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Introduction Type 1 diabetes mellitus (T1DM) is a disease characterized by the attack of pancreatic islet B cells by anti-glutamic acid decarboxylase (GAD) antibodies.1 In the search for a solution, Voltarelli et al. performed peripheral blood autologous stem cells transplant (PBASCT) in patients with newly diagnosed T1DM with encouraging results.2,3 These results have been replicated.4,5 Intensive conditioning using 200 mg/kg of cyclophosphamide plus antithymocyte globulin employed are not without serious risk and several complications have occurred including one death, extended hospital management and higher costs.3,6 Therefore, we decided to carry out an PBASCT, using a less costly and outpatient- simplify method.7,8 Patients and Methods This phase 3, single-arm study was performed at Hospital Universitario in Monterrey, México. Between January 2010 and July 2013, we included patients within first 3 months of type 1 diabetes diagnoses, 8 to 25 years old, with positive antibodies anti GAD, C peptide levels > 1.0 ng/mL, with or without previous ketoacidotic crisis. Ethics committee approved and written informed consent was obtained (www.clinicaltrials.gov as NCT01121029). The objectives were to determine baseline and 3-month serum levels of C-peptide, glycated hemoglobin (HbA1c), anti-GAD, quantify the insulin levels needed during the follow-up period, the morbidity associated with the procedure and the need for inhospital management. PBASCT was performed at the outpatient setting. Stem cells were mobilized using CFM 1.5 g/m2 I.V./day, 2 consecutive days, GCS-F , 10 µg/kg/day 6 days. In All patients we collected at least 2.0 x 106 CD34+ cells/kg. The conditioning consisted in CFM 500 mg/m2/day IV + fludarabine 30 mg/m2/day PO for 4 days. Cells were infused 24 hours after the last dose of chemotherapy. Ciprofloxacin (500 mg/bid), fluconazole (100 mg/qd), and acyclovir (400 mg/bid) were prescribed to all patients until the graft was reached. After the 3 months of follow-up, patients were categorized in 3 groups: Complete responders (CR) defined as total independence of insulin , non-responders (NR) those achieving Results Fifteen patients were included, 6 women and 9 men. Mean time from diagnosis was 80.06 days (SD ± 44.81). The mean AUC of the C-peptide level was 283.28 (SD 213.58). Baseline measurements of anti-GAD and HbA1c showed means of 10.42 U/mL (SD ± 13.26) and 7.94% (SD ± 1.93%), respectively. A mean of 12.12 x 106 CD34+ (SD ± 8.2) was obtained. A statistically significant difference was found in the number of CD34+ cells collected between both sexes. In males a mean of 15.84x106/kg was obtained versus 6.54x106/kg in the female subgroup (p = 0.026). The myeloid engraftment was noticed in a median of 14 days (range 11-20 days) and the lower platelet count was 63x106/ml. Grade I-II adverse events occurs in 40% and were mainly nausea, vomiting, fever, alopecia and one case of hemorrhagic cystitis that resolved rapidly. Four patients developed fever during the period of neutropenia, and all improved with oral antibiotics and without hospitalization. Transplant related mortality at 100 days was 0%. A median follow-up of patients included in this analysis was 441 days (148-1261). Anti-GAD titers were reduced overall by 93.83% (p = 0.016). HbA1c values were modified downward by 15.01%, (p = 0.093). A1c levels showed a mean decrease of 0.87% in the 3 months of study. Overall, the daily insulin requirements decreased from 0.41 U/kg to 0.32 U/kg at the third month (p=0.46). Six patients achieved insulin independence. As mentioned, 3 were non-responders, and the rest were partial responders. Conclusion A simplify PBASCT in a outpatient setting is secure and a potential therapeutic strategy for early onset type 1diabetes. Disclosures No relevant conflicts of interest to declare.

