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Chimeric Antigen Receptor (CAR) T cell therapy has demonstrated efficacy in B cell malignances. However, the treatment is not harmless and, in some patients, can lead to a fatal endpoint. For this reason, the knowledge and the early recognition and management of the side effects related to CAR-T cell therapy for the multidisciplinary team is essential. In this article, we have summarized the current recommendations for identification, gradation and management of cytokine release syndrome related to CAR-T cell therapy.

The results of hematopoietic stem cell transplant (HSCT) for primary immunodeficiency diseases (PID) have been improving over time. Unfortunately, developing countries do not experience the same results. This first report of Brazilian experience of HSCT for PID describes the development and results in the field. We included data from transplants in 221 patients, performed at 11 centers which participated in the Brazilian collaborative group, from July 1990 to December 2015. The majority of transplants were concentrated in one center (n = 123). The median age at HSCT was 22 months, and the most common diseases were severe combined immunodeficiency (SCID) (n = 67) and Wiskott-Aldrich syndrome (WAS) (n = 67). Only 15 patients received unconditioned transplants. Cumulative incidence of GVHD grades II to IV was 23%, and GVHD grades III to IV was 10%. The 5-year overall survival was 71.6%. WAS patients had better survival compared to other diseases. Most deaths (n = 53) occurred in the first year after transplantation mainly due to infection (55%) and GVHD (13%). Although transplant for PID patients in Brazil has evolved since its beginning, we still face some challenges like delayed diagnosis and referral, severe infections before transplant, a limited number of transplant centers with expertise, and resources for more advanced techniques. Measures like newborn screening for SCID may hasten the diagnosis and ameliorate patients' conditions at the moment of transplant.

Under a Creative Commons license.-- et al., Dendritic cells (DCs) are antigen-presenting cells that drive immune responses and tolerance and are divided in different subsets: myeloid DCs (mDCs: lineage-; HLA-DR+, 11c+), plasmacytoid dendritic cells (pDCs: HLA-DR+, CD123+), and monocyte-derived DCs (moDC: lineage-, 11c+, 16+). After hematopoietic stem cell transplantation (HSCT), low DC counts in the recipients' peripheral blood (PB) have been associated with worse outcomes, but the relevance of DC graft content remains unclear, and there are few data in the setting of unrelated donor HSCT. We evaluated the DC graft content and monitored DC recovery in PB from 111 HSCT recipients (median age, 17 years; range 1 to 74), who received bone marrow (46%), umbilical cord blood (32%), or PB (22%) from unrelated (81%) or related donors (19%). In 86 patients with sustained allogeneic recovery, patients with higher counts of all DC subsets (pDC, mDC, and moDC) 3 weeks after engraftment had lower incidence of nonrelapse mortality (NMR) and acute graft-versus-host disease (aGVHD) and better survival. pDC counts were associated with more striking results: patients with higher pDC counts had much lower incidences of NRM (3% versus 47%, P < .0001), lower incidence of aGVHD (24% versus 67%, P < .0001), and better overall survival (92% versus 45%, P < .0001). In contrast, higher pDC counts in the graft was associated with an increased risk of aGVHD (55% versus 26%, P= .02). Our results indicate that DC counts are closely correlated with HSCT outcomes and warrant further prospective evaluation and possible early therapeutic interventions to ameliorate severe aGVHD and decrease mortality., The research reported in this publication was supported by grants from Fundação de Amparo a Pesquisa do Estado de Sao Paulo (FAPESP process no. 2012/11730-7). M.V.G. was supported by Conselho Nacional de Desenvolvimento Cientifico e Tecnológico (CNPq process no. 142026/2009-3). V.R. was supported in part by the National Institute for Health Research, Oxford Biomedical Research Centre at the Oxford University Hospitals NHS Trust, and the University of Oxford.

Patients with refractory severe aplastic anemia (SAA) who lack a matched sibling or unrelated donor need new therapeutic approaches. Hematopoietic SCT (HSCT) using mismatched or haploidentical related donors has been used in the past, but was associated with a significant risk of GVHD and mortality. Recently, the use of post-transplant cyclophosphamide (Cy) has been shown to be an effective strategy to prevent GVHD in recipients of haploidentical HSCT, but the majority of reports have focused on patients with hematology malignancies. We describe the outcome of 16 patients who underwent haploidentical transplantation using a reduced-intensity conditioning regimen with post-transplant Cy. Stem cell sources were BM (N=13) or PBSCs (N=3). The rate of neutrophil engraftment was 94% and of platelet engraftment was 75%. Two patients had secondary graft failure and were successfully salvaged with another transplant. Three patients developed acute GVHD being grades 2-4 in two. Five patients have died and the 1-year OS was 67.1% (95% confidence interval: 36.5-86.4%). In our small series, the use of a reduced-intensity conditioning with post-transplant Cy in haploidentical BMT was associated with high rates of engraftment and low risk of GVHD in patients with relapsed/refractory SAA.

