Objectives: The purpose of this study was to evaluate the predictive capacity of the European LeukemiaNet (ELN) classification of genetic risk in patients with acute myeloid leukaemia (AML) undergoing allogeneic stem cell transplantation (alloSCT). Methods: We retrospectively analysed 274 patients transplanted at our centre between 2004 and 2014. Results: The ELN grouping is comparable to the Southwest Oncology Group/Eastern Cooperative Oncology Group (SWOG/ECOG) stratification in predicting the outcome after alloSCT [overall P = 0.0064 for disease-free survival (DFS), overall P = 0.003 for relapse]. Patients with an intermediate-1 profile have a significantly elevated 5-yr relapse incidence as compared to favourable risk patients, that is 40% vs. 15%, [hazard ratio (HR) 2.58, P = 0.048]. An intermediate-1 risk profile is an independent predictor for relapse as determined by multivariate Cox regression analysis (HR 3.05, P = 0.023). In intermediate-1 patients, the presence of an FLT3 internal tandem duplication (FLT3-ITD) is associated with a significantly increased relapse incidence (P = 0.0323), and a lower DFS (P = 0.0465). FLT3-ITD is an independent predictor for overall survival, DFS and relapse incidence in the intermediate-1 subgroup. Conclusions: The ELN stratification of genetic risk predicts the outcome of patients with AML undergoing alloSCT. Patients with an intermediate-1 profile have a high risk for treatment failure due to relapse, which prompts the development of alternative treatment strategies.

Introduction: Allogeneic stem cell transplantation (alloSCT) has become an integral part in the therapy of patients with malignancies of the lympho-hematopoietic system. One of the main reasons for treatment failure after alloSCT is relapse of the underlying disease, which, in the majority of cases, is associated with a poor prognosis. Adoptive immunotherapy by the use of donor lymphocyte infusions (DLI) was shown to be effective in this setting. However, the conditions and the optimal timing of DLI administration for prophylaxis or treatment of (impending) relapse remains controversial.

Elderly patients with acute leukemia are increasingly treated with chemotherapy protocols. The aim of the following allogeneic SCT is to cure patients with acute leukemia >60 years of age. Between 7/1999 and 12/2014 141 elderly patients, 82 males and 59 females, with AML (n=133) or ALL (n=8) were transplanted at the Charité University Medicine Berlin, Germany. Median age was 64 years (60-75) .Stage of disease was CR1 in 72 patients (pts), CR2 in 19 pts and not in remission in 50 pts. Stem cell donors were HLA identical siblings (n=25) or matched unrelated donors (n=116). Conditioning regimens were FLU/BU/ATG n=118, age adapted FLAMSA-RIC n=7, TBI 2 Gy/FLU/ATG n=16. 60/141 patients are alive (43%), 81/141 pts are dead (57%). Causes of death are Non-Relapse mortality (NRM), e.g. GvHD +/- infection in 34/141 pts (24%) and persistence/relapse of acute leukemia in 47/141 pts (33%). Median f/u of the surviving patients is 24 months (3-104). Probability of survival (OS), disease free survival (DFS) and NRM for the whole group (n=141)at 5 years were 0.36, 0.30 and 0.31.Influence of age groups (group 1=60-64 years, n=75, group 2=65-69 years, n=51, group 3 =70 -75 years, n=15) on OS was 0.30, 0.45 and 0.51 (2y), no significant difference, ns., on DFS 0.24, 0.37 and 0.46 ns., NRM 0.30, 030, 0.22 ns. Influence of donor on OS at 5 years was also not significant (Matched unrelated donor, MUD 0.36, sibling donor 0.37). Status of disease before SCT showed also no sign. Difference between the groups: OS in CR1 pts 0.35 vs CR2 pts 0.43 vs No CR 0.38., as did the 3 different conditioning regimens: 2 Gy TBI at 5 years 0.46, FLAMSA at 18 months 0.36 and FLU/BU at 5 years 0.35. 141 patients with acute leukemia and age between 60 and 75 years underwent allogeneic SCT. In this high risk patient group 36% become long term survivors. With a f/u up to 100 months, cure of a part of the pts is possible. We did not find significant differences in age splits, conditioning protocols or type of donor. One has to keep in mind, that the elderly pts are highly selected regarding performance status.

For patients with refractory acute myeloid leukemia (AML), allogeneic stem cell transplantation (alloSCT) represents the only curative approach. We here analyzed the long-term outcome of 131 consecutive patients with active AML, which was either primary refractory or unresponsive to salvage chemotherapy, transplanted at our center between 1997 and 2013. After a median follow-up of 48 months for the surviving patients, disease-free survival (DFS) at 5 yr post alloSCT was 26% (94% CI: 17-35). Relapses, most of which occurred within the first 2 yr from transplant, were the predominant cause of treatment failure affecting 48% (95% CI: 40-58) of patients, whereas non-relapse mortality was 26% (95% CI: 20-36) at 5 yr and thereafter. A marrow blast count >= 20% before alloSCT was an independent prognosticator associated with an inferior DFS (HR: 1.58, P = 0.027), whereas the development of chronic graft-versus-host disease (cGvHD) predicted an improved DFS (HR 0.21, P < 0.001) and a decreased relapse incidence (HR: 0.18, P = 0.026), respectively. These results indicate that alloSCT represents a curative treatment option in a substantial proportion of patients with refractory AML. A pretransplant blast count <20% before alloSCT and the development of cGvHD are the most important predictors of long-term disease control.

