and 8-year overall survival was 52% and 50% (P=0.87), respectively. In conclusion, alloTSCT followed by thalidomide maintenance reduced the rate of recurrence or progression during a follow-up period of up to 10 years but failed to improve PFS significantly. This study was registered with ClinicalTrials.gov (NCT00777998).

Background The aim of this phase 2 study (NCT00777998) was to compare autologous-allogeneic tandem stem cell transplantation (auto-allo) and tandem autologous transplantation (auto-auto), both followed by maintenance therapy in transplant-eligible patients with newly diagnosed multiple myeloma (NDMM). Methods Between 2008 and 2014 a total of 210 MM patients ≤60 years of age were included from 23 German Centers within an open-label, parallel-group, multicenter clinical trial to investigate whether auto-allo versus auto-auto followed by a 2-year maintenance therapy with thalidomide (100mg/daily), respectively, has benefit on outcome. Patients received autologous peripheral blood stem cell transplantation followed by allogeneic transplant when a matched related or unrelated donor would be available; otherwise, or if they declined allogeneic transplant, they received two autologous transplants. The primary endpoints were 4-year progression-free survival (PFS) and overall survival (OS). Results 178 patients underwent second transplant, of whom auto-allo received 132 and auto-auto 46 patients. The median age was 51 years (range 26-61), respectively. 32 patients in the auto-allo group and 8 patients in the auto-auto group did not receive thalidomide maintenance. The 4-year PFS was 47%(95% CI, 38-55%) for auto-allo and 35% (95% CI, 21-49%) for auto-auto, with median survival times of 40 and of 30 months (P=0.26). The 4-year OS was 66% (95% CI, 57-73%) for auto-allo and 66% (95% CI, 50-78%) for auto-auto (P=0.91). 53 (40%) patients in the auto-allo group and 28 (61%) in the auto-auto group showed progression or relapse of MM. Estimated cumulative incidence of relapse/progression was 40% (95% CI, 33-50%) for auto-allo and 63% (95% CI, 50-79%) for auto-auto (P=0.01). The estimated cumulative incidence of 4-year non-relapse mortality was 13% (95% CI, 8-20%) for auto-allo and 2% (0.3-2) for auto-auto (p=0.04). With long-term follow-up of patients, 8-year PFS was 43% (95% CI, 34-52%) for auto-allo versus 21% (95% CI, 7-35%) for auto-auto (P=0.10). Furthermore, 8-year OS was 55% (95% CI, 45-65%) for auto-allo and 50% (95% CI, 32-68%) for auto-auto (P=0.87). Median OS was not reached in both groups. Multivariate analysis on PFS at last follow-up (median, 8 years) showed a hazard ratio of 0.67 (95% CI, 0.44-1.02; P=0.06) for auto-allo (with auto-auto as reference). Other factors for improved outcome were absence of del(17p) or t(4;14), CR after induction and thalidomide maintenance. Subgroup analysis for patients with present high-risk cytogenetic features including del(17p) or t(4;14) showed a hazard ratio of 0.55 (95% CI, 0.22-1.39; P=0.21) for auto-allo (with auto-auto as reference). Conclusion This prospective phase 2 study of auto-allo transplant versus auto-auto showed reduced rates of MM recurrence or progression. At long-term follow-up, auto-allo appeared to improve PFS, while OS was comparable. The aim of this phase 2 study (NCT00777998) was to compare autologous-allogeneic tandem stem cell transplantation (auto-allo) and tandem autologous transplantation (auto-auto), both followed by maintenance therapy in transplant-eligible patients with newly diagnosed multiple myeloma (NDMM). Between 2008 and 2014 a total of 210 MM patients ≤60 years of age were included from 23 German Centers within an open-label, parallel-group, multicenter clinical trial to investigate whether auto-allo versus auto-auto followed by a 2-year maintenance therapy with thalidomide (100mg/daily), respectively, has benefit on outcome. Patients received autologous peripheral blood stem cell transplantation followed by allogeneic transplant when a matched related or unrelated donor would be available; otherwise, or if they declined allogeneic transplant, they received two autologous transplants. The primary endpoints were 4-year progression-free survival (PFS) and overall survival (OS). 178 patients underwent second transplant, of whom auto-allo received 132 and auto-auto 46 patients. The median age was 51 years (range 26-61), respectively. 32 patients in the auto-allo group and 8 patients in the auto-auto group did not receive thalidomide maintenance. The 4-year PFS was 47%(95% CI, 38-55%) for auto-allo and 35% (95% CI, 21-49%) for auto-auto, with median survival times of 40 and of 30 months (P=0.26). The 4-year OS was 66% (95% CI, 57-73%) for auto-allo and 66% (95% CI, 50-78%) for auto-auto (P=0.91). 53 (40%) patients in the auto-allo group and 28 (61%) in the auto-auto group showed progression or relapse of MM. Estimated cumulative incidence of relapse/progression was 40% (95% CI, 33-50%) for auto-allo and 63% (95% CI, 50-79%) for auto-auto (P=0.01). The estimated cumulative incidence of 4-year non-relapse mortality was 13% (95% CI, 8-20%) for auto-allo and 2% (0.3-2) for auto-auto (p=0.04). With long-term follow-up of patients, 8-year PFS was 43% (95% CI, 34-52%) for auto-allo versus 21% (95% CI, 7-35%) for auto-auto (P=0.10). Furthermore, 8-year OS was 55% (95% CI, 45-65%) for auto-allo and 50% (95% CI, 32-68%) for auto-auto (P=0.87). Median OS was not reached in both groups. Multivariate analysis on PFS at last follow-up (median, 8 years) showed a hazard ratio of 0.67 (95% CI, 0.44-1.02; P=0.06) for auto-allo (with auto-auto as reference). Other factors for improved outcome were absence of del(17p) or t(4;14), CR after induction and thalidomide maintenance. Subgroup analysis for patients with present high-risk cytogenetic features including del(17p) or t(4;14) showed a hazard ratio of 0.55 (95% CI, 0.22-1.39; P=0.21) for auto-allo (with auto-auto as reference). This prospective phase 2 study of auto-allo transplant versus auto-auto showed reduced rates of MM recurrence or progression. At long-term follow-up, auto-allo appeared to improve PFS, while OS was comparable.

