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High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is widely used as a salvage therapy for relapsed or high-risk diffuse large B-cell lymphoma (DLBCL). To investigate the safety and efficacy of regimens including high-dose MCNU followed by ASCT for DLBCL, we analyzed the data from prospective multicenter trials. Twenty-nine patients were analyzed, and the median follow-up time for survival patients was 70 months. Fifteen patients received MCVC conditioning regimen, and fourteen patients received MEAM regimen. Major toxicities associated with these conditioning regimens included nausea (69%), anorexia (66%), febrile neutropenia (62%), diarrhea (59%), and mucositis (34%). One patient who developed severe sinusoidal obstructive syndrome and acute lung injury died without disease progression, and overall therapy-related mortality at 5 years was 3%. No patient developed therapy-related hematological malignancy. At 5 years, overall survival and progression-free survival in all patients were 82.8 and 58.2%, respectively. The 5-year OS in patients treated by the MCVC and MEAM regimens were 73.3 and 92.9%, respectively. These results suggest that regimens including high-dose MCNU followed by ASCT are feasible and effective for the treatment of relapsed or high-risk DLBCL. Further investigation is needed to evaluate of these regimens.

BackgroundSuccessful recovery from acute lung injury requires inhibition of neutrophil influx and clearance of apoptotic neutrophils. However, the mechanisms underlying recovery remain unclear. We investigated the ameliorative effects of vascular endothelial growth factor (VEGF)-C/VEGF receptor 3 (VEGFR-3) signalling in macrophages in lipopolysaccharide (LPS)-induced lung injury.MethodsLPS was intranasally injected into wild-type and transgenic mice. Gain and loss of VEGF-C/VEGFR-3 signalling function experiments employed adenovirus-mediated intranasal delivery of VEGF-C (Ad-VEGF-C vector) and soluble VEGFR-3 (sVEGFR-3) or anti-VEGFR-3 blocking antibodies and mice with a deletion of VEGFR-3 in myeloid cells.ResultsThe early phase of lung injury was significantly alleviated by the overexpression of VEGF-C with increased levels of bronchoalveolar lavage (BAL) fluid interleukin-10 (IL-10), but worsened in the later phase by VEGFR-3 inhibition upon administration of Ad-sVEGFR-3 vector. Injection of anti-VEGFR-3 antibodies to mice in the resolution phase inhibited recovery from lung injury. The VEGFR-3-deleted mice had a shorter survival time than littermates and more severe lung injury in the resolution phase. Alveolar macrophages in the resolution phase digested most of the extrinsic apoptotic neutrophils and VEGF-C/VEGFR-3 signalling increased efferocytosisviaupregulation of integrin αvin the macrophages. We also found that incubation with BAL fluid from acute respiratory distress syndrome (ARDS) patients, but not from controls, decreased VEGFR-3 expression and the efficiency of IL-10 expression and efferocytosis in human monocyte-derived macrophages.ConclusionsVEGF-C/VEGFR-3 signalling in macrophages ameliorates experimental lung injury. This mechanism may also provide an explanation for ARDS resolution.

Objectives We conducted a phase-II study to evaluate the efficacy and safety of dasatinib in patients newly diagnosed with chronic-phase chronic myeloid leukaemia (CML-CP) in Japan (IMIDAS PART 2 study). Methods Seventy-nine patients were administered 100 mg dasatinib once daily. We examined pre-treatment and post-treatment influences of various factors. The BCR-ABL1 international scale (IS), halving time (HT), and reduction rate of BCR-ABL1 transcript within the initial 1 or 3 months of therapy (RR-BCR-ABL11m,3m) were the post-treatment factors investigated to predict the molecular response. Results The estimated major molecular response (MMR), molecular response 4.0 (MR4.0), and molecular response 4.5 (MR4.5) rates were 77.2%, 49.4%, and 35.4%, respectively, at 12 months. Grade 3/4 non-haematologic adverse events were infrequent. Multivariate analysis showed that age >65 years was significantly correlated with MR4.0 and MR4.5 (deep molecular response: DMR) at 12 months. All post-treatment factors at 3 months predicted DMR by univariate analysis. However, RR-BCR-ABL13m was the only significant landmark for predicting DMR by multivariate analysis. Conclusions Primary treatment of CML-CP with dasatinib enabled early achievement of MMR and DMR, particularly in elderly patients, with high safety. Furthermore, RR-BCR-ABL13m was found to be a more useful predictor of DMR than HT-BCR-ABL1 and BCR-ABL1 IS. This article is protected by copyright. All rights reserved.

Adult T-cell leukemia-lymphoma (ATL) is a mature T-cell malignancy associated with human T-cell leukemia virus type 1 (HTLV-1) infection. Japan is the most endemic country for HTLV-1 and ATL in the world. Recent nationwide studies of Japanese blood donors reported that HTLV-1 carriers spread from endemic areas to non-endemic areas. Therefore, the latest information on nationwide epidemiological and clinical data for ATL is necessary to guide clinical practice. We undertook a multicenter, hospital-based survey of newly diagnosed ATL patients from 2010 to 2011. A total of 996 patients with ATL were registered from 126 hospitals across Japan. Of those, 922 (487 men and 435 women) were included in the analysis. The median age at diagnosis was 68 years (interquartile range, 60-75 years). Overall, 67.2% of ATL was diagnosed in the Kyushu-Okinawa area. The most common subtype was acute (49.5%), followed by lymphoma (25.7%), chronic (14.2%), and smoldering (10.6%). Lymphoma type was more prevalent in men (60%), whereas chronic was more prevalent in women (60%). Half of patients with lymphoma type were aged over 70 years, whereas one-third of patients with the chronic type were aged under 60 years. All of these characteristics were different from those of the previous nationwide surveys in the 1980s and 1990s. This survey clarified that half of current patients with ATL are aged over 68 years who were unable to receive intensive cytotoxic therapies. New less toxic agents for aged patients and further strategies to prevent the development of ATL from HTLV-1 carrier status are needed.

Summary Background A previous dasatinib discontinuation (DADI) trial showed that 31 (49%) of 63 patients with chronic-phase chronic myeloid leukaemia who were treated with second-line or subsequent dasatinib could discontinue the drug safely. However, the safety and efficacy of discontinuing first-line dasatinib remains unclear. In this trial (the first-line DADI trial) we aimed to assess molecular relapse-free survival at 6 months after discontinuation of dasatinib in patients with chronic myeloid leukaemia who had been treated with first-line dasatinib and had maintained deep molecular response for at least 1 year. Methods The first-line DADI trial was a single-arm, multicentre, phase 2 trial done at 23 hospitals in Japan. Patients with newly diagnosed chronic-phase chronic myeloid leukaemia without hepatosplenomegaly and extramedullary mass, who received at least 24-month dasatinib treatment and had a sustained deep molecular response (defined as BCR-ABL1/ABL1 international scale ≤0·0069% in at least four successive samples spanning a 12 month period) were enrolled. Other eligibility criteria were an age of 15 years or older, an Eastern Cooperative Oncology Group performance status score of 0–2, and no primary organ dysfunction. The primary outcome was molecular relapse-free survival (also known as treatment-free remission) after discontinuation of dasatinib at 6 months and was analysed in all patients who completed the 12-month consolidation phase. Safety was assessed in all patients who received treatment. This study closed early due to accrual and is registered with the UMIN Clinical Trials Registry (UMIN000011099). Findings Between Sept 20, 2013 and July 12, 2016, 68 patients who had a deep molecular response after receiving first-line dasatinib for at least 24 months were enrolled and assigned to the consolidation phase. Nine patients were excluded during the consolidation phase and one patient was excluded after study completion because of meeting exclusion criteria. 58 patients discontinued dasatinib and were assessed. 32 (55%) of 58 patients had treatment-free remission at 6 months after dasatinib discontinuation, and median follow-up was 23·3 months (IQR 11·7–31·0). Treatment-free remission at 6 months was 55·2% (95% CI 43·7–69·6). No non-haematological adverse events worse than grade 2 occurred before dasatinib discontinuation. The most common haematological adverse event was anaemia (14 [21%] of 68 treated patients); three (4%) of 68 treated patients had grade 3 neutropenia and one (1%) had grade 4 lymphopenia. Interpretation Our findings suggest that dasatinib could be safely discontinued after first-line treatment in patients with chronic myeloid leukaemia who had received at least 36 months of therapy and sustained deep molecular response; however, further confirmation in larger trials is needed. Funding Epidemiological and Clinical Research Information Network.

There have been no studies on the distribution of causes of macrocytic anemia with respect to mean corpuscular volume (MCV) cutoff values. We retrospectively investigated the causes of macrocytic anemia (MCV ≥100 fL) among 628 patients who visited the outpatient hematology clinic in Tohoku University Hospital. To ensure data validity, we also analyzed data from 307 patients in eight other hospitals in the Tohoku district. The leading causes of macrocytic anemia (number of patients, %) were myelodysplastic syndromes (121, 19.3 %), suspected bone marrow failure syndromes (BMF; 74, 11.8 %), aplastic anemia (51, 8.1 %), plasma cell dyscrasia (45, 7.2 %), and vitamin B12 deficiency (40, 6.4 %) in Tohoku University Hospital. We made three primary findings as follows. First, the most common cause of macrocytic anemia is BMF. Second, lymphoid and solid malignancies are also common causes of macrocytosis. Third, macrocytic anemia may be classified into three groups: Group 1 (megaloblastic anemia and medications), which can exceed MCV 130 fL; Group 2 (alcoholism/liver disease, BMF, myeloid malignancy, and hemolytic anemia), which can exceed MCV 114 fL; and Group 3 (lymphoid malignancy, chronic renal failure, hypothyroidism, and solid tumors), which does not exceed MCV 114 fL. These conclusions were supported by the results from eight other hospitals.

Occult hepatitis B virus (HBV) infection is a clinical challenge, but its relationship to clinicopathologic features and the risk of progression to malignant lymphoma (ML) are poorly defined. We estimated the prevalence of HBV infection of 1,358 patients with newly diagnosed ML. HBV infection was more prevalent in ML than in control patients. The occult HBV infection group had a higher median onset age, no liver or spleen involvement, and higher prevalence of diffuse large B-cell lymphoma than the other groups, indicating that occult HBV infection is a distinct clinicopathologic entity. J. Med. Virol. 88:2206-2210, 2016. © 2016 Wiley Periodicals, Inc.