Severe aplastic anemia (SAA) is characterized by the absence of progenitor hematopoietic cells in bone marrow caused mainly by autoimmunity. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the treatment of choice for young newly diagnosed patients with SAA. The preferred source of stem cells is bone marrow (BM) due to improved overall survival (OS) and lower incidence of graft versus host disease (GVHD). In Latin American countries, many patients have received peripheral blood stem cell transplantation (PBSCT) for several reasons: lower cost, apheresis without anesthesia, no bone punctures and faster hematological recovery. Moreover, due to patient family or donors idiosyncratic factors, there is a lack of acceptance to surgical harvesting of bone marrow. Therefore we describe the Latin American experience with allo-HSCT using PBSC in SAA patients. One hundred and ninety patients with acquired SAA that received allo-HSCT using PBSC between 1997- 2014 were included. The allo-HSCT was performed at 4 centers of Perú, Colombia and México. All donors were HLA-identical siblings mobilized with G-CSF. The choice of the conditioning regimens was made on each institution. Primary outcome was OS; incidence of GVHD, outcome of patients > 40 years old and effect of conditioning regimens on survival were studied. The median of CD 34+ cells administered was 4.22 X 10⁶/kg (range 0.70-22.28). Median of neutrophil and platelet recovery was 11 days (range 7-35) and 12 days (range 8-25) respectively. Neutrophil recovery for anti-thymocyte globulin (ATG)-based regimens presented at a median of 11 days (range 7-28) and for non-ATG based regimens 14 days (range 9-35) (P The incidence of acute graft versus host disease (aGVHD) was 19.5% (8.4% was grade III-IV). Chronic GVHD (cGVHD) was 24.7% and extensive manifestations presented in 5.9% of patients. No relation between the conditioning regimen used (ATG vs non-ATG based regimens) and the incidence of aGVHD (P=0.066) or cGVHD (p=0.613) was found. The administration of ≥3.0X10⁶ CD 34/Kg related to higher incidence of aGVHD grade III and IV (P=0.05), but not cGVHD (P=0.709) or extensive cGVHD (P=0.428). The presence of aGVDH and cGVHD was associated with higher mortality (P Time from diagnosis to transplant ≥ 100 days was not a predictor of death (P=0.458). A total of 63% of patients were considered heavily transfunded and this factor was not related to relapse (P=0.96), aGVHD (P=0.75) or cGVHD (P=0.39). Nineteen patients (10%) lost their grafts; most of them had received non-ATG conditioning regimens (P=.016). Four patients (2%) developed secondary malignancies after transplant: acute myeloid leukemia (2), myelodisplastic syndrome (1) and hairy cell leukemia (1). In multivariate analysis, the use of non-ATG based regimens (P3 X10⁶/kg CD34(P=0.04) were independent negative predictors of survival. Infections were the leading cause of death. The second cause was GVDH and related complications. The transplant was successful in 95% of patients. The OS achieved in this study at 10 years with ATG-based regimens and PBSC (82%) is comparable to that (84%) reported from the WPSAA-EBMT (Haematologica 2009) using BM. In the study reported by EBMT-CIBMTR (Blood 2007) the 5 years OS was 85% using BM in patients ≤20 years and 64% in patients > 20 years. In our study the incidence of aGVHD and cGVHD was similar the aforementioned study of WPSAA-EBMT using PBSC (19.5% vs 17%) and (24.5 vs 22%) respectively. In conclusion allo-HSCT in SAA patients using PBSC is an effective treatment resulting in cure in the majority of cases. Patients conditioned with ATG had a 10-year OS similar to that reported with BM as the source of stem cells, a prospective and comparative study is needed to definitively establish if it is safe to perform a HSCT using peripheral blood as a source of stem cells. Disclosures No relevant conflicts of interest to declare.

Objective: To investigate the iron status of women at term and its impact in their neonates. Study design: Serum ferritin (SF) was measured in 201 women at term and in their newborns. The relationship between maternal and infant SF and hemoglobin (Hb) and the effects of partial prenatal care and iron supplementation were analyzed. Results: 86% of the women had iron deficiency (ID) at term and 46% were anemic. 13 (7.5%) of the babies born to the 172 iron deficient mothers were also iron deficient, but none of the babies born to the 29 mothers with SF levels12mgr;g/L. The mean cord ferritin level (103.6 +/- 75mgr;g/L) and Hb (164 +/- 20 g/L) were significantly higher in babies born to mothers who had SF12mgr;g/L, compared to babies born to iron deficient mothers (73.5 +/- 49mgr;g/L and 156 +/- 16 g/L). The respective values in iron deficient babies were 7.1 +/- 3.5mgr;g/L and 157 +/- 9.0 g/L, compared to 82.8 +/- 52.8mgr;g/L and 162 +/- 17.5 g/L in the iron sufficient babies. Conclusion: ID was diagnosed in 86% of women at term and in 7.5% of their neonates. A placental iron threshold, limiting iron acquiscition by the fetuses of women with severe ID, is suggested.

Background Cytoskeleton-free microvesicles can be generated from normal red blood cells (RBCs). These RBC vesicles maintain a representative sampling of the lipid bilayer and several membrane proteins. We investigated RBC antigen segregation and persistence of immunoreactivity in RBC microvesicles. Methods Cytoskeleton-free RBC microvesicles were generated from erythrocytes expressing known RBC antigens. Antigen segregation into vesicles was documented by immunospecific antigen-antibody binding using IgG eluates and 125 I Protein A. 125 I Protein A counts per minute (cpm) ratios between antigen-positive vesicles sensitized with 11 eluates compared with those of vesicles incubated with normal human serum are reported. Results Cytoskeleton-free RBC microvesicles preserved the antigenic expression of the original RBCs. Differences in cpm between eluate-sensitized vesicles and those incubated with normal human serum ranged from 3:1 for the Fy b antigen to 65:1 for the D antigen. Conclusions This study demonstrates that molecules bearing common RBC antigens segregate into microvesicles, fully preserving their epitope-bearing activity. The major proteins of the RBC cytoskeleton are not required for such antigen expression.