In the German multicentre ALL studies, all patients (pts) with induction failure or after relapse are candidates for allogeneic SCT. We report here our single center data on 57 pts. Median age was 28 years (18-57). ALL subtypes were: Ph+ ALL (n=8), B-lineage (pre B, B, pro B) (n=36), T lineage (pre T, mature T, thymic) (n=13). Before conditioning, 12/57 pts had induction failure, 31/57 pts were in CR2, 8/57 pts in 2. relapse, and 6/57 pts in CR3. Median duration of CR1 (n=45) was 21 months (2-107), CR2 (n=14) was 4 months (1-168). Pts with induction failure had at least GMALL, Induction I+II followed by 2 further protocols. Induction chemotherapy of relapse varied and consisted of the GMALL protocol, ALL relapse protocol, IdaFLAG, CLAEG, GIMEMA protocol, and local therapy of extramedullary leukemia. 27/37 pts transplanted in CR2 or CR3 reached CR after 1. chemotherapy, 7 after 2. chemotherapy, and 3 after 3. chemotherapy. Conditioning regimen was myeloablative (12Gy TBI + Cy/ VP16) in 49 pts, reduced intensity conditioning (8Gy TBI or Flu+Bu+ATG) in 7 pts, and Treosulfan in 1 pt. Donors were matched unrelated donors (MUD) in 35 pts, HLA identical siblings in 21 pts, and a HLA-compatible child in 1 pt. GvHD prophylaxis was mainly CSA/MTX, since 2005 ATG was given in MUD additionally. 13/57 pts (23%) are alive in continuous CR (CCR). The median follow-up after allo-SCT for surviving pts is 155 months (5-222). 26/57 pts died due to relapse, 18/57 pts due to treatment-related mortality (TRM), mainly GvHD and/or infections. Probability of leukemia free survival (LFS) at 48 months is 25% for pts with induction failure, 30% for pts in CR2, 12% for pts in second relapse, and 33% for pts in CR3. Adult ALL pts after 1. relapse can only be cured by allo-SCT, but the relapse rate is high. The same is true for ALL pts with induction failure/primary refractory. Perspective in the GMALL studies is to transplant pts with molecular failure before hematologic relapse occurs. In patients with induction failure, up to now, allo-SCT is the only chance of cure. In B-lineage ALL, Blinatumomab may improve the results as bridging to allo-SCT.

Introduction: In acute myeloid leukemia (AML) genetic risk factors are among the strongest predictors for overall outcome. Recently, the European Leukemia Net (ELN) proposed a revised classification based on the presence or absence of specific cytogenetic and/or molecular aberrations. Here, we evaluated the prognostic significance of this system in patients with AML undergoing allogeneic stem cell transplantation (alloSCT).

Allogeneic stem cell transplantation (alloSCT) in first complete remission (CR1) has become a standard of care for many patients (pts) with intermediate or high risk acute myeloid leukemia (AML). Furthermore, pts with relapsed AML may be salvaged by re-induction and subsequent alloSCT. Here, we analyzed the outcome of pts with AML transplanted beyond CR1 at our center between 1996 and 2013. 120 pts (50 female, 70 male) with a median age of 49 (19-72) years were retrospectively analyzed as of June 30th, 2013. 92 pts had de novo AML and 28 pts had secondary or therapy-related AML. 63 pts were in CR2 whereas 57 pts were refractory to re-induction therapy and had active disease at the time of alloSCT. The SWOG/ECOG cytogenetic risk profile was favorable in 16 pts, intermediate in 53 pts, and unfavorable in 34 pts (unknown: 11 pts, undetermined: 6 pts). Conditioning consisted of a 12 Gy TBI-based myeloablative regimen (MAC) in 51 pts. 61 pts received reduced intensity conditioning (RIC: FLU/BU/ATG) and 9 pts were conditioned using the FlamsaRIC protocol. A matched related donor was available in 33 pts. 62 pts had a matched-unrelated donor and 25 pts had a mismatched unrelated donor. After a median follow-up of 39 (3-185) months, 44 pts are alive and in CR. Causes of death were relapse in 37 pts or non-relapse mortality (NRM) in 36 pts. At 1, 3, and 5 years after alloSCT projected overall survival (OS) or disease-free survival (DFS) of the entire cohort was 50% (41-60%), 40% (30-50%), and 39% (29-49%) or 48% (39-58%), 39% (30-49%), or 38% (28-47%). At the same time points the cumulative incidence of relapse (CIR) or NRM (CINRM) was 25% (19-35%), 31% (23-41%), and 32% (24-42%) or 25% (21-38%), 28% (21-38%), or 30% (22-40%). In univariate analysis pts refractory to re-induction therapy had a significantly lower 3-year DFS (26%) as compared to pts transplanted in CR2 (54%) (HR 1.8 (95%CI: 1.1-2.8), p=0.01), due to an increased relapse rate (40% vs 24%, p=0.003). Similarly, an interval of ≤12 months from diagnosis to alloSCT was predictive for a lower 3-year DFS as compared to an interval of >12 months (21% vs 52%) (HR 2.0 (95%CI: 1.2-3.3), p=0.002), due to an increased relapse incidence (47% vs 23%, p<0.001). All other factors examined, i.e. gender, cytogenetic risk, AML subtype, age group, type of conditioning, donor, or year of alloSCT, were not predictive for OS, DFS, CIR, or CINRM. In multivariate analysis, remission status and time from diagnosis to transplantation were identified as independent prognosticators for OS, DFS, and CIR. In sum, our data indicate that pts with AML beyond CR1 may be successfully salvaged by alloSCT. In particular, pts transplanted in CR2 benefit the most. Pts refractory to re-induction may be candidates for alloSCT as well. However, these pts have a poorer outcome due to a high relapse rate irrespective of the cytogenetic risk profile and the conditioning regimen used.

Patients receiving radiotherapy often experience toxicity of the skin and mucous membranes. While radiotherapy is a mainstay of myeloablative conditioning for allogeneic hematopoietic stem cell transplantation (ASCT), no risk factors for radiotoxicity have been identified in this setting. Here, we report on a patient with excessive radiation-induced toxicity after ASCT who carried a heterozygous mutation in the Ataxia telangiectasia mutated (ATM) gene. This is the first case to suggest a genetic basis for increased radiotoxicity after myeloablative ASCT.