Adult T-cell leukemia (ATL) is an aggressive malignancy of peripheral T cells infected with human T-cell leukemia virus type 1 (HTLV-1). The prognosis of patients with aggressive ATL remains poor because ATL cells acquire resistance to conventional cytotoxic agents. Therefore, development of novel agents is urgently needed. We examined the effects of YM155, sepantronium bromide, on cell proliferation and survival of ATL or HTLV-1-infected T-cell lines, S1T, MT-1, and MT-2. We found that YM155 suppressed cell proliferation in these cells and induced cell death in S1T and MT-1 cells. Both real-time quantitative polymerase chain reaction and immunoblot analyses showed suppression of survivin expression in S1T, MT-1, and MT-2 cells. In addition, we observed the cleavage of caspase-3 and poly(ADP-ribose) polymerase in YM155-treated S1T and MT-1 cells, indicating that YM155 induces caspase-dependent apoptosis in these cells. To clarify the mechanism of drug tolerance of MT-2 cells in terms of YM155-induced cell death, we examined intracellular signaling status in these cells. We found that STAT3, STAT5, and AKT were constitutively phosphorylated in MT-2 cells but not in S1T and MT-1 cells. Treatment with YM155 combined with the STAT3 inhibitor S3I-201 significantly suppressed cell proliferation compared to that with either YM155 or S3I-201 in MT-2 cells, indicating that STAT3 may play a role in tolerance of MT-2 cells to YM155 and that STAT3 may therefore be a therapeutic target for YM155-resistant ATL cells. These results suggest that YM155 presents potent antiproliferative and apoptotic effects via suppression of survivin in ATL cells in which STAT3 is not constitutively phosphorylated. YM155 merits further investigation as a potential chemotherapeutic agent for ATL.

Febrile neutropenia is often observed in patients with hematologic malignancies, especially in those with acute leukemia. Meropenem has potent and broad antibacterial activity against gram-positive and gram-negative bacteria, and is recommended as first-line empiric therapy for febrile neutropenia. In contrast, the safety and efficacy of doripenem in patients with febrile neutropenia and hematologic malignancies is limited. In this randomized, prospective, cooperative, open-label trial, we compared doripenem (1.0 g every 8 h) to meropenem (1.0 g every 8 h) as first-line empiric antibacterial treatment of febrile neutropenia. To evaluate efficacy and safety, 133 hospitalized patients with acute leukemia or high-risk myelodysplastic syndrome, who developed febrile neutropenia during or after chemotherapy, were randomized to each drug. Resolution of fever within 3 to 5 days without treatment modification (i.e., the primary endpoint) did not significantly differ between the doripenem and meropenem groups (60.0% vs. 45.6%, respectively; P = 0.136). However, resolution of fever within 7 days of treatment was significantly higher in the doripenem group than in the meropenem group (78.4% vs. 60.2%, respectively; P = 0.037). Similar rates of adverse events (grades 1–2) were observed in both groups. Thus, we conclude that both drugs are safe and well-tolerated for the treatment of febrile neutropenia in patients with acute leukemia or high-risk myelodysplastic syndrome, and that the clinical efficacy of doripenem is noninferior to that of meropenem. UMIN Clinical Trial Registry number: 000006124

Tyrosine kinase inhibitors (TKI) are used for primary therapy in patients with newly diagnosed CML. However, a reliable method for optimal selection of a TKI from the viewpoint of drug sensitivity of CML cells has not been established. We have developed a FRET-based drug sensitivity test in which a CrkL-derived fluorescent biosensor efficiently quantifies the kinase activity of BCR-ABL of living cells and sensitively evaluates the inhibitory activity of a TKI against BCR-ABL. Here, we validated the utility of the FRET-based drug sensitivity test carried out at diagnosis for predicting the molecular efficacy. Sixty-two patients with newly diagnosed chronic phase CML were enrolled in this study and treated with dasatinib. Bone marrow cells at diagnosis were subjected to FRET analysis. The ΔFRET value was calculated by subtraction of FRET efficiency in the presence of dasatinib from that in the absence of dasatinib. Treatment response was evaluated every 3 months by the BCR-ABL1 International Scale. Based on the ΔFRET value and molecular response, a threshold of the ΔFRET value in the top 10% of FRET efficiency was set to 0.31. Patients with ΔFRET value ≥0.31 had significantly superior molecular responses (MMR at 6 and 9 months and both MR4 and MR4.5 at 6, 9, and 12 months) compared with the responses in patients with ΔFRET value

Dasatinib is a novel, oral, multi-targeted kinase inhibitor of breakpoint cluster region-abelson (BCR-ABL) and Src family kinases. The study investigated pharmacokinetic (PK) and pharmacodynamic (PD) analyses of dasatinib in 51 newly diagnosed, chronic phase, chronic myeloid leukemia patients.The dasatinib concentration required to inhibit 50 % of the CrkL (CT10 regulator of kinase like) phosphorylation in bone marrow CD34+ cells (half maximal (50 %) inhibitory concentration (IC50)CD34+cells) was calculated from each patient's dose-response curve using flow cytometry. PK parameters were obtained from the population pharmacokinetic analysis of dasatinib concentrations in plasma on day 28 after administration.Early molecular responses were not significantly associated with PK or PD (IC50 CD34+cells) parameters. However, the PK/PD parameter-time above IC50 CD34+cells-significantly correlated with BCR-ABL transcript level at 3 months (correlation coefficient (CC) = -0.292, P = 0.0375) and the reduction of BCR-ABL level at 1 or 3 months (CC = -0.404, P = 0.00328 and CC = -0.356, P = 0.0104, respectively). Patients with more than 12.6 h at time above IC50 CD34+cells achieved a molecular response of 3.0 log reduction at 3 months and those more than 12.8 h achieved a deep molecular response less than 4.0 log reduction at 6 months at a significantly high rate (P = 0.013, odds ratio = 4.8 and P = 0.024, odds ratio = 4.3, respectively).These results suggest that the anti-leukemic activity of dasatinib exhibits in a time-dependent manner and that exposure for more than 12.8 h at time above IC50 CD34+cells could significantly improve prognosis.

CD56, the neural cell adhesion molecule (NCAM), is a member of the immunoglobulin superfamily and is associated with cell-to-cell adhesion and migration.1 Among haematological malignancies, CD56 expression has been described mainly in NK/T cell lymphoma, plasma cell myeloma and acute myeloid leukaemia, and rarely in B cell lymphomas, accounting for no more than 0.5% of all B lymphomas.2–8 Malignant lymphoma constitutes

Chronic hepatitis C virus (HCV) infection conditions are proposed to be an HCV syndrome of hepatic, extrahepatic or systemic disorders with malignancies such as a malignant lymphoma (ML).[1] HCV is...

Autologous stem cell transplantation (ASCT) is a treatment option for HIV-positive patients with non-Hodgkin lymphoma (NHL) and multiple myeloma (MM). However, the prognosis after ASCT in HIV-positive Japanese patients remains unclear. The aim of this study was to evaluate the impact of HIV infection on transplant outcomes after ASCT in Japan. Using the national database of the Japan Society for Hematopoietic Cell Transplantation, we retrospectively evaluated patients with NHL (n = 3862) and MM (n = 2670) who underwent their first ASCT between 2001 and 2014. The presence of HIV antibody was used to diagnose HIV infection. Fifty-six patients with NHL (1.4%) and 23 with MM (.8%) were positive for HIV antibody. Among patients with NHL overall survival (OS) was lower in HIV-positive patients than in HIV-negative patients (5-year OS: HIV-positive patients, 44% versus HIV-negative patients, 65%; P .001). In a multivariate analysis HIV infection was significantly associated with an increased risk of overall mortality (hazard ratio, 2.30; P .001). The incidence of relapse was higher in HIV-positive patients (P = .036), whereas there was a similar incidence of nonrelapse mortality (P = .879). OS in patients with MM was similar between those with/without HIV infection (5-year OS: HIV-positive patients, 61% versus HIV-negative patients, 63%; P = .988). HIV infection was associated with a higher risk of overall mortality and relapse after ASCT for NHL in a Japanese population.

Approximately 70% of the ITP patients responded to high dose of intravenous immunoglobulin. The 2011 ASH guidelines recommend an initial dose of 1 g/kg as a one-time dose. This dosage may be repeated if necessary. The EU recommendations described that adult ITP patients at high risk of bleeding or prior to surgery to correct the platelet count should be indicated for the administration of intravenous immunoglobulin. Adverse events with intravenous immunoglobulin are common, but generally acceptable. High doses of immunoglobulin are thought to be involved in the Fc receptor blockade of macrophages in the reticuloendothelial system. Several other mechanisms were elucidated.

The term “platelet” whose function was the adhesive characteristic was first used by Bizzozero in 1882. The word “purpura” is the Latin derivative of the Greek word “porphyra,” which is used to designate purple fish. The pathophysiology of this disease had not been unknown until 1951. This chapter describes the history of immune thrombocytopenia.

Platelets are formed from the cytoplasm of megakaryocytes (MKs) that reside in the bone marrow (BM). MKs arise from hematopoietic stem cells in the osteoblastic niche in BM. The primary regulator of megakaryopoiesis is thrombopoietin. It is generally accepted that MKs migrate into the vascular niche and produce platelets; however, the mechanism by which platelets are formed and released from MKs remains controversial. The most prevalent proposed mechanism regarding platelet formation is the proplatelet model; in this model, MKs form long extensions (proplatelets) by remodeling their cytoplasm and release cell fragments into sinusoid vessels. Detached cell fragments in the circulating blood are heterogeneous population of cells in regard to size, shape, or structure. Large fragments (platelet progenitors) are believed to have the ability to convert into mature platelets. After leaving BM sinusoids, these platelet progenitors may convert into individual mature platelets in the bloodstream.

There are several management options for chronic refractory ITP patients. As the chance of inducing a durable remission is low, the objective of the next treatment is the achievement of adequate stable platelet levels while minimizing adverse events. This chapter includes anti-D immunoglobulin, cyclophosphamide, vincristine and vinblastine, danazol, Syk inhibitor, and other drugs (azathioprine, cyclosporine, mycophenolate mofetil, interferon, and ascorbic acid). While in the near future, several new agents might be used clinically for treating refractory ITP.