Purpose PCNSL standard treatment encompass 2 phases: induction and consolidation. Induction consists of high-dose methotrexate-based polychemotherapy for most patients and consolidation is still to be defined. ASCT is an effective treatment and despite the advancements in this technique for other disease sites, its role in PCNSL remains unclear. This systematic review aims to evaluate toxicity and outcomes of ASCT as upfront treatment in PNCSL. Material and Methods In accordance to PRISMA guidelines, a systematic review of the literature was conducted on studies reporting ASCT in PCNSL. EMBASE, MEDLINE and Cochrane databases were systematically searched for relevant studies until May 2016. All clinical trials (CT) evaluating the role of ASCT as up front treatment for PCNSL (excluding recurrence or salvage) were included. Studies were classified into 2 groups for statistical analysis: (1) Regimens containing thiotepa (either on induction or intensification regimen or conditioning regimen; (2) Regimens without thiotepa. Dichotomous outcomes were summarized as risk ratios (RRs). The size effect of the intervention for time-to-event outcomes was calculated by the pooled hazard ratio (HR), followed by the confidence interval (CI) of 95%. For determining derivative of expected events, the Z-Score for two-tailed p-value was calculated based on relative risk of each study. Results From 1803 references, 7 articles (6 phase 2; 1 pilot trial) from 2006 to 2016 were selected, comprising a total of 181 patients. For up front treatment of PCNSL with ASCT regimens containing thiotepa plus or minus WBRT: total of 128 patients were identified in 5 studies. Patient's median age was 54,5 (range, 54 to 57), KPS ranged from 70 to 90, WBRT was allowed in 3 studies and a median of 81% of the patients completes the ASCT protocol. Median complete response rate (CRR) was 69% (range, 54 to 81%), 2-years progression free survival (2PFS) 69% (range, 54 to 81%) and 2-years overall survival (2OS) 84% ranging from 83 to 91% in a median follow-up time of 15 to 63 months. Median neurotoxicity rates (NR) and treatment related mortality (TRM) were 3% (0 to 33%) and 3% (0 to 13%), respectively. (2) Up front ASCT regimens without thiotepa plus or minus WBRT: total of 53 patients were identified in 2 studies. Patient's median age was 52,5 (range, 52 to 53), KPS ranged from 70 to 80, WBRT was allowed in 1 study and a median of 59% of the patients completes the ASCT protocol. Median CRR was 31% (range, 18 to 44%), 2PFS 44% (range, 25 to 62%), 2OS of 65% ranging from 60 to 70% in a median follow-up time of 28 to 34 months. Median NR and TRM were 4% (0 to 8%) and 4%, respectively. Regimens containing thiotepa were associated with better 2OS (RR 0.46; IC95 0.27 to 0.80; P=0.006; Z=2.76) and increased 2PFS (RR 0.52; IC95 0.37 to 0.74; P=0.0002; Z=3.69). The addition of WBRT wasn't associated with better 2OS (RR 0.94; IC95 0.53 to 1.67; P=0.082; Z=0.22) Conclusions Up front ASCT in the management of PCNSL is associated with high CRR and excellent 2OS and 2PFS when thiotepa is added to the regimen. Close to 200 patients treated in CT settings with up front ASCT for PCNSL were found in the literature and at least 4 different treatment scenarios were described. An important rate (>10%) of TRM was seen in two studies however ASCT was seem to be safe in most of the publications. Disclosures No relevant conflicts of interest to declare.

