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Bruton's tyrosine kinase (BTK) plays a key role in cell survival in B cell malignancies, such as chronic lymphocytic leukemia (CLL). Covalent inhibitors of BTK, such as ibrutinib and acalabrutinib, while effective, have been associated with the occurrence of resistance mutations. The most prevalent site of mutation, C481, renders covalent BTK inhibitors unable to form a covalent bond with BTK leading to diminished efficacy and disease progression. Small molecule-induced protein degradation offers a unique approach to target BTK for the treatment of B-cell malignancies. Chimeric Targeting Molecules (CTMs) catalyze ubiquitylation and proteasomal degradation of target proteins and are comprised of a ubiquitin ligase binding element ("harness"), a linker, and a target binding element ("hook"). NX-2127 is a CTM that contains a BTK hook linked to a cereblon (CRBN) harness. NX-2127 degrades 50% of cellular BTK (DC50) at < 5 nM across multiple cancer cell lines and in human PBMCs. BTK CTMs impair viability in the BTK-dependent ABC-DLBCL cell line, TMD8 (EC50: < 15 nM after 72 hours). Importantly, NX-2127 induces degradation of the mutated BTK-C481S in cells and inhibits proliferation of BTK-C481S mutant TMD8 cells more effectively than ibrutinib (NX-2127 EC50 values of < 30 nM versus > 1 μM for ibrutinib). Oral administration of NX-2127 in mice leads to dose-proportional exposure in plasma and BTK degradation to In addition to potent BTK degradation, NX-2127 possesses IMiD-like properties through the design of the CRBN binding harness that catalyzes the degradation of CRBN neosubstrates Aiolos (IKZF3) and Ikaros (IKZF1). This activity is associated with increased T cell activation and anti-tumor effects of the IMiD drugs lenalidomide and pomalidomide. In primary human T cells, NX-2127 catalyzes the degradation of Aiolos and Ikaros with of 25 nM and 54 nM, respectively, potencies which are similar to those of lenalidomide (20 nM and 343 nM, respectively). Corresponding with such degradation, NX-2127 stimulates T cell activation as measured by increased IL-2 production in primary human T Cells in a manner similar to lenalidomide and pomalidomide. The dual activity of BTK degradation combined with immunomodulation of NX-2127 supports its development for the treatment of B-cell malignancies. Disclosures Robbins: Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Kelly:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Tan:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. McIntosh:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Wu:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Konst:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Kato:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Peng:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Mihalic:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Weiss:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Perez:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Tung:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Kolobova:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Borodovsky:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Rountree:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Tenn-McClellan:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Noviski:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Ye:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Basham:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Ingallinera:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. McKinnell:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Karr:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Powers:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Guiducci:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company. Sands:Nurix Therapeutics: Current Employment, Current equity holder in publicly-traded company.

Bruton's tyrosine kinase (BTK) is a key component of B cell receptor signaling and is involved in B cell development and function. BTK plays a crucial role in cell survival in B cell malignancies such as Chronic Lymphocytic Leukemia (CLL), and covalent inhibitors of BTK, such as ibrutinib, have been successful clinically. However, long-term therapy with covalent BTK inhibitors has been shown to generate resistance mutations, which lead to disease progression. New treatments are needed to address this unmet medical need. Small molecule-induced protein degradation offers a unique approach to inhibiting BTK function. Chimeric Targeting Molecules (CTMs) mediate ubiquitylation and proteasomal degradation of specific target proteins. CTMs are comprised of a ubiquitin ligase binding element ("harness"), a chemical linker, and a target binding element ("hook"). Use of CTMs to degrade both WT and ibrutinib-resistant forms of BTK present a novel approach to targeting BTK and could affect both its catalytic and potential scaffolding functions. We have identified multiple CTMs that catalyze BTK degradation in multiple B cell lines; the concentration of one of such CTM, NRX0492, required to degrade 50% BTK (DC50) was < 1 nM after 4 hours. BTK CTMs impair viability in the BTK-dependent ABC-DLBCL cell line, TMD8 (EC50: < 10 nM after 72 hours). These CTMs also induce degradation of the ibrutinib-resistant C481S mutant form of BTK in cells and confer loss of viability in BTKC481S mutant TMD8 cells with EC50 values of < 10 nM compared to > 1 µM for ibrutinib. Oral administration of NRX0492 in mice leads to dose-proportional exposure in plasma and BTK degradation in circulating and splenic B cells: at 6 hours after a single oral dose of NRX0492, 11% BTK remained in mouse splenocytes compared to 100% BTK in mice dosed with vehicle (P < 0.0001). In a WT TMD8 xenograft model, NRX0492 treatment resulted in similar tumor growth inhibition (TGI) as compared to ibrutinib over 23 days of daily oral administration: 54.4% TGI for NRX0492 and 55.8% for Ibrutinib, both as compared to placebo (P = 0.0006 and P = 0.0004, respectively). Notably, in a TMD8 BTKC481S xenograft model, NRX0492 demonstrated superior TGI as compared to ibrutinib: 51.3% versus 15.2%, (P = 0.033). Preclinical safety and toxicity studies for BTK CTMs are ongoing to inform plans for clinical development. CTM-mediated degradation of BTK may provide an alternative therapeutic approach for B cell malignancies, particularly in the ibrutinib-resistant setting. Disclosures Kelly: Nurix Therapeutics: Employment. Robbins:Nurix Therapeutics: Employment. Tan:Nurix Therapeutics: Employment. Tenn-McClellan:Nurix Therapeutics: Employment. McIntosh:Nurix Therapeutics: Employment. Wu:Nurix Therapeutics: Employment. Konst:Nurix Therapeutics: Employment. Kato:Nurix Therapeutics: Employment. Perez:Nurix Therapeutics: Employment. Tung:Nurix Therapeutics: Employment. Kolobova:Nurix Therapeutics: Employment. Ingallinera:Nurix Therapeutics: Employment. McKinnell:Nurix Therapeutics: Employment. Weiss:Nurix Therapeutics: Employment. Noviski:Nurix Therapeutics: Employment. Ye:Nurix Therapeutics: Employment. Peng:Nurix Therapeutics: Employment. Cardozo:Nurix Therapeutics: Employment. Mihalic:Nurix Therapeutics: Employment. Basham:Nurix Therapeutics: Employment. Rountree:Nurix Therapeutics: Employment. Karr:Nurix Therapeutics: Employment. Bence:Nurix Therapeutics: Employment. Zapf:Nurix Therapeutics: Employment. Sands:Nurix Therapeutics: Employment.

We retrospectively analyzed 12 consecutive adult severe aplastic anemia patients who received unrelated umbilical cord blood transplantation after a reduced-intensity conditioning regimen (RI-UCBT). The conditioning regimen consisted of 125 mg/m2 fludarabine, 80 mg/m2 melphalan, and 4 Gy of total body irradiation. The median infused total nucleated cell number and CD34+ cell number were 2.50 × 107/kg and 0.76 × 105/kg, respectively. Eleven of the 12 patients achieved primary neutrophil and platelet engraftment. All patients who achieved engraftment had complete hematologic recovery with complete donor chimerism, except for one patient who developed late graft failure 3 years after RI-UCBT. Two of the 12 patients died of idiopathic pneumonia syndrome, and the remaining 10 patients are alive, having survived for a median of 36 months. Our encouraging results indicate that RI-UCBT may become a viable therapeutic option for adult severe aplastic anemia patients who lack suitable human leukocyte antigen-matched donors and fail immunosuppressive therapy.

Introduction: Follicular lymphoma (FL) is the second most common type of non-Hodgkin cell lymphoma, and usually manifests as a disseminated disease. Bone marrow (BM) involvement, which occurs in 40-70% of cases, is often seen in follicular lymphoma and thought to be associated with less favorable prognosis. Diagnosis of BM involvement has traditionally been based on morphological findings, and BM involvement has been determined using histology alone in most clinical trials. Immunocytologic or molecular studies, such as flow cytometry (FCM) and polymerase chain reaction (PCR), have become more readily available, and their usage has clearly documented minimal BM involvement reproducibly. In this study, we evaluated the impact of BM involvement detected by FCM and PCR on the outcome of patients treated for FL. Methods: Patients who were diagnosed with biopsy-proven FL between 2004 and 2015 at our institution were included in the study. All patients had received a staging bone marrow examination before treatment with immunotherapy-based regimen. Immunocytologic [FCM] and/or molecular [PCR] studies were always performed if the patients did not have morphological BM involvement. We used 4- or 6- color FCM, and performed PCR analysis of Bcl-2/IgH rearrangement and/or IgH rearrangement detected by modified BioMed-2 protocol. A total of 90 patients were included, and the median follow-up duration was 36 months (range, 6|122 months). The BM status was classified using into 3 categories: morphological, minimal, and negative BM involvement. Minimal BM involvement was defined as BM involvement detected by FCM or PCR without morphological evidence. Morphological and minimal BM involvements were detected in 37 (41%) and 38 (42%) patients, respectively. The primary outcome measure was progression-free survival (PFS). PFS curves were plotted using the Kaplan-Meier method and compared by the log-rank test. Multivariate analyses were performed using a Cox linear regression model. There were significant differences in gender, LDH levels, stage, nodal sites, and FL International Prognostic Index (FLIPI) between patients with and without morphological BM involvement (Table1). Results: The 3-year PFS rate for patients with negative BM involvement was significantly better than that for patients with minimal or morphological BM involvement (84.8% vs. 40.3% vs. 60.5%; p= 0.043) (Figure 1). There was no statistical difference in 3-year PFS between patients with morphological BM involvement and those with minimal BM involvement. The difference of 3-year PFS rate between patients with minimal BM involvement and those with negative BM involvement was significant for patients with FLIPI low-intermediate risk (88.9% vs. 51.5%; p= 0.032) and those with advanced stage disease (90.0% vs. 33.6%; p= 0.027), but there were no significant differences in patients deemed FLIPI high risk and those with limited stage disease. Multivariate analysis revealed that BM involvement, including morphological and minimal involvement, was a significant poor prognostic factor (hazard ratio 4.885 [95% confidence interval 1.16-20.56], p = 0.0305). Conclusion: At the start of treatment, bone marrow involvement was seen in most FL patients. Patients without any BM involvement had an excellent prognosis. Patients with minimal BM involvement had an equally poor prognosis as those with morphologic BM involvement. Table 1 FLIPI: Follicular Lymphoma International Prognostic Index Table 1. FLIPI: Follicular Lymphoma International Prognostic Index Table 2 BM state positive: including morphological and minimal bone marrow involvement. Table 2. BM state positive: including morphological and minimal bone marrow involvement. Figure Figure. Disclosures Ishikawa: Mundipharma KK: Research Funding.