We retrospectively analyzed the impact of cytogenetic abnormalities grouped according to the monosomal karyotype (MK) classification or the Southwest Oncology/Eastern Cooperative Oncology Group (SWOG/ECOG) definition in 263 patients with acute myeloid leukemia (AML) who underwent allogeneic stem cell transplantation (alloSCT) in complete remission (CR) at our center. Risk grouping using the MK criteria shows a highly significant difference in 5-yr overall survival (OS) ranging between 67%, for the most favorable, and 32%, for the poorest risk group (P = 0.001). Although similarly precise in predicting OS, the MK scheme better separates patients with respect to relapse incidence as compared to the SWOG/ECOG grouping (P = 0.0001 vs. P = 0.01). Notably, patients displaying non-MK abnormalities (MK-) had a 5-yr relapse incidence identical to those cytogenetically normal (CN), that is 24%. Multivariate analysis revealed that the MK classification is an independent prognosticator and superior in predicting OS (hazard ratios, HR 3.74, P = 0.01) and relapse incidence (HR 3.74, P = 0.005) as compared to the SWOG/ECOG criteria. Finally, subgroup analysis revealed that the prognostic capacity of the MK classification is highly significant in patients treated with standard myeloablative conditioning prior to alloSCT (P = 0.0011 for OS, P = 0.0007 for relapse). In contrast, the MK grouping failed to predict OS or relapse incidence in patients treated with reduced intensity conditioning. Taken together, these results indicate that the MK classification is superior in predicting the overall outcome of patients with AML undergoing alloSCT in CR. Furthermore, our data suggest that the genetic risk profile of MK- and CN patients is mostly overlapping in this setting.

In the German multicenter study group for Adult ALL (GMALL) high risk (HR) and very high risk (VHR) pts are candidates for allogeneic stem cell transplantation in CR1 from HLA matched siblings or unrelated donors. The risk factors are: VHR: Philadelphia chromosome positive ALL (Ph+ALL); HR of B-lineage ALL (HR-B): leukocytes > 30/nl at diagnosis and/or delayed CR > 3 weeks (other B) or pro B-ALL and of T-lineage ALL (HR-T): early-T-ALL and mature T-ALL. In addition standard risk pts were candidates for SCT in case of molecular failure or molecular relapse (SR-Mol). 106 high risk ALL pts in CR1 underwent allogeneic SCT between 1995 and 2012 at our center. Median age was 38 years (17 – 67). 70 pts were male, 36 female. 40/106 pts had Ph+ALL (VHR), 57/106 pts were HR pts (HR-B n = 32: pro-B-ALL n = 15, other B n = 17; HR-T n = 25: early T n = 17, mature T n = 4, thymic n = 4). 9/106 pts belonged to the SR-Mol group. Stem cell donors were matched related donors (MRD) in 42 pts and compatible unrelated donors in 64 pts. The conditioning regimen was 12 Gy TBI ± CY or VP16 in 86 pts, other n = 1, and in pts > 55 years 8 Gy TBI + FLU(n = 5) or FLU + BU (n = 14). 60/106 (57 %) pts with high risk ALL transplanted in CR1 are alive, 46/106 (43 %) pts are dead. The median follow-up of the surviving pts is 64 months (5 – 172). Causes of death were leukemia in 16/106 pts (15%) and transplant-related mortality (TRM) in 30/106 pts (28%). In Ph+ALL 19/40 pts (47 %) are alive in CR (CCR), 12/40 are dead due to TRM and 9/40 due to leukemia. In HR-B ALL 23/32 pts (71 %) are in CCR, 8/32 are dead due to TRM and 1/32 due to leukemia. In HR-T ALL 11/25 pts (44 %) are in CCR, 10/25 died due to TRM and 4/25 due to leukemia. In SR-Mol 7/9 pts (77 %) are in CCR, 2/9 died due to leukemia. Probability of survival (OS) for all pts at 96 months is 0.48, probability of disease free survival (DFS) at 96 months is 0.47, probability of TRM at 96 months is 0.34. OS was 0.5 for pts with myeloablative conditioning (MAC) (n = 86) and 0.38 for pts with RIC (n = 19), n.s. OS was different for the 4 risk groups: VHR 0.42, HR-B 0.67, HR-T 0.27, SR-Mol 0.74, but not sign. (0.09). DFS: VHR 0.42, HR-B 0.68, HR-T 0.24, SR-Mol 0.76 (0.04) and TRM: VHR 0.34, HR-B 0.26, HR-T 0.58, SR-Mol 0.0 (0.026). In HR-B OS was better for pro-B-ALL than other B-lineage (0.73.vs. 0.66, resp.). OS was lower in early-T-ALL (0.24). In mature T-ALL 3/4 pts are dead, in thymic ALL 1/4 pts. Long term survival and probably cure can be reached in high risk ALL pts after allogeneic stem cell transplantation in CR1. OS in HR-B pts is better than in HR-T-ALL due to lower relapse rate and lower TRM. If the quality of remission before allogeneic SCT could be improved in HR-T-ALL, has to be studied. Allogeneic SCT in SR-Mol show promising data, though in a small patient cohort. The results of Ph+ALL can be improved by thyrosine kinase inhibitors in induction chemotherapy, but was not given regularly in our pts. For all pts the TRM-rate due to GvHD and infection has to be improved.

Leukemia-associated antigens such as proteinase-3 (PR 3) and Wilms' tumor protein-1 (WT-1) are potential targets of T-cell responses, which can be monitored by T-cell assays within vaccination trials and after allogeneic stem cell transplantation (SCT). In chronic myeloid leukemia (CML) an aberrant cytokine profile of antigen-specific T-cells with predominant TNF-alpha secretion has previously been described. The aim of this study was to investigate whether these TNF-alpha(+)/IFN-gamma(-) CD8(+) T-cells can also be observed in AML patients after SCT. Eight HLA-A2+ AML patients at different time points after SCT were evaluated for HLA-A2-restricted CD8(+) T-cell responses against PR 3, WT-1 and influenza-A using pentamer staining and different cytokine-based T-cell assays. Antigen-specific T-cell immune responses against influenza-A and PR 3 were observed in 4/8 patients, WT-1-specific T-cells could be detected in 3/8 patients. Interestingly, four different cytokine secretion profiles of antigen-specific T-cells were detected: (1) IFN-gamma(+)/TNF-alpha(+), (2) IFN-gamma(+)/TNF-alpha(-), (3) TNF-alpha(+)/IFN-gamma(-) and (4) IFN-gamma(-)/TNF-alpha(-). TNF-alpha(+)/IFN-gamma(-)CD8(+) T-cells are an interesting biological phenomenon which can obviously be observed also in AML patients. This finding has important implications for both T-cell biology and monitoring within immunotherapy trials. The functional characterization of these TNF-alpha(+)/IFN-gamma(-)CD8(+) T-cells needs further investigations.