PURPOSE In contrast to 5-azacytidine (5-aza), allogeneic stem-cell transplantation (HSCT) represents a curative treatment strategy for patients with myelodysplastic syndromes (MDS), but therapy-related mortality (TRM) limits its broader use in elderly patients with MDS. The present prospective multicenter study compared HSCT following 5-aza pretreatment with continuous 5-aza treatment in patients with higher-risk MDS age 55-70 years. METHODS One hundred ninety patients with a median age of 63 years were enrolled. Patients received 4-6 cycles of 5-aza followed by HLA-compatible HSCT after reduced-intensity conditioning or by continuous 5-aza if no donor was identified. RESULTS Twenty-eight patients did not fulfill inclusion criteria (n = 20), died (n = 2) withdrew informed consent (n = 5), or were excluded for an unknown reason (n = 1). 5-aza induction started in 162 patients, but only 108 (67%) were eligible for subsequent allocation to HSCT (n = 81) or continuation of 5-aza (n = 27) because of disease progression (n = 26), death (n = 12), or other reasons (n = 16). Seven percent died during 5-aza before treatment allocation. The cumulative incidence of TRM after HSCT at 1 year was 19%. The event-free survival and overall survival after 5-aza pretreatment and treatment allocation at 3 years were 34% (95% CI, 22 to 47) and 50% (95% CI, 39 to 61) after allograft and 0% and 32% (95% CI, 14 to 52) after continuous 5-aza treatment ( P < .0001 and P = .12), respectively. Fourteen patients progressing after continuous 5-aza received a salvage allograft from an alternative donor, and 43% were alive at last follow-up. CONCLUSION In older patients with MDS, reduced-intensity conditioning HSCT resulted in a significantly improved event-free survival in comparison with continuous 5-aza therapy. Bridging with 5-aza to HSCT before is associated with a considerable rate of dropouts because of progression, mortality, and adverse events.

BACKGROUND:We previously showed that human anti-T-lymphocyte globulin (ATLG) plus ciclosporin and methotrexate given to patients with acute leukaemia in remission, having allogeneic haemopoietic stem-cell transplantation with peripheral blood stem cells from an HLA-identical sibling donor after myeloablative conditioning, significantly reduced 2-year chronic graft-versus-host disease (cGVHD) incidence and severity, without increasing disease relapse and infections, and improves cGVHD-free and relapse-free survival (cGRFS). The aim of an extended follow-up study was the assessment of long-term outcomes, which are, in this context, scarcely reported in the literature. We report unpublished data on quality of life (QoL) from the original study and the results of a follow-up extension. METHODS:In the original open-label study, patients with acute myeloid and lymphoblastic leukaemia in first or subsequent remission, having sibling HLA-identical allogeneic peripheral blood stem-cell transplantation, were randomly assigned (1:1) to receive ATLG plus standard GVHD prophylaxis with ciclosporin and short-term methotrexate (ATLG group) or standard GVHD prophylaxis without ATLG (non-ATLG group). Conditioning regimens were cyclophosphamide 120 mg/kg with either total body irradiation (12 Gy) or busulfan (12·8 mg/kg intravenously or 16 mg/kg orally), with or without etoposide (30-60 mg/kg). Randomisation was stratified according to centre and disease risk. The primary endpoint was cumulative incidence of cGVHD at 2 years. The primary and secondary endpoints, excluding QoL, have been published. QoL, assessed using European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-HDC29 questionnaires, was an unpublished secondary endpoint, which we now report here. A follow-up extension was then done, with the primary endpoint cumulative incidence of cGVHD. Enrolment has been completed for both studies. The original trial (number, NCT00678275) and follow-up extension (number, NCT03042676) are registered at ClinicalTrials.gov. FINDINGS:In the original study, from Dec 14, 2006, to Feb 2, 2012, 161 patients were enrolled and 155 were randomly assigned to either the ATLG group (n=83) or to the non-ATLG group (n=72). In the follow-up study, which started on Feb 7, 2017, and was completed on June 30, 2017, 61 patients were included in the ATLG group and 53 were included in the non-ATLG group. Global health status showed a more favourable time course in the ATLG group compared with the non-ATLG group (p=0·02; treatment by visit interaction). ATLG was descriptively superior to non-ATLG at 24 months for physical function (points estimate -14·8 [95% CI -26·4 to -3·1]; p=0·014) and social function (-19·1 [-38·0 to -0·2]; p=0·047), gastrointestinal side-effects (8·8 [2·5-15·1]; p=0·008) and effect on family (13·5 [1·2-25·8]; p=0·032). Extended follow-up (median 5·9 years [IQR 1·7-7·9]) confirmed a lower 5-year cGVHD incidence (30·0% [95% CI 21·4-41·9] vs 69·1% [59·1-80·1]; analysis for entire follow-up, p<0·001), no increase in relapses (35·4% [26·4-47·5] vs 22·5% [14·6-34·7]; p=0·09), improved cGRFS (34·3% [24·2-44·5] vs 13·9% [7·1-22·9]; p=0·005), and fewer patients still in immunosuppression (9·6% vs 28·3%; p=0·017) in the ATLG group compared with the non-ATLG group. 5-year overall survival, relapse-free survival, and non-relapse mortality did not differ significantly between groups. INTERPRETATION:The addition of ATLG to standard GVHD prophylaxis improves the probability of surviving without disease relapse and cGVHD after myeloablative peripheral blood stem-cell transplantation from an HLA-identical sibling donor for patients with acute leukaemia in remission. Further additional benefits are better QoL and shorter immunosuppressive treatment compared with standard GVHD prophylaxis without ATLG. Therefore, in this setting, ATLG plus standard GVHD prophylaxis should be preferred over the standard GVHD prophylaxis alone. FUNDING:Neovii Biotech.