Background Hemophagocytic lymphohistiocytosis (HLH) is a rare non-neoplastic, frequently fatal disease of childhood. HLA-matched bone marrow transplantation (BMT) can bring about long-term remission and an eventual cure. Methods We report on the beneficial effect of BMT in a 2-month-old male using a less intensive conditioning regimen. The regimen included busulfan at 4 mg/kg/day (total dose 16 mg/kg), etoposide at 300 mg/m 2 /day (total dose 900 mg/m 2 ), and cyclophosphamide at 50 mg/kg/day (total dose 150 mg/kg). Prophylaxis for graft-vs.-host disease included methotrexate and cyclosporine. Results An absolute neutrophil count of 500 μL was noticed on +day 12 (engraftment day). At present, i.e., 400 days after the procedure, the patient is asymptomatic, his physical examination is normal, and a slightly increased level of gamma-glutamyl-transpeptidase (GGT) and alkaline phosphatase are the only laboratory abnormalities. Conclusions In this case, the conditioning regimen was adequate for the eradication of the disease and allowed persistent engraftment without significant toxicity. The results in our patient suggest that a less toxic regimen is feasible and permits rapid engraftment without compromising the effectiveness of chemotherapy.

Four multitransfused patients with severe aplastic anaemia (SAA) are described. Two received a BMT after conditioning with cyclophosphamide (Cy) plus antithymocyte globulin (ATG). Both suffered a graft failure (GF) and had a second transplant with PBSC from the original donor. Two other patients received a PBSCT as a first option, with Cy as the only conditioning drug. The four patients received methotrexate (MTX) and cyclosporine (CYA) as post-grafting immunosuppression. The two BMT patients with GF were successfully rescued with a PBSC second transplant. In the two cases where a PBSCT was done as a first option no GF was observed and a successful and complete haematological recovery was achieved. In conclusion, PBSCT rescued two SAA patients with GF after BMT. PBSCT without ATG as a first option produced a quick and complete haematological recovery in two additional patients, suggesting that PBSCT without ATG can be an alternative to BMT plus ATG in SAA as a first transplant option.

Gilbert's syndrome (GS) is a benign, familial condition characterized by recurrent asymptomatic non-hemolytic low-grade indirect hyper-bilirubinemia. Conditions related to fasting, stress or co-morbidity might reveal the disease in asymptomatic individuals. Seven patients who were treated for a hematological malignancy were identified with reversible indirect hyper-bilirubinemia. Liver function tests in all of them, including bilirubin levels were normal before the therapeutic maneuver, which was the delivery of combined chemotherapy in three cases and a bone marrow transplantation in four (three allografts and one autograft). Bilirubin levels returned to normal in all five patients following treatment. GS should not be overlooked in individuals exposed to these treatments who develop hyperbilirubinemia and jaundice.

Introduction Primary immune thrombocytopenia (ITP) is an acquired autoimmune disorder that involves antibody and cell mediated destruction of platelets as well as suppression of their production. Prednisone is the initial standard therapy in adults1. High-dose dexamethasone as front-line therapy given as pulses of 40 mg per day for 4 consecutive days, was effective in 85% of patients, nevertheless, 50% relapsed within six months2. The prices of ITP drugs for 1 month of treatment in an adult range from prednisone; $16, eltrombopag; $5,934, intravenous immune globulin (IVIG) (80 g); $9,648, to rituximab (2 g); $15,5963. Only prednisone/dexamethasone and eltrombopag are available in oral presentation, for this reason, ambulatory treatment is an alternative for these patients. The trombopoietin receptor agonists are effective for the treatment of patients with chronic ITP, although response is dependent on continued administration. Eltrombopag is a small molecule agonist of the c-mpl (TpoR) receptor, which is the physiological target of thrombopoietin. This drug effectively raises the platelet count in adult patients (aged 18 years and over) as second/third line therapy, that is for patients refractory to corticosteroids and IVIG who have had their spleen removed or when splenectomy is not an option4. Our group, as well as others, has previously sought to improve response rates in these patients, particularly with the use of rituximab5, 6. To our knowledge neither eltrombopag nor romiplostim have been used as front line therapy in ITP, therefore the purpose of this study was to assess the efficacy of eltrombopag and dexamethasone in this setting. Patients and Methods This was a prospective, phase 2 study, using the combination of eltrombopag (50 mg PO once a day for 4 weeks) and high-dose dexamethasone (40 mg PO days 1,2,3,4) in untreated adult patients with immune thrombocytopenia or in patients with less than 7 days of treatment with corticosteroids. Complete response (CR) was defined as an increase in platelet count >100×109/L. Partial response (PR) was defined as an increase in the platelet count greater to 30 ×109/L according to standard criteria. Duration of response was considered from the day of initial administration to the first time of relapse (platelet count Results Twelve consecutive patients were enrolled from June 2012 to June 2013, 6 women and 6 men. The median age at diagnosis was 50 years (range, 20 - 80 years). The median platelet count at diagnosis was 7 x 109/L (range, 2 - 29 x 109/L). Patients were followed for a median of 2.5 months (range 1.1 - 13). After steroid treatment at day +5, ten patients had responded (83.3%), five had achieved CR (41.7%), and five PR. After completing treatment with eltrombopag at day +34, all patients responded (100%), nine patients achieved CR (75%) and three PR (25%). Two patients relapsed in a median time of 39.5 days (range, 30.1 - 49), both regaining CR after treatment with another high-dose dexamethasone course and low-dose rituximab (4 doses of 100 mg every week). At 3 months follow-up 66.7% remained in CR and 33.3% in PR (n=6). At 6 months follow-up two patients remained in CR and two in PR (n=4). Time to best response achieved was 34 days from diagnosis (range, 19 – 64.1). At the end of follow-up 9 patients (75%) remained in CR and 3 patients in PR (25%). Total treatment cost per patient was $1,640 approximately. Conclusion Currently the initial treatment of ITP patients is based on prednisone or high dose dexamethasone with or without IVIG. This approach is associated with high cost and high relapse rate. The results from our pilot study suggest that high dose dexamethasone and eltrombopag are very effective as first line treatment for acute ITP in adults. This treatment is ambulatory, affordable and well tolerated; however, we still don't know if this approach will have a favorable impact on the relapse rate of this disease. Disclosures: Off Label Use: Eltrombopag as first line treatment for ITP.