Leukemia-associated antigens such as proteinase-3 (PR3) and Wilms' tumor protein-1 (WT-1) are potential targets of T-cell responses, which can be monitored by T-cell assays within vaccination trials and after allogeneic stem cell transplantation (SCT). In chronic myeloid leukemia (CML) an aberrant cytokine profile of antigen-specific T-cells with predominant TNF-α secretion has previously been described. The aim of this study was to investigate whether these TNF-α(+)/IFN-γ(-) CD8(+) T-cells can also be observed in AML patients after SCT. Eight HLA-A2(+) AML patients at different time points after SCT were evaluated for HLA-A2-restricted CD8(+) T-cell responses against PR3, WT-1 and influenza-A using pentamer staining and different cytokine-based T-cell assays. Antigen-specific T-cell immune responses against influenza-A and PR3 were observed in 4/8 patients, WT-1-specific T-cells could be detected in 3/8 patients. Interestingly, four different cytokine secretion profiles of antigen-specific T-cells were detected: (1) IFN-γ(+)/TNF-α(+), (2) IFN-γ(+)/TNF-α(-), (3) TNF-α(+)/IFN-γ(-) and (4) IFN-γ(-)/TNF-α(-). TNF-α(+)/IFN-γ(-) CD8(+) T-cells are an interesting biological phenomenon which can obviously be observed also in AML patients. This finding has important implications for both T-cell biology and monitoring within immunotherapy trials. The functional characterization of these TNF-α(+)/IFN-γ(-) CD8(+) T-cells needs further investigations.

Stem cell transplantation (SCT) has contributed to improved overall survival particularly in high risk adult ALL patients and the indication for SCT is a matter of ongoing discussion. We report the results obtained over a period of 18 years in a large center. Patients received first line treatment according to three consecutive trials of the German Multicenter Study group for Adult ALL (GMALL) and risk stratification was performed accordingly. In the most recent trial patients with high risk and very high risk factors are candidates for allogeneic stem cell transplantation (SCT) in CR1 from matched sibling or unrelated donors. The risk factors are: very high risk (VHR): Philadelphia chromosome positive ALL (Ph+ALL); high risk group (HR) of B-lineage ALL (HR-B): leukocytes > 30/nl at diagnosis and/or delayed CR > 3 weeks (other B) or pro B-ALL and of T-lineage ALL (HR-T): early-T-All and mature T-ALL. In addition standard risk patients were candidates for SCT in case of molecular failure or molecular relapse (SR-Mol). 106 high risk ALL patients in CR1 underwent allogeneic SCT between 1995 and 2012 at our center. Median age was 38 years (17 – 67). 40/106 patients had Ph+ALL (VHR), 57/106 patients were HR patients (HR-B n = 32: pro-B-ALL n = 15, other B n = 17; HR-T n = 25: early T n = 17, mature T n = 4, thymic n = 4). 9/106 patients belonged to the SR-Mol group. Stem cell donors were matched related donors (MRD) in 42 patients and compatible unrelated donors in 64 patients. The conditioning regimen was 12 Gy TBI ± Cyclophosphamide or VP16 in 86 patients, other n = 1, and in patients > 55 years 8 Gy TBI + Fludarabine (n = 5) or Fludarabine + Busulfan (n = 14). ATG as GvHD and rejection prophylaxis was given since 5/2005 in all patients with unrelated SCT and in reduced intensity conditioning regimens (RIC). Results 60/106 (57 %) patients with high risk ALL transplanted in CR1 are alive, 46/106 (43 %) patients are dead. The median follow-up of the surviving patients is 64 months (5 – 172). Causes of death were leukemia in 16/106 patients (15%) and transplant-related mortality (TRM) in 30/106 patients (28%), mainly infections ± GvHD (n = 24), secondary malignancies (n = 2) and other (n = 4). In Ph+ALL 19/40 patients (47 %) are alive in CR (CCR), 12/40 are dead due to TRM and 9/40 due to leukemia. In HR-B ALL 23/32 patients (71 %) are in CCR, 8/32 are dead due to TRM and 1/32 due to leukemia. In HR-T ALL 11/25 patients (44 %) are in CCR, 10/25 died due to TRM and 4/25 due to leukemia. In SR-Mol patients 7/9 patients (77 %) are in CCR, 2/9 died due to leukemia. Probability of survival (OS) for all patients at 96 months is 0.48, probability of disease free survival (DFS) at 96 months is 0.47, probability of TRM at 96 months is 0.34. OS was 0.50 for patients with myeloablative conditioning (MAC) (n = 86) and 0.38 for patients with RIC (n = 19), n.s. OS was different for the 4 risk groups: VHR 0.42, HR-B 0.67, HR-T 0.27, SR-Mol 0.74, but not significant (0.095). DFS: VHR 0.42, HR-B 0.68, HR-T 0.24, SR-Mol 0.76 (0.041) and TRM: VHR 0.34, HR-B 0.26, HR-T 0.58, SR-Mol 0. (0.026). In HR-B OS was better for pro-B-ALL than other B-lineage (0.73.vs. 0.66, resp.). OS was lower in early-T-ALL (0.24). In mature T-ALL 3/4 patients are dead, in thymic ALL 1/4 patients. In Conclusion Long term survival and probably cure can be reached in high risk ALL patients after allogeneic stem cell transplantation in CR1. OS in pro-B-ALL and B-lineage-HR-ALL patients is better than in Ph+ALL or in HR-T-ALL due to lower relapse rate and lower TRM. Whether the quality of remission before allogeneic SCT could be improved in Ph+ALL and HR-T-ALL, has to be studied. Allogeneic SCT in SR with molecular failure or relapse show promising data, though in a small patient cohort. For all patients the TRM-rate due to GvHD and infection has to be improved due to better supportive care. Disclosures: No relevant conflicts of interest to declare.