Introduction: There is an increase application of haploidentical stem cell transplantation (haplo-HSCT) based on post-transplant cyclophosphamide without T cells depletion in patients lacking identical HLA donor. One important issue in haplo-HSCT is related to immunosuppression and immune reconstitution, leading to infection complications. Objective: To analyze the incidence and risk factors of viral infections in patients undergoing haploidentical BMT in a single Brazilian Cancer Center. Methodology: We analyzed 31 consecutive patients with hematological malignancies (80%) and severe aplastic anemia, who underwent haplo-HSCT from 2010 to 2015. Nine patients (29%), 16 (51%), and 6 (19%) used myeloablative (MA), non-myeloablative (NMA) and reduced intensive conditioning (RIC) regimen, respectively. All grafts were T cell replete and 29 (93.5%) of the haplo-HSCT used GCSF-stimulated bone marrow source. All patients have received mycophenolate mofetil (MMF), tacrolimus, and post-transplant Cyclophosphamide (Cy) as post transplant immunosuppression. MMF was discontinued on D+35 in NMA regimen and on D+90 in MA and RIC regimen. Viral monitoring tests were performed from graft infusion to D+180 post transplant. Quantitative PCR for CMV and Adenovirus were performed weekly and quantitative PCR for EBV every 14 days. BK virus and HHV-6 quantitative PCR were performed only for patients with clinical suspicious. Besides daily absolute lymphocyte count, CD4+ T lymphocyte count was done on D+100 and D+180 post transplant. The event reactivation / viral infection was assessed in the first 6 months post haplo-HSCT. Results: Patients median age was 34 years (range, 7 to 74). The median graft CD34+ cells infused was 2,79 x106/kg (0,56 to 5,88x106/kg), time to MMF suspension was on D+41 (range 30 to 161) and median patients engraftment was on day 18 (13 to 34). All patients achieved full donor chimerism by D+28 to 34+ post transplant. The median number of lymphocytes on D+30 and D+100, was 223x103/ul and 705x103/ul respectively, and median number of CD4+ lymphocytes on the D+100 and D+180 was 108/mm3 and 158/mm3, respectively. The cumulative incidence of viral reactivation on D+180 was 85.7%. Mortality related to viral infection was 10% and the overall survival in 180 days 74.8%. Thirty patients were CMV IgG+ (96%) and only five donors (16.1%) were CMV IgG-. First CMV reactivation occurred in 24/31 (77,4%) patients, 33,3% (8/24) had subsequent CMV reactivations. The median time of CMV reactivation was on D+41 (21-67). Documented CMV pneumonia occurred in 3 patients. Time to MMF suspension was associated to CMV reactivation (P=0,043) and we found that suspension after day + 40 had higher risk of reactivation, with sensitivity of 62,5% and specificity of 71,4% (IC 95% 0,517 - 0,989, P=0.045; ROC curve). There was no association between CMV reactivation and conditioning regimen, age, number of CD34+ cells infused (Table 1). Interestingly, age presented a linear correlation for second reactivation with an increased risk of 6% per year (HR 1.06, IC95 [1.02 to 1.11]; P=0,007). CMV reactivation was not associated with greater risk of death (P=0,194). The second more frequent viral infection was BK virus cystitis (n=11, 35.5%) and was not correlated with increased death risk (P=0,573) or any other proposed predictors factors. Parvovirus B19 infection occurred in 4 patients (12%) and adenovirus reactivation in 3 (9%). All patients who had adenovirus reactivation also had CMV reactivation and BK virus cystitis. Median lymphocytes and CD4+ counts were similarly in patients with (p = 0.385) or no (P = 0.800) CMV reactivation. The incidence of grade II-IV acute GVHD was 25.8% and there was no correlation to viral reactivation (P=0,351) or time to MMF suspension (P=0,63). However, all patients with acute GVHD II-IV showed reactivation of CMV. Conclusion: CMV reactivations and infections in our setting seems to be higher than previously reported in the literature, probably because of high CMV IgG+ positive recipient/donor population in Brazil. Early MMF suspension (before D+40) is an effective and safe measure to control CMV reactivation in patients submitted to cy post haplo-HSCT. Disclosures No relevant conflicts of interest to declare.