Introduction Bone marrow (BM) involvement is an important prognostic factor in DLBCL, which is incorporated into the new prognostic index of NCCN-IPI in rituximab era. Although BM involvement has been evaluated with bone marrow biopsy (BMB), the recent international criteria for staging of non-Hodgkin lymphoma and Hodgkin lymphoma (Lugano criteria) proposed omission of BMB as pre-treatment evaluation in selected cases. However, validity of omission of BMB remains uncertain. Our institute previously reported that the detection of BM clonality using flow cytometry (FCM) or immunoglobulin heavy chain rearrangement (IgR) has prognostic value in DLBCL. Aim of this study is to inspect prognostic value of PET-defined BM involvement combined with clonality of BM. Patients and Methods We studied consecutive DLBCL patients who were diagnosed in our institute in 2007-2014, received rituximab combined with CHOP-like regimen and undertook pre-treatment staging by FDG-PET/CT, FCM and PCR using BM aspirates. We reviewed the medical records, the staging FDG-PET/CT reports, DICOM images (if available), FCM and IgR reports. BM uptake of FDG was classified as focal or diffuse pattern. Diffuse uptake pattern was not regarded as lymphoma involvement on staging unless lymphoma was proven histologically or cytogenetically. B-cell clonality of BM was defined as positive, either when PCR amplification detected clonal immunoglobulin heavy chain (FR1, FR2, FR3) gene rearrangements with multiplex BIOMED-2 primer sets or when FCM detected κ/λ deviation among B-cell population. Results One-hundred thirty four patients were identified: median age 69.5 years old (range, 19 - 89), 76 male (57%), LDH above the upper limit in 60(45%), stage ≥ 3 in 69(51%), bulky mass in 10(7.5%), abnormal lymphocytes in BM detected microscopically in 13(9.7%), IPI score were distributed as 0-1 in 46(34%), 2 in 31(23%), 3 in 30(22%) and 4-5 in 27(20%). Thirty patients (22% of the whole cohort) were positive for BM FDG-PET uptakes; the uptake patterns were focal in 23(77%) and diffuse in 7(23%). Follow-up time was median 741 days (range, 31 - 1766). B-cell clonality of BM was found in 20 patients (15%) with FCM and in 27 patients (20%) with IgR. B-cell clonality was more frequently observed in the patients with BM FDG-PET uptake (FCM-based clonality: 37% for positive vs 10% for negative, p-value, 0.002; IgR-based clonality: 38% for positive vs 18% for negative, p-value, 0.034). In addition, IPI score was significantly worse in the BM FDG-PET uptake patients (IPI ≥2: 93% in positive BM FDG-PET uptake vs 58% in negative BM FDG-PET uptake, p-value, < 0.001). Abnormal lymphocytes by BM aspiration did not affect PFS in our cohort significantly (0.14). Patients with BM FDG-PET uptake had more extranodal lesions than patients without BM FDG-PET uptake (mean 0.66 vs 1.6, p-value, < 0.001). In entire cohort, 2-year PFS and 2-year OS were 70% and 83%, respectively. Pretreatment BM FDG-PET uptake had negative impacts on PFS (2-year PFS, 74% for negative vs 53% for positive, p-value, 0.017). Clonality in BM detected with IgR had negative effect on PFS (2-year PFS, 74% for negative vs 55% for positive, p-value, 0.017)(Figure). IPI were also a significant prognostic factor for PFS (2-year PFS, 92% for IPI Conclusion Some previous studies showed that BM examination, as well as FDG-PET, had merits for more precise survival prediction. In our study, B-cell clonality of BM is an adverse prognostic factor for PFS that is independent of IPI and the impact of BM FDG-PET status was limited. Although BM clonality was more frequent in the patients whose FDG-PET uptake of BM were focal, BM clonality should be examined combined with FDG-PET. Figure 1. Figure 1. Disclosures No relevant conflicts of interest to declare.

Delayed engraftment or graft failure is one of the major complications after cord blood transplantation (CBT). To investigate factors impacting engraftment, we conducted a retrospective analysis of adult patients who underwent reduced-intensity CBT at our institute, in which preparative regimens mainly consisted of fludarabine, melphalan, and total body irradiation with graft-versus-host (GVH) disease prophylaxis using single calcineurin inhibitors. Among 152 evaluable patients, the cumulative incidence of neutrophil engraftment was 89%. High total nucleated cell and CD34+ cell dose were associated with the faster speed and higher probability of engraftment. In addition, the degree of human leukocyte antigen (HLA) mismatch in the GVH direction was inversely associated with engraftment kinetics, whereas no statistically significant association was observed with the degree of HLA mismatch in the host-versus-graft direction. Similarly, the number of HLA class I antigens mismatched in the GVH direction, but not in the host-versus-graft direction, showed a negative correlation with engraftment kinetics. HLA disparity did not have significant impact on the development of GVH disease or survival. This result indicates the significant role of HLA disparity in the GVH direction in the successful engraftment, raising the novel mechanism responsible for graft failure in CBT.

Abstract 1162 Poster Board I-184 Backgrounds Umbilical cord blood can be an alternative stem cell source for the patients of hematological diseases. However, little is known about chronic GVHD (cGVHD) and graft versus leukemia/lymphoma (GVL) effect in reduced-intensity cord blood transplantation (RICBT). We had been demonstrated that cGVHD in CBT is tolerable compared with that in BMT and that the occurrence of cGVHD could result in good prognosis. Here, we analyzed the clinical picture of chronic GVHD following RICBT and the GVL effect. Methods We reviewed medical records of 192 patients with hematological diseases who had received CBT between Jan. 2004 and Dec. 2008 who had been free from disease progression for more than 100 days after RICBT at Toranomon Hospital, Tokyo, Japan. Median age was 54 years (17-82). Most of them had diseases in advanced status (n=168). Most of the pre-transplant conditioning were reduced intensity consisted of fludarabine, melphalan and TBI 4Gy (n=157). GVHD prophylaxis were tacrolimus (Tac) alone (n=99) and Tac plus mycophenolate mofetil (MMF) (n=93). HLA disparities were as follows; 6/6 (n=9), 5/6 (n=38), 4/6 (n=142), and 3/6 (n=3). Underlying diseases were AML (n=58), myelodysplastic syndrome (n=36), ALL (n=23), lymphoma (n=64) and others (n=11). Results The Median observation period after the transplantation was 924 days (range, 109–1944). Chronic GVHD was admitted in 114 patients (59.4%) consisted of limited type 88 (45.8%) and extensive type 26 (13.5%) in classical criteria, and mild type 96 (50.0%), moderate type 15 (7.8%), and severe type 3 (1.6%) in NIH consensus criteria of cGVHD. The target organs of cGVHD were skin 87.5%, liver 40.6%, and mouth mucous membranes 32.8 %, eye 23.4%, and the lungs only 7.8% (COP3 and BOS2). Except 21 cases ( 10.9%) required systemic steroid or MMF therapy. The median of Karnofsky score of cGVHD was 90%(40-100). During observation period, no patients except one patient caused by heart failure were died of cGVHD. In multivariate analysis, high-risk disease (p=0.019) and preceding acute GVHD (p=0.026) are related to the occurrence of cGVHD, and cGVHD increased overall survival (p Conclusion Although the frequency of cGVHD was not low, the severity was mild, and the death related to cGVHD is rare in RICBT. NIH consensus criteria is useful for the evaluation of cGVHD severity. Some effect of GVL may play a role on better survival and lower relapse rate in RICBT. Disclosures No relevant conflicts of interest to declare.

Invasive fungal infections (IFI) are significant complications after allogeneic hematopoietic stem cell transplantation. We previously reported that 3-year cumulative incidence of IFI was 10.2 % and median onset of IFI was day 20 post reduced-intensity umbilical cord blood transplantation (RI-CBT) under the prophylaxis by fluconazole or micafungin (Biol Bone Marrow Transplant2007;13:771). In recent years, voriconazole (VOR) has been employed in IFI prophylactic regimens during bone marrow or peripheral blood stem cell transplantation in several clinical trials and reports, but the safety and efficacy during umbilical cord blood transplantation is unclear. In order to address this issue, we prospectively administered VOR to 46 high risk recipients of RI-CBT for IFI prophylaxis, between August 2007 and May 2008. All of the patients had no prior episode of IFI and were treated in reverse isolation in laminar airflow-equipped rooms. The plasma trough concentration of VOR and serum galactomannan index was obtained once a week. Chest CT scan was performed for persistent fever under the administration of broad antibiotics. Proven and probable IFI were defined according to revised EORTC/MSG criteria. Median age was 58 years old (range, 21–82). Twenty-three were AML, 10 were non-Hodgkin lymphoma, 6 were aplastic anemia, 5 were ALL, 1 was CML, and 1 was multiple myeloma. All patients were at high risk of IFI, except one patient with lymphoma in CR; 22 had high risk underlying diseases, 17 had prior transplantation, and 6 were very severe aplastic anemia. All patients received fludarabine-based preparative regimens. Graft-versus-host disease (GVHD) prophylaxis consisted of tacrolimus & mycophenolate mofetil in 30, tacrolimus alone in 15, and cyclosporine alone in 1. Additional immune suppressive therapy against pre-engfraftment immune reactions (Transplant2005;80:34) or GVHD were administered in 35 patients; 19 received corticosteroid (CS), 7 beclomethasone (BDP), 5 CS & BDP, 1 CS & BDP & infliximab, 1 CS & infliximab, 1 CS & BDP & etanercept, and 1 CS & methotrexate. Forty-two patients achieved neutrophil recovery > 500/uL on day 21 post-transplant at medium (range, 11–38). The median length of VOR prophylaxis from transplantation was 85 days (range, 6–422) for patients who survived longer than 100 days. The total number of patient-days on VOR was 4241 days. There were no proven IFI. Two patients developed probable pulmonary aspergillosis during VOR administration (at day 71 and 75; 1-year cumulative incidence 4.3 %.) No breakthrough infections by candida or zygomycetes were detected. VOR was well tolerated, except in 2 patients who discontinued VOR due to abnormal liver test and severe visual disturbance. Two patients developed probable pulmonary aspergillosis after switching from VOR to other antifungals (at day 80 and 263 under the administration of micafungin and itraconazole, respectively). Thus, VOR can be safely administered, and have reduced the incidence of IFI, with no breakthrough infections by candida or zygomycetes, indicating possible superiority of incorporating this drug as an IFI prophylactic regimen in RI-CBT.