In acute myeloid leukemia (AML), FLT3 mutations are associated with a poor prognosis, particularly the internal tandem duplication (ITD/FLT3). In Latin America there are few epidemiological data about these mutations.This study assessed the prevalence of FLT3 mutations in patients with AML at four reference hematology centers from Latin America. We included 138 samples of patients attending the Hematology Service of three Mexican University Hospitals (Monterrey,México D.F. and Puebla) and one Colombian center (Medellín) with a diagnosis of AML from different morphologic subgroups according to the French-American-British classification from 2006 to 2011. AML was diagnosed by morphology according to the FAB classification, by immunohistochemical staining and/or by immunophenotype according to each particular case. For sample processing DNA was extracted from peripheral blood or bone marrow with the automatic Maxwell®16 System (Promega Corporation, Madison, WI) using the principle of cellular lyses and binding nucleic acids to magnetized silice particles or the QIAAmp DNA Blood Kit (QIAGEN, Mexico City). The quality and DNA concentration was evaluated with the NanoDrop ND-1000 spectrophotometer (NanoDrop Technologies, Inc., Wilmington, DE). Then internal tandem duplication and kinase domain mutations detection was performed with the GeneAmp PCR System 9700 (Applied Biosystems, Foster City, CA), through amplification of exons 14,15 with specific primers of FLT3 gen region, using the Seeplex® FLT3 Genotyping kit (Seegene, Rockville, MD, USA) or according to Kottaridis et al (1). Later, an electrophoretic analysis of the amplified products was made in a 2% agarose gel stained with ethidium bromide or in polyacrylamide gel electrophoresis (PAGE) and were observed by transilumination. In the Puebla samples the products were analyzed by capillary electrophoresis (ABI3130, Applied Biosystems, Foster City, CA). For detection of D835X mutations the exon 20 amplicom was subjected to digestion with EcoRV and analyzed by 4.5% PAGE. The patients were cytogenetically classified into three risk groups: favorable, intermediate, and adverse. Results We analyzed 138 samples of AML patients and found FLT3 mutations in 28 patients, for a prevalence of 20.3%. The median age was 47 years (5-96). Only four patients had the KD FLT3 mutation (3% of total population). The FLT3 mutation positive group was older than the negative (47 vs. 39 years), had higher WBC/mm3 (66.0 vs. 56.4 x 109/dl), higher hemoglobin values (9.3 vs. 8.6 g/dl), and lower platelet counts (72.6 vs. 92.5 x109/dl), although there were not statistically significant differences. Thirteen patients had AML M2, nine the monocytic variety, four had M3 and two M1. On cytogenetics 25% , 62.5% and 12.5% had favorable, intermediate and unfavorable risk karyotypes respectively. The rate response to standard Induction Chemotherapy was 78.3 % for the FLT3 positive group vs. 74.1 % for the non-mutated group. Nineteen of 28 patients (67.8%) with FLT3 mutations died, compared to 47 of 100 (42.72%) in those without the mutation. The median survival was 4.9 months for the FLT3 mutated group vs 20.4 months for the FLT3 negative group, P= 0.009. The cytogenetic intermediate risk group (62.5%) was further analyzed and no statistically significant difference in overall survival between FLT3 non-mutated and FLT3 mutated patients was found (P= 0.22). Younger patients ( References 1. Kottaridis PD, Gale RE,Frew ME et al. The presence of a FLT3 internal tandem duplication in patients with acute myeloid leukemia (AML) adds importatnt prognostic information to cytogenetic risk group and response to the first cycle of chemotherapy: analysis of 854 patients from the United Kingdom Medical Research Council AML 10 and 12 trials. Blood.2001; 98: 1752-1759 2. Emerenciano M, Meneses J, Vasquez ML et al, Brazilian Collaborative Study Groupof Infant Acute L. Clinical relevance of FLT3 gene abnormalities in Brazilian patients with infant leukemia.Leuk Lymphoma. 2008; 49 (12):2291-2297. Disclosures: No relevant conflicts of interest to declare.