Introduction: The treatment of human hematologic malignancies has rapidly advanced through the application of genomic platforms that have identified drug-able targets and companion diagnostics (e.g. BCR-ABL, IDH-1) and added new classes of targeted agents to the established compendium of cytotoxics. Despite these advances, the complexity, redundancy and promiscuity of cellular transformation remain incompletely understood at the molecular level. This has led to a renewed interest in whole cell experimental models for drug discovery. Laboratory platforms that measure cellular response to cytotoxic insult at the phenotypic level have been shown to correlate significantly with clinical response, and have the capacity to provide insights into chemotherapy selection and drug development. The Ex Vivo Analysis of Programmed Cell Death (EVA/PCD) uses metabolic and morphologic features of drug induced cell death to measure both cytotoxic and targeted drug effects in human primary cultures. We applied EVA/PCD in 20 heavily pre-treated, drug refractory patients from the Hospital Israelita Albert Einstein (HIAE) in Sao Paulo - Brazil. Methods: Peripheral blood, node biopsy or bone marrow aspirates were submitted by overnight courier. Cells isolated by density centrifugation were evaluated by dose response curves that were interpolated to provide LC50 values for comparison with our databases by Z-score. Patients with Acute Lymphoblastic Leukemia (ALL, N=5) , Acute Myeloid Leukemia (AML, N=6), Non-Hodgkin Lymphoma (NHL, N=4) or Multiple Myeloma (MM, N=4) had received a mean of 5, median of 4 (range 1-8) prior therapies, 7 with prior bone marrow transplantation (BMT). Results: of 20 specimens, 16 (80%) provided viable tumor for EVA/PCD. A mean of 8, median of 7(range 3-22) cytotoxics and a mean 7, median of 5(range 1-20) targeted agents were evaluated. Findings were reported by day 7. Nine of 16 patients were treatment candidates, with 5 lost to follow up, 3 dying of sepsis before evaluation and 1 achieving complete remission (CR) with radiation plus Rituximab. Of 7 patients who received assay directed therapy there were 3 CR (43%), 2 partial responses (PR: 28%) and 2 progressive disease (PD: 29%) for an overall response rate of 71%. Conclusion: These results establish the feasibility of laboratory directed therapy in heavily pre-treated patients, with 80% of submitted samples providing actionable results. Although the extremely advanced state of these patients limited the capacity to undergo treatment in some cases, the achievement of CR's and PR's in this drug refractory cohort is of interest. Clinical responses by disease, treatment history and drugs received will be reported. Studies correlating molecular profiles with phenotypic analyses are currently under development. Disclosures Evans: Rational Therapeutics: Employment. Nagourney:Rational Therapeutics: Employment.

Introduction: Busulfan (Bu) is used in the conditioning regimen for hematopoietic stem cell transplantation (HSCT). Therapeutic drug monitoring (TDM) of Bu with subsequents adjustments doses based on a “target” therapeutic concentration may reduce toxicity after HSCT. Objectives: To evaluatethe impact of TDM of Bu and clinical outcomes in patients with acute leukemia that underwent to allogeneic matched related donor (MRD) and allogeneic matched unrelated donor (MUD) HSCT. Patients and methods: From January 2009 to January 2014, we prospectively analyzed 42 patients with diagnosis of acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) who underwent TDM of Bu (IV or oral) before transplantation (test dose) and TDM on 1st day of conditioning regimen. Samples were collected at 0, 30’, 60’ and subsequently every hour until 6 hours after administration of busulfan. The plasma was extracted by HPLC (High Performance Liquid Chromatography). All the patients that were submitted to TDM had a test dose 15 days to 48 hours before transplantion. The dose of Bu was adjusted during the first day of the conditioning regimen based on test dose. At the same time we analyzed 21 patients in the retrospective group who did not underwent TDM (from 2004 to 2010). Results: In the retrospective group (n=21), all of them underwent to MRD transplantation. Six (46.2%) were in first complete remission (CR1), 18(85.7%) patients received Bu and cyclophosphamide (BuCy) and the mean of age was 38 years (18-55 Yo). The median of CD34+ cells was 5.4 x 106/kg. The second group consisted by patients that received oral Bu (n= 21): 7 (33.3%) underwent to MUD transplantation, 14 (66.6%) to MRD transplantation, 8 (44.4%) patients were second complete remission (CR2), 4 (22.2%) had active disease status with a mean age of 32.7 years (14-58 Yo). Fifteen (71.4%) received BuCy and 16 (76.2%) received cells from peripheral blood. The median of CD34+ cells was 5.8 x106/kg. The median area under the curve (AUC) in 24 hours was 4950 μMol.min (3196.6- 8212 μMol.min). The third group was IV Bu (n= 21): 7 (33.3%) patients underwent MRD and 14 (66.6%) MUD transplantation, 7 (33.3%) patients were CR1, 7 (33.3%) had active disease or prior HSCT with a mean of age 52.7 years (20-74 Yo). The majority of patients received fludarabine and Bu (n=18; 85.7%) as conditioning and bone marrow was the main source. Immunosuppression was based on FK-506 and methotrexate (90.5% of patients). The median of AUC in 24 hours was 5690 μMol.min (3539.6- 8881.8 μMol.min). The cumulative incidence (CI) of sinusoidal obstructive syndrome (SOS) in the retrospective group and IV Bu were 9.5% for both, while in the group oral Bu it was at 19% (p = 0.566). The median AUC of Bu received during conditioning for those who died of SOS was lower in oral Bu than IV Bu (4872 uMol.min vs 5732 uMol.min respectively). The CI of acute graft-versus-host disease (aGVHD) at D+100 was 38.1% in the retrospective group, 40.6% in oral Bu and 42.9% in IV Bu. Chronic GVHD was 13.6% in oral Bu, 34% in IV Bu and 42.9% in the retrospective group (p = 0.142). The CI of relapse at D+100 was 19% in IV Bu, 4.8% in the retrospective group and oral Bu did not have this event. The IC of death at D+100 was 34.9% in group oral Bu, 9.5% in IV Bu and 14.3% in the retrospective (p = 0.102). The CI of relapse at 1.5 years was 35.8% in the IV Bu, 34.8% in oral Bu and 14.3% in the retrospective group. The CI of death at 1.5 years was 9.5% in group IV Bu, 53.5% in oral Bu and 34.3% in the retrospective (p = 0.015). Among patients who died until D+100, the median of AUC was 5732 μMol.min (5578.5-6818.5 μMol.min) during the conditioning for IV Bu and 4872 μMol.min (3448-8212 μMol.min) for oral Bu. The range between the AUC was large and there was no correlation with patients who died. Conclusion: In acute leukemia SOS had an impact on mortality at D+100 after HSCT (p Disclosures No relevant conflicts of interest to declare.