BACKGROUND: The overall survival of patients with newly diagnosed chronic myeloid leukemia (CML) has improved significantly since the introduction of tyrosine kinase inhibitors (TKIs), and recently, some patients with CML who achieve stable deep molecular response (DMR) to TKI therapy could safely suspend treatment. In addition to European LeukemiaNet criteria (ELN), the European Society for Medical Oncology (ESMO) proposed that less than 0.01% of BCR-ABL1 transcript (MR4.0) on the International Scale (IS) after 18 months is optimal for patients to achieve treatment-free remission. Branford et al. indicated that major molecular response (MMR; less than or equal to 0.1% of BCR-ABL1 IS ; MR3.0) at three months predicts stable undetectable BCR-ABL1 transcript levels during imatinib treatment. However, second-generation TKIs induce more rapid and deeper responses at early time points compared to imatinib; however, whether early molecular response predicts MR4.0 by 18 months to second-generation TKI therapy, remains unclear. AIMS: We retrospectively analyzed BCR-ABL1 transcript levels in patients with CML in chronic phase (CML-CP) at 3, 6, 12, and 18 months after initiating dasatinib treatment to identify molecular milestones that would predict MR4.0 by 18 months. METHODS: Fifty-nine newly diagnosed patients with CML-CP were included in this study. The median age was 61 years (18-81 years), 72% of whom were males, and patients older than 65 years comprised 31% of the overall enrollment. Eighty-six percent of them had low and intermediate Sokal scores. Patients received 100 mg of dasatinib once daily. Dose interruption or reduction was allowed if drug-related grade 3 non-hematological toxicity or grade 3 or worse hematological toxicity occurred.BCR-ABL1/ ABL ratio IS (BCR-ABL1 IS) was performed at approximately 3-month intervals. To assess the kinetics of response, we calculated halving time (HT) of BCR-ABL1 IS. HT-BCR-ABL1 was calculated as described by Branford et al. We used a receiver-operating characteristic (ROC) curve to identify the cut-offs in transcript levels at three and six months. Mann-Whitney test was used to determine statistical significance. Categorical variables were compared using Fisher's exact test. Factors were subjected to multivariate analysis using Cox regression; differences with p RESULTS: The median BCR-ABL1 IS level before therapy was 82.1% (range 13.5-157.9 %). The estimated MMR by 12 months and MR4.0 by 18 months were 86.4% and 50.8%, respectively. We analyzed each into a cohort that achieved MR4.0 by 18 months (MR4.0 cohort) and a cohort that did not achieve MR4.0 (non-MR4.0 cohort). The BCR-ABL1 IS level in each cohort is indicated in the Table. Median HT-BCR-ABL1 IS 0-3 months was 10.8 days (6.5-71.3 days) in MR4.0 cohort, and 13.0 days (8.5- 169.6 days, p CONCLUSION: Even though dasatinib is highly-priced, dasatinib treatment results in higher rates of molecular responses in newly diagnosed patients with CML-CP. Assessment of molecular reduction within six months has become an important landmark to predict MR4.0 by 18 months during dasatinib treatment for patients with the aim to achieve treatment-free remission. Disclosures Oyake: Astellas: Speakers Bureau; Celgene: Honoraria; Chugai: Honoraria; Kyowa-Hakko Kirin: Honoraria. Ito:Bristol-Myers Squibb: Honoraria; Celgene: Honoraria; Ono: Honoraria.

The international phase III DASISION trial demonstrated improved efficacy of dasatinib versus imatinib in treatment-naive patients with chronic myeloid leukemia in the chronic phase (CML-CP). We report efficacy and safety outcomes in a Japanese population from the final, 5-year follow-up of DASISION. At the end of the study, 77% (20/26) of dasatinib-treated and 61% (14/23) of imatinib-treated patients remained on initial therapy. Improved responses were observed in Japanese patients who received dasatinib versus imatinib (complete cytogenetic response: 96 vs 87%; major molecular response: 88 vs 74%; BCR-ABL1 ≤0.0032% International Scale [MR4.5]: 58 vs 52%). In patients who achieved BCR-ABL1 ≤10% at 3 months, 5-year progression-free survival and overall survival rates were high with dasatinib (96 and 96%) and imatinib (88 and 100%). The majority of adverse events were grade 1/2 in Japanese patients. Pleural effusion occurred more frequently in dasatinib-treated Japanese patients versus all patients (42 vs 28%), with no treatment discontinuations. Overall, in Japanese patients, dasatinib maintained its safety profile and had higher or comparable response and survival outcomes compared with imatinib or with all patients in DASISION. These findings demonstrate the long-term efficacy and tolerability of dasatinib and support frontline treatment of Japanese patients with CML-CP with dasatinib.

Recent advances in surgical corrections and supportive care for congenital heart disease have resulted in increasing numbers of adult survivors who may develop hematological malignancies. Treatments including chemotherapy for such patients may cause serious hemodynamic or cardiac complications, especially in those receiving stem cell transplantation. We present a 29-year-old woman with acute lymphoblastic leukemia and congenital heart disease. She had been diagnosed with pulmonary atresia with an intact ventricular septum at birth, and the anomaly was surgically corrected according to the Fontan technique at age 9 years. Her induction chemotherapy required modifications due to poor cardiac status with Fontan circulation. However, after surgical procedures including total cavopulmonary connection and aortic valve replacement at first complete remission, her cardiac status was significantly improved. Subsequently, she underwent cord blood stem cell transplantation at the third complete remission. She required intensive supportive care for circulatory failure as a pre-engraftment immune reaction and stage III acute graft versus host disease of the gut, but recovered from these complications. She was discharged on day 239, and remained in complete remission at 1-year post-transplantation.

Occult hepatitis B virus (HBV) infection is a clinical challenge, but its relationship to clinicopathologic features and the risk of progression to malignant lymphoma (ML) are poorly defined. We estimated the prevalence of HBV infection of 1,358 patients with newly diagnosed ML. HBV infection was more prevalent in ML than in control patients. The occult HBV infection group had a higher median onset age, no liver or spleen involvement, and higher prevalence of diffuse large B-cell lymphoma than the other groups, indicating that occult HBV infection is a distinct clinicopathologic entity. J. Med. Virol. 88:2206-2210, 2016. © 2016 Wiley Periodicals, Inc.

The overall survival of patients with multiple myeloma has significantly improved over the last decade, mainly due to the use of novel agents such as thalidomide, lenalidomide and bortezomib; however, multiple myeloma remains incurable due to its eventual relapse, necessitating urgent development of newer agents. YM155 is a novel small molecule that suppresses transactivation of survivin and induces apoptosis in various cancer cell types. However, the effects of YM155 on multiple myeloma cells have not been fully elucidated. We herein found that YM155 inhibited proliferation of and induced caspase-dependent apoptosis in myeloma cells, partially via the suppression of survivin, myeloid cell leukemia sequence-1, and X-linked inhibitor of apoptosis protein. Interestingly, YM155 suppressed c-Myc protein expression via the proteasomal degradation. Moreover, YM155 increased F-box and WD-40 domain protein 7α expression that is a component of the Skp, Cullin, F-box-like ubiquitin ligase complex, suggesting that YM155-induced c-Myc down-regulation may be due to the proteasomal degradation through ubiquitination by F-box and WD-40 domain protein 7α. These results warrant further clinical evaluation of YM155 in MM patients.

Introduction We previously reported an interim analysis of the DADI (dasatinib discontinuation) trial. The results showed that 48% of patients with chronic myeloid leukemia in the chronic phase who maintained a deep molecular response (DMR) for ≥ 1 year could discontinue second- or subsequent-line dasatinib treatment safely at a median follow-up of 20 months. However, the results from longer follow-up periods would be much more useful from a clinical perspective. Patients and Methods The DADI trial was a prospective, multicenter trial conducted in Japan. After confirming a stable DMR for ≥ 1 year, dasatinib treatment subsequent to imatinib or nilotinib was discontinued. After discontinuation, the loss of DMR (even of 1 point) was defined as stringent molecular relapse, thereby triggering therapy resumption. The predictive factors of treatment-free remission (TFR) were analyzed. Results The median follow-up period was 44.0 months (interquartile range, 40.5-48.0 months). The estimated overall TFR rate at 36 months was 44.4% (95% confidence interval, 32.0%-56.2%). Only 2 patients developed a molecular relapse after the 1-year cutoff point. The presence of imatinib resistance was a significant risk factor for molecular relapse. Moreover, high natural killer cell and low γδ+ T-cell and CD4+ regulatory T-cell (CD25+CD127low) counts before discontinuation correlated significantly with successful therapy discontinuation. Conclusion These findings suggest that discontinuation of second- or subsequent-line dasatinib after a sustained DMR of ≥ 1 year is feasible, especially for patients with no history of imatinib resistance. In addition, the natural killer cell count was associated with the TFR.

Background We conducted a phase II study to evaluate the efficacy and safety of dasatinib in Japanese patients with imatinib-resistant or imatinib-intolerant chronic myeloid leukemia (CML). Methods From 2009 to 2011, 54 CML-chronic phase (CP) patients with resistance (n = 40) or intolerance (n = 25) to imatinib were registered to undergo dasatinib treatment. Eleven patients showed both resistance and intolerance to imatinib. Coincidentally, the resistance criteria in this study were the same as a non-optimal response to tyrosine kinase inhibitors (TKIs) as defined in the European LeukemiaNet (ELN) 2013 recommendations. Results The overall incidence rate of major molecular response (MMR) at 12 months was 62.3% (n = 47). Forty patients with resistance to imatinib who were ‘warning’ and ‘failure’ patients based on the ELN 2013 recommendations were assessed; cumulative MMR and MR4.5 rates were 62.5% (n = 39) and 21.0% (n = 40), respectively, at 12 months. Twelve patients who showed a BCR-ABL transcript level >1% on the international scale did not achieve a MMR or discontinued dasatinib treatment because of insufficient effects. With regard to safety issues, grade 3/4 non-hematologic adverse events (AEs) were infrequent. Conclusions Patients with non-optimal responses (who meet ELN 2013 warning and failure criteria) to imatinib should be switched quickly to dasatinib, which is less toxic in CML-CP patients, to improve their prognoses. A BCR-ABL1 IS of