Background: Glucocorticoids commonly cause drug-induced diabetes. This association is well recognized but available evidence does not answer clinically relevant issues in subjects without diabetes. Methods: Thirty-five individuals without diabetes with a recent diagnosis of acute lymphoblastic leukemia or nonHodgkin’s lymphoma on high-dose glucocorticoid therapy were studied. Close systematic monitoring of fasting and postprandial glycemia and fasting insulin determinations, HOMA-insulin resistance and HOMA β-cell function were performed. The primary objective was to define the incidence of secondary diabetes in patients treated with highdose glucocorticoids. Secondary objectives were to specify the intensity, the moment it appears and the evolution of hyperglycemia, in addition to the risk factors, mechanisms and impact of continuous and cyclical glucocorticoids on the development of hyperglycemia. Results: Mean age of patients was 38.4 ± 18.7 years. The incidence of diabetes was 40.6% and was found after the first week; half the time it occurred between the second and fourth. Two-thirds spontaneously normalized by eight weeks. Continuous glucocorticoid administration had a higher incidence of fasting hyperglycemia (P= 0.003). Mean peak insulin levels were significantly higher in cases of diabetes. Conclusions: High-dose prednisone for 2 to 3 months produced an elevated incidence of diabetes, usually with mild hyperglycemia occurring between the second and fourth week, normalizing spontaneously in all cases. Hyperglycemia was more frequent with continuous doses and occurred in cases with increased insulin resistance. The clinical and therapeutic characteristics of our participants, who were otherwise healthy, could represent the clinical setting of many patients with illness from other medical areas that might require high doses of GC for six to twelve weeks.

To determine if dexamethasone has a role in the treatment of meningeal leukemia, 8 consecutive patients with acute lymphoblastic and signs or symptoms of CNS were included in the study. After the confirmation of leukemic blast cells on cerebrospinal fluid, they received intrathecal and IV dexamethasone; 3 days later the patients received “triple” intrathecal chemotherapy with dexamethasone, methotrexate and cytarabine, and the spinal fluid was studied again. All patients had good clinical response and 7 out of the 8 patients showed reduction on the CSF cell count after the use of dexamethasone alone. The results suggest that dexamethasone is a lympholytic agent that could play a more active role in the prevention and therapy of meningeal leukemia and should be preferred over hydrocortisone in the so called “triple” intrathecal chemotherapy for the prevention and treatment of CNS leukemia. © 1995 Wiley-Liss, Inc.

Abstract 3332 Introduction Corticosteroids are the initial standard therapy for primary immune thrombocytopenia (ITP). A short course of high-dose dexamethasone as initial therapy is an alternative to prednisone with high initial responses, but about half of the patients relapse. Low dose rituximab has been used in the treatment of relapsed ITP, showing a similar activity to the standard dose. The aim of this prospective study was to evaluate the efficacy, safety and response duration of low-dose rituximab plus short pulses of high-dose dexamethasone as front-line therapy in newly diagnosed ITP adults. Methods Patients ≥18 years old with newly diagnosed received dexamethasone, 40 mg/day/i.v. for 4 consecutive days (+1, +2, +3, +4), rituximab was administered at a fixed dose of 100 mg as an i.v. infusion weekly for 4 consecutive doses (days +1, +8+, +15 and +22). The use of rescue therapy was allowed, using the same schedule of dexamethasone, before day 30, but only if the platelet count was < 20×109/L. A complete blood cell count was performed at enrollment, weekly for the first 28 days, monthly until month 6 and then every 3 months. The degree of response was defined as follows: a complete response (CR) was a platelet count ≥ 100 × 109/L; a complete sustained response (CSR) was considered if it was maintained for six months. Partial response (PR) was defined as a platelet level between 50 and 100 × 109/L; an overall response (OR) was defined as partial or complete response. Patients with a platelet count Results Twenty-one consecutive patients were enrolled from December 2009 to December 2011 (17 women and 4 men); median age was 51 years (range, 18–82). The median platelet count at baseline was 5.19 × 109/L (range, 0.3–24.2 × 109/L). Patients were followed for a median of 12 months (range, 1–25). At day +28, sixteen patients (76.2%) had CR, three patients had PR (14.3%), with the OR being 90.5%. At month six, 16 of 21 patients (76.2%) had achieved CSR. Seven patients received a second course of dexamethasone (one at day +8 and six at day+15) (Table 1). The median duration of response was 12 months (range, 7–25 months). The median time to reach TTR and TCR was 8 days (range, 4–28). Partial response was achieved in two patients who were further treated with danazol and prednisone, being subsequently splenectomized. The relapse rate was 15.8%. The 6- and 12- month cumulative RFS were both 84%; the 6- and 12-month cumulative TFS probabilities were 94% and 87%, respectively (Fig. 1). Overall, combination therapy in our group was well tolerated with a lower incidence of adverse effects during infusion in this trial according to the data reported in previous studies. Conclusions The combination of low-dose rituximab and high-dose dexamethasone as front-line therapy for adults with ITP was effective and safe with a high OR rate and a low incidence of relapse. These data need to be confirmed in a prospective randomized clinical trial including a sample size with enough power to reach statistically significant conclusions. Disclosures: No relevant conflicts of interest to declare.