Allogeneic stem cell transplantation (alloSCT) is a curative procedure for myelofibrosis. Elderly people are mainly affected, limiting the feasibility of myeloablative regimens. The introduction of reduced-intensity conditioning (RIC) made alloSCT feasible for older patients. Nevertheless, the incidence of myelofibrosis is not negligible in young patients, who are theoretically able to tolerate high-intensity therapy. Very few data are available about the efficacy of RIC-alloSCT in younger myelofibrosis patients. This study included 56 transplanted patients aged <55 years. Only 30% had a human leucocyte antigen (HLA)-matched sibling donor, the others were transplanted from a fully-matched (36%) or partially-matched (34%) unrelated donor. All transplants were conditioned according the European Society for Blood and Marrow Transplantation protocol: busulfan-fludarabine + anti-thymocyte globulin, followed by ciclosporin and mycophenolate. One patient experienced primary graft failure. Incidence of graft-versus-host disease grade II-IV was 44% (grade III/IV 23%). One-year non-relapse mortality was 7% and the 5-year cumulative incidence of relapse was 19%. After a median follow-up of 8·6 years, the estimated 5-year progression-free survival and overall survival (OS) was 68% and 82%, respectively. Patients with fully-matched donor had a 5-year OS of 92%, in contrast to 68% for those with a mismatched donor (P = 0·03). The most important outcome-determining factor is donor HLA-matching. In conclusion, RIC-alloSCT ensures optimal engraftment and low relapse rate in younger myelofibrosis patients, enabling the possibility of cure in this group.

Background: We previously demonstrated that the addition of human anti-T lymphocyte globulin (ATLG) to cyclosporine and methotrexate, given to acute leukemia patients in remission undergoing allogeneic hematopoietic stem cell transplantation (HSCT) with peripheral blood stem cells (PBSC) from an HLA-identical sibling donor after a myeloablative conditioning, significantly reduces 2-yr cGVHD incidence (primary endpoint) and severity without increasing disease relapse and infections, improving cGVHD/relapse-free survival (cGRFS). Since very limited information on long-term follow-up has been reported, we extended the observation time of the original study. Methods: Between 2005 and 2012, 161 patients were randomized to receive or not ATLG in addition to cyclosporine and methotrexate. 155 patients were included in the full analysis set. Quality of life (QoL), assessed using EORTC-QLQ-C30 and QLQ-HDC29 questionnaires, was the unpublished secondary endpoint. An extension of follow-up was then performed with the aim of evaluating the long-term outcome. The trial is registered at ClinicalTrials.gov (NCT03042676, NCT00678275). Findings: Global health status (p=0·02), physical function (p=0·014), social function (p=0·047), gastrointestinal side-effects (p=0·008) and impact on family (p=0·032) scored higher in the ATLG arm. Extended follow-up (median 5.9 years) confirmed a lower 5 -yr cGVHD incidence (30·0% vs 69·1%, p<0·001), no increase of relapses (32·4% vs 25·5%, p=0·09), an improved cGRFS (34·4% vs 13·9%, p=0·005), fewer patients still in immunosuppression (9·6% vs 28·3%, p=0·017) in the ATLG arm. 5-yr overall survival, relapse-free survival and non-relapse mortality didn't significantly differ between arms. Interpretation: ATLG improves QoL after HLA identical sibling HSCT with PBSC and its beneficial effect on cGVHD incidence and cGRFS is confirmed even after long-term follow-up. Trial registration number: The trial is registered at ClinicalTrials.gov (NCT03042676, NCT00678275). Funding: NEOVII Biotech provided the study drug and a research grant but did neither have access to data nor decide to submit the manuscript. Declaration of Interest: FB, and NK received speaker-fees and served on the advisory boards for NEOVII Biotech; NK received a research grant from NEOVII Biotech; all the remaining authors declare no competing financial conflict of interest. Ethical Approval: The study was approved by each competent local Ethics Committees, conducted according to the Helsinki declaration.