(INTRODUCTION) Several clinical studies have revealed that dasatinib demonstrated deep and fast responses. We report a phase II study to evaluate the efficacy and safety of dasatinib in patients with newly diagnosed chronic-phase chronic myeloid leukemia (CML-CP) in Japan (IMIDAS PART2 study). (PATIRNTS AND METHODS) Between July 2011 and June 2013, a total of 79 consecutive patients with CML-CP received 100 mg dasatinib daily as a first-line therapy. Treatment was continued until disease progression or until toxicity became unacceptable. The primary end-point was the rate of major molecular response by 12 months. Secondary end-points included the rate of complete cytogenetic response, rate of molecular responses with a 4.5 log reduction (MR4.5) by 12 months, and adverse events. The median age was 62 years, ranging from 27 to 80 years. Patients older than 65 years comprised 41.7% of all patients. Two-thirds of patients (68.4%) were male. Nearly all patients were ECOG performance status 0. Most patients (83.6%) had low and intermediate Sokal scores. The BCR-ABL1 International Scale (BCR-ABL1 IS) in the peripheral blood was measured by the central laboratory center (BML, Tokyo, Japan). (RESULTS) The median BCR-ABL1 IS before therapy was 54.0% (7.8-230.2). Seventy patients (88.6%) received dasatinib therapy for 12 months. The median BCR-ABL1 ISs were 0.25 % at 3 months (range 0.0002-52.2 %, n =77), 0.03 % at 6 months (range not detected-29.2 %, n = 75) and 0.008 % at 12 months (not detected -0.86 %, n = 70). MMR rate was 77.2% (95% CI, 67.9-86.5 %) by 12 months. The rates of CCyR and MR4.5 by 12 months were 88.6% (95% CI; 81.5-95.7 %) and 35.4% (95% CI; 24.8-46.1 %), respectively (Figure 1). Multivariate analysis of MMR or MR4.5 by 12 months showed that female sex (odds ratio 1.1, P = 0.92, odds ratio 1.7, P = 0.35, respectively), low and intermediate Sokal score (odds ratio 0.9, P = 0.90, odds ratio 3.2, P =0.23, respectively), and BCR-ABL1 IS less than 54% at diagnosis (RR =odds ratio 0.8, P = 0.74, odds ratio 0.7, P = 0.55, respectively) were not significantly correlated with MMR by 12 months nor MR4.5 by 12 months (Table 1). However, patients who were more than 62 years old were significantly correlated with MR4.0 and MR4.5 by 12 months (odds ratio 2.8, P =0.04, odds ratio 3.5, P =0.01). Treatment-related all AEs were reported in 98.7% patients (78 of 79). Grade 3/4 non-hematologic AEs were observed in only a few cases. Lymphocytosis (more than 4x 109/L) was observed in 34.1% of patients, which was within grade 2. Only 9 patients withdrew the study because of adverse events (4 patients), ineffectiveness (3 patients), and others (2 patients). (DISCUSSION AND CONCLUSION) The incidence of lymphocyte predominance may depend on a history of previous cytomegalovirus (CMV) infection in CML-CP patients (Leukemia. 2011 25(10): 1587-97). Although the frequency of CMV-positive patients was unknown in this study, that of blood donors in Japan was almost positive in the ages with 60s or older. The median age of CML-CP patients in this study was 62 years. Therefore, we assumed that some immunological effects induced by dasatinib might have improved the clinical efficacy in Japanese CML-CP patients compared to those worldwide. Our phase II study to evaluate the efficacy and safety of dasatinib in patients with newly diagnosed CML-CP in Japan revealed that the first-line dasatinib treatment of CML-CP leads to earlier achievement of MMR and MR4.5 with high safety. Elder age patients (>62 years) were significantly associated with achievement of MR4.5. Disclosures Shindo: Sysmex Corporation: Research Funding. Sakamoto:Yakult: Other: Remuneration; Takeda Pharmaceutical: Consultancy.

Background: Invasive fungal infections (IFIs) incur significant morbidity and mortality in neutropenic patients with hematological malignancies (HEM) after chemotherapy. The risk for these infections is related to the intensity and duration of neutropenia, and varies from 2% to 40%. Mortality rates associated with documented IFIs are considerable, reportedly ranging from 30% to 60%. Empirical antifungal therapy is the standard care for neutropenic patients with HEM, who remain febrile despite broad-spectrum antibacterial treatment. Several antifungal agents including voriconazole (VRCZ) or liposomal amphotericin B (L-AMB) have been studied as empirical therapy for febrile neutropenia (FN). However, limited data are available concerning the efficacy of micafungin (MCFG) in FN patients with acute myeloid leukemia (AML). Methods: We conducted a randomized, cooperative group, open-label trial comparing MCFG (150 mg once daily) with L-AMB (2.5 mg/kg once daily) as a first-line empirical antifungal treatment for 102 hospitalized FN patients with AML (MCFG, 53; L-AMB, 49). The efficacy end point was a favorable overall response, as determined by a five-component end point according to the criteria of Walsh et al (N Engl J Med 2004; 351: 1391). Results: At the time of enrolment, there were no significant differences in the demographics or baseline characteristics between the two groups. The mean treatment duration for MCFG and L-AMB was 14.8 and 17.1 days, respectively. The efficacy rates of MCFG and L-AMB were not significantly different (58.5% vs. 44.9%, p = 0.1698*), evaluated based on: (1) successful treatment of baseline fungal infection (3/5cases (5.7%) vs. 0/1case (0%), p = 0.170*), (2) absence of breakthrough fungal infection (90.6% vs. 98.0%, p = 0.112*), (3) survival for ≥7 days after study completion (88.7% vs. 89.8%, p = 0.855*), (4) absence of premature study drug discontinuation due to poor efficacy or drug-related adverse events (67.9% vs. 75.5%, p = 0.396*), and (5) resolution of fever during neutropenia (66.0% vs. 55.1%, p = 0.258*). However, discontinuation due to drug-related adverse events occurred less frequently in the MCFG group (1.9% vs. 12.2%, p = 0.038*). In safety evaluation, adverse events of creatinine increase and hypokalemia were less often in the MCFG group than in the L-AMB group (9.4% vs. 26.5%, P=0.023*, 22.6% vs. 57.1%, P=0.0004*). *: Chi square test. Conclusions: MCFG was as effective as L-AMB, and better tolerated than L-AMB as an empirical antifungal therapy in FN patients with AML. Disclosures Ishida: Kyowa Hakko Kirin Co: Research Funding; Nippon Shinyaku Co: Research Funding; CHUGAI PHARMACEUTICAL CO: Research Funding; Astellas Pharma Inc.: Other: Astellas Pharma Inc. (Tokyo, Japan) supported this clinical study with a grant; the sponsor was not involved in the design of study, the enrollment of patients, the collection, analysis, interpretation of the data., Research Funding.

partial, PR (dFLC decrease > 50%) and no response (NR). Patients with baseline and day 100 post-transplant FLC among the CIBMTR cohort were the subjects of this study. Baseline characteristics were assessed. Progression free and overall survival (PFS, OS) were assessed based on the 2012 criteria using the KaplanMeier method. Results: Of 1536 patients, FLC data was available in 104, from 28 North American centers. Median age at transplant was 57 years (Table). Cardiac involvement was reported in 40%; 13% had 4/> organs involved. Majority of patients (71%) had no prior therapy. Day 100 responses were: CR (13), VGPR (65), PR (15) and NR (11). Median follow up was 50 months with 18 deaths (15 from AL). Kaplan-Meier curves for PFS and OS (figure) showed that patients with CR had the best outcomes followed by VGPR. Patients with PR and NR appeared to have equally worse outcomes. Upon combining CR/VGPR versus PR/NR responses, there was a significant difference in OS (p 0.005). Conclusions: In this highly selected AL cohort from a multi-institutional transplant registry, we validate the 2012 criteria. Patients with CR/VGPR have excellent outcomes compared to those with PR/NR. Figure Progression-Free Survival PO-175 The incidence and clinical features of HBV reactivation in multiple myeloma patients treated with novel agents and/or ASCT: a retrospective multicenter study in Japan Y. Tsukune, M. Sasaki, Y. Yahata, H. Tamura, A. Onodera, M. Koike, S. Ito, Y. Ishida, Y. Imai, J. Tanaka, A. Isoda, M. Matsumoto, S. Tanosaki, J. Hua, M. Hagihara, H. Sugimori, T. Odajima, N. Komatsu Department of Hematology, Juntendo University School of medicine; Division of Hematology, Nippon Medical School; Department of Hematology, Juntendo University Shizuoka Hospital; Department of Medical Oncology, Iwate Medical University School of Medicine; Hematology/Oncology, Iwate Medical Department of Hematology, University School of Medicine; Department of Hematology, Tokyo Women’s Medical University; National Hospital Organization Hishigunma Hospital; Department of Hematology, The Fraternity Memorial Hospital; Department of Hematology, Eiju General Hospital; Daito Bunka University. Graduate School of Sports and Health Science, Dept. of Preventive Medicine; Daito Bunka University School of Sports and Health Science, Faculty of Health Science Background: An estimated 2 billion people worldwide have been or are currently infected with hepatitis B virus (HBV), HBV seroprevalence is particularly high in Eastern Asia. HBV reactivation during or after immunosuppressive or cytotoxic therapy has been reported not only in HBsAg positive patients but also in some patients with resolved HBV infection who are negative for HBsAg but seropositive for anti-HBc and/or anti-HBs. Antiviral therapy initiated after hepatitis onset is often insufficient to control HBV reactivation and may lead to death from fulminant hepatitis. In the era of novel agents (bortezomib, thalidomide, and lenalidomide), there have been few reports about HBV reactivation in multiple myeloma (MM) patients and the standard prophylaxis strategy for hepatitis is yet to be established. Patients and Methods: Between January 2006 and June 2014, 99 symptomatic myeloma patients with HBsAg positivity or resolved HBV infection who were treated with novel agents and/or autologous stem cell transplantation (ASCT) were included. Data analyzed included age, gender, M-protein, stage (Durie-Salmon stage, international staging system), laboratory findings, treatment and outcomes using questionnaires. Results: One of 9 HBsAg positive patients developed hepatitis. Among 90 MM patients with resolved HBV infection, HBV reactivation occurred in 15.8% (3 of 19 patients) in the ASCT group and 7.8% (5 of 71 patients) in the non-ASCT group, after 64.5 (7-140) months from the start of chemotherapy; none of them developed hepatitis by means of monitoring HBV DNA levels monthly and administering entecavir. In 5 of these 8 cases, HBV reactivation was noted during bortezomib administration. HBV reactivation has no significant association with age, gender, stage, laboratory findings, and treatment. Conclusion: Since the introduction of rituximab, HBV reactivation has been reported in some malignant lymphoma patients with resolved HBV infection who received rituximab and steroid containing regimen. In the era of novel 15th International Myeloma Workshop, September 23-26, 2015 e183

BACKGROUND: Febrile neutropenia (FN) is often observed in hematological malignancy (HEM). Although most are considered to be due to bacterial infections, it is often difficult to specify the focuses and pathogens of infections in FN patients. Presepsin (Pre-SEP) is a subtype of soluble CD14, which is a receptor for lipopolysaccharide (LPS)/LPS-binding protein complexes and is expressed on the myeloid and monocytic cells' surface. Recently, Pre-SEP has been shown to be a useful biomarker for assessing the severity of sepsis. However, little is known about the biological characteristics of Pre-SEP in FN patients. Therefore, we compared the Per-CEP to the established infection markers including procalcitonin (PCT) and C-reactive protein (CRP) continually in FN patients. METHODS: We measured Pre-SEP concentration in the plasma, PCT and CRP on Day 0, 2, 4, 7 and 14 after the onset of FN and compared them to those of non-febrile neutropenic patients. Furthermore we evaluated the impact of Pre-SEP, PCT and CRP on the diagnosis and assessment of active infection status in FN, using the cut-off value by setting to 314 pg/ml, 0.50 ng/ml and 0.30 mg/ml. Correlation analysis was performed using Peason's correlation coefficient test. RESULTS: Sixty-two hospitalized FN patients with HEM (AML 14, ALL 9, MDS 14, NHL 13, MM 8, ATL 2, others 2 cases) were treated according to IDSA guideline. Figure 1 showed the each data in Pre-SEP, PCT and CRP value on day 0, 2, 4, 7 and 14. The frequency of less than the cut-off value at day 0 of FN onset were 33.8 %, 77.4 % and 37.1 % in Pre-SEP, PCT and CRP respectively, indicating that Pre-SEP showed the highest sensitivity. On day 0, a significant correlation was not observed between Pre-SEP and PCT (P=0.457, correlation coefficient: 0.096) but it was observed between Pre-SEP and CRP (P CONCLUSION: (1) Pre-SEP is available even in neutropenia. (2) Pre-SEP is a useful biomarker for infection on the onset of FN as well as CRP. (3) Pre-SEP can help more sensitive assessment of infection. Figure 1. Figure 1. Disclosures No relevant conflicts of interest to declare.