Abstract 4458 Introduction The combination of rituximab and alemtuzumab have been used to treat CLL. This combination is feasible without excessive toxicity. Both antibodies have been used as monotherapy for the treatment of autoimmune diseases, including autoimmune hemolytic anemia (AHA) and Immune thrombocytopenic purpura (ITP). Objective Evaluate the efficacy and safety of the combination of low dose alemtuzumab and rituximab in patients with AHA and ITP. Material and methods patients diagnosed with AHA (clinical and biochemical data of hemolysis) or ITP (less than < 50 K/μl) who failed or relapsed after first line therapy (steroids) were included. Basal lymphocyte count and immunoglobulin levels were assessed. Patients received alemtuzumab 10 mg SC on days 1,2 and 3 followed by rituximab 100 mg IV on days 4,11,18 and 25. Complete response (CR) was defined as normal hemoglobin in the absence of hemolysis and platelet count >150K/μl; and partial response (PR): increase of 2 g/dl of hemoglobin and platelets 50-149K/μl The effect of the antibodies combination was evaluated by lymphocyte B, T and NK count 8 and 24 weeks after their administration. Prophylactic bactrim, acyclovir and itraconazole were given for the first 2 months. Results We included 13 patients, and eleven were evaluable, 5 patients in the AHA group and 6 in the ITP group, demographic data is shown on table 1. For AHA the 5 patients achieved CR with a median follow up of 37 weeks; only 1 patient relapsed after the 49th week of follow up. For the ITP group 2 patients achieved CR, 2 patients PR and 2 were classified as non responders. Alemtuzumab and rituximab combination quickly depleted B lymphocites falling to zero or near zero at the 8th week determination, with a sustained decrease at 24th week, in which levels did not return to pre-treatment levels. Conclusions These initial results indicate that low dose alemtuzumab and rituximab combination is safe and demonstrate promising activity for AHA and ITP refractory patients including durable complete responses and as a steroid spring therapy. Disclosures: Off Label Use: alemtuzumab for refractory autoimmune cytopenias rituximab for refractory autoimmune cytopenias.