Abstract Introduction: 5-azacytidine treatment prolongs survival in older patients with high-risk MDS compared to standard of care options outside allogeneic stem cell transplantation (AHSCT) wich is still the only potentially curative treatment option that is however associated with a considerable treatment-related morbidity and mortality (TRM). Reduced-intensity conditioning (RIC) prior to transplantation has broadened the application of this therapeutic approach also to elderly MDS patients. Here we present results from a prospective multicenter trial of the German MDS and Cooperative Transplant Study Group comparing 5-azacytidine (5-Aza) treatment alone with 5-Aza induction followed by AHSCT according to donor availability in elderly patients with newly-diagnosed untreated HR MDS aged 55-70 years (EudraCT Number 2010-018467-42). Primary endpoint was overall survival (OS) at three years after 5 Aza induction in both arms; major secondary endpoints were to assess the response rate, event-free survival (EFS) at three years, toxicity, treatment-related mortality (TRM) and the impact of the comorbidity-index (HCT-CI) on outcome in both treatment arms. Methods and Patients Patients with proven de novo or therapy-related MDS / CMML (WBC <13 GPT/l) according to FAB and risk profile according to IPSS: intermediate II-risk or high-risk or intermediate I with high-risk cytogenetic and patients with secondary AML (according to WHO) and blasts ≤ 30 % (= RAEB-t according to FAB) and sufficient organ function, could be included. A donor search was started at the time of inclusion and all patients were scheduled to receive 4 to 6 cycles of 5-Aza induction therapy. In case a HLA -identical sibling or a 10/10 HLA compatible unrelated donor could be identified during the first cycles of 5-Aza and patients had at least stable disease they were allocated for a busulfan-based RIC allograft. In case no suitable donor could be identified 5-Aza was continued until progression or unacceptable toxicity. This protocol-defined primary analysis uses the full 5% alpha error for the primary analysis. A final follow-up analysis will be performed once all patients have been followed-up at least for three years but no later than January 2019. Results Between June 2011 and November 2016 190 patients with a median age of 63 years from 14 German centers were included into the trial. Following 5-Aza induction, only 109 out of 190 patients (57%) were eligible for allocation to one of the treatment arms and proceeded to AHSCT (n=83) or continued 5-Aza therapy (n=26). Reasons for premature study termination of 81 patients (43%) within the first 5-Aza cycles included progressive disease (n=25; 31%), death (n=14; 17%), inclusion or exclusion criteria not fulfilled (n=18, 22%), withdrawal of informed consent (n=7; 9%), adverse events (n=7; 9%) or other reasons (n=10; 12%). Regarding the primary study endpoint and after 5 Aza induction therapy in an intention to treat analysis the OS at 3 years was 49% (95% CI: 36-61%) after AHSCT and 22% (95% CI: 6-44%) after continuous treatment with 5-Aza (p= 0.027). The time dependent Hazard ratio for AHSCT decreased over time: while at 1 year the HR was still 1.4 due to early TRM, this HR decreased to 0.35 at 2 years and 0.09 at 3 years. EFS at 3 years was 35% (95% CI: 22-48%) after AHSCT and 0% after 5-Aza continuous treatment (p< 0.001). The TRM after AHSCT at 1 and 3 years was 17% (95% CI 10-26%) and 23% (95% CI: 14-33%), respectively. Conclusions This prospective phase 3 study comparing 5-Aza followed by AHSCT with continuous 5-Aza therapy in older patients (55 to 70 years) suffering from higher-risk MDS demonstrates an improved EFS and OS in favor of AHSCT. Induction therapy with 5-Aza prior to AHSCT is associated with a considerable rate of drop outs due to progression, adverse events, and mortality prior to AHSCT. The study was registered under ClinicalTrial.gov: NCT01404741. The study was supported by a research grant from Celgene, Germany. Figure. Figure. Disclosures Kroeger: Celgene: Honoraria, Research Funding; Neovii: Honoraria, Research Funding; JAZZ: Honoraria; Riemser: Honoraria, Research Funding; Sanofi: Honoraria; Novartis: Honoraria, Research Funding. Bethge:Miltenyi Biotec GmbH: Consultancy, Honoraria, Research Funding; Neovii GmbH: Honoraria, Research Funding. Schlenk:Pfizer: Research Funding, Speakers Bureau. Kobbe:Amgen: Honoraria, Research Funding; Celgene: Honoraria, Other: Travel Support, Research Funding; Roche: Honoraria, Research Funding. Bug:Novartis Pharma: Honoraria, Research Funding; Jazz Pharmaceuticals: Other: Travel Grant; Celgene: Honoraria; Astellas Pharma: Other: Travel Grant; Janssen: Other: Travel Grant; Amgen: Honoraria; Neovii: Other: Travel Grant. Scheid:Celgene: Honoraria; Janssen: Honoraria; Novartis: Honoraria, Research Funding; Takeda: Honoraria, Research Funding; BMS: Honoraria; Amgen: Honoraria. Krönke:Celgene: Honoraria. Stelljes:Novartis: Honoraria; Amgen: Honoraria; JAZZ: Honoraria; MSD: Consultancy; Pfizer: Consultancy, Honoraria, Research Funding. Beelen:Medac: Consultancy, Other: Travel Support. Platzbecker:Celgene: Research Funding.

BACKGROUND:Chronic graft-versus-host disease (GVHD) is the leading cause of later illness and death after allogeneic hematopoietic stem-cell transplantation. We hypothesized that the inclusion of antihuman T-lymphocyte immune globulin (ATG) in a myeloablative conditioning regimen for patients with acute leukemia would result in a significant reduction in chronic GVHD 2 years after allogeneic peripheral-blood stem-cell transplantation from an HLA-identical sibling.METHODS:We conducted a prospective, multicenter, open-label, randomized phase 3 study of ATG as part of a conditioning regimen. A total of 168 patients were enrolled at 27 centers. Patients were randomly assigned in a 1:1 ratio to receive ATG or not receive ATG, with stratification according to center and risk of disease.RESULTS:After a median follow-up of 24 months, the cumulative incidence of chronic GVHD was 32.2% (95% confidence interval [CI], 22.1 to 46.7) in the ATG group and 68.7% (95% CI, 58.4 to 80.7) in the non-ATG group (P<0.001). The rate of 2-year relapse-free survival was similar in the ATG group and the non-ATG group (59.4% [95% CI, 47.8 to 69.2] and 64.6% [95% CI, 50.9 to 75.3], respectively; P=0.21), as was the rate of overall survival (74.1% [95% CI, 62.7 to 82.5] and 77.9% [95% CI, 66.1 to 86.1], respectively; P=0.46). There were no significant between-group differences in the rates of relapse, infectious complications, acute GVHD, or adverse events. The rate of a composite end point of chronic GVHD-free and relapse-free survival at 2 years was significantly higher in the ATG group than in the non-ATG group (36.6% vs. 16.8%, P=0.005).CONCLUSIONS:The inclusion of ATG resulted in a significantly lower rate of chronic GVHD after allogeneic transplantation than the rate without ATG. The survival rate was similar in the two groups, but the rate of a composite end point of chronic GVHD-free survival and relapse-free survival was higher with ATG. (Funded by the Neovii Biotech and the European Society for Blood and Marrow Transplantation; ClinicalTrials.gov number, NCT00678275.).