Background: In vitro observations have indicated that preplatelets, which are anucleate discoid particles that can reversibly into proplatelet fragments, are one of platelet progenitos from cultured megakaryocytes (MKs) (Thon JN, et al. JBC 2010). Recently, we identified that bone marrow (BM) MKs form and release two types of platelet progenitors, using intra-vital imaging and ultra-structural analysis of mice BM (Kowata S, et al. Thrombosis and Haemostasis 2014). However, in vivo, how the platelet progenitors translate into individual platelets after leaving BM remains poorly understood. To elucidate whether platelet progenitors have an ability of conversion into individual platelets, we performed following experiments. Methods: We isolated platelet progenitors rich fraction from whole blood of enhanced green fluorescence protein (EGFP) transgenic mice by the centrifugation (100 g, 15 min) and bovine serum albumin gradient. Mature platelets were isolated from whole blood of EGFP mice by the centrrifugation (100 g, 15 min). In vivo: The freshly enriched progenitor rich fraction or mature platelets, both of which were positive for EGFP, was transfused into wild type mice. The peripheral blood was obtained and analyzed by flow cytometry continually. The EGFP positive mature platelets in platelet gate were counted. In vitro: The freshly enriched progenitor isolates were cultured in IMDM medium at 37°C. The continual change of their characteristics in the shape and size were assessed using fluorescent microscopy with high resolution. Time-lapse images of the processes were also captured. All animal procedures were approved by the Institutional Animal Care and Use Committee of Iwate Medical University. Results: The length and size of platelet progenitors were extremely varied (Fig. 1). The red, yellow, green, and dark blue segments in the bar chart indicate the platelet progenitors (5um). The frequency of platelet progenitor was 4% at normal condition (Fig. 1 graph on the left), but increased remarkably to 3-fold at recovery from acute thrombocytopenia (Fig.1 graphs in the middle). The maximum length of platelet progenitor was more than 200 µm (Fig. 1 picture in the top right). These data were consisted with the concept from our previous study of intra-vital imaging of BM MKs (Thrombosis and Haemostasis 2014). In vivo: Flow cytometric analysis showed that there was a time-dependent increase in EGFP platelet number in the gate of mature platelet, after the injection of EGFP positive platelet progenitor rich fraction. The control was carried out using EGFP positive mature platelets instead of platelet progenitors rich fraction. (mean ± SD, 0 h: 100%, 3h: 111 ± 6.8%, 6h: 105 ± 7.1% n=3, control 0 h: 100%, 3h: 101± 6.0%, 6h: 94 ± 5.2% n=3, Data were shown as % of the number of EGFP positive mature platelets at 0 h. P Figure 1. Figure 1. Disclosures Ishida: Bristol-Myers Squibb: Honoraria.

Introduction: Adult T-cell leukemia-lymphoma (ATL) is a distinct peripheral T-cell lymphomacaused by human T-lymphotropic virus type I (HTLV-1), which is endemic in Japan. Only a small percentage of HTLV-1 carriers infected through breast-feeding develop the disease. Previous nationwide surveys during 1980s-2000s in Japan provided a comprehensive view on the clinio-epidemiological profiles of ATL, including the establishment of the subtype-classification (i.e., the Shimoyama criteria: acute, lymphoma, chronic, and smoldering type) based on the diversity of the clinical features and prognosis. Treatment strategies have been developed by the subtype-classification; watchful waiting for indolent ATL, intensive chemotherapy followed by allogeneic hematopoietic stem cell transplantation (allo-HSCT) for aggressive ATL. The aim of this 11th survey is to characterize the current clinio-epidemiological features of ATL in Japan in the light of previous surveys. Methods: In 2013-14, we conducted an anonymous, cross-sectional, hospital-based survey of patients with ATL who were newly diagnosed during 2010-2011 across Japan. First, we asked 2500 hospitals with departments of hematology and dermatology to participate in this survey, and then we sent questionnaires to 128 participating hospitals to accumulate data of ATL. Skilled five hematologists reviewed the data of each questionnaire sheet, and the agreements of ATL diagnosis including the subtypes between the central review and participating hospitals were evaluated using Kappa statistics. Most of the collected data were analyzed by descriptive statistics. Results: A total of 996 ATL patients were registered; of these, 41 were eliminated because of the insufficient information for the diagnosis of ATL. Overall diagnostic agreement on subtype of ATL was substantial, with a kappa value 0.71 (standard error, 0.021); most of the disagreement was within aggressive/indolent category, acute vs. lymphoma types or acute vs. unfavorable chronic types. Among the 955 evaluable patients (M/F ratio, 1.12), 70% were diagnosed in the southwest region of Japan (Kyusyu/Okinawa) where HTLV-1 is endemic, which was consistent with the past surveys. The mean age at diagnosis was 68.3 years (median 68.8, range 24.7-100.3), which was significantly higher than 60.3 years in 1994-1995 and 57.7 years in 1986-1987. The proportion of ATL patients aged over 65 years was 79 % in this survey (whereas, 48% in the 1990-1991 survey), which indicates that the allo-HSCT is not applicable to the majority of current ATL patients in Japan. The proportion of acute, lymphoma, chronic, and smoldering types was 48, 28, 10 and 13%, respectively. The proportion of smoldering and chronic types tended to be greater than previous surveys (7% and 10% in the 1988-1997 surveys combined). The proportion of subtype by age group in this survey showed that the older in age at diagnosis are, the higher proportion of lymphoma subtype (10% in those aged younger than 40 years, 20% in those 50-59, and 31% in those 70 years or older. Discussion: This 11th survey revealed several clinio-epidemiological features of current ATL in Japan different from those in past two decades. First, a considerably increasing proportion of elderly ATL patients were diagnosed, which may be expected from a recent distribution of nationwide HTLV-1 carriers in Japan (Satake, et al, 2011). Second, there is an increasing tendency in the proportion of indolent types of ATL. This may be partly influenced by participation of the dermatology departments for the first time, because early phase of ATL localized in skin were frequently diagnosed in the dermatology department. Third, the proportion of lymphoma subtype was increased with age, which suggests that aging-related unknown mechanisms may affect the subtype distribution. More detailed analysis and subsequent surveys are planned to further evaluate clinical features and the efficacy of modern therapies on prognosis of ATL. Disclosures Ishizawa: Kyowa Kirin: Speakers Bureau; GSK: Research Funding; Takeda: Research Funding; Celgin: Speakers Bureau; Kyowa Kirin: Research Funding; Celgin: Research Funding; Janssen: Research Funding; Takeda: Speakers Bureau; Pfizer: Speakers Bureau. Ishida:Bristol-Myers Squibb: Honoraria. Ishida:Kyowa Hakko Kirin Co., LTD: Honoraria, Other: Research Funding to my institution; Bayer Pharma AG: Other: Research Funding to my institution; Celgene K.K.: Other: Research Funding to my institution. Tobinai:Gilead Sciences: Research Funding. Watanabe:Daiichi Sankyo Co., Ltd.: Research Funding.

Background: Thrombotic microangiopathy (TMA) and veno-occlusive disease (VOD) as well as acute GVHD (aGVHD) are closely relevant to inflammation and coagulation involving endothelium in the setting of allogeneic hematopoietic stem cell transplantation (allo-HSCT), which is named as transplantation associated coagulopathy (TAC) to overcome challenges and achieve better survival. Recombinant thrombomodulin (rTM) is a new drug for treating disseminated intravascular coagulation (DIC) approved by the Japanese Ministry of Health, Labour and Welfare in 2008. Membranous TM has many aspects to inhibit inflammation via activated Protein C (APC), lectin-like domain, and activated thrombin-activatable fibrinolysis inhibitor as well as to inhibit coagulation by binding factor IXa and Xa through APC. We investigated the effects of rTM on levels of the biomarkers and examined whether we could prevent TAC using rTM among registered patients in the SIGHT study group. We reported that significant improvements in elevation of TNF-α, E-selectin, VCAM-1, HMGB-1, PAI-1 and PDMP were exhibited following alloHSCT with rTM-treatment. Here we studied which biomarker were predictive for TAC and contributed to reduce the probability of these complications. Methods: SIGHT study group was composed of 70 hospitals and research centers in Japan. Patients eligible for alloHSCT treatment for hematopoietic disorders who secured attending physicians clearance were permitted in the study. Blood samples were collected from the patients before and after transplantation through day 28. Levels of cytokines (IL-6, TNF-α, HMGB1, MCP-1, RANTES) and soluble molecules (VCAM-1, E-selectin, PAI-1, PDMP) were measured by ELISA. rTM was administered as a prophylactic therapy for TAC in day 4-14 after alloHSCT. The dose of rTM, 380 u/kg, was employed as same dose as the treatment for DIC. Control group received 100 u/kg heparin, or no anti-coagulation therapy as prophylaxis at the same schedule as the rTM group. Patients were not randomized to these three arms but allowed to select one by their physician's decision. Complications following transplantation were reported by attending physicians. Results: The subjects were 293 patients who underwent alloHSCT in SIGHT study group between June 2010 and February 2014. 194 patients out of them, in whom complications following alloHSCT were reported, were analyzed to measure level of above biomarkers. No G3/4 adverse events of bleedings or severe organ damages were reported. Regarding complications following alloHSCT, the rate of developing aGVHD and VOD was significantly lower in rTM group than without it (36.5% vs. 62.2%, p=0.000; 12.5% vs. 24.5%, p=0.032, respectively), while TMA did not differ (8.4% vs. 10.2%, p=0.961). Stepwise multivariate logistic regression analyses revealed that anti-coagulation therapy without rTM was an independent risk factor for aGVHD (p=0.000, odds ratio=3.006) and VOD (p=0.015, odds ratio=2.65). We explored candidates for predictive biomarkers for TAC following alloHSCT. Only HMGB-1 levels were useful markers associated with risk of VOD among them (p=0.001, odds ratio=1.433). Also, the levels of HMGB-1 since the day of transplantation were significantly associated with risk of VOD after analyzing the whole dynamics of HMGB-1 level. E-selectin, PAI-1, VCAM-1, PDMP, and HMGB-1 were found to be closely relevant to one another by the principal component analysis (principal component loading=0.797, 0.876, 0.675, 0.780, and 0.691, respectively). Conclusion: The present findings suggested that rTM had the possibility to play a therapeutic role for aGVHD and VOD. HMGB-1 worked as an inflammatory cytokine, which exhibited peak level on the day of transplantation influenced by toxicity of conditioning regimen. VOD develop in relatively early days up to 20 days after alloHSCT, the elevation of HMGB-1 levels since day 0 after transplantation could be an early predictive biomarker for it. Once condition regimens are initiated, HMGB-1 is released from the injured cells including endothelial cells. HMGB-1 induces to release inflammatory cytokines and express adhesion molecules as well as tissue factor on endothelium (Yang H. Proc Natl Acad Sci USA. 2010;107:11942). These reactions facilitate pro-coagulant state resulting in VOD. We concluded that HMGB-1 was a major factor for VOD and rTM was effective to treat VOD attributable to suppression on HMGB-1. Disclosures Ishida: Bristol-Myers Squibb: Honoraria.