Umbilical cord blood transplantation with reduced-intensity conditioning (RICBT) has been widely applied to various diseases. However, little information on long-term outcome of RICBT in advanced mature or immature lymphoid malignancies has been available so far. We retrospectively reviewed patients who had lymphoid malignancies and underwent RICBT as the first allogeneic transplant at our institute from Jan. 2002 to Apr. 2008 consecutively, excluding those who had active infection before RICBT. This study includes 110 CB recipients who diagnosed as lymphoblastic lymphoma (LBL)/acute lymphoblastic leukemia (ALL) (n=26, including 12 Ph positive) and mature lymphoid malignancies (n=84, 29 DLBCL, 6 FL/CLL, 16 peripheral T-cell lymphoma, 5 HL, 6 MM, and 22 adult T-cell leukemia (ATL)). Median age was 53 (range 26–79). The numbers of HLA-A, B and DR antigen mismatches were 0 (1.8%), 1 (8.1%) and 2 (89.1%). Median number of total nucleated cells (TNC) and CD34 positive cells infused were 2.68 x 107/kg and 0.87 x 105/kg, respectively. Majority (81.8%) had advanced disease (relapse or refractory disease), 36 cases (32.7%) had poor performance status (ECOG PS≥ 3), and 27 cases (24.5%) had prior autologous transplant. Conditioning regimen consisted mainly of fludarabine 125mg/m2, melphalan 80–140 mg/m2, and 0–8 Gy TBI. Cyclosporine A or taclolimus±mycophenolate mofetil were used as GVHD prophylaxis. Eighty five percent of the cases who survived longer than 28 days showed neutrophil recovery (median 19 days (11–44)). The incidence of grades II–IV acute GVHD and chronic GVHD among evaluable patients were 42.3% and 37.6%, respectively. Median follow-up time of survivors was 1422 days (109–1896). Overall survival (OS) and progression-free survival (PFS) were 36.9%(27.8–46.0) and 30.6%(22.0–39.3) at 1 year, and 25.3%(17.0–33.6) and 22.8%(14.9–30.8) at 3years, respectively. Treatment related mortality (TRM) and relapse mortality (RM) at 500days were 41.9% and 28.6%, respectively. The diagnosis-based PFS at 3 years were 33.8% for ALL, 20.7% for DLBCL, 33.3% for FL/CLL, 25.5% for PTCL, 40.0% for HL, 20.0% for MM, and 9.1% for ATL. In univariate analyses, factors significantly associated poor PFS were the diagnosis of ATL, high disease risk, poor PS (≥ 2), high HCT-CI (≥ score 2), and high LDH level (high tumor burden). Factors associated higher TRM were poor PS (≥ 2) and lower TNC infused (4Gy), although Ph chromosome was not associated with OS or PFS. In multivariate analyses of all patients, poor PS (≥ 2) was the only significant factor associated with lower OS (RR 2.63, p=0.0093), PFS (RR2.13, p=0.0338) and not only higher TRM (RR 2.30, p=0.0148),but higher RM (RR 2.94, p=0.0081), suggesting poor PS group have highly advanced disease. Interstingly, higher LDH level, not poor PS, was found to be the only significant factor associated with lower OS and PFS in multivariate analysis of mature lymphoid malignancies. Although the high TRM should be improved, these data indicate RICBT to have sufficient potential to achieve long-term durable remission for both immature and mature lymphoid malignancies except ATL in advanced status. Lower tumor burden (low LDH level) in mature lymphoid malignancies and higher dose of TBI in ALL may be the keys to further improve long-term outcome.

Although cord blood (CB) transplantation with reduced-intensity conditioning (RICBT) has been widely applied to those who lack available related or unrelated donors and are not eligible for conventional conditioning, the optimal pre-transplant conditioning has not been established yet. Intravenous busulfan (ivBu) has been incorporated in conditioning regimens before bone marrow or peripheral blood stem cell transplantation, but the feasibility in cord blood transplantation has been controversial. In order to address this issue, we retrospectively reviewed patients who underwent RICBT including ivBu. Twenty-one patients, who were at ECOG performance status of 2 or less and received RICBT at our institute from June 2007 to April 2008 consecutively, were included in this study. Median age was 56 years (range, 21–71). Seventeen were AML, 3 were ALL, and 1 was MDS RA. All but 2 (MDS RA and ALL in CR2) were not in remission, 5 had CNS involvement, and 9 had history of prior transplantation. Seventeen had HCT-specific comorbidity index score ≥1, including 8 ≥2, and 6 ≥3. Fludarabine phosphate 125–180mg/m2 and ivBu 6.4–12.8mg/kg were used in all patients. All but 2 received additional melphalan (Mel) or total body irradiation (TBI); Mel 80–140mg/m2 for 10, 2–8Gy of TBI for 8, and Mel 40mg/m2 plus 4Gy of TBI for 1. Graft-versus-host disease prophylaxis consisted of tacrolimus plus mycophenolate mofetil in 11, tacrolimus alone in 8, and cyclosporine alone in 1. Single cord blood units, matched at 4/6 in 20 and 5/6 in 1, of 2 x 107/kg of recipient body weight at minimum were infused. Seventeen achieved neutrophil recovery ≥500/μl on day 19 post-transplant at medium (range, 12–30). Among 4 who failed to achieve neutrophil recovery, 2 experienced early disease progression, 1 showed rejection, and 1 died before engraftment due to interstitial pneumonia. All 17 patients who achieved neutrophil engraftment and 1 who died before engraftment showed complete donor-type chimerism on 13 days post-transplant at medium (range, 8–35). Median follow-up time of survivors was 398 days (range, 162–532) post-transplant. Cumulative incidence of non-relapse mortality at day 100 and day 365 post-transplant were both 19%. No VOD/SOS was observed. Disease-free survival and overall survival (OS) at 1 year post-transplant were 40±11% and 61±9%, respectively. Thus, ivBu can be safely administered, and have potential to achieve successful engraftment as well as sufficient disease control, indicating possible benefit of incorporating this drug in pre-transplant conditioning of RICBT. The optimal dosing schedule or combination with other therapeutic modalities needs further investigation in prospective clinical trials.

Although unrelated cord blood transplantation (UCBT) has become a viable therapeutic option widely applicable for adult patients with hematological diseases, UCBT for severe aplastic anemia (SAA) remains to be controversial due to higher incidence of graft failure (GF) relative to the other stem cell sources. To evaluate the feasibility of UCBT for SAA, we retrospectively analyzed results for 11 adult patients with SAA who received first UCBT after reduced-intensity conditioning regimen (RI-UCBT) in Toranomon Hospital. Median age was 49 years (range, 20–70). Nine of them were non-responders to intensive immunosuppressive therapy and were multiply transfused, and two patients were fulminant type with no neutrophils in peripheral blood at diagnosis. The conditioning regimen consisted of fludarabine 125mg/m2, melphalan 80mg/m2, and 4 Gy of total body irradiation. Graft-versus-host disease prophylaxis was composed of cyclosporine alone (n=2), tacrolimus alone (n=2), and tacrolimus plus mycophenolate mofetil (n=7). Median total nucleated cell number and median CD34+ cell number were 2.65 × 107/kg (range, 1.83–4.39) and 0.70 × 105/kg (range, 0.27–1.52), respectively. Serological HLA disparities were as follows; 6/6 (n=3), 5/6 (n=2), and 4/6 (n=6). Ten of the 11 patients achieved primary neutrophil and platelet engraftment. Median time to an absolute neutrophil count > 0.5×109/liter and an unsupported platelet count > 20×109/liter were 18 days (range, 12–28) and 42.5 days (range, 26–64) respectively. All patients who achieved engraftment resulted in complete hematological recovery with complete donor chimerism, except for one patient who developed late GF at three years after UCBT. All 2 who experienced GF (1: primary GF, 1: late GF) were rescued by second RI-UCBT. Two of the 11 patients died from IPS (n=2), and remaining 9 patients are alive, having survived for 18.7 months (range, 2–71 months). Six out of 7 patients who survived more than 6 months were free from immunosuppressant. The probabilities of overall survival and event-free survival at 2 years after UCBT were 77.8% and 68.2%, respectively. Our results here strongly indicated feasibility and effectiveness of RI-UCBT for adult SAA patients with high engraftment rate and low treatment-related mortality. RI-UCBT could be considered as a viable therapeutic option for those who lack suitable HLA-matched sibling donors and failed immunosuppressive therapy.

Background: HHV6 reactivation has been increasingly recognized in allogeneic haematopoietic stem cell transplant recipients, particularly in umbilical cord blood transplantation. In adult recipients, HHV6 has been associated with limbic encephalitis (HHV6-LE), which causes anterograde amnesia and epilepsy. The CNS disorder confined to the hippocampal regions; the presence of abnormal MRI signals involving the hippocampus, and detection of HHV6 DNA inCSF. However, the clinical features of the syndrome have not been well characterized. Methods: In this study we retrospectively reviewed the medical records of 139 umbilical cord blood transplantation recipients with reduced-intensity conditioning between January 2006 and December 2007 at Toranomon Hospital in Japan to determine the incidence of HHV6-LE among these patients. The diagnosis was based on the acute development of retrograde amnesia, confusion, coma and seizures accompanied by charascteristic MRI findings of abnormal high signal intensity on flair and T2 weighted images in the hippocampus and mesial temporal lobes, and the detection of HHV6 DNA in CSF. Eighty-six were received foscarnet before the onset of HHV6-LE as prophylaxis. All the patients who manifested suspicious symptoms of HHV6-LE were treated with foscarnet. Results: HHV6-LE was diagnosed in 11/139 for a cumulative incidence of 7.2%. The median age was 49 years (range 36–82), 3 were female. Diseases treated were AML/MDS (8), ALL (1), diffuse large B-cell lymphoma (1), and aplastic anemia (1). All 11 were conditioned with fludarabine-based reduced-intensity regimen, and tacrolimus alone (5) or tacrolimus+mycophenolate mofetil (6) were used as GVHD prophylaxis. Five of them had started foscarnet before the onset of HHV6-LE as a prophylaxis. Median symptom onset was on day +20 (range, 12–50). Initial symptoms included confusion in 9, retrograde amnesia in 8, and seizures in 5. MRI demonstrated hyppocampal and mesial temporal lobe FLAIR/T2 high signal intensity in 8/11. Initial CSF analysis demonstrated a median WBC count was 7 (range, 1–21)/μl, median protein was 49 (range, 44–337) mg/dl, median glucose was 107 (range, 62–269) mg/dl. No positive results of bacterial or viral cultures were observed in any of the patients. Median HHV6 DNA levels in the CSF was 20000 (range, 200–80000) copies/ml. Median HHV6 DNA levels in peripheral blood was 200 (range, 0–300000) copies/ml. Remarkably, 7 patients were negative for HHV6 in peripheral blood even within 6 days prior to the onset of CNS symptoms. All were treated with foscarnet at 50–100mg/kg of body weight, and clinical symptoms improved in 9 evaluable patients (2 were not evaluable due to severe pulmonary complications). The virus was cleared in the CSF successfully in 7 patients evaluated. Seven died with the median survival of 32 days (range, 7–346) from diagnosis of limbic encephalitis. HHV6-LE was not a direct cause of death in any of them (2 were from infection, 2 from IP, 2 from relapse, and 1 from MOF). Four were alive as of July 31, 2008, and what is of extreme interest is that all were those who received foscarnet as a prophylaxis. None of the factors analysed failed to reach statistical significance regarding the impact on the onset of HHV6-LE. Conclusions: High incidence of HHV6-LE as well as reactivation of the virus was observed in CB recipients. HHV6 DNA monitoring in peripheral blood may not be sufficient to predict the development of HHV6-LE. Although clinical manifestations were severe in some cases, foscarnet therapy was effective in all evaluable cases. Possible positive impact of prophylactic foscarnet therapy on better survival was suggested, which needs further evaluation by prospective study.