Introduction:The combination of a myeloablative dose of intravenous (iv) busulfan with cyclophosphamide (BuCy2) is the standard conditioning regimen for allogeneic hematopoietic stem cell transplantation in AML.In patients older than 40 years, it can be associated to high non relapse mortality (NRM).The same myeloablative dose of busulfan combined to fludarabine (BuFlu) may be associated to a lower NRM.Materials (or patients) and methods: The standard conditioning with iv busulfan at a dose of 0.8 mg/kg/6 h for 4 consecutive days for a total dose of 12.8 mg/kg, in combination with cyclophosphamide at the dose of 60 mg/kg/day for 2 consecutive days for a total dose of 120 mg/kg (BUCY2 arm) was randomly compared to the same dose of busulfan combined with fludarabine at the dose of 40 mg/m 2 /day for 4 consecutive days, for a total dose of 160 mg/m2(BUFLU arm).Eligible were patients with a diagnosis of AML in 1st or 2nd complete remission (CR) with an age Z40 andr65 years, and the availability of an HLA compatible sibling or unrelated donor.The GvHD prophylaxis was based on conventional Cyclosporine A and Methotrexate.In case of unrelated donors, ATG was given at a total dose of 5 mg/kg.The primary study end-point was the one-year NRM using an intent-to-treat analysis.Results: 252 patients were assessed for eligibility: 125 were randomized to BuCy2 (121 received the allocated intervention, 3 withdrew consent and 1 relapsed before conditioning) while 127 were randomized to BuFlu (124 received the allocated intervention and 3 relapsed before conditioning).Patients were stratified according to donor type and remission (1st vs. 2nd or more).The main clinical and transplant characteristics were well balanced between the randomization arms.The median age was 51 years, 85% of patients was in 1st remission and the ELN risk subgroups were good (11%), intermediate-1 (49%), intermediate-2 (16%) and adverse (25%).The donor was a sibling related (45%) or matched unrelated (55%) while the stem cell graft was the peripheral blood in the majority of cases.On an intent to treat basis, at 1 year, the NRM in the BUCY2 arm was 17.2% vs. 7.9% in the BUFLU (Gray Test P ¼ 0.03).At 2 years and throughout the study, the same significantly different NRM was observed between study arms being respectively 18.2% vs. 8.9% and 19% vs. 9.7% (Gray Test P ¼ 0.05) (Figure 1).By forest plots analysis the experimental treatment was better in all strata and particularly in patients in CR1.A non-significant lower incidence of relapse was documented in the BUCY2 vs. the BUFLU arm being 22.1% vs. 25.2% at 1 year, respectively (Gray test 0.47) and no difference could be detected by forest plot analysis in any strata.At 4 year, in the BuFlu and the BuCy2 arm respectively, the leukemia free survival was 51% vs. 42% and the overall survival 55% vs. 54%.The overall (grade II-IV) cumulative incidence of acute GVHD was slightly higher in the BuCy2 arm and this difference was significant (P ¼ 0.0083) when only grade III and IV were considered. Conclusion:The conditioning regimen based on Busulfan and Fludarabine was associated with a lower non-relapse mortality and less acute GvHD (grade III-IV), with a similar incidence of relapse and comparable LFS and OS.This myeloablative, albeit reduced toxicity program is a valid alternative for older AML patients.