[Background] Survivin is a member of the inhibitor of apoptosis protein (IAP) family with its dual roles in mitosis and apoptosis, and emerges as an attractive target for cancer therapy. YM155, a novel molecular targeted agent, suppresses survivin, which is overexpressed in many tumor types. However, the effect of this agent on multiple myeloma (MM) cells remains unclear. [Materials & Methods] Five human MM cell lines, RPMI8226, U266, KMS20, KMS28PE, and KMS34 were used in this study. Cell proliferation and cell death were evaluated by MTT assay and by flow cytometric analysis with annexin V/PI staining. Gene and protein expressions were analyzed with quantitative PCR (qPCR) and immunoblot, respectively. For proteasome inhibitory assay, cells were treated with YM155 and/or proteasome inhibitor MG132 for 6 hours. [Results] YM155 inhibited cell proliferation of these cells in a dose- and time-dependent manner. Annexin V assay showed that YM155 induced apoptosis in these cells. To better understand these effects of YM155 on MM cells, we evaluated the intracellular signaling and apoptosis-associated protein status. Immunoblot analyses showed that YM155 reduced not only survivin but also Mcl-1 and XIAP expressions. We also observed the activation of caspase-3 and PARP in YM155-treated cells, indicating that YM155 induces caspase-dependent apoptosis. In contrast, YM155 did not affect phosphorylation status of Erk1/2 and STAT3. Interestingly, YM155 suppressed c-Myc and IRF4 protein expressions, both of which are recognized as an important transcription factor in the pathogenesis of MM. In addition, qPCR assay showed that YM155 treatment did not reduce c-Myc mRNA level. On the other hand, proteasome inhibitor prevented the suppression of c-Myc expression by YM155 treatment, indicating a proteasomal degradation of c-Myc by YM155. [Conclusion] YM155 suppresses cell proliferation and survival in MM cells in part via not only inhibiting anti-apoptotic proteins such as survivin, Mcl-1 and XIAP but also suppressing c-Myc oncoprotein expression. Further study is needed to clarify the molecular mechanism of c-Myc degradation induced by YM155. Our results may provide a new concept in c-Myc-targeting therapy for MM because c-Myc oncoprotein have been considered undruggable. Disclosures Ishida: Bristol-Myers Squibb: Honoraria.

Background: We conducted a phase II study to evaluate the efficacy and safety of dasatinib in patients with newly diagnosed chronic-phase chronic myeloid leukemia (CML-CP) in Japan (IMIDAS PART2 study; UMIN000006358). Several groups reported that some of CML patients who achieved stable deep molecular response (DMR) level or deeper could stop Tyrosine Kinase Inhibitor (TKI) and approximately 40% of these patients could keep therapy free survival by cessation of TKI. Discontinuation of TKI has emerged as a new goal of treatment in CML. Achievement of DMR is necessary for discontinuation of TKI. The aim of the present study was to analyze the prognostic significance of (i) BCR-ABL transcript International Scale (BCR-ABL IS) levels, (ii) the halving time and (iii) velocity of BCR-ABL transcript elimination using an optimized cutoff according to receiver operating characteristic (ROC) analysis. Methods: Eighty newly diagnosed CML-CP patients were included in this study. Patients received dasatinib 100mg once daily. Treatment has continued until disease progression or unacceptable toxicity. Clinical efficacy and safety was partially reported in 55th ASH Meeting. We sought to investigate the impacts of above 3 parameters within the initial 1 or 3 months of therapy. Halving time was calculated by the method, described by Branford et al. Velocity of BCR-ABL transcript elimination at 1 or 3 months (V-BCR-ABL1m or 3m respectively) was calculated as BCR-ABL IS at 1 or 3 months (BCR-ABL IS1m or 3m respectively) divided by that at diagnosis. Results: One patient was withdrawal before administration of dasatinib. Seventy-nine patients administered dasatinib 100 mg once daily. The estimated MMR and DMR rates were 92.1 % (95%CI, 76.8-97.3 %) and 60.9% (95%CI; 42.3-73.4 %) by 12 months respectively. The patients who had already achieved DMR at 3 months were excluded from landmark analysis. The cut off values for prediction of DMR at 12 months were obtained by ROC analysis. Those of BCR-ABL IS1m and BCR-ABL IS3m were 11.7% and 0.284% respectively. Those of halving times on 0-1 month and 0-3months (halving time1m and 3m) were 17.8 and 13.6 days respectively. Those of V-BCR-ABL1m and V-BCR-ABL3m were 0.321 and 0.018 respectively. The estimated DMR at 12 months, 95% CI and probability (P), obtained by Kaplan-Myer analysis, were shown in Figure 1. Odd' ratio, obtained by Chi-square test, was shown in Table 1. The patients with less than 0.321 at V-BCR-ABL1m showed the highest DMR at 12 months (80%), the least probability (P=0.009) and the least odd' ratio (0.175). At 3 months, there were similar data in these parameters among BCR-ABL IS3m, halving time3m and V-BCR-ABL3m. Figure 1 showed the cumulative DMR rate according to the cutoff values in V-BCR-ABL1m and V-BCR-ABL3m. V-BCR-ABL1m 0.321 and V-BCR-ABL3m 0.018 separated best. Conclusion: These data strongly suggested that V-BCR-ABL1m,3m would be a significant landmark to predict DMR at 12 months as well as BCR-ABL IS1m,3m, halving time1m,3m. Among them, less than 0.321 in V-BCR-ABL1m was identified as an optimized predictive cutoff value of DMR at 12 months. Disclosures Ishida: Bristol-Myers Squibb: Honoraria.

PO-272 Survivin suppressant YM155 induces cell death via proteasomal degradation of c-Myc in multiple myeloma cells M. Asahi, S. Ito, Y. Ishida Hematology & Oncology, Department of Internal Medicine, Department of Medical Oncology, Iwate Medical University School of

e242 [U266 (p53 mutant), OPM-2 (p53 mutant), KMS-18 (p53 WT/-), JJN3(p53 WT/-), MM.1S (p53 WT)]. Effects on downstream substrates were analysed by Western blotting. Elevated HUWE1 expression was confirmed in MM cell lines and primary CD138+ MM cells compared to healthy CD138+ cells at both the gene and protein level ( 2-fold). shRNA knockdown of HUWE1 significantly decreased (p 0.01) the proliferation of all MM cell lines, regardless of p53 status; this effect was maintained when cells were cultured in the presence of bone marrow stromal cells. Conversely, we show that MM cell lines that carry mutant p53 were largely resistant to the MDM2 inhibitor Nutlin-3. Finally, we have demonstrated that HUWE1 depletion is associated with a significant increase of cells in G2/M, an accumulation of p53 and MIZ1 and a decrease in MYC protein levels (p 0.05). The proteasome is an established target in MM and there are opportunities for more specific targeting of enzymes within the UPS. Here we demonstrate that the E3 ligase HUWE1 is important in the growth and survival of MM cells and offers a more valuable therapeutic target than MDM2. Future work will investigate the effect of small molecule inhibitors of HUWE1 in MM.

e214 Conclusions: Our results demonstrate the potent, rapid activity of filanesib which induces a cell cycle blockade through the inhibition of KSP, leading to apoptosis in MM. Furthermore, this agent showed significant synergy with pomalidomide and dexamethasone, what supports the clinical ““Pomdefil”” trial, recently activated in the context of the Spanish Myeloma Group (GEM).

Background: Thrombotic microangiopathy (TMA) and sinusoidal obstruction syndrome (SOS) as well as acute GVHD are major complications after allogeneic hematopoietic stem cell transplantation (alloHSCT) to overcome to achieve better overall survival. These complications are closely relevant to inflammation and coagulation involving endothelium, which are named as transplantation-associated coagulopathy (TAC). Recombinant thrombomodulin (rTM) is a new drug for treating DIC approved by Japanese Ministry of Health, Labour and Welfare in 2008. Membranous TM has many aspects to inhibit inflammation via activated Protein C (APC), lectin-like domain, and activated thrombin-activatable fibrinolysis inhibitor as well as to inhibit coagulation by binding factor IXa and Xa through APC. Biomarkers such as inflammatory cytokines and endothelial molecules are expected to be clue in elucidating TAC. We established SIGHT study group to explore above complications following alloHSCT. In the present study, we investigated the effects of rTM on levels of the biomarkers and whether we could prevent TAC using rTM among registered patients in the SIGHT study group. Patients and methods: SIGHT study group covered nationwide institutes more than 70 in Japan. Patients whoever were eligible for alloHSCT to treat hematopoietic disorders by physicians decision were permitted and written informed consent was requested to register in the study. Blood samples were collected from the patients before and after transplantation through day 28. Levels of cytokines (IL-6, TNF-α, HMGB1, MCP-1, RANTES) and soluble molecules (VCAM-1, E-selectin, PAI-1, PDMP) were measured by ELISA. rTM was administered as a prophylactic therapy for TAC in day 4-14 after alloHSCT. Control group was received heparin or no anti-coagulation therapy as prophylaxis during same schedule as rTM group. Patients were not randomized to these three arms but allowed to select one by their physicians decision. The primary endpoint was a comparison of fluctuation of these biomarkers in three arms. Secondary endopoint was a comparison of the rate of developing TAC. Results: The subjects were 293 patients who underwent alloHSCT in SIGHT study group between June 2010 and February 2014. 271 patients out of them were analyzed to measure level of these biomarkers. There was no significant difference in all characteristics but GVHD prophylaxis between two groups. rTM group received more cyclosporine than control group (p=0.05). MCP-1 and IL-6 exhibited more significant elevations on day 7 after alloHSCT, while HMGB-1 did on the day of alloHSCT. In contrast, the levels of TNF-α, E-selectin, VCAM-1, PAI-1 and PDMP exhibited increment since around day 7 after alloHSCT. Significant improvements in TNF-α, E-selectin, VCAM-1, HMGB-1, PAI-1 and PDMP was shown after rTM-treatment, but not shown in control group. Regarding complications following alloHSCT, the rate of developing acute GVHD and SOS was significantly lower in rTM group than without it (36.5% vs 62.2%, p=0.000; 12.5% vs 24.5%, p=0.032, respectively), while TMA did not differ (8.4% vs 10.2%, p=0.961). Stepwise multivariate logistic regression analyses revealed that anti-coagulation therapy without rTM and the level of PAI-1 on day 28 after HSCT were independent risk factor for acute GVHD (p=0.000, odds ratio=3.006; p=0.000, odds ratio=1.068, respectively). Also anti-coagulation therapy without rTM and the level of HMGB-1 on day 28 after HSCT were significantly predictive for risk of SOS (p=0.015, odds ratio=2.650; p=0.001, odds ratio=1.433, respectively). Tacrolimus was significantly good risk of SOS (p=0.022, odds ratio=0.404). The level of VCAM-1 on day 28 after HSCT was significantly associated with risk of TMA (p=0.040, odds ratio=1.001). Conclusions: We identified predictive biomarkers for TAC following alloHSCT, which were PAI-1 for acute GVHD, HMGB-1 for SOS, and VCAM-1 for TMA, respectively in this study. The present findings suggest that rTM has the possibility to play a therapeutic role for acute GVHD and SOS induced by suppression on these biomarkers. Endothelial and pro-coagulant biomarkers were released delayed compared with inflammatory biomarkers. TMA is reported to develop around day 44 in median after alloHSCT. Further studies are needed whether rTM should administer later or longer to improve TMA than the present duration after alloHSCT. Disclosures No relevant conflicts of interest to declare.