Blood stream infection (BSI) is a major cause of transplant-related mortality (TRM) following allogeneic hematopoietic stem cell transplantation, and to overcome it, reduced-intensity preparative regimens were developed in recent years. However, little information has been reported on BSI after reduced-intensity cord blood transplantation (RI-CBT). To clarify the characteristics of BSI after RI-CBT, we compared the incidence of microbiologically documented BSI before day 100 between RI-CBT and reduced-intensity non-cord blood allogeneic hematopoietic stem cell transplant (RI-non-CBT) recipients in Toranomon hospital, Japan. RI-non-CBT group includes related bone marrow (rBM), related peripheral blood stem cell (rPBSC) and unrelated bone marrow (uBM) transplantation. We retrospectively reviewed the first events of BSI in 211 consecutive adult patients between Jan 2004 and July 2006. One hundred and fifteen patients received RI-CBT and 96 patients received RI-non-CBT (4 from rBM, 34 from rPBSC and 58 from uBM). The median ages of patients in both groups were 55 years. All of the preparative regimens were fludarabine-based and prophylaxis against GVHD was tacrolimus alone in most of the RI-CBT recipients and combination of calcinurin inhibitor and short-term methotrexate in most of the RI-non-CBT recipients. The median time to achieve neutrophil engraftment was delayed in RI-CBT group (day 20 vs. day15). The cumulative incidence of engraftment at day 60 was 73.0% in RI-CBT group versus 90.6% in RI-non-CBT group. The cumulative incidence of BSI was 39.3% at day 100 and RI-CBT group tended to have more BSI compared to RI-non-CBT group (46.1% vs. 31.3%, p=0.0122), particularly at the early points after transplantation. Median day of positive culture for bacteremia was earlier (day 9 vs. day 14) in RI-CBT group. In spite of reduced-intensity preparative regimen, RI-CBT in adults is associated with higher rates of BSI at early time points after transplantation.

Background Late-onset hemorrhagic cystitis (HC) is a common viral infections after allogeneic hematopoietic stem cell transplantation (HSCT). Most cases of HC occurring after HSCT are self-limited, but they can cause pain, pollakiuria, and prolonged hospitalization. In cases with progression of HC, ureteral stenosis has occurred and occasionaly resulted in obstructive renal failure. Several risk factors associated with HC after bone marrow transplantation(BMT) and peripheral blood stem cell transplantation(PBSCT) have been reported in several studies. However, most of these risk factors for HC after cord blood transplantation(CBT) have not been observed in detail. Subjects and methods We retrospectively analyzed the clinical records of 461 patients who underwent HSCT at Toranomon Hospital between November 2002 and December 2006. Median age of the patients was 53 years (range 17– 79). Source of HSCT was peripheral blood (PB) in 79 patients (17%), cord blood (CB) in 281 patients (61%), bone marrow (BM) in 101 patients (22%). Underlying diseases were AML(n= 146), ALL(n=61), MDS(n=68), ATL(n=34), CML(n=8), NHL (n=109), other(n=35). The most frequently used conditioning regimens were fludarabine (Flu), alkylating agent (melphalan, busulfan or cyclophosphamide) with total body irradination (TBI).The most frequently used prophylaxis regimens for graft-versus-host disease (GVHD) were calcineurin inhibitor (CI) alone or CI plus methotrexate. HC was defined as the presence of sustained microscopic hematuria for more than 7 days at least 10 days after HSCT in the absence of other conditions such as gynecologic-related bleeding, multiple organ dysfunction, or sepsis. HC was graded according to the following criteria: grade0 = no HC, grade1 = microscopic hematuria, grade2 = macroscopic hematuria, grade3 = macroscopic hematuria with clots, grade4 = macroscopic hematuria requiring instrumentation for clot evacuation or causing urinary retention. BK virus and adenovirus were detected by PCR on urinary samples in all patients who developed HC. Results Overall, 73 patients (16%) developed HC. The median day of presentation was 55 days (range 10 to 505 days). HC cases were graded as follows: grade 1 (8%), grade 2 (64%), grade 3 (24%), grade 4 (4%). The following variables were associated with a higher incidence of HC: CB source vs BM vs PB (14.2% vs 19.8% vs 16.5%, p Conclusion We concluded that there is no significant disparity in the rate of HC among CBT and other HSCT, and immune reconstitution in parallel with BK and adenovirus viruria after CBT stand comparison with other HSCT.

Objectives: Non-infectious pulmonary complications (NIPC) are fatal disorders following allogeneic SCT. NIPCs include idiopathic pneumonia syndrome (IPS), diffuse alveolar hemorrhage (DAH), adult respiratory distress syndrome (ARDS), which occur early period (early NIPCs), and late onset NIPCs (LONIPCs) such as bronchiolitis obliterans (BO), cryptogenic organizing pneumonia (COP), and interstitial pneumonia (IP). There has been little information on NIPCs following cord blood transplantation (CBT). We tried to characterize NIPCs after CBT by estimating the incidence, types of NIPC, and prognosis, and to identify risk factors for them. Methods: We reviewed medical records of 246 patients (291 transplants) with hematological diseases who had received CBT between Jan. 2002 and Dec. 2006 at Toranomon Hospital, Tokyo, Japan. Median age was 55 years (17–79). Most of them had diseases in advanced status (n=255). Median follow-up time was 901 days (111–2470). Most of the pre-transplant conditioning were reduced intensity consisted of fludarabine, melphalan and TBI 4Gy (n=223). Cyclosporine (CSP) (n=102) or tacrolimus (Tac) alone (n=173) and Tac with methotrexate (n=18) or mycophenolate mofetil (n=19) were used as GVHD prophylaxis. HLA disparities were as follows; 6/6 (n=14), 5/6 (n=73), 4/6 (n=198), and 3/6 (n=6). Diagnosis of NIPC was made by Chest X-ray, computed tomography, bronchoscopy, broncho-alveolar lavage (BAL) and pulmonary function test. Infectious complications were excluded by positive result of culture, galactomannan test, and RT-PCR of sputum, pleural effusion and BAL fluid. Results: The incidence of NIPCs was 33.7% (n=98). Most of NIPCs (95 patients) were developed within 100 days after transplant (median, 17days, range, 2–57). Early NIPCs can be subdivided into 2 on the basis of presence (n=48) or absence (n=47) of pleural effusion (PE). LONIPCs were observed in only 11 cases (4.5%), including 3 cases of COP, 6 of IP, and 2 of BO, and 8 of them occurred within 100 days after transplant. Multivariate analysis revealed 3 risk factors for early NIPCs; GVHD prophylaxis with CSP over Tac (p=0.036, RR 1.65), grade III–IV acute GVHD over grade 0–II (p=0.007, RR 1.84), and 2 and greater HLA mismatch over less than 2 (p=0.046, RR 1.587). The CT finding of IPS with PE revealed ground-glass opacity of lung field, similar to that of COP. IPS with PE responded favorably to low dose corticosteroid therapy as same as COP. In contrast to low 1-year overall survival (OS) of IPS without PE (11.1%, 95%CI: 1.9–20.3), that of IPS without PE was significantly high (53.1%, CI: 38.8–67.4). Among LONIPC patients, those who developed LONIPC later than day 100 post-transplant (n=3), no one required long-term oxygen therapy or died directly from respiratory failure due to the lung diseases. Discussion: The incidence of IPS was relatively high, whereas that of LONIPCs was low after reduced-intensity CBT using single calcineurin inhibitor as GVHD prophylaxis. Although IPS with PE showed good prognosis similar to COP, further accumulation and more precise investigation of laboratory and clinical data are warranted to clarify the biological mechanism of IPS with PE and without PE or to descriminate IPS from engraftment syndrome or capillary leak syndrome.

Backgrounds: Umbilical cord blood can be an alternative stem cell source for the patients with hematological malignancies requiring allogeneic stem cell transplantation. However, little is known about graft versus leukemia/lymphoma (GVL) effect in cord blood transplantation (CBT). Here, we analyzed chronic GVHD (cGVHD) in CBT compared with that in BMT and evaluated the relevance between cGVHD and GVL. Patients/methods: We retrospectively studied 162 patients who had been free from disease progression for more than 100 days after either unrelated BMT (n=75) or CBT (n=87) at Toranomon Hospital from January 2002 to October 2006. Median age of the patients was 52 years old (BMT vs CBT: 49 vs 53). Underlying diseases were acute leukemia (n=88), myelodysplastic syndrome (n=17), lymphoma (n=39) and others (n=18). Conditioning regimens were mainly composed of Fludarabine 125–180 mg/m2 with several combinations of Melphalan 80–140 mg/m2, Busulfan 8–16mg/kg and/or total body irradiation (4–8 Gy). Results: The Median observation period after the transplantation was 612 days (range, 109–1944). The cumulative incidence of cGVHD was 84% in BMT and 62% in CBT (p=0.09). The severity of cGVHD was analyzed based on its type; limited or extensive. In CBT, the percentage of the former type was 34% (vs 25% in BMT) and the latter was 23% (vs 48% in BMT). High-risk disease (p=0.03) and preceding acute GVHD(p=0.03) are related to the occurrence of cGVHD. RICBT tended to increase cGVHD compared to CBT using BU/CY or CY/TBI regimen, Multivariative analysis showed that cGVHD increased overall survival (p Discussion: We demonstrated that cGVHD in CBT is tolerable compared with that in BMT and that the occurrence of cGVHD could result in good prognosis. Our analysis also suggested that CBT could have GVL effect as well as BMT.