Abstract Introduction Allogeneic stem cell transplantation is a curative and increasingly used treatment approach for a variety of hematological malignancies. Late complications such a chronic graft-versus-host disease (cGvHD) is a major risk factor, which significantly influences morbidity and mortality after allogeneic stem cell transplantation (ASCT). The incidence of cGvHD is higher when peripheral blood stem cells are used as stem cell source. There is a strong need for preventing cGvHD after ASCT without increasing the risk of relapse. Patients and Methods We performed a multicenter, multinational, open-label, randomized study comparing anti-lymphocyte globulin (ATG-Neovii®) 10mg/kg on day -3,-2 and -1 with no ATG in 155 patients with acute myeloid (n=110) or lymphoblastic leukemia (n=45) in 1st complete remission (CR; n= 139) or 2nd CR (n=16) who received peripheral blood stem cells from their HLA-identical sibling (n=148) or relatives (n=7) after standard TBI (12Gy)/Cyclophosphamide (120mg/kg) or Busulfan (16mg/kg)/Cy (120mg/kg) based myeloablative conditioning regimen and sufficient organ function. Standard GvHD prophylaxis consisted of cyclosporine A and a short course of MTX (10mg/m² on day +1,+3,+6 and +11). Major inclusion criteria were: acute myeloid or lymphoblastic leukemia in 1st or 2ndCR, age 18-65 years, HLA-identical sibling or relatives, peripheral blood stem cell as stem cell source, and a myeloablative conditioning regimen. The primary study aim was to compare the cumulative incidence of cGvHD at 2 years after ASCT. Results Out of 161 randomized patients from 27 centers and 4 nations, 6 were withdrawn before conditioning and ASCT due to leukemia progression, or cancellation of the donor. 155 patients were analyzed for safety and efficacy; 83 were randomized to ATG and 72 to non-ATG. The treatment groups were comparable regarding recipient and donor age and sex, CMV serostatus, disease (AML vs ALL), 1st or 2ndCR. The median time to leukocyte (>1.0x10e9/l) and platelet (> 20x 10e9/l) engraftment was significantly delayed in the ATG group (18 vs 15 days, p< 0.001 and 20 vs 13 days, p<0.001). The incidence of acute GvHD grade I-IV was 25% for the ATG arm and 36% for the non-ATG arm (p=0.32) and for severe grade III/IV acute GvHD 2% and 7%, respectively (p=0.2). Regarding the primary endpoint, the cumulative incidence of cGvHD at 2 years was 36% % (95% CI 26-51%) in the ATG and 73% (95% CI 63-84% ) in the non-ATG arm (p<0.0001). In the ATG group 74% of the patients with any cGvHD had only limited episodes and 26% had an extensive episode, compared to 49% and 51% for non-ATG (p=0.04). There was no higher rate of infectious complications (58% for ATG vs 54% for non-ATG), CMV reactivation (22 vs 24%) and of EBV reactivation (2.4 vs 1.4%). The cumulative incidence of therapy related mortality at 2 years was 13% (95% CI 7-22%) for the ATG arm and 10% (95% CI 5-20%) for the non-ATG arm (p=0.57), resulting in 2 year relapse-free and overall survival of 59%% (95%CI 49-70%) and 75% (95% CI 66-85%) for the ATG group and of 65% (95% CI 52-77%) and 79% (95% CI 69-89%) for the non-ATG group (p=0.44 and p=0.20, respectively). Conclusion This randomized cGvHD prevention study provides evidence that ATG-Neovii® 3x 10mg/kg within a myeloablative preparative conditioning regimen for HLA-identical sibling peripheral blood stem cell transplantation is highly effective in preventing limited and extensive cGvHD without obvious increase of infectious complications and relapse, resulting in similar overall survival rates. Disclosures Kröger: Neovii: Research Funding.

Within a prospective protocol, the incidence and impact of achievement of molecular remission (mCR) and high-risk cytogenetics was investigated in 73 patients with multiple myeloma (MM) after autologous (auto) -allogeneic (allo) tandem stem cell transplantation (SCT). After induction chemotherapy, patients received melphalan 200 mg/m(2) before undergoing auto-SCT, followed 3 months later by melphalan 140 mg/m(2) and fludarabine 180 mg/m(2) before allo-SCT. Sixteen patients had high-risk cytogenetic features, defined by positive FISH for del(17p13) and/or t(4;14). Overall, 66% of the patients achieved CR or near-CR, and 41% achieved mCR, which was sustained negative (at least 4 consecutive samples negative) in 15 patients (21%), with no significant difference in incidence between the patients with high-risk cytogenetics and others (P = .70). After a median follow-up of 6 years, overall 5-year progression-free survival was 29%, with no significant difference between del 17p13/t(4;14)-harboring patients and others (24% versus 30%; P = .70). The 5-year progression-free survival differed substantially according to the achieved remission: 17% for partial remission, 41% for CR, 57% for mCR, and 85% for sustained mCR. These results suggest that auto allo tandem SCT may overcome the negative prognostic effect of del(17p13) and/or t(4;14) and that achievement of molecular remission resulted in long-term freedom from disease. (C) 2013 Published by Elsevier Inc. on behalf of American Society for Blood and Marrow Transplantation.

Myelofibrosis (MF) is a clonal myeloproliferative neoplasm, in which the JAK2-V617F mutation is frequently observed. The appearance in up to 50% of the cases makes the JAK2 mutation attractive as therapeutical target. In 2012 Ruxolitinib (Ruxo) a pan-JAK inhibitor was approved for the treatment of MF and showed efficacy in disease treatment, irrespectively of the JAK2V617 mutation status. Currently allogeneic stem cell transplantation (allo SCT) remains the only curative treatment option for MF. To further improve transplant outcome in MF reduction of spleen size and constitutional symptoms prior transplantation is a reasonable target. Harnessing graft versus myelofibrosis post transplantation by immune-modulating drugs may help to reduce the risk of relapse. Ruxolitinib may be used as pre- and post-transplantation drug to improve transplant outcome. However the impact of Ruxolitinib on the immune system, especially on T-cells, is poorly understood. Here we investigated the effects of Ruxolitinib on T-cells in vivo and in vitro.

Lenalidomide may prevent relapses after allogeneic stem cell transplantation by promoting the immune-mediated graft-versus-tumor effect. We performed a prospective phase HI study to define the dose-limiting toxicity and the immunologic effects of lenalidomide given early (day 100-180) after allograft for four cycles in patients with multiple myeloma. According to the Fibonacci design, 24 patients with a median age of 53 years were included. Dose-limiting toxicity was organ toxicity owing to graft-versus-host disease, and the maximum tolerable dose was 5 mg. The incidence of graft-versus-host disease after lenalidomide was 38%, occurring after a median of 22 days, and was beside organ toxicity, a leading cause to discontinue the study in 29% of the patients. Immune monitoring revealed a significant increase in peripheral gamma-interferon secreting CD4(+) and CD8(+) T cells within the first week of lenalidomide treatment followed by a delayed increase in T regulatory cells. Furthermore, natural killer (NK) cells isolated from the peripheral blood of patients evidenced a significantly improved antimyeloma activity after lenalidomide treatment. The immune effect might have contributed to the increased CR rate from 24-42% after lenalidomide treatment because nonresponding patients showed significantly less natural killer and T cell activation. (Study registered under: NCT 00778752.) (C) 2013 ISEH - Society for Hematology and Stem Cells. Published by Elsevier Inc.