Background: Immune thrombocytopenia (ITP) is an autoimmune disease in which anti-platelet antibody (APA) is produced. APA-coated platelets are captured and phagocytized by macrophages in the spleen. Recent study revealed that spleen tyrosine kinase (Syk) inhibitor is effective in the treatment of ITP, because Syk phosphorylation is the key step of the phagocytosis by macrophages. Activated Fc receptor signal transduction is initiated by phosphorylation of immunoreceptor tyrosine-based activation motifs (ITAMs) tyrosine residues by SRC family kinases. Recruitment of Syk to dually phosphorylated ITAMs triggers the activation of Syk. To prove the hypothesis that the inhibition of SRC family kinase induces the decreased phosphorylation of Syk, resulting in decreased phagocytosis by macrophages, a SRC family kinase inhibitor, dasatinib, was used in the experiments. Methods, Results and Discussion: In vitro study; Murine macrophage cell line, RAW, was incubated with APA coated murine platelets for 30 minutes. Phagocytosis by RAW was significantly decreased with dasatinib (100nM, p In vivo study; (1) Three hours before APA intra-peritoneal injection, dasatinib (2.5mg/kg) was oral-administrated. Six hours after APA injection, platelet counts were measured. The platelet counts were 366 ± 164 x109/L with dasatinib (n=4, mean ± SD) and 114 ± 51 x109/L without dasatinib (n=4)(P=0.026)(Figure 2). (2) Osmotic pump, filled with APA, were inserted in murine intra-peritoneal cavity and dasatinib (2.5mg/kg) was oral-administered once daily for 7 days. The platelet counts were 499 ± 98 x109/L with dasatinib (n=4, mean ± SD) and 82 ± 131 x109/L without dasatinib (n=4) at day 7 (p Conclusion: Dasatinib inhibits phosphorylation of Syk, inducing decreased phagocytosis of APA-coated platelets via decreased SRC family kinase activity. These findings reveal that SRC family kinase controls the efficiency of phagocytosis in part through the regulation of Syk function. Dasatinib might be effective in the treatment of ITP. Disclosures No relevant conflicts of interest to declare.

Introduction: The immunophenotypic analysis of plasma cells using flow cytometry (FCM) is useful for the diagnosis for multiple myeloma (MM) and the detection of MM cells after treatment. CD138 is a well-known surface marker identifying plasma cells, although decreased CD138 expression on plasma cells is frequently observed in MM patients with relapsed or progressive disease. Thus, more stable MM antigens are needed. The SLAM family molecule CD229 has recently been reported to be specifically overexpressed on MM cells including their clonogenic precursors, suggesting that it may be a good marker to identify MM cells. Furthermore, some surface antigens, i.e., costimulatory molecule CD86 (B7-2), its receptor CD28, IL-6 receptor (CD126), insulin-like growth factor-1 (CD221), and coinhibitory molecule B7-H1 (PD-L1, CD274), were reported to be associated with poor prognosis. This study aimed to validate the potential of CD229 as a new MM cell marker and the efficacy of immunophenotypes on MM cells as prognostic markers in a multicenter study. Patients & Methods: Two-hundred thirteen patients comprising 144 newly diagnosed (18 asymptomatic and 126 symptomatic) MM patients, 25 refractory/relapsed MM patients, and 44 monoclonal gammopathy of undetermined significance (MGUS) patients were enrolled. Immunophenotyping of plasma cells in bone marrow was performed with standard 3-color FCM, in which plasma cells were gated by CD38-highly positive cells and 9 parameters, i.e., expression of MM antigens (CD138, CD229) and prognosis-related antigens previously reported (CD28, CD45, CD56, CD86, CD126, CD221, CD274) on MM cells, were analyzed. Expression levels of prognosis-related antigens were compared between patients in high-risk categories, i.e., International Scoring System (ISS) stage II/III, high-risk chromosomal abnormalities [t(4:14), t(14:16), del17p] by FISH, high-risk group stratified by the International Myeloma Working Group (IMWG) [ISS stage II/II and t(4:14) and/or del17p], high serum lactase dehydrogenase (LDH) level, or revised ISS stage III, and other patients. The revised ISS is a powerful new tool to predict outcome in MM patients treated with novel agents based on 3 factors: serum LDH level, ISS stage, and high-risk chromosomal abnormalities [Oliva S, et al. EHA2014, Abstract #S1289]. Differences between continuous variables were evaluated using the Mann-Whitney U-test. Results: 1) CD229 was expressed on almost all MM cells, even on low CD138-expressing MM cells. MM cells from ISS stage II/III patients expressed significantly lower levels of CD138 than those from ISS stage I patients (P = 0.0004). Furthermore, although CD138 expression levels in symptomatic MM patients were lower than those in patients with asymptomatic MM and MGUS and the expression was decreased in refractory/relapsed MM patients, CD229 expression levels on plasma cells were similar in MGUS and MM patients. 2) Newly diagnosed MM patients with high-risk chromosomal abnormalities or in the IMWG high-risk group had higher levels of CD86 and CD126 compared with other patients (P = 0.0056 and 0.0248 in high-risk chromosomal abnormalities, P = 0.0221 and 0.0396 in IMWG high-risk group, respectively). Furthermore, patients in revised ISS stage III had higher levels of CD126 compared with others (P = 0.0646). 3) Although the serum IL-6 level was significantly higher in ISS stage II/III patients, in patients with high LDH levels, and in revised ISS stage III patients compared with other groups, there was no correlation between serum IL-6 levels and expression levels of the IL-6 receptor CD126 on MM cells. Conclusion: CD229 has the potential to become a new marker for the identification of MM cells and target for immunotherapy. High expression levels of CD86 and CD126 were associated with high-risk patients, and CD126 may be associated with survival in patients treated with novel agents. FCM analysis may be useful for predicting prognosis as well as detecting malignant clones. Further studies are in progress to clarify the significance of those molecules on MM cells. Disclosures No relevant conflicts of interest to declare.

Introduction: B7-H1 (also known as PD-L1 or CD274), a co-inhibitory molecule of the B7 family, is detected on various tumor cells and associated with tumor evasion from cytotoxic T lymphocyte (CTL)-mediated immune surveillance. Our previous study showed that B7-H1 expression levels on plasma cells from multiple myeloma (MM) patients were significantly upregulated compared with those cells from monoclonal gammopathy of undetermined significance patients and healthy volunteers. B7-H1-expressing MM cells had a proliferative advantage and were resistant to antimyeloma agents (Tamura et al. Leukemia 2013). However, it remains unknown whether cellular responses in B7-H1-expressing MM cells are affected by the interaction of B7-H1 molecules with their receptors, i.e., PD-1 and CD80. We thus investigated the reverse signal derived from B7-H1 binding to their receptors on MM cells and examined the clinical characteristics of B7-H1-highly positive MM patients in a multicenter study. Methods: 1) We established B7-H1-expressing MM cell lines called MOSTI expressing high levels of CD38 and CD138 from bone marrow mononuclear cells of myeloma patients and B7-H1-positive MM cells (B7-H1.KMS28PE) stably transfected with the B7-H1 gene. 2) B7-H1 knockdown MOSTI cell lines were obtained using B7-H1-specific short-hairpin RNA expressing a lentiviral vector. 3) The proliferative potential was examined by BrdU incorporation using flow cytometry (FCM) and the MTT assay. 4) Drug-induced apoptotic cells were stained with annexin V and propidium iodide (PI) and detected in FCM. 5) Magnetic Dynabeads were coupled with PD-1-Ig or CD80-Ig fusion proteins. B7-H1-expressing MM cells were co-cultured with the beads, and the binding capacity of the beads to B7-H1+ MM cells, drug sensitivity, and cell proliferation of B7-H1+ MM cells were analyzed. 6) We classified 105 cases with newly diagnosed MM into two groups according to B7-H1 expression levels on plasma cells and compared the clinical characteristics associated with prognosis between B7-H1-highly-expressing MM patients (n=43) and other patients (n=62). Results: 1) Knockdown of B7-H1 expression in MOSTI cells significantly suppressed cell proliferation and increased melphalan-induced apoptosis. These results demonstrated that B7-H1 expression is directly associated with aggressive myeloma behavior including cell growth and drug resistance. 2) B7-H1 molecules on MOSTI and B7-H1.KMS28PE cells bound more strongly to PD-1-Fc than to CD80-Fc. The binding of PD-1-Fc to MOSTI cells was inhibited by anti-B7-H1 antibody in a concentration-dependent manner. In MOSTI cells treated with PD-1-Fc beads, apoptosis induced by both melphalan and bortezomib was markedly inhibited in comparison with the cells treated with control Ig. PD-1-Fc bead-treated B7-H1.KMS28PE cells were also resistant to melphalan-induced apoptosis. However, CD80-Fc bead-treated cells did not show drug resistance. Resistance to antimyeloma agents via the reverse signal from PD-1 to MM cells was inhibited by the PI3K/AKT inhibitor LY294002. In Western blot analysis, phospho-AKT expression was significantly upregulated in PD-1-Fc-treated MM cells. However, the cell growth of PD-1-Fc-treated MOSTI cells was the same as that of control Ig-treated cells. These data indicate that the reverse signal delivered from B7-H1 expressed on MM cells bound to PD-1 induced the drug resistance of MM cells thorough the Akt signaling pathway. 3) Patients with B7-H1 highly-expressing MM cells tended to have the poor-risk cytogenetic abnormality t(4;14) (P=0.0703). Furthermore, fibroblast growth factor receptor 3 was significantly upregulated on MM cells in those B7-H1-highly positive patients (P=0.0141). Expression levels of CD56, CD45, and CD221, which were reported to be poor prognostic markers in MM, were siginificantly higher in B7-H1-highly positive patients compared with others. Conclusion: Our study revealed a new mechanism via which the interaction between B7-H1 on MM cells and PD-1 molecules not only inhibits tumor-specific CTLs but also induces the drug resistance of MM cells through the Akt signaling pathway. Furthermore, B7-H1 expression on MM cells may be associated with t(4;14) translocation and poor prognostic MM antigens. Thus, B7-H1 may be a reasonable target for immunotherapy. Disclosures No relevant conflicts of interest to declare.