Promising results of cord blood transplants from unrelated donors have been reported in adults. To compare of outcomes of bone marrow transplants (BMT, n = 51), and umbilical cord blood transplants (UCBT, n = 110) from unrelated donors in adult patients with acute myeloid leukemia (AML) / myelodysplastic syndrome (MDS), we analyzed retrospectively the results of 161 adult patients with AML and MDS in our hospital. We reviewed medical records of 161 patients with AML/MDS who had received a hematopoietic stem cell transplant from an unrelated donor between August 2000 and April 2007 at Toranomon Hospital, Tokyo, Japan. Patient’s median age was 55 years (17–71). Diagnoses include de novo AML (n =85), MDS overt AML (n=48), refractory anemia (RA) (n=13), and refractory anemia with excess of blasts (RAEB) (n=15). Disease status consisted of standard (CR1 of AML and RA, n=30) and advanced (other status, n=131). Recipients of UCBT had more advanced disease than recipients of BMT at the time of transplantation (89 percent vs. 65 percent, P We conclude that UCBT from an unrelated donor is a therapeutic option for adult AML/MDS patients who lack an HLA-identical donors. Higher mortality, especially from non-relapse causes, is the biggest problem to be solved to increase the feasibility of this approach.

Backgrounds: For more than 10 years, umbilical cord blood has become an alternative stem cell source for the patients with hematological malignancies requiring allogeneic stem cell transplantation. Cord blood transplantation (CBT) can be performed more quickly than other stem cell transplantation, since cord blood units are preserved in the deep freeze and 1–3 HLA mismatched donors are acceptable. Considering these advantage, we examined the feasibility of cord blood transplantation using reduced-intensity regimens (RI-CBT) for adult relapsed patients after allogeneic tranplantation. Patients/methods: We reviewed medical records of 26 patients who received RI-CBT at Toranomon Hospital between November 2003 and June 2006. Median age of the patients was 36 years (range, 20–66). Underlying diseases were acute leukemia (n=17), myelodysplastic syndrome (n=4) and lymphoma (n=5). The stem cell source of the first transplantation were bone marrow from sibling donor (n=2), bone marrow from unrelated (n=5) donor, peripheral blood stem cell from sibling donor (n=5) and unrelated cord blood (n=14). Conditioning regimens comprised fludarabine 125–180 mg/m2 in several combination with melphalan 80–140 mg/m2, Busulfan 8–16mg/kg and total body irradiation (TBI) (4–8 Gy). Graft-versus-host disease (GVHD) prophylaxis was cyclosporine (n=5) or tacrolimus (n=21). Median number of total nucleated cells and CD34+ cells was 2.56×106 cells/kg (1.91–5.94), and 0.86×105 cells/kg (0.57–1.77) respectively. HLA disparities were 5/6 (n=2), 4/6 (n=22), and 3/6 (n=2). Results: Median observation period was 58 days (range, 32–380). Overall survival for 1 year was 15% and 16 patients were died of disease progression (n=5) and infection (n=11). The infection in 4 patients was considered to be caused by regimen related toxicity (RRT). No grade IV toxicities (NCI-CTC Ver.3.0) were observed. The duration between two transplantations was longer in surviving patients compared to dead patients (98 days (range, 39–2108) and 262 days (range, 95–901), respectively), although significant difference was not detected. The stage of the disease in the second transplantation, conditioning regimens and HLA disparities did not influence to the outcome. Discussion: We demonstrated that RI-CBT could be an available and feasible treatment for the relapsed patients after stem cell transplantation. Moreover, the RRT is acceptable even in the patients with an advanced disease.

Despite the fact that the majority of cord blood grafts were human leukocyte antigen (HLA) disparate at one to two antigens, acute graft-versus-host disease (GVHD) was less severe after cord blood transplantation (CBT) compared to unrelated bone marrow transplantation. On the other hand, engraftment failure is a serious problem after CBT. We retrospectively analyzed the influence of HLA compatibility on engraftment after reduced-intensity umbilical cord blood transplantation (RI-CBT). We analyzed the clinical outcome of patients who underwent first RI-CBT at Toranomon hospital between January 2002 and December 2005. Those who had died within 28 days from the day of transplant were excluded from these analyses. All 156 patients had hematological malignancies including 41 with AML, 21 with ALL, 6 with CML, 19 with MDS, 31 with malignant lymphoma, 14 with adult T-cell leukemia/lymphoma, 6 with other diseases. Median age was 54 years (range, 17–79 years). All of them were considered to be inappropriate for conventional stem cell transplantation due to the lack of an HLA-identical related donor, age >50 years old and/or organ dysfunction. The preparative regimens were mainly composed of fludarabine 125 mg/m2, melphalan 80 mg/m2, and 4 Gy total body irradiation. GVHD prophylaxis was composed of cyclosporine or tacrolimus alone. Eight, 46, 98 and 4 patients received 6 of 6, 5 of 6, 4 of 6 and 3 of 6 HLA antigen matched cord blood in graft-versus-host (GVH) direction. Primary engraftment failure was diagnosed in 18 patients (11.5%). Median time to engraftment was 19 days (range, 11–55 days) for the total patient group. In GVH direction, the cumulative incidence of engraftment at day 100 were 94.4% in 5 to 6 of 6 antigen matched cord blood and 85.3% in 3 to 4 of 6 antigen matched cord blood (p=0.001). Median time to engraftment was 17 days (range, 11–36 days) in 5 to 6 antigen matched cord blood and 20 days (range, 11–55 days) in 3 to 4 antigen matched cord blood. In host-versus-graft direction, the cumulative incidence of engraftment at day 100 were 90.9% in 5 to 6 antigen matched cord blood and 87.5% in 3 to 4 antigen matched cord blood (p=0.5895). Median time to engraftment was 18.5 days (range, 11–55 days) in 5 to 6 antigen matched cord blood and 19 days (range, 11–49 days) in 3 to 4 antigen matched cord blood. In univariate analysis, both total cell dose (>3 x 107/kg) and CD34 positive cell dose (>1 x105/kg) were significantly associated with the engraftment (p=0.0009 and p=0.0005). Age, gender, risk, GVHD prophylaxis, blood type mismatch and early immune reaction were not associated with the engraftment kinetics. Multivariate analysis revealed 5 to 6 antigen mismatch in GVH direction was a significant independent factor for engraftment (p=0.0073), as well as CD34 positive cell dose. In conclusion, HLA disparities in GVH direction are associated with engraftment in adult patients receiving reduced-intensity umbilical cord blood transplantation using calcineurin inhibitor alone for GVHD prophylaxis.

Background: Therapeutic outcomes for hematological diseases have recently been markedly improved due to the introduction of hematopoietic stem cell transplantation (HSCT), improvement of therapeutic regimens, and advancement of support therapy. Although invasive fungal infections have been one of the major causes of morbidity and mortality after cord blood transplantation(CBT), proper prophylactic and therapeutic approach to them has not been clearly established yet. To address this, we performed retrospective analysis to assess the effectiveness and safety of various antifungal agents for prevention and treatment of invasive fungal infections. Patients and Methods: Medical records of a total of 188 patients who underwent umbilical CBT at Toranomon hospital between March 2002 and December 2005 were reviewed. The diagnosis included AML (n=53), ML (n=32), MDS (n=25), ALL (n=24), ATL (n=22), CML (n=7), AA (n=5), MM (n=3), and others (n=17). The median age was 54 (range; 17–79). The conditioning regimen consisted of fludarabine (125mg/m2), melphalan (80 mg/m2) and 4 Gy TBI for most of the patients. The incidence of breakthrough invasive fungal infection within 50 days after transplant was analysed. Results: Forty-eight of the 188 were administered prophylactic anti-fungal agents other than fluconazole (FLCZ) due to prior mold infection, intorelant to FLCZ, and so on, were excluded. Remaining 140 patients who received FLCZ categolized into 2 groups; those who had empirically switched FLCZ to micafungin (MCFG) and/or amphotericin B (AMPH) and/or itraconazole (ITCZ) capsule at the first sign of infection (group A, n=69), and those who had continued FLCZ (group B, n=71). Four breakthrough invasive fungal infections were observed, 3 of them were invasive pulmonary aspergillosis (IPA), and 1 of them was tricosporon sepsis. Interestingly, all of these 4 were in group B, whereas no breakthrough infections were observed in those who were in group A. All 3 diagnosed IPA died of its exacerbation despite MCFG and/or AMPH treatment. Conclusion: Proper administration of prophylactic anti-fungal agents can reduce the incidence of invasive fungal infection early after CBT. Although FLCZ has less activity to aspergillus, prophylactic FLCZ is effective enough to prevent breakthrough fungal infection. Immediate switch to other agents at the first sign of infection, such as MCFG, AMPH, ITCZ which are active against aspergillus could be recommended to prevent breakthrough infections.