Abstract 6 Acute promyelocytic leukemia (APL) is a curable disease, and contemporary treatment based on the combination of all-trans retinoic acid (ATRA) with anthracyclines results in overall survival (OS) rates of around 90% at five years. Unfortunately, the treatment outcome of patients with APL in developing countries is significantly less. A recent Brazilian study had reported an OS of 53% with a first 5-days mortality of 13.4%. The International Consortium on Acute Promyelocytic Leukemia (IC-APL) is an initiative of the International Members Committee of the ASH and the project aims to reduce this gap through the establishment of international network, which was launched in Brazil, México and Uruguay. All patients with a suspected diagnosis of APL were immediately started on ATRA, while bone marrow samples were shipped to a national central lab where genetic verification of the diagnosis was performed. Results of the immunofluorescence for PML was obtained within hours and upon confirmation of the diagnosis, patients were enrolled in a protocol identical to the PETHEMA-LPA 2005, except for the replacement of idarubicin by daunorubicin. Supportive care aimed at maintaining platelet counts above 30,000/μl and fibrinogen levels above 150 mg/dl. In each country, cases were discussed every other week through internet and whenever needed international experts were involved. As of June 2009, 102 (70 Brazil, 25 Mexico, 7 Uruguay) APL patients were enrolled. The median age was 34 y (range: 9–72y) with 55 males (54%).The median white blood cell counts (WBC) at baseline was 3.6×109 /L(range: 0.2–149.7). The distribution of the relapse risk score at diagnosis according to PETHEMA-GIMEMA criteria was 14 low (14%), 54 intermediate (53%) and 34 high risk(33%) respectively. The incidence of low risk APL appeared lower than the values reported in developed countries. Of 102, 97 patients have toxicity and response data available. Of these 97, 12 (12.3%)experienced at least three symptoms/signs of differentiation syndrome (DS) and 77 (79%) patients achieved a complete remission (CR). Twenty-three deaths occurred and the cause of deaths included 9 hemorrhage, 8 infection, 2 DS . The 7 and 30 day mortality rates were 8% and 19.6%, respectively, and the one- year overall survival was 75% (95%CI:68%–84%). The median follow-up time among survivors was 14 months (range: 1.3–35). Among 77 patients who achieved CR, the 1-year OS and disease-free survival from the date of CR was 95% (95% CI: 89%–100%). Only one patient relapsed. For patients surviving a minimum of 30 days the outcome was similar to that reported by the twin PETHEMA-LPA 2005 protocol in European patients. Prognostic factors for overall survival were examined using log-rank test as well as multivariate Cox models. Factors predicting OS were a high relapse risk score at baseline (1-year OS: 59% for high, 87% for intermediate, 91% for low, p=0.0007) and age. The 1-year OS was 85% for age Disclosures: Sanz: Amgen Inc.: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Background: Acute graft-versus-host disease (GvHD) is mediated by activated T lymphocytes. Alemtuzumab is an unconjugated, humanized IgG1 kappa monoclonal antibody which targets the CD52 antigen on T lymphocytes and other cells and has been used successfully in conditioning regimens for allogeneic transplantation to remove donor T cells so as to prevent GvHD. Patients and methods: Eighteen patients with steroid-refractory acute GvHD ≥ grade II were analyzed to evaluate the safety and efficacy of alemtuzumab. The patients received subcutaneous alemtuzumab 10 mg daily on days 1–5. The proportion of patients with grade II, III and IV were eight, eight and two, respectively. The main organ involved was the liver in four, gut in five, skin and liver in three, and skin and gut in three patients. Results: Fifteen out of 18 patients (83%) responded to alemtuzumab with 6 (33%) complete and 9 (50%) partial responses. All three unresponsive patients died of GvHD. Ten of 15 responders are alive at a median follow-up of 9 months (range 2–23) after alemtuzumab, with limited, extensive and no signs of chronic GvHD in 1, 4, and 5 patients, respectively. Fourteen patients (78%) developed some kind of infection; eleven of them developed cytomegalovirus reactivation. All patients tolerated alemtuzumab with minimal side effects; grade 3 neutropenia and thrombocytopenia were seen in six and four patients, respectively. Conclusions: Alemtuzumab is a well tolerated agent and has a beneficial effect in the treatment of steroid-refractory acute GvHD. Infections are common and anti-infective prophylaxis is mandatory.

Using a reduced intensity stem cell transplantation (RIST) schedule, 24 patients with Ph1 (+) chronic myelogenous leukemia (CML) in first chronic phase were prospectively allografted in four Latin American countries: Mexico, Brasil, Colombia and Venezuela, using HLA-identical siblings as donors. Median age of the patients was 41 years (range 10 to 71); there were 8 females. Patients received a median of 4.4 x 106/ Kg CD34 cells. Median time to achieve above 0.5 x 109/L granulocytes was 12 days, range 0–41, whereas median time to achieve above 20 x 109/L platelets was also 12 days, range 0–45. Twenty two patients are alive 81 to 830 (median 497) days after the RIST. The 830-day probability of survival is 92%, whereas median survival has not been reached, being above 830 days. Eleven patients (46%) developed acute graft versus-host disease (GVHD), whereas 7 of 23 (30%) developed chronic GVHD. Two patients died 43 and 210 days after the RIST, one as a result of sepsis and the other one of chronic GVHD. The 100-day mortality was 4.4 %, whereas the transplant-related mortality was 8%. RIST for patients with CML in chronic phase seems as an adequate therapeutic option.

Using a nonmyeloablative stem cell transplantation (NST) program previously shown to be effective in individuals receiving allografts in México, 29 patients with either acute myelogenous leukemia (AML, n = 12) or chronic myeloid leukemia (CML, n = 17) from the Latin American Cooperative Onco Hematology Group (LACOHG) were prospectively given allogeneic bone marrow allografts. Patients received a modified NST conditioning regimen consisting of oral busulphan 4 mg/kg on Days −6 and −5, IV cyclophosphamide 350 mg/m2 on Days −4, −3, and −2, IV fludarabine 30 mg/m2 on Days −4, −3, and −2, oral cyclosporine A 5 mg/kg twice daily starting on Day −1 (continuing until Day 180), and IV methotrexate 5 mg/m2 on Days +1, +3, +5, and +11. Median patient age was 43 years (range, 10–63). All patients engrafted; median time to achieve an absolute neutrophil count >0.5 x 109/L was 14 days (range, 0–21), whereas the median time to achieve a platelet count >20 x 109/L was 12 days (range, 0–21). Follow-up periods ranged between 39 and 519 days (median, 249). In patients with CML, the median overall post-transplant survival has not been reached, whereas the 519-day overall survival was 88%, and the 100-day mortality was 0%. In patients with AML, the median overall post-transplant survival has not been reached, the 459-day overall survival was 66%, and the 100-day mortality was 8%. The results from this multicenter, multinational study complement and further support the efficacy of our NST preparative regimen. The initial experience obtained from individuals with CML and AML receiving allografts in 2 institutions in México has now been extended into other Latin American countries, and the results are acceptable.