BACKGROUND: Dasatinib is a second-generation BCR-ABL inhibitor that has a 325-fold higher potency than imatinib and a 16-fold higher potency than nilotinib in vitro. Recent reports suggested that absolute lymphocytosis in response to dasatinib for chronic phase (CP) –chronic myeloid leukemia (CML) might be associated with favorable response. However, as the fluctuation of lymphocytosis was often observed, it is sometimes difficult to define lymphocytosis. To evaluate how much increase and how long continuation of lymphocytosis affects the better clinical efficacy, we developed an index (DL index; Dasatinib induced Lymphocytosis index) that combines duration and increase of lymphocytosis. The aim of this study was to test the DL index as a predictor of Major Molecular Response (MMR) at 12 month. PATIENTS and METHODS: The DL area was based on a graph plotting the absolute lymphocyte counts and was the area under the lymphocyte curve using trapezoidal method. DL index was DL area divided by weeks. For example, DL index12W was defined as (DL area from 4 to 12 weeks) divided by (12-4) weeks. We tested the DL index12W in 30 patients who developed MMR at 12 months (MMR group) and 9 patients without MMR (non-MMR group). RESULTS and DISCUSSION: DL score12w in MMR group and non-MMR group were 2714.0 (95% CI; 2286.0-3142.2, n=30) and 1559.9 (95% CI; 1006.9- 2113.0, n=9) respectively. There was a significant difference between MMR group and non-MMR group in DL index12W by t-test(Figure 1, p=0.0016). A significant linear relationship was obtained between DL index12w and the peaked lymphocyte counts within 12 weeks by Spearman's correlation coefficient rank test (Figure 2, p=1.97E-07, correlation coefficient=0.91). The DL index12w, 2,113, which was the upper limit of non-MMR group 95% CI, is equivalent to 2,909/µl in lymphocyte count, and the DL index12w, 2,286, which is the lower limit of MMR group 95% CI, equivalent to 3,123/µl in lymphocyte count. Therefore, we divided all patients (n=39) into two groups, equal or more than 3,123/µl and less than 3,123/µl in the peaked lymphocyte counts. The patients with the peaked lymphocyte counts ≥ 3,123/µl reached MMR at 12 months (19/20=95.0%) to compare those less than 3,123/µl (11/19=57.9%) (p=0.0075). CONCLUSION: The peaked lymphocyte number, induced by the DL index12w, which calculation was extremely easy, was associated with molecular response. These data suggests that this tool can be useful in interpreting the results of molecular response at 12 months. Figure 1 Figure 1. Figure 2 Figure 2. Disclosures No relevant conflicts of interest to declare.

BACKGROUND: Febrile neutropenia (FN) is often observed in cases of hematological malignancy such as acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL) and myelodysplastic syndrome (MDS). Carbapenem antibiotics having a potent and broad antimicrobial activity against both gram-positive and gram-negative bacteria including Pseudomonas aeruginosa, are good candidates as the first-line therapy drug in high-risk FN patients. In the IDSA guideline 2010 on the use of antimicrobial agents in FN, mono-therapy with an anti-pseudomonal beta-lactam, such as piperacillin-tazobactam, cefepime or carbapenem [only meropenem (MEPM) and imipenem-cilastatin], is recommended as an empirical therapy for high-risk FN patients. Doripenem (DRPM) is a newer carbapenem with few data available as for the efficacy and safety in the setting of FN patients. Therefore, we conducted a randomized, cooperative group, open-label trial comparing DRPM (1.0 g every 8 hours) with MEPM (1.0 g every 8 hours) as the first-line empirical antibacterial therapy for high-risk FN patients with hematological malignancy including AML, ALL and high-risk MDS. PATIENTS and METHODS: One hundred and forty-six hospitalized high-risk FN patients with hematological malignancy (AML 76, ALL 43, APL 13, MDS-AML 9, MDS-RAEB 5 cases) during or after chemotherapy were randomized to each drug group (DRPM: n=73, MEPM: n=73). The study drug was started to administer as a mono-therapy and continued at least for 5 days without drug toxicity, and the efficacy and safety were evaluated. RESULTS: The overall response rate at 7 days in DRPM and MEPM group were not significantly different (DRPM: 67.6%, MEPM: 52.9%, respectively, P=0.098). Both the resolution of fever by mono-therapy at day 3 to 5 (DRPM: 56.9%, MEPM: 47.0%, respectively, p=0.26), and survival at day 30 (DRPM: 98.4%, MEPM: 98.5%, respectively, p=0.312) were not significantly different in the two groups. The frequency of cases needed for anti-MRSA agent and antifungal agent were a little less often in DRPM rather than in MEPM group [DRPM: 36.9%, MEPM: 50.0% (p=0.185), DRPM: 26.1%, MEPM: 32.3% (p=0.535), respectively]. Only grade 1-2 adverse events were observed in both groups (liver dysfunction, renal dysfunction, diarrhea and rash), and they were less often in DRPM group significantly (DRPM: 29.8%, MEPM: 40.8%, respectively, p=0.046). These adverse events were clinically acceptable in the two groups, and most of patients could continue the treatment by both study drugs. CONCLUSIONS: Our clinical study suggested that DRPM had the non-inferiority of efficacy in comparison with MEPM as the first-line empirical therapy in high-risk FN patients with hematological malignancy, and both drugs could be generally well tolerated. Disclosures No relevant conflicts of interest to declare.

Bendamustine is an alkylator containing a benzimidazole ring; it only has partial cross-resistance with the other alkylating agents. Several studies have shown that bendamustine is effective as a single agent or as combined treatment with rituximab for low-grade B-cell lymphoma. Although bendamustine has a favorable safety profile, the occurrence of myelosuppression and lymphocytopenia is relatively frequent. In lymphocytopenia, CD4-positive (CD4+) T-cell recovery is specifically impaired. If this occurs over a prolonged period of time, patients are at risk of opportunistic infections, such as cytomegalovirus (CMV) reactivation. This is a risk for bendamustine-treated patients, although the actual frequency of CMV reactivation in these patients is not clear. In this study, we prospectively evaluated the occurrence of CMV reactivation in relapsed or refractory low-grade B-cell lymphoma patients who were treated with bendamustine alone or in combination with rituximab. We simultaneously investigated the immune state of the patients. We analyzed CMV pp65 antigen in leukocytes, immunoglobulin (Ig) G, IgM, and IgA levels, and the CD4+:CD8+ lymphocyte ratio prior to treatment and after the third and sixth courses of treatment. There were 29 patients enrolled in the study. The median age was 68 years old (range, 28–83 years). Patients were treated a median of 2 times prior to bendamustine treatment; these treatments included chemotherapy and radiotherapy. There were 15 patients (51%) who completed 6 courses of chemotherapy. The immune status of the patients is shown in Figure 1. The median CD4+ lymphocyte count prior to treatment was 218/µL, which decreased to 75/µL by the end of treatment. The median of IgG, IgM, and IgA concentrations before treatment were 909, 52, and 147 mg/dL, respectively; by the end of treatment, the IgG, IgM, IgA concentrations had decreased to 832, 30, and 110 mg/dL, respectively. The extent of CD4+ T-cell depression during treatment appeared to be more severe than the Ig depression. CMV pp65 antigen was detected in 3 patients after the third course of treatment, and in 2 patients after the sixth course of treatment. None of the patients had any symptoms and CMV pp65 antigen count returned to negative without any treatment. The median CD4+ lymphocytes count in patients with or without CMV reactivation is shown in Table 1. There is a trend that the depression of CD4+ cells after the 6th course of bendamustine increases the risk of CMV reactivation. This is the first study to prospectively analyze CMV reactivation in low-grade B-cell lymphoma patients treated with bendamustine. In this study, we found that CMV reactivation by bendamustine occurred in approximately 15% of patients. On the other hand, the risk of symptomatic CMV disease, which would require medical intervention, does not appear to be high in bendamustine-treated patients. Most patients with relapsed or refractory low-grade B-cell lymphoma who are administered bendamustine therapy are in an immunosuppressed condition at the beginning of treatment. This is due to heavy chemotherapy pretreatment, which is often performed using rituximab. In addition to this, the decrease in CD4+ lymphocytes observed during bendamustine treatment, is likely to increase the risk of opportunistic infections, such as CMV reactivation. In future studies, we aim to investigate the risk factors for symptomatic cytomegalovirus infection in patients treated with bendamustine, especially in combination with rituximab. We hope that our study, which evaluates the risk of opportunistic infections in bendamustine treated patients, will be beneficial in determining the optimal timing for a preemptive approach for CMV infection. This will be helpful in establishing safe bendamustine treatment regimens in relapsed or refractory low-grade B-cell lymphoma patients. Figure 1 Figure 1. Table 1. The median number of lymphocytes, CD4+ lymphocytes and CD4/8 ratio in patients with or without cytomegalovirus reactivation Parameter All patients CMV reactivation p value + - Before treatment (n=24) Lymph (/µl) 996 1518 (n=5) 987 (n=19) 0.24 CD4+ cells (/µl) 218 261 218 0.96 CD4/8 ratio 0.69 0.60 0.69 0.54 After the 3rd course (n=23) Lymph (/µl) 980 1330 (n=5) 944 (n=18) 0.39 CD4+ cells (/µl) 130 118 130 0.52 CD4/8 ratio 0.20 0.12 0.20 0.16 After the 6th course (n=15) Lymph (/µl) 628 579 (n=5) 902 (n=10) 0.27 CD4+ cells (/µl) 75 36 118 0.035 * CD4/8 ratio 0.20 0.17 0.21 0.35 *; significant Disclosures No relevant conflicts of interest to declare.