Purpose Cytogenetic abnormalities as detected by conventional karyotyping are among the strongest predictors for the long-term outcome of patients (pts) with acute myeloid leukemia (AML). However, up to 50% of pts are cytogenetically normal (CN) and the screening for mutations of the FLT3 and the NPM1 genes allowed to further dissect this heterogeneous group. Allogeneic stem cell transplantation (alloSCT) has become an integral part of the post-remission therapy for pts with intermediate or high-risk AML in case an HLA-compatible donor is available. Here, we analyzed the impact FLT3 and NPM1 mutations on the outcome of pts with CN-AML who underwent alloSCT at our center between 2006 and 2013. Pts and Methods Follow-up data of all pts were prospectively collected in a computer database and retrospectively analyzed as of June 30th, 2013. 101 pts (46 female, 55 male) with a median age of 54 (range: 18-75) years with CN-AML were included. 71 pts had de novo AML, whereas 30 pts had secondary or therapy-related AML. All pts were treated in a German multicenter AML trial and received at least two courses of induction therapy. The FLT3 and NPM1 mutational status was as follows: 14 pts were FLT3-mutated/NPM1 wild-type, 15 pts were NPM1 mutated/FLT3 wild-type, 22 pts were FLT3-mutated/NPM1 mutated, and 50 pts were wild-type for both FLT3 and NPM1. At alloSCT, 62 pts were in first complete remission (CR1), 16 pts were in CR2, and 23 pts had refractory disease. In 96 pts alloSCT was performed using peripheral blood stem cells (PBSCs), 5 pts received a bone marrow (BM) graft. Conditioning consisted of standard myeloablative conditioning (MAC) (6x2 Gy TBI and 2x60 mg/m2 cyclophosphamide) in 24 pts. 77 pts received reduced intensity conditioning (RIC) (2x4 mg/kg oral busulfan, 6x30 mg/m2 fludarabine and 4x10 mg/kg ATG). A matched related donor was available for 27 pts, whereas 55 pts or 19 pts were transplanted from a matched-unrelated or mismatched unrelated donor. Results After a median follow-up of 11 (range: 1-83) months for the surviving pts, 64 pts are alive and in CR. Causes of death were relapse or NRM in 26 pts or 12 pts, respectively. At 1, 3 and 5 years projected overall survival (OS) or disease-free survival (DFS) of the entire cohort was 67% (57-77%), 58% (46-69%), and 54% (42-67%) or 60% (51-71%), 57% (47-68%), or 50% (37-54%). At the same time points the cumulative incidence of relapse (CIR) or non-relapse mortality (CINRM) was 27% (19-38%), 30% (22-43%), and 37% (36-52%) or 12% (6-21%) remaining stable thereafter. Subgroup analysis showed that the presence of a NPM1 mutation in the absence of mutated FLT3 is associated with a significantly lower CIR, i.e. 8%, at 3 years. In the other subgroups the CIR ranges between 32% for pts lacking FLT3 and NPM1 mutations and 37% for pts carrying both mutations (p=0.002). In univariate analysis, pts with refractory disease had a significantly lower DFS (p=0.0002) and a higher relapse incidence (p=0.0001) as compared to pts transplanted in CR. All other factors examined, i.e. AML subtype, stem cell source, type of conditioning, donor/HLA-match were not associated with OS, DFS, or relapse incidence. Notably, there was no correlation between FLT3 or NPM1 mutational status and remission status at the time of alloSCT. OS did not differ significantly between the four subgroups due to an increased NRM in patients with NPM1-mutated CN-AML. Finally, in multivariate analysis only remission status was identified as an independent prognosticator for DFS and relapse incidence, whereas alloSCT from a mismatched unrelated donor predicted a higher NRM. Conclusions Taken together, our results indicate that pts with high-risk AML, as defined by the presence of a FLT3-mutation, may achieve durable long-term remissions following either MAC and RIC-alloSCT from related an unrelated donors. In turn, the presence of a mutation of the FLT3 gene may not per se predict a poor outcome in this setting. In contrast, remission status is among the strongest predictors for long-term outcome in patients with CN-AML undergoing alloSCT. Disclosures: No relevant conflicts of interest to declare.