Hairy cell leukemia (HCL) is an uncommon B-cell lymphoid neoplasia, representing 2–3% of all leukemias. It is more common in men, with a median age at diagnosis of 52 years. The hair-like projections on its surface are its principal characteristic. Although its etiology has not been established, the recent gene sequencing of HCL identified the presence of the BRAF V600E mutation, absent in other malignant neoplasias of the lymph cells. The clinical course of the disease is usually indolent. The majority of patients initially present weakness and fatigue, pancytopenia and splenomegaly. HCL must be distinguished from other indolent lymphoid neoplasias such as prolymphocytic leukemia, splenic marginal zone lymphoma, the variant of HCL (HCLv), and mantle cell lymphoma. Peripheral blood flow cytometer is essential for the detection of CD11c, CD19, CD20, CD22, CD25, and CD10, as well as a bone marrow aspirate to detect immunophenotypes. In addition, a bone biopsy is useful to perform an immunohistochemistry analysis for TRAP, DBA-44 and A1 annexin. Purine analogues remain the first line of treatment. However, interferon and rituximab are a valid option, if the ideal treatment is unavailable. New discoveries in the pathophysiology of HCL have brought the creation of pharmaceuticals with distinct therapeutic targets. These pharmaceuticals are currently undergoing testing.

Background Reports dealing with clinical outcomes of classical Hodgkin's lymphoma in low- to middle-income countries are scarce and response to therapy is poorly documented. This report describes the characteristics and clinical outcomes of patients with classical Hodgkin's lymphoma from a single institution in Latin America. Method A retrospective study was conducted over ten years of patients with classical Hodgkin's lymphoma treated at a referral center. Progression-free and overall survival rates were estimated by Kaplan–Meier analysis. The univariate Cox regression model was used to estimate associations between important variables and clinical outcomes. Main results One hundred and twenty-eight patients were analyzed. The mean age was 28.5 years. The five-year progression-free and overall survival were 37.3% and 78.9%, respectively. Of the whole group, 55 (43%) were primary refractory cases. Only 39/83 (47%) patients with advanced disease vs. 34/45 (75.6%) in early stages (p-value = 0.002) achieved complete remission. Those with advanced disease had a five-year overall survival of 68.7% vs. 91.8% for early disease (p-value = 0.132). Thirty-one patients relapsed (24.2%) and 20 (64.5%) received a transplant. The hazard ratio for progression with bone marrow infiltration was 2.628 (p-value = 0.037). For death, an International Prognostic Score ≥4 had a hazard ratio of 3.355 (p-value = 0.050) in univariate analysis. Two-thirds of classical Hodgkin's lymphoma patients diagnosed at advanced stages had a low progression-free survival but an overall survival similar to high-income countries. Conclusion Patients diagnosed with classical Hodgkin's lymphoma in Northeastern Mexico had a significantly low progression-free survival rate and presented with advanced disease, underscoring the need for earlier diagnosis and improved contemporary therapeutic strategies in these mainly young productive-age Hodgkin's lymphoma patients.

Thrombotic thrombocytopenic purpura (TTP) is a disease with a high rate of mortality if a proper treatment is not instated. Plasmapheresis with plasmatic exchange is the treatment of choice. Diagnosis is performed demonstrating microangiopathic hemolytic anemia, a negative direct Coombs test and thrombocytopenia. Among the clinical data, neurological and renal alterations stand out. When there is a reasonable suspicion in the diagnosis, plasmapheresis must be initiated immediately. There are different diseases that may be similar to the TTP signs and symptoms, especially in pregnant women. TTP has a high risk of relapse and may leave sequelae.

A patient with hairy cell leukemia (HCL) and vasculitis was treated only with interferon alpha-2b. A good, rapid response was obtained without using corticosteroids or immunosuppressors. Interferon may prove to be useful for the systemic therapy of patients with vasculitis associated with HCL.

Stroke represents a public health enemy. Currently, and in spite of multiple clinical trials, thrombolysis remains as the only approved therapy. Most preclinical trials and animal trials employing stem cell-based therapies have shown very promising evidence of benefits. The aim of this review is to provide a landscape of what has been done in human clinical trials, and what are the possible ways that stem cell therapy may enhance functional recovery in stroke patients.

Eight patients with idiopathic severe aplastic anemia received acyclovir as the initial treatment to ascertain if this antiviral therapy could be effective. Three patients showed improvement, but only one had a sustained recovery. The responses could be coincidental, but it seems that some patients can benefit from acyclovir. More studies are needed on the role of viruses and antiviral therapy in relation to severe aplastic anemia.