Abstract Abstract 2376 Allogeneic stem cell transplantation (HSCT) for multiple myeloma is a potential curative treatment approach. A high number of relapses after allogeneic stem cell transplantation after reduced intensity conditionings underlying the need of post transplant strategies to improve remission rates and disease free survival. Lenalidomide is an effective drug in treatment of multiple myeloma patients. The efficacy and the immunmodulatory properties on T- and NK- cells may augment the Graft versus Myeloma effect after HSCT, but myelosuppression as well as induction of GvHD is a concern of using the drug early after allogeneic stem cell transplantation. Study objective was to determine the maximal tolerable dose (evaluating three dose levels) of lenalidomid after HSCT in patients with multiple myeloma. A total of 18 patients with multiple myeloma were enrolled so far. Lenalidomide as single agent maintenance treatment was started between 100 and 180 days after HSCT. In the first subgroup three patients started with dose of 5 mg daily from day 1 till 21 for duration of four cycles. In this group dose limited toxicities not appear. The next higher dose level was 10 mg/d lenalidomide for a total of 6 patients. In this cohort of patients, 3 patients showed dose limiting toxicities, which were caused by an acute pancreatitis in one case, elevated liver enzymes (CTC grade III), attribute to liver GvHD in one case and renal insufficiency in one patient. Because 3 patients in 10 mg cohort developed DLT, the maximum tolerate dose has been declared as 5 mg. So far 6 additional patients were treated with this dose level (5 mg/d, day 1–21). In these cohort four patients experienced CTC grad III toxicity was observed: two cases with acute GvHD, one case with elevated liver enzymes and one case with intolerance and dizziness. Beside lenalidomide’s effect on myeloma cells, the drug is a known immune modulator. We therefore, analysed T- and NK cell subsets of patient peripheral blood by flow cytometry after lenalidomide treatment. An increase of 6% in activated CD3 cells was observed, as indicated by expression of HLA-DR molecules. Furthermore, except for the increase of whole CD8 cell number, we also observed increased proinflammatory CD8/INFg+ T cell numbers (1,5% to 4,5% p=ns). Along with the T cell date, NK cells expressed more activating receptors, like NKp44 and less inhibitory receptors, like NKG2A, support the immunmodulatory efficacy of lenalidomide. We concluded 5 mg lenalidomide as a single agent is the maximum tolerate dose if used early after allogeneic stem cell transplantation (day 100 – 180). Lenalidomide has high immune modulatory properties that might increase the risk of GvHD by activating CD8 cell. Combining lenalidomide with immunosuppressive drugs such as dexamethasone or bortezomib may reduce the risk of GvHD. Disclosures: Schonland: Celgene: Research Funding. Kröger: celgene: Research Funding.

Abstract 1201 Poster Board I-223 Introduction: Autologous stem cell transplantation followed by a dose-reduced conditioning and allogeneic stem cell transplantation from HLA-identical siblings has become a treatment option for patients with multiple myeloma. However, only a minority of the patients with multiple myeloma has an HLA-identical sibling and the experience using unrelated donor in this setting is limited. Patients and Methods: From 1997 to 2007, 73 patients (male:45; female:28) with multiple myeloma stage II/III and a median age of 49 years (r, 29-64) were included in a prospective trial to determine the efficacy of a tandem auto-allogeneic stem cell transplantation SCT) from HLA-identical sibling (n=24) or unrelated donors (n=45). Unrelated donor were either fully HLA matched (n=29) or had one mismatch (n=16).Deletion 13q14 could be analyses in 64 pts was found to be positive in 66% of the pts. Del13q14 was more present in patient with unrelated (n=42) than with related (n=22) donors. Stem cell source was PBSC (n=69) or bone marrow (n=4). Induction-chemotherapy consisted of a median of 4 cycles anthracycline-based therapy in 60 pts, or of thalidomide- (n=3) or bortezomib- (n=8) based regimen. 6 pts did not respond to induction therapy and received salvage chemotherapy before autologous SCT. Conditioning prior auto SCT consisted of melphalan 200mg/m 2 . After a median of 110 days (range 39-228) patients received a reduced intensity regimen with melphalan (140 mg/m 2 )/fludarabine regimen followed by allogeneic SCT from related (n=24) or unrelated (n=45) donors. GvHD prophylaxis consisted of anti-lymphocyte globulin (ATG-Fresenius®), cyclopsorin A and short course of MTX. Results: No primary or secondary graft failure was observed and leukocyte engraftment was achieved after a median of 15 days (range, 9-27), respectively. Acute graft-versus-host disease (GvHD) grade II to IV occurred in 38% and chronic GvHD in 22% of the patients. Limited GvHD was seen in 16 % and extensive GvHD was seen in 6 % of the patients. There was no difference regarding incidence of GvHD between HLA-identical sibling and unrelated donors. Overall response rate at day 100 was 94% including 55% complete remission (CR) and did not differ between related and unrelated SCT. Cumulative incidence (CI) of non-relapse mortality at one year was 20% (95% CI:11-29%) and did not differ between MUD and MRD (21 vs 17%, p 0.35). The cumulative incidence of relapse at 3 and 5 years was 30% (95% CI:19-41%) and 42% (95% CI: 29-55%), respectively with no difference between related and unrelated SCT at 5 years: 36 vs 44%(p= 0.6). The only significant factor for higher relapse incidence at 5 years was the presence of del13q14 (60 vs 20%, p= 0.007). After a median follow up of 40 months (r., 26-100), the estimated 5-year progression-free (PFS) and overall survival (OS) rates were 31% (95%CI: 19-43%) and 54% (95% CI: 42-64%), respectively, with no difference between related and unrelated SCT. Due to the higher relapse incidence only presence of del13q resulted in a significant worse 5- year OS and DFS (45 vs 77%, p=0.02 and 18 vs 57%, p=0.04). Conclusions: Unrelated donors as stem cell source for auto-allogeneic tandem stem cell transplantation for newly diagnosed myeloma patients resulted in similar NRM, relapse-incidence, DFS and OS than HLA-identical sibling transplantation and can therefore be used as alternative stem cell source. Outcome after transplantation is better for patients lacking del 13q14. Disclosures: No relevant conflicts of interest to declare.