Between 1994 and 2011 343 adult patients with acute myeloid leukemia (AML) underwent allogeneic stem cell transplantation (SCT). 244 pts were transplanted in CR 1, CR 2 or CR 3 and 99 pts were transplanted with active disease. 56/99 pts were male, 43/99 pts were female. Median age was 50 years (17 – 70). 65 pts had primary AML, 22 pts secondary AML after MDS and 12 pts had therapy related (t-AML). 45/99 pts had induction failure (primary refractory), in 3/99 pts AML was untreated (Fanconi, SCID, active NHL), 39/99 pts were transplanted for AML in first relapse and 12/99 pts were transplanted for AML in second relapse. Median blast count in the bone marrow before conditioning was 20 % (5 – 90). 21 pts had extramedullary leukemia, mainly meningeosis and skin involvement. Karyotype was intermediate in 60 pts and high risk in 33 pts. In 5 pts karyotype analysis was not done, in 1 patient favourable. Induction failure was defined as blast persistence after two cycles of chemotherapy including high dose ARAC. Pts transplanted in first relapse had an untreated relapse (n = 15) or had received another chemotherapy. Pts with meningeosis had received intrathecal therapy. Donors for SCT were HLA identical siblings in 35/99 pts or unrelated donors in 64/99 pts. Conditioning regimen was myeloablative (MAC) (12 Gy TBI + CY) in 42 pts (since 1995), reduced intensity conditioning (RIC) (FLU/ BU/ATG) in 42 pts (since 1998) and FLAMSA-RIC in 15 pts (since 2007). After allogeneic SCT 4/99 pts had progression of leukemia, 95/99 went in remission. 24/99 pts are alive, 4 with AML and 20 pts in CCR. Median remission duration of the 20 pts in CCR is 47 months (0.5 - 130). 75/99 pts are dead. Causes of death are leukemia in 48/75 and TRM in 27/75 pts, mainly gvhd and infection. Probability of survival at 60 months, 90 months and 120 months for the whole group is 0.26, 0.19 and 0.08, respectively. The stage of disease at conditioning had no significant influence. Probability of survival at 60 months and 90 months for primary refractory pts was 0.3 and 0.22, in first relapse 0.26 und 0.13 and in second relapse 0.19 and 0.19. The conditioning regimen was not randomized and showed a trend for better survival in RIC vs. MAC vs. FLAMSA RIC, at 60 months 0.42 vs. 0.17 vs. 0.1 (at 30 months), at 90 months 0.25 vs. 0.14. After induction failure or after first relapse SCT is the only curative therapy. About 25% of the pts can enjoy a long lasting remission (at 5 years). The high relapse rate and high TRM rate has to be improved by preemptive DLI therapy and better supportive care.

Abstract Abstract 1998 Purpose: In patients with newly diagnosed acute myeloid leukemia (AML) rapid achievement of remission by induction chemotherapy is an important predictor for long-term disease control. In turn, patients who fail to attain early blast clearance after the first chemotherapy course have an inferior outcome. Here, we investigated the impact of early blast clearance on the overall outcome of patients with AML undergoing allogeneic stem cell transplantation (alloSCT) in first complete remission (CR1) as consolidation therapy. Patients and Methods: 169 (90 female, 79 male) patients with AML who underwent alloSCT in CR1 at our center between 1994 and 2011 were included. Data were prospectively recorded in our transplant data base and retrospectively analyzed as of December 31st, 2011. In detail, 107 patients (64%) had de novo AML, 31 patients (18%) had AML evolving from myelodysplastic syndrome (MDS), and 31 patients (18%) had therapy-related AML. According to the criteria of the SWOG/ECOG, cytogenetic risk was either favorable (6 patients, 4%), intermediate (104 patients, 62%), or poor (47 patients, 27%). Prior to alloSCT all patients were treated in a German multicenter AML trial and received at least two courses of induction chemotherapy, i.e. either standard “7+3” (daunorubicin 60 mg/m2, day 3–5 and Ara-C 100 mg/m2, day 1–7) or a “high-dose Ara-C” containing regimen (Ara-C 1–3 g/m2). In 98 patients (58%) induction chemotherapy resulted in blast clearance after the first course, whereas 71 patients (42%) failed to achieve early remission, but entered remission after 1 or 2 subsequent courses. Median age at transplantation was 47 years (range: 17–69 years). In 146 patients (86%) alloSCT was performed using peripheral blood stem cells (PBSCs), whereas 23 patients (14%) received a bone marrow (BM) graft. Conditioning consisted of standard myeloablative conditioning (MAC: 6 × 2 Gy TBI and 2 × 60 mg/m2 cyclophosphamide) in 81 patients (48%), whereas 86 patients (52%) received reduced intensity conditioning (RIC: busulfan 2 × 4 mg/kg, fludarabine 6 × 30 mg/m2 and ATG 4 × 10 mg/kg). A matched related donor was available in 82 patients (49%), whereas 68 patients (40%) or 19 patients (11%) were transplanted from a matched-unrelated or mismatched unrelated donor. Results: After a median follow-up of 45 months (range: 3–196 months) for the surviving patients, 91 patients (54%) are alive and in continuous remission. Causes of death were relapse in 38 patients (22%) or NRM in 33 patients (19%). At 1, 3 or 5 years projected overall survival (OS) was 72±6%, 58±6%, or 54±8% for all patients. Probability of relapse or non-relapse mortality (NRM) at 1, 3, and 5 years was 20±10% (20±11%), 31±12% (20±11%), and 34±12% (20±11%). Although there was no statistically significant difference in OS at 3 and 5 years between patients who achieved early blast clearance as compared to patients who failed to do so (p=0.09), disease-free survival (DFS) and probability of relapse differed significantly between the two groups at 3 years (77±8% vs 55±14%) or 5 years (75%±9% vs 52%±14%) following alloSCT (p=0.02). There was no significant difference in NRM between the two subgroups. Likewise, there was no statistically significant difference between patients conditioned with either MAC or RIC. In multivariate analysis cytogenetic risk group and remission status were identified as independent prognostic factors for DFS and probability of relapse. Conclusions: These results suggest that in patients with AML undergoing alloSCT in CR1 early blast clearance, i.e. following the first course of induction chemotherapy, predicts a very favorable outcome. Disclosures: No relevant conflicts of interest to declare.