Previous reports about comparison between unrelated donor and cord blood for acute leukemia with myeloablative regimens showed that at least relapse rate (RR) and overall survival (OS) were not significantly different in the two groups. However we have not yet understood comparison among R-PBSCT, U-BMT, and U-CBT with reduced intensity regimens for elderly AML/MDS patients. The 1st purpose of this report was to investigate OS and causes of death and the 2nd was to investigate engraftment, incidence of acute/chronic GVHD, and RR for AML/MDS patients received R-PBSCT, U-BMT, and U-CBT with reduced intensity regimens. We reviewed medical records of 62 AML/MDS patients who had received RIST between June 2001 and March 2005 at Toranomon Hospital, Tokyo, Japan. 20 patients received R-PBSCT, 19 patients U-BMT, and 23 patients U-CBT. Median age was 56 years (17–70). Primary diseases were de novo AML (n=34) and MDS overt leukemia (n=11), and MDS (n=17) including advanced (n=47) or standard (n=15). Median follow-up was 7.2 months (1.5–37). Conditioning regimen consisted of Fludarabine (Flu) + Busulfan (BU) with cyclosporine (CyA) + MTX in R-PBSCT, Flu + BU + TBI 4Gy with CyA or tacrolimus +MTX in U-BMT, and Flu + Melphalane (Mel) + TBI 4Gy with tacrolimus only in U-CBT, respectively. G-CSF was used after RIST until neutrophile engraftment. HLA disparities were 6/6 match (n=18) and 5/6 (n=2) in R-PBSCT, 6/6 (n=18) and 5/6 (n=1) in U-BMT, and 5/6 (n=2) and 4/6 (n=21) in U-CBT, respectively (P500/μL)/platelet recovery (>20,000/μL) were observed 100% (median 16.5 days) and 90% (13.5) in R-PBSCT, 90% (20) and 79% (26) in U-BMT, and 91% (21.5) and 70% (41.5) in U-CBT, respectively (P In this report, the differences were followings; HLA disparities, infused CD34 cell dose, conditioning regimen with GVHD prophylaxis, neutorphile and platelet engraftment. The incidence of acute/chronic GVHD, OS, RR, and causes of death were same among three groups. This Flu+Mel+TBI 4Gy + tacrolimus with U-CBT would be feasible and acceptable for elderly patients with AML/MDS. Figure Figure

Allogeneic stem cell transplantation has been potentially curative approach for advanced malignant lymphoma. Unrelated umbilical cord blood cell has become a viable source of transplantation for those who lack suitable donors, but the outcome of the transplantation with reduced-intensity conditioning has not been clearly defined yet. We have therefore analysed the outcome of the patients with advanced malignant lymphoma who have undergone reduced-intensity unrelated cord blood transplantation (RI-UCBT). Thirty patients (median age, 47 years; range 27–69 years) underwent RI-UCBT with a preparative regimen consisting mainly of fludarabine 125 mg/m2, melphalan 80 mg/m2, and 4 Gy of total body irradiation since June 2002 to June 2005 with a mean follow-up of 353 days (59–621 days). The types of lymphoma included in this study were DLBCL (11 cases), PTCL (5), Hodgkin disease (5), Follicular lymphoma (5), AITL (2), ALCL (1), and nasal NK/T lymphoma (1). All the patients were heavily treated before proceeding to RI-UCBT, including 9 with prior autologous and 1 allogeneic transplantation. The median infused total cell dose was 2.71 x 107/kg (range, 1.76–4.76 x 107/kg). Graft-versus host disease (GVHD) prophylaxis was composed of cyclosporine or tacrolimus alone. Twenty-four patients (80%) achieved primary neutrophil engraftment at a median of 23 days (12–33 days), and 18 (60%) achieved platelet engraftment at a median of 40 days (26–77 days). Fourteen patients (57.1%) developed grade II to IV acute GVHD at a median of 31 days (15–59 days). Five patients subsequently relapsed and all died within 2 years. Fifteen patients died of non-relapse causes such as infection (8), GVHD (3), IP (2), and others (2). Transplant-related mortality (TRM) within 100 days was 54%. The estimated 1-year probability of overall survival was 24% (95%CI: 1–46%). In subgroup analyses, standard risk patients (CR1, CR2, PR1, n=5) showed 80% while high risk (n=25) showed 13% overall survival at 1 year. These data suggest that RI-UCBT is a feasible option for patients with refractory lymphoma who lack HLA-matched donors. Although the patients in standard risk can expect reasonably good overall survival, the beneficial effect is only limited to small part of the high risk patients. To further improve the outcome, RI-UCBT should be investigated among patients with less advanced diseases in a well-designed clinical trial. Figure Figure

Invasive fungal infection is one of the most fatal complications after stem cell transplantation (SCT). EBMT group reported the risk factors of invasive fungal infections were delayed neutrophile engraftment and steroid use for acute graft versus host disease (GVHD) in cord blood transplantation with myeloablative regimens. However it has not been clear about invasive fungal infections after RICBT. The 1st purpose of this report was to investigate the incidence and pathogens of invasive fungal infections and the 2nd was to identify the risk factors for fungal infections after RICBT. We reviewed medical records of 103 patients with hematological diseases who had received RICBT between March 2002 and May 2005 at Toranomon Hospital, Tokyo, Japan. Median age was 57 years (17–79). Primary diseases were advanced (n=81) or standard (n=22). Median follow-up was 14 months (0.5–27). Conditioning regimen was fludarabine 125 mg/m2, melphalan 80 mg/m2 and TBI 4 Gy. GVHD prophylaxis was cyclosporine (n=67) or tacrolimus (n=43). Median total nucleated cells (TNC): 2.8 x 10^7 cells (1.7–5.2); Median CD34+: 0.78 x 10^5 cells (0.01–3.28); HLA match: 6/6 (n=2), 5/6 (n=16), 4/6 (n=88), 3/6 (n=1). Fluconazole 200mg/day was used as prophylaxis of fungal infections. Diagnosis of invasive fungal infection was made with the following EORTC/MSG criteria. The following factors were considered potential predictors of outcomes about 2nd purpose: patient’s age, infused TNC dose, disease status at transplantation, speed of netrophile engraftment, pre-engraftment reactions (PER) which we reported (Clin Cancer Res.10:3586–92, 2004), and acute GVHD. Neutrophile (>500/μL) and platelet recovery (>20,000/μL) were observed in 83% at day 60 (median; 22 day), 55% at day 100 (43day), respectively. Cumulative incidence of acute GVHD (II-IV) was 33%. OS were 39% (95% CI: 29–50) in all cases, 67% (95% CI: 47–87) in standard, and 32% (95% CI: 20–43) in advanced (p In our experience with reduced intensity cord blood transplantation, the only risk factor for invasive fungal infections was steroid use for PER within 30 days. Invasive fungal infections, especially invasive aspergillosis, remain an important complication after allogeneic stem cell transplantation, regardless of the type of conditioning regimens and the sources of stem cells. Figure Figure

Introduction: ATL in advanced stage is a lymphoid malignancy with poor prognosis, its mean survival time being a few months. Allogeneic hematopoietic stem cell transplantation has been shown to be potentially curative approach, but the availability of HLA-matched donor, either of related or unrelated, limits its application to many of the patients. Cord blood has been widely used as an alternative donor cells. We report here the feasibility of RICBT for patients with advanced ATL. Patients and Methods: Eighteen patients with advanced ATL, including 11 acute type and 7 lymphoma type, who underwent RICBT between March 2002 and June 2005 at our institution, were retrospectively analyzed. Eighty percent of them were chemo-refractory at the time of transplant. Median age of the patients was 59 years (27–79). Pretransplant conditioning regimen consisted of fludarabine 125 mg/m2, melphalan 80 mg/m2 and TBI 4 Gy. GVHD prophylaxis was either cyclosporine (CSP, n=11) or tacrolimus (TAC, n=7) alone. The median number of infused nucleated cells and CD34 positive cells were 2.83 (1.95–4.83) x 107 and 1.00 (0.40–2.91) x 105, respectively. All the patients received CB units with HLA mismatches at 1 (n=8) or 2 (n=10) loci. Results: Neutrophil and platelet engraftment were observed in 15 (83.3%, median 16 days) and 14 patients (77.8 %, median 42 days). Two died before engraftment. Five of the engrafted patients (30%) developed acute GVHD (grade II–IV). Although 14 out of 15 patients who survived over 30 days achieved complete remission, 6 died of non-relapse mortality (NRM) within 100 days post-transplant (5 sepsis, 1 encephalitis), and another 6 died of relapse (median 225 days post-transplant). Five of the 7 patients who were alive beyond 100 days developed chronic GVHD (4 limited, 1 extensive). One patient experienced rapid tumor regression along with the chronic GVHD after cessation of TAC at day 146 post-transplant, indicating possible GvATL effect. Estimated 1-year overall and progression-free survival rates were 27.9 +/− 9.0 % and 17.2 +/− 12.8 %, respectively. Among 9 survivors beyond 100 days post-transplant, 5 remain alive at median follow-up of 17 months but only 2 of them remain progression free. Univariate analyses revealed high age (over 60), poor ECOG performance status (over 2) and high sIL-2R level (over 10000IU/L) as poor factors for survival. TAC dramatically decreased the day 100 mortality (14.3%) compared with CSP (45.5%). Conclusion: This pilot study indicates that our RICBT is feasible even for the ATL patients in advanced stage. Day 100 mortality was improved by using TAC but eventually the overall survival decreased to comparable level with CSP. To further improve the outcome, RICBT should be investigated for patients in early stage of the disease, or new approach to prevent late relapse should be explored.

Allogeneic stem cell transplantation (allo-SCT) is a curative treatment for advanced myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). The therapeutic benefits are attributable to myeloablative radiochemotherapy and graft-versus-leukemia effect, whereas severe regimen-related toxicity (RRT) limits the efficacy of allo-HSCT to young patients without co-morbidities. Reduced-intensity stem-cell transplantation (RIST) using a non-myeloablative preparative regimen has been developed to decrease RRT, whilst preserving an adequate antitumor effect. RIST may be a curative treatment for heavily pretreated elderly patients with myeloid malignancies. Umbilical cord blood from unrelated donors has been used as an alternative stem cell source. We report the results of reduced-intensity unrelated cord-blood transplantation (RI-UCBT) in patients with advanced or high-risk myeloid malignancies. Forty-eight patients (median age, 59 yr; range, 17–70) underwent RI-UCBT with a preparative regimen consisting of fludarabine 125 mg/m2, melphalan 80 mg/m2, and 4 Gy of total body irradiation from 2002 to 2004. Twelve-seven patients were classified as AML not otherwise categorized, 16 as AML with multilineage dysplasia, 4 as RAEB and 1 as RA. The disease status at transplant was 2 CR1, 5 CR2 or CR3, 3 untreated and 38 refractory. The median infused total cell dose was 2.8 (range, 1.8–4.5) x 107/kg. HLA match was 6/6 in 1, 4/5 in 8, and 4/6 in 39 cases. GVHD prophylaxis was composed of cyclosporine (n=25) or tacrolimus alone (n=23). Fourty-three patients achieved primary neutrophil engraftment after a median of 20 days. Twelve patients developed grade II–IV acute GVHD and 7 developed chronic GVHD. Fifteen patients achieved CR. Eleven patients experienced relapse. Thirty-one patients died as a result of relapse (n=10), GVHD-associated complications (n=10), or infection (n=11). With a median follow-up of 489 days (range, 192–768), 17 of 48 patients are alive, resulting in a 2-year overall survival rate of 31% (95% CI, 16% to 45%). GVHD prophylaxis influenced outcomes (p These data suggest that RI-UCBT may be an effective option for patients with high-risk myeloid malignancies who lack an HLA-matched donor. RI-UCBT is associated with high TRM, providing a rationale for a larger clinical study, which should be modified to focus on enhancing any GVL effect, minimizing toxicities, and controlling infectious complications. Figure Figure Figure Figure