From 2002 to 2007, 49 myeloma patients who relapsed following autologous SCT were included in a prospective multicenter trial to determine the efficacy of a reduced melphalan/fludarabine regimen followed by allogeneic SCT from unrelated donors. All patients showed leucocyte and platelet engraftment after a median of 15 and 19 d, respectively. Grade II-IV acute graft-versus-host disease (GvHD) occurred in 25% of patients and 35% had chronic GvHD. Overall response rate at day 100 was 95% including 46% complete remission (CR). Cumulative incidence of non-relapse mortality at 1 year was 25% [95% confidence interval (CI): 13-37%] and was significantly lower for human leucocyte antigen (HLA)-matched compared to -mismatched SCT (10% vs. 53%, P = 0.001). The cumulative incidence of relapse at 3 years was 55% (95% CI: 40-70%). After a median follow up of 43 months, the estimated 5-year progression-free and overall survival rates were 20% and 26% respectively and were significantly better for matched in CR at day 100 (41% vs. 7%, P = 0.04 and 56% vs. 16%, P = 0.02). We conclude that optimal donor selection is mandatory for a low non-relapse mortality and high relapse incidence, which remains a major concern, should be improved by including post-transplant strategies to upgrade remission status.

Abstract Abstract 2308 Poster Board II-285 Introduction: Dose-reduced conditioning followed by allogeneic stem cell transplantation has become a treatment option for patients with multiple myeloma. However, the experience using unrelated donor is limited. Patients and Methods: From 2002 to 2007, 49 myeloma patients with relapse to a prior autologous SCT were included in a prospective multicenter trial to determine the efficacy of a reduced melphalan (140 mg/m2)/fludarabine regimen followed by allogeneic SCT from unrelated donors. GvHD prophylaxis consisted of anti-lymphocyte globulin (ATG-Fresenius®), cyclopsorin A and short course of MTX. Results: No primary or secondary graft failure was observed and all patients showed leukocyte and platelet engraftment after a median of 15 and 19 days, respectively. Acute graft-versus-host disease (GvHD) grade II to IV occurred in 25% and chronic GvHD in 35% of the patients. Limited GvHD was seen in 29 % and extensive GvHD was seen in 6 % of the patients. Overall response rate at day 100 was 95% including 46% complete remission (CR). Cumulative incidence (CI) of non-relapse mortality at one year was 25% (95% CI: 13-37%) and significantly lower for HLA matched compared to mismatched SCT (10% vs. 53%, p=0.001). During follow-up 22 patients experienced relapse (54 %) resulting in a cumulative incidence of relapse at 1, and 3 years of 27% (95% CI: 14-40%) and 55% (95% CI: 40-70%), respectively. The median time to relapse was 318 days (r: 56 – 861). After a median follow up of 43 months, the estimated 5-year progression-free (PFS) and overall survival (OS) rates were 20% and 26%, respectively and were significantly better for matched in CR at day 100 (41 vs. 7%, p=0.04 and 56 vs. 16%, p=0.02). Conclusions: Allogeneic stem cell transplantation from unrelated donors after a reduced intensity regimen is feasible, but an optimal donor selection is mandatory for a low non-relapse mortality. The high relapse incidence remains a major concern should be improved by including posttransplant strategies to upgrade remission status. Disclosures: No relevant conflicts of interest to declare.

Background: Patients with haematogical diseases and undergoing stem cell or bone marrow transplantation are at high risk for an invasive fungal infection. The appearance and course of this is a significant threat to the overall success of transplantation. The optimal antifungal prophylaxis for stem cell transplanted patients has not yet been clearly etablished. Whereas oral medication seems to be convenient it is often hampered in the course of administration by mucositis or/and unclear absorption. We analysed the impact of antimycotic prophylaxis in our unit. We started with Voriconazol (tbl.) or Itraconazol (solution) followed by an early switch to liposomal amphotericin B with a dose 1 mg/kgBW, if the patients didn’t tolerate oral medications. Patients and methods: 48 patients (18f/30m) with a history of possible (n=4), probable (n=1) or proven (n=3) invasive fungal infection according to EORTC-MSG criteria or no (n=40) fungal infection underwent allogeneic stem cell transplantation in our centre between 08/2005 and 05/2006. Mean age was 47 (6–67) and underlying disease was acute leukaemia (18 AML, 5 ALL, 3 NHL, 4 MM, 4 CML, 14 other). Transplants were unrelated in 38 and related in10 cases. Results: Prophylaxis started on average 6 days prior to transplant (mean 6, range 0–19) with ITZ (n=24), VOR (n=8) or LAMB (n=8). 8 pts. developed early signs of fungal infection precluding analysis within the prophylaxis population. 15/24 pts. on ITZ and 3/8 pts. on VOR needed a switch to i.v.-medication with LAMB. 3/24 pts. starting with ITZ developed a fungal infection (2 possible, 1 probable). Pts. starting with VOR or LAMB required empiric therapy in 1 and 4 cases, respectively. 12 pts. after switching to LAMB required no further antifungal-therapy. Conclusions: In our experience antifungal prophylaxis with oral medication being switched to LAMB in case of mucositis or side effects is an effective and tolerated option to prevent invasive fungal infection in patients during allogeneic stem cell or bone marrow transplantation.