Abstract 4547 Introduction: The 2005 NIH consensus criteria (NCC) for acute and chronic graft-versus-host disease (aGVHD, cGVHD) are the gold standard for classifying GVHD in trials but they are not routinely used in the clinic, in part due to uncertainty about their prognostic value. To address this limitation we analyzed NIH-defined GVHD in 147 consecutive acute lymphoblastic leukemia (ALL) patients who received a first myeloablative transplant at our center between 1995 and 2009. Methods: Median age was 31 years (range: 17–56). Disease status was CR1 (50%), CR>1 (22%) or no CR (28%). Myeloablative conditioning consisted of 12 Gy TBI ± etoposide ± cyclophosphamide. Donors were HLA-matched related (42%), -matched unrelated (46%) or -mismatched (12%) and peripheral blood stem cells (74%) or bone marrow (26%) were given. GVHD-prophylaxis consisted of CSA/MTX (72%), CSA/prednisolone (19%) or other CSA-based regimens (9%). ATG was given in HLA-mismatched transplants (12%) and since 2005 also in matched unrelated transplants (11%), according to GMALL study protocols. Preemptive donor lymphocyte infusions (DLI) were a treatment option in case of mixed chimerism or minimal residual disease. Results: Median follow-up was 60 months (8–185). Projected overall survival (OS) at 1, 2 and 5 years was 64%, 56% and 49%. 5-year cumulative incidence of relapse was 33% and of non-relapse mortality (NRM) 25% (7% infections, 9% aGVHD, 7% cGVHD, 2% other). Median time until onset of classic aGVHD was 20 days (5–95). Cumulative incidence of classic aGVHD was 41% for grade I/II and 29% for grade III/IV. Among patients with classic aGVHD, skin, liver or gut involvement was seen in 94%, 32% and 34%. Late aGVHD was observed in 12% at a median of 100 days (range 100–240). Among late aGVHD cases 82% were subclassified as persistent or recurrent classic aGVHD. Median time until onset of chronic GVHD was 115 days (14–294) measured from transplant or DLI with a cumulative incidence for mild, moderate and severe forms of 13%, 15% and 25%. Mouth, skin, eyes, liver, joints and fascia, gut, lung and other organs were involved in 91%, 70%, 61%, 48%, 27%, 19%, 10% and 6% of cGVHD cases. cGVHD was subclassified as classic cGVHD and overlap syndrome in 40% and 60% of cases. 62% had progressive or quiescent type of onset. In multivariate Cox regression analysis with GVHD as time-dependant covariate (table 1) classic aGVHD grade III/IV was associated with inferior OS due to higher NRM. Comparable effects were seen for late aGVHD. In contrast, moderate and severe cGVHD were associated with superior OS due to lower relapse incidence. Classic and overlap cGVHD had no differential prognostic impact. 34 patients without GVHD after cessation of immunosuppression received preemptive DLI. In this subgroup cumulative incidence of classic aGVHD, late aGVHD or cGVHD was 62%, 6% and 62%. Organ involvement was comparable to non-DLI associated GVHD. In a time-dependant multivariate analysis, patients who developed NIH-defined cGVHD after DLI had improved OS (HR 0.21, 95%CI: 0.054–0.81, P=0.023) due to lower relapse incidence (HR 0.26, 95%CI: 0.043–0.91, P=0.048) compared to patients without cGVHD after DLI. Conclusions: This is the first study on the natural history and prognostic impact of NIH-defined GVHD in ALL patients. We found that severe classic aGVHD leads to higher NRM and inferior OS with similar effects seen for late aGVHD. cGVHD had a positive impact on OS and relapse rate, both after transplant and after preemptive DLI, indicating a potent graft-versus-leukemia effect. Although our cohort contains some heterogeneity we believe that this data supports the use of the NCC as diagnostic and prognostic tool in ALL patients. Multivariate Cox regression analysis for OS, relapse and NRM with GVHD as time-dependant covariate. Only results for GVHD are shown. Disclosures: No relevant conflicts of interest to declare.

Abstract Abstract 2028 Purpose: A monosomal karyotype, as defined by the presence of two or more autosomal monosomies or a single autosomal monosomy in the presence of at least one structural chromosomal abnormalities (core binding factor abnormalities excluded), was shown to confer to a highly unfavorable prognosis in patients (patients) with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) treated with conventional chemotherapy. Here, we investigated the prognostic impact of a monosomal karyotype on the outcome of patients with AML or MDS following allogeneic stem cell transplantation (alloSCT). Patients and Methods: 254 patients who underwent alloSCT at our center between 1994 and 2010 were retrospectively analyzed. 204 patients (80%) had AML (de novo AML: 167 patients, therapy-related AML (tAML), AML evolving from MDS: 37 patients) and were in CR1 (157 patients (77%) or CR>1 (47 patients (23%). 50 patients had MDS (RA/RCMD: 36 patients, RAEB-I: 7 patients, RAEB-II: 9 patients). Median age was 47 years (range: 17–72 years). 223 patients (88%) received peripheral blood stem cells (PBSCs), 31 patients (12%) received bone marrow (BM). Conditioning consisted of standard myeloablative conditioning (MAC) in 134 patients (53%), whereas 120 patients (47%) received reduced intensity conditioning (RIC). 13 patients (5%) had a core-binding factor leukemia (CBF group), 117 patients (46%) were cytogenetically normal (CN group), 79 patients (31%) had an unfavorable risk MK-negative karyotype (MK– group), 26 patients (10%) had a highly unfavorable MK-positive (MK+ group). In 19 patients (8%) the karyotype was unknown/not evaluable. Results: After a median follow-up of 51 months (range: 3–191 months) for the surviving patients, 134 patients (53%) are alive and in remission. Causes of death were relapse in 53 patients (21%) or NRM in 58 patients (23%). At 1, 3 or 5 years projected OS (DFS) was 70±6% (66±6%), 57±6% (56±6%) or 54±7% (54±7%). At 3 years patients in the MK+ group had a statistically significantly lower OS (DFS) of 29% (29%) as opposed to 52% (52%) in the MK– group, 68% (66%) in the CN group, or 67% (55%) in the CBF-group (p<0.001). Likewise, the probability or relapse was highest in the MK+ group (72%) as compared to the MK- group (37%), the CN group (24%), or the CBF group (14%) (OS: p=0.001, DFS: p=0.003). There was no statistically significant difference in non-relapse mortality between the four groups. Conclusions: These data indicate that karyotypic abnormalities remain the most important prognostic factors predicting the outcome of patients with AML or MDS. In particular, the presence of a monosomal karyotype provides a strong negative prognostic prediction for these patients undergoing alloSCT. Therefore, our data suggest that these patients should be referred to alloSCT in CR (AML) or early stage disease (MDS). Disclosures: No relevant conflicts of interest to declare.