Introduction: Although allogeneic hematopoietic stem cell transpslantation is the only curative treatment for patients with MF, the potential role of cord blood transplantation remains still unclear. We report the results of RICBT for hematological diseases with primary and secondary MF. Patients and Methods: We reviewed medical records of 179 patients with advanced hematological diseases who received RICBT between March 2002 and June 2005 at our institution. Of 179 patients, pre-transplant bone marrow specimens were available for 82 patients. We evaluated bone marrow specimens by aspiration and trephine biopsy. Aspiration may be not enough to evaluate marrow fibrosis, but could reflect fibrotic change in bone marrow (Am J Clin Pathol1971; 56: 25). One patient had primary MF and 47 had secondary. Underlying diseases for secondary MF included AML/MDS (35), ALL (6), CML (1), severe aplastic anemia (2), malignant lymphoma (2), essential thrombocythemia (1). For staging of MF, we used pathological criteria by Michiels (Int J Hematol2000; 76: 133). MF0: no reticulin fibrosis (n=35), MF1: slight reticulin fibrosis (n=38), MF2: marked increase in reticulin and slight to moderate collagen fibrosis (n=8), MF3: advanced collagen fibrosis-osteosclerosis (endophytic bone formation) (n=1). Median age of the patients was 55 years (17–71). Most of the conditioning regimens were fludarabine 125 mg/m2, melphalan 80 mg/m2 and TBI 4 Gy. GVHD prophylaxis was cyclosporine (n=35) or tacrolimus (n=47). The median number of infused nucleated cells: 2.66 x 10e7 cells (1.67_5.24 x 10e7); CD34 positive cells: 0.69 x 10e5 cells (0.11_3.90 x 10e5); HLA disparity: 6/6 (n=4), 5/6 (n=14), 4/6 (n=60), 3/6 (n=4). Results: Neutrophil engraftment at day 50 was observed in 70.8 % with MF (median 22 days) and 73.7 % without MF (median 22 days). Platelet engraftment at day 100 was observed in 40.0 % with MF (median 42 days) and 60.0 % without MF (median 40 days). There was no statistical significance in neutrophil and platelet engraftment between patients with MF and without MF. Of 48 patients, 6 showed biopsy-proven MF greater than stage 1. Their neutophil and platelet engraftment was observed in 100 % (median 22 days) and 66.7 % (median 48 days), respectively. Cumulative incidence of acute GVHD (II–IV) was 17 % with MF and 28 % without MF. There was no statistical significance. The estimated OS was 25 % with MF and 52 % without MF (p=0.03) (Figure 1). Most cause of death with MF was relapse. Conclusion: Despite of marrow fibrosis, neutophil and platelet engraftment was not influenced. These results have suggested that RICBT is feasible for MF. However, the existence of MF could be poor prognostic factor of RICBT for hematological diseases due to relapse. Figure Figure

Backgrounds: Adult acute lymphoblastic leukemia (ALL) has poor prognosis despite intensive chemotherapy. Allogeneic hematopoietic stem cell transplantation is an optimal therapeutic strategy in relapsed ALL patients. HLA-matched unrelated donation is difficult in some cases because of the rapid disease progression. Cord blood transplantation (CBT) excells other measures in its availability, render it particularly effective in urgent situations; however, the outcome of CBT for adult ALL cases has not yet been clarified. Patients/Methods: We reviewed medical records of 22 adult ALL patients who received CBT at Toranomon Hospital between January 2002 and June 2005. Median age of the patients was 54.5 (range 18–68). Disease status were CR1 (n=4), CR2 (n=3), RL1 (n=8), RL2 (n=1) and primary induction failure (n=6), respectively. 18 patients recieved fludarabine based regimen and the other received CY/TBI myeloablative regimen. Fludarabine based conditioning regimen was consisted of fludarabine (125 mg/m2), melphalan (80–140 mg/m2) and TBI (4–8Gy). GVHD prophylaxis was cyclosporine (n=12) or tacrolimus (n=10). Median total nucleated cell and CD34+ cell counts were 2.6×106 cells/kg (1.6–4.4) and 0.7×105 cells/kg (0.2–3.2), respectively. HLA disparity was 5/6 (n=1), 4/6 (n=20) and 3/6 (n=1). Results: The probability of disease free survival at 2 years was 59%. Overall survival curves of each conditioning regimen were depicted as below. Half of the relapsed/refractory ALL patients achieved complete remission and remained disease free after CBT. Discussion: Adult ALL patients without any suitable donor should be considered as a candidate for CBT. Figure Figure

Backgrounds: Cytomegalovirus (CMV) infection is a major complication after allogeneic hematopoietic stem-cell transplantation. We and other groups recently reported the feasibility of cord blood transplantation using reduced-intensity regimens (RI-CBT) for adult patients with advanced hematologic diseases. We have little information on the clinical features of CMV reactivation after RI-CBT. Patients/methods: We reviewed medical records of 142 patients who received RI-CBT at Toranomon Hospital between January 2002 and March 2005. Median age of the patients was 55 years (range 17–79). Underlying diseases were chemorefractory hematologic diseases (n=136) and severe aplastic anemia (n=6). Conditioning regimens comprised fludarabine 125 mg/m2, melphalan 80 mg/m2 and total body irradiation (TBI) (4–8 Gy). Graft-versus-host disease (GVHD) prophylaxis was cyclosporine (n=86) or tacrolimus (n=56). Median number of total nucleated cells and CD34+ cells was 2.7×106 cells/kg (0.39–4.8), and 0.73×105 cells/kg (0.03–5.7) respectively. HLA disparity was 6/6 (n=3), 5/6 (n=21), 4/6 (n=116), and 3/6 (n=2). All the patients were monitored CMV-antigenemia weekly and received pre-emptive ganciclovir or foscarnet. Results: CMV antigenemia tested positive in 77 patients on a median of day 36 (range, 4–87) after RI-CBT. Median of maximal CMV antigenemia was 22 per 50,000 leukocytes (range, 1–1806). CMV diseases developed in 18 patients on a median of day 40 (range 15–99); enterocolitis (n=18), and adrenalitis (n=1). CMV-antigenemia remained negative in two patients, when CMV disease was diagnosed. CMV disease was successfully treated using ganciclovir or foscarnet in 17 patients, and the other patient died of septic shock. Multivariate analysis revealed grade II–IV acute GVHD as a risk factor (odds, 95% CI). Discussion: CMV reactivation and diseases develop early after RI-CBT. Optimal strategy for preventing CMV disease should be established in RICBT.

HPS are rare but often-fatal conditions characterized by an inappropriate and sustained activation of the cellular immune system leading to accumulation of activated macrophages and a cytokine storm. HPS consists of primary and secondary Hemophagocytic Lymphohistiocytosis (HLH). Secondary HLH occurs at any age and the genetic contribution remains uncertain. Clinical features in patients with HLH are fever, cytopenias, liver dysfunction, hepato-splenomegaly, and the presence of hemophagocytosis in the bone marrow as well as other reticuloendothelical tissues. We will report on the hematological abnormalities and the clinical course of 20/152 patients who received RI-CBT and developed secondary HLH in adult patients with hematological disease in early phase after RI-CBT. The 1st purpose was to investigate the incidence of HLH and pattern of chimerism. The 2nd was to identify the risk factors after UCBT. We reviewed medical records of 152 patients with hematological diseases who had received RI-CBT between January 2002 and April 2005 at Toranomon Hospital, Tokyo, Japan. Diagnosis of HLH was made with the followings; high fever, cytopenias, and hemophagocytic findings in bone marrow examination. Time to event curves were plotted by using the actuarial method of Kaplan-Meier, and differences between curves were analyzed by log-rank tests. The following factors were considered potential predictors of outcomes about 2nd purpose: patient’s age, HLA disparity, infused TNC dose/CD34 dose, disease/disease status at transplantation, GVHD prophylaxis and sepsis which coincided with HLH. All factors were tested for the proportional hazards assumption. Patient’s median age was 55 years (17–79), Primary diseases consisted of standard (n=31) and advanced (n=121). HLA disparities were 4/6 match (n=123), 5/6 (n=22), and others (n=7). Total nucleated cell/CD34 cell dose were 3.46×10E7/kg (1.6–5.2) and 0.78×10E5/kg (0.1–3.3), respectively. Main conditioning regimen was Fludarabine (125mg/m2) +Melphalan (80mg/m2) or Busulfan (8mg/kg) +TBI 4Gy with cyclospoline (n=89) and tacrolimus (n=63) as GVHD prophylaxis and received single cord blood unit. Twenty patients were diagnosis with HLH and the incidence of HLH was 13% (95%CI; 8–18) and median onset day was 18.5 days (range; 10–29). In patients with sepsis (n=46) and without sepsis (n=106), the incidence of HLH was 28% (95%CI; 15–41) and 7% (95%CI; 3–12), respectively (P HLH is fatal complication after allogeneic peripheral stem cell and unrelated bone marrow transplantation. However in RI-CBT, the incidence would be higher and earlier onset than other sources. The most of HLH patients died by multi-organ failure. In this report the most important risk factor was sepsis which coincided with HLH. Figure Figure

Backgrounds: Cytomegalovirus (CMV) infection is a major complication after allogeneic transplantation; however clinical significance of CMV reactivation after cord blood transplantation remains unclear. Objective: We retrospectively investigated the incidence of CMV antigenemia, and CMV diseases, and its prognosis in adult patients who underwent reduced-intensity cord blood transplantation (RI-CBT) Patients/ Methods: We reviewed medical records of 77 patients who received RICBT at Toranomon Hospital between January 2002 and March 2004. Median age of the patients was 55 years (range 17–79). Underlying diseases were chemorefractory hematologic diseases (n=76) and severe aplastic anemia (n=4). Conditioning regimen comprised fludarabine (125 mg/m2), melphalan (80 mg/m2), and TBI 4-8Gy. GVHD prophylaxis was cyclosporine (n=69) or tacrolimus (n=11). Median total nucleated cells and CD34+ cells was 2.4×106 cells/kg (0.39–4.3), and 0.81×105 cells/kg (0.05–5.7) respectively. HLA disparity was 6/6 (n=3), 5/6 (n=12), 4/6 (n=63), and 3/6 (n=2). All patients were monitored CMV-antigenemia weekly and received pre-emptive gancyclovir or foscarnet. Results CMV antigenemia tested positive in 47 patients on a median of day 32 (range, 12–55) after RICBT. The cumulative incidence of CMV reactivation at day 100 was 0.70. Seven and 29 patients were treated with preemptive ganciclovir and foscarnet, respectively. Adverse events of them were myelosuppression in 3 patients given ganciclovir, and mild hyponatremia in a patient given foscarnet. CMV diseases developed in 15 patients on a median of day 39 (range 15–92); enterocolitis (n=13), pneumonia (n=1), and encephalitis (n=1). Seven of 15 patients were resolved with antiviral treatment, and the other patients were fatal with CMV infection. Univariate analysis showed any risk factors for CMV reactivation. Discussion CMV reactivation and diseases develop early after cord blood transplantation. Opitimal strategy for preventing CMV disease should be established in RICBT.