Abstract Abstract 899 Introduction: The classic definition of acute (aGVHD) and chronic graft-versus-host disease (cGVHD) was based on a cut-off day 100 after transplantation, but this did not reflect that aGVHD can occur later and that symptoms of aGVHD and cGVHD can occur simultaneously. In 2005 a NIH consensus classification was proposed which included 1) classic aGVHD, occurring before day 100, 2) persistent, recurrent or late aGVHD occurring thereafter, 3) classic cGVHD and 4) an overlap syndrome with simultaneous features of aGVHD and cGVHD. Only few studies have evaluated this classification and no studies have determined the differential impact of reduced intensity (RIC) and myeloablative conditioning (MAC). Method: We retrospectively analyzed 202 AML patients who were transplanted between 1999 and 2008. 102 patients received RIC (generally 6×30 mg/m2 FLU, 4×4 mg/kg BU, 4×10 mg/kg ATG) and immunosuppression with CSA/MMF and 100 patients received MAC (generally 6×2 Gy TBI and 2×60 mg/kg CY) and CSA/MTX. Donors were HLA-matched related (n=82), -matched unrelated (n=88) or -mismatched (n=32). Result: Leukocyte recovery was faster after RIC than after MAC (14 vs. 19 days, P<0.001) but time to reach full donor chimerism was similar (60 vs. 56 days, P=0.12). The cumulative incidence of classic aGVHD was lower after RIC than after MAC (40 vs. 67%, P<0.001) and it occurred later (31 vs. 23 days, P=0.041). No difference was seen in organ manifestations and in the overall aGVHD grade. The cumulative incidence of late aGVHD was low and did not differ between RIC and MAC (9 vs. 7%, P=NS). 13/16 patients with late aGVHD had persistent or recurrent classic aGVHD and 3/16 had de novo late aGVHD. Late aGVHD was less severe after RIC (grade III/IV 22 vs. 86%, P=0.041). The first signs of cGVHD were observed on days 86 after RIC and 97 after MAC with median onset on days 167 and 237, respectively (P=NS). The cumulative incidence of cGVHD tended to be lower after RIC (36 vs. 51%, P=0.088) and it tended to be less severe. Organ manifestations were similar except for cGVHD of the joints and fascia which affected 11% of MAC but no RIC patients (P=0.0021). More than half of cGVHD cases were subclassified as overlap cGVHD with no significant differences between RIC and MAC (51 vs. 65%, P=0.26). In multivariate Cox regression analysis of the whole cohort the only significant risk factor for aGVHD was MAC (HR 2.33, 95%CI 1.51–3.59, p<0.001). In RIC patients the administration of bone marrow lead to less aGVHD (HR 0.13, 95%CI 0.016–0.98, P=0.047). The only relevant risk factor for late aGVHD was prior aGVHD (HR 3.65, 95%CI 1.040–12.81, P=0.043). The most important risk factors for cGVHD were prior aGVHD (HR 2.77, 95%CI 1.64–5.67, P<0.001), female-to-male transplantation (HR 1.94, 95%CI 1.12–3.35, P=0.017) and advanced disease (HR 1.95, 95%CI 1.2–3.1, P=0.018). In multivariate Cox regression analysis with GVHD as time-dependant covariate aGVHD grade III/IV (HR 2.41, 95%CI: 1.51–3.87, P=0.001) and late aGVHD grade III/IV (HR 3.037, 95%CI 1.29–7.18, P=0.011) were associated with inferior overall survival (OS) while moderate cGVHD had a positive effect (HR 0.42, 95%CI 0.18–0.97, P=0.043). Classic and overlap cGVHD had no differential prognostic impact. Conclusion: This study in AML patients shows that previously established GVHD risk factors remain valid for the new NIH classification. It also confirms the major impact of conditioning intensity on GVHD incidence, the negative prognostic impact of severe aGVHD and the benefit of moderate cGVHD. The new category late aGVHD may only include few patients but will allow more adequate allocation to therapies or clinical trials. Whether the subgroups classic and overlap cGVHD are clinically relevant remains to be determined. Disclosures: No relevant conflicts of interest to declare.

BACKGROUND:Disease stage is the most important prognostic parameter in allogeneic hematopoietic cell transplantation (HCT) for acute lymphoblastic leukemia, but other factors such as donor/host histocompatibility and gender combination, recipient age, performance status and comorbidities need to be considered. Several scoring systems are available to predict outcome in HCT recipients; however, their prognostic relevance in acute lymphoblastic leukemia is not well defined.DESIGN AND METHODS:In the present study we evaluated a modified EBMT risk score (mEBMT) and the HCT-specific comorbidity index (HCT-CI) in 151 adult acute lymphoblastic leukemia patients who received allogeneic HCT from 1995 until 2007 at our center.RESULTS:Disease status was first complete remission (CR1) (47%), CR>1 (21%) or no CR (32%). Overall survival (OS) at one, two and five years was 62%, 51% and 40% and non-relapse mortality (NRM) was 21%, 24% and 32%. Median mEBMT was 3 (0-6). Higher mEBMT was associated with inferior OS (hazard ratio per score unit (HR): 1.50, P<0.001), higher NRM (HR: 1.36, P=0.042) and higher relapse mortality (HR: 1.68, P<0.001). Disease stage was the predominant prognostic factor in this score. Comorbidities were present in 71% of patients with mild hepatic disease (29%), moderate pulmonary disease (28%) and infections (23%) being the most common. Median HCT-CI was 1 (0-9). In univariate analysis a trend for inferior OS (HR: 1.08, P=0.20) and higher NRM (HR: 1.14, P=0.11) with increasing HCT-CI was observed but the level of significance was not reached. In additional analyses we found that reduced Karnofsky Performance Status (KPS) was associated with inferior OS (HR: 1.34, P=0.023) and higher relapse mortality (HR: 1.71, P=0.001) when analyzed univariately. However, KPS was associated with disease stage and significance was lost in multivariate analysis.CONCLUSIONS:The mEBMT was prognostic in our patient cohort with predominant influence of disease stage, whereas a trend but no significant prognostic value was observed for the HCT-CI.