[Introduction] The effectiveness of allogeneic hematopoietic stem cell transplantation (allo-HSCT) against autoimmune disease has been suggested by studies in animal models and patients who had undergone transplantation for hematological disorders. However, its significant treatment-related mortality (TRM) has limited its application to life-threatening cases. Reduced-intensity stem cell transplantation (RIST) is a rapidly expanding treatment strategy and diminishes TRM by decreasing conditioning regimen toxicity compared to conventional myeloablative transplants. The benefit of RIST for autoimmune disease still remains unclear. [Purpose] The purpose of this study is to analyze outcomes of patients with autoimmune diseases treated with RIST for coexisting hematological diseases. [Patients and Methods] Between April 2001 and March 2004, 19 patients (median age, 53 y; range, 20-70) underwent RIST from allogeneic donor. All of the patients were considered inappropriate for conventional allo-HSCT due to age > 50 years and/or organ dysfunction (generally attributable to autoimmune disease-related). Stem cell sources were unrelated CB (n=10), unmanipulated related PB (n=7) and unmanipulated unrelated BM (n=2). The preparative regimens were Flu/Mel-based (n=11), Flu/Bu-based (n=7), and Flu/CY (n=1). The primary disease were NHL (n=7), MDS (n=4), AML (n=3), HD (n=2), ATL (n=2), and SAA (n=1). Concurrent autoimmune diseases were ulcerative colitis (n=4), psoriasis (n=3), rheumatoid arthritis (n=2), interstitial pneumonitis (n=2), atopic dermatitis (n=1), ITP (n=1), CIDP (n=1), polychondritis (n=1), SLE (n=1), and MCTD (n=1). Eleven out of 19 patients were active in autoimmune disease, and seven needed immunosuppressive therapy. [Results] Median follow up period is 174 days (range, 33–987). All patients achieved neutrophile engraftment (median 22 days; range 12–42) and sustained 100% donor chimerism without DLI. 13 patients (68%) developed grade II-IV acute GVHD, and six (31%) developed chronic GVHD. Nine patients (47%) who were treated with steroid, died of transplant-related toxicity; sepsis (n=7), GI bleeding (n=1), and multiple organ failure (n=1). One patient died of leukemia relapse. As of August 2004, ten patients are alive at median follow-up of 402 days, and the actuarial overall survival rate is 51 % at 2 years. Regarding the clinical response for autoimmune disease, no patients experienced flares of the disease: complete remission is observed in seven patients (70%) and they become therapy-free. In the other three patients (30%), disease remains stable. [Conclusion] Our results suggest that a strategy that incorporates RIST for autoimmune disease may be worth considering for further intense evaluation. It may have a considerable graft-versus-autoimmunity (GVA) effect due to the recipient lymphoablation and reconstitution of donor T cells. Organ failure due to autoimmune disease, impaired immune response, and GVHD may contribute to high TRM. Management of regimen-related toxicity and the control of GVHD will be the focus of future investigation.

The potential role of RICBT in adults remains unclear. This study reports the results of RICBT for adults with hematological diseases. The 1st purpose of this report was to investigate the risk factors of non-relapse mortality (NRM) within day 100 of RICBT and the 2nd was to identify its prognostic factors. We reviewed medical records of 107 patients with advanced hematological diseases who had received RICBT between March 2002 and June 2004 at Toranomon Hospital, Tokyo, Japan. Median age of the patients was 55 years (17–79). Primary diseases were advanced (n=88) or standard (n=19). Median follow-up was 14 months (0.5–27). Conditioning regimen was fludarabine 125 mg/m2, melphalan 80 mg/m2 and TBI 4 Gy. GVHD prophylaxis was cyclosporine (n=87) or tacrolimus (n=26). Median total nucleated cells (TNC): 3.2 x 10^7 cells (1.7–4.3); Median CD34+: 1.4 x 10^5 cells (0.21–3.28); HLA match: 6/6 (n=4), 5/6 (n=3), 4/6 (n=95), 3/6 (n−1). Time to event curves were plotted by using the actuarial method of Kaplan-Meier, and differences between curves were analyzed by log-rank tests. The following factors were considered potential predictors of outcomes about 1st and 2nd purpose: age, weight, sex, risk, HLA disparities, TNC, CD34+, GVHD, pre-engraftment reactions (PER) that we have reported (Clin Cancer Res.10:3586-92, 2004), and use of steroids for PER. All factors were tested for the proportional hazards assumption. Neutrophile (>500/μL) and platelet recovery (>20,000/μL) were observed in 77.9% at day 60 (median; 19.5 day), 48.7% at day 100 (45.5 day), respectively. Primary graft failure was occurred in 8% of all cases. Cumulative incidence of acute GVHD (II-IV) and chronic GVHD were 39.8% and 21.1%, respectively. Causes of NRM included infections (n=30), regimen related mortality (RRM) (n=19), and GVHD (n=6). Incidence of NRM at day 100 was 51.6% (95% CI: 42–61), 33 patients with use of steroids for PER had NRM at day 100 of 75% (95% CI: 67–94), as compared to 39% (95% CI: 25–48) in 77 patients without use of steroids (p RICBT is associated with a high NRM. This study has demonstrated status of underlying diseases and use of corticosteroid for PER as a significant prognostic factor. Eligibility of RICBT needs to be investigated, and further studies are warranted to clarify the pathogenesis of PIR and its optimal management. Figure Figure

[Background] Non-myeloablative regimens have been proven to allow engraftment following allogeneic stem cells transplantation with minimal procedure-related toxicity and lower costs. Cord blood has emerged as an appealing alternative source of hematopoietic stem cells for unrelated donor transplantation, but delayed engraftment and frequent transfusion were reported. No studies have formally evaluated the cost of reduced-intensity cord blood transplantation (RICBT). [Purpose] To evaluate the relationship among costs, baseline patient characteristics, and major complications of RICBT, we performed an economic analysis of data in a clinical trial of RICBT for hematologic diseases at a single institution. [Patients and Methods] Ninety-three patients with hematological diseases (median age, 55y; range, 17–79: median body weight, 53kg; range, 38–75) underwent RICBT from March 2002 to May 2004 in Toranomon Hospital. Mean follow-up period was 77 days (range, 13–863). Data on resource use, including hospitalizations, medical procedures, medications, and diagnostic tests, were abstracted from subjects’ clinical trial records. Resources were valued using the Japanese national insurance reimbursement system for inpatient costs at one hospital and average wholesale prices for medications. Monthly costs were calculated and stratified by treatment group and clinical phase. [Results] The median initial inpatient cost was $80,400 (range, 41,300–154,700). When baseline variables were considered, disease status was significant predictor of costs. When clinical events were considered, in-hospital death was associated with higher costs. The mean length of total inpatient days was 78 days (range, 31–222), and the mean length of inpatient days post transplant was 51 days (range, 15–131). The mean units of transfused RBC, Platelet, and FFP were 27u, 224u, and 27u, respectively. [Discussion] This study firstly demonstrates that the cost of RICBT was much higher as compared to previous RIST using peripheral blood or bone marrow. RICBT is an attractive therapy, however, economic problem lies before prevalence of RICBT. The increased numbers of transfusions and supportive care would have effects on costs. The association between mortality and higher costs suggest that prevention of clinical complication may have significant economic benefits. Interventions that decrease these complications may have favorable cost-benefit ratios, and will be the focus of future investigation.

Background: Graft failure, graft rejection, or disease relapse post allogeneic hematopoietic stem cell transplantation(HSCT) is life-threatening and serious complication that necessitate consideration for a second transplantation. Graft failure has been more frequently reported in patients with aplastic anemia with T-cell depletion of the graft, in cord blood transplants, or when unrelated or HLA-mismatched related donors were used. In second allogeneic stem cell transplant setting, current questions include suitable stem cell source, additional conditioning, immunosuppression, and the use of a different donor, still remain unknown. We performed a feasibility study of reduced intensity umbilical cord blood transplantation (RI-UCBT) in adult patients with graft failure or disease relapse after first allogeneic transplantation. Patients and Methods: Nine patients (median age, 53 years; range 17–68) with advanced hematological diseases [AML (n=4), ALL (n=2), MDS (n=2), ATL (n=1)] who showed relapse or graft failure after first allogeneic transplantation underwent RI-UCBT with single cord blood unit at Toranomon Hospital between May 2003 and February 2004. Eight cases were in non-CR at transplant. A median time from first to second transplant was 226 days (range 31–475). The median number of mononuclear cells transfused was 2.3 x 107 /kg (range 1.8–3.5). HLA disparities were as follows; 5/6 in two cases, 4/6 in seven cases. Conditioning regimen mainly consisted of fludarabine 25 mg/m2 on days -7 to −3, melphalan 40mg/m2 (n=8) or busulfan 4mg/kg(n=1) day −3 to −2, and 4 Gy total body irradiation on day −1. Graft-versus-host disease (GVHD) prophylaxis was composed of ciclosporin alone (n=6) and tacrolimus alone (n=3). Results: All of them achieved primary neutrophil engraftment (>500/μL) after a median of 22 days (range, 15–32) and achievement of donor T-cell chimerism was confirmed. Four cases developed grade II-IV GVHD, and one case developed limited chronic GVHD. Of all the nine cases received RI-UCBT, seven died from relapse (n=4), sepsis (n=2), and TMA (n=1). Two survived without relapse for +232 and +81 days, respectively. Discussion: Although the number of patients is small and the follow-up period is short, our results corroborate that RI-UCBT for graft failure or relapse post first transplant is tolerated and may be worth considering for further evaluation. Neutrophil engraftment was achieved, however, disease relapse rate and treatment-related mortality is high. The management of disease status and development of ideal conditioning regimen will be the focus of future investigation.