Introduction: Hematopoietic stem cell transplantation (HSCT) is an effective treatment option for patients with hematological and neoplastic diseases. Despite recent improvements, HSCT is still associated with a significant risk of mortality. Determining risk factors for death within the first 100 days after HSCT could help to identify patients who would benefit from interventions in order to decrease that risk. We have previously reported that increased fluid accumulation during conditioning chemotherapy and in the early period after HSCT was associated with decreased survival (Costa EMM et al, ASH 2013Abstract #4512). Herein, we expand that series of patients and we further analyze the impact of weight gain on early (100-days) mortality in patients who underwent HSCT at our institution. Objective: To determine the impact of weight gain during the first 10 days post-HSCT on 100 days mortality. Methods:We retrospectively reviewed the medical charts of 331 patients who underwent HSCT at our institution from January, 2007 until December, 2013. Information on patients' body weight (BW) was measured daily, starting at admission. The highest BW recorded until until the first 10 days post-SCT (D+10) was used to calculate the BW increase in relation to the baseline BW. Based on our previous study, we used a cutoff of 6% gain in BW to identify a group of patients with increased risk of complications. The primary endpoint was mortality within 100 days post HSCT. Overall survival (OS) was estimated from the time of HSCT until death, and surviving patients were censored at last follow-up. A logistic regression model and a Cox model were fit to determine variables that predicted death within 100 days and OS, respectively. Statistical analysis was performed with STATA (v11.0) and alfa error was defined as 5%. Results: Median age was 43 years old (range Conclusion: A ≥6% BW gain by D+10 is a risk factor for early mortality in both autologous and allogeneic HSCT. The most common cause of death in these patients is infectious-related complications. An increase in BW is related to the development of an inflammatory state, probably induced by the conditioning regimen. BW gain is a simple variable that can be easily used to determine prognosis of patients post-allogeneic HSCT, and further studies are needed to determine its etiology. Disclosures No relevant conflicts of interest to declare.

Introduction: Hematopoietic stem cell transplantation (HSCT) was offered primarily as a therapeutic option for severe sickle cell disease in the context of myeloablative matched sibling donor transplants over the last two decades and helped to establish the benefits of transplantation for this disorder. In recent years, the transplant community has set out to explore ways to make stem-cell transplantation more available to patients with the disease, define indications and better timing, and offset toxicities with novel approaches to conditioning and better supportive care. In this context, neurological complication such as stroke disease and blood flow alteration in medial cerebral artery constitute the main indications of HSCT but neurological complications are the main causes of TRM in D+100 and is important to find ways to prevent this problem. Objective: Describe early neurological complications in sickle patients undergoing related HSCT on single specialized center and its following after the early diagnosis. Material and Methods: Seven patient were undergone related HSCT for sickle disease from 2011 to 2013. All patients filled inclusion criteria in the study and signed agreement term. Results: Seven HSCT were developed in the period, being four males. The average age was 13 years old (7-24). The HSCT indications were previous stroke, cerebral flow alteration on Doppler, acute chest syndrome and alloimunization. All patient were on blood transfusion therapy. The conditioning regimen was BuCy + ATG and the GVHD prophylaxis was MTX and CSA. Related donors were chosen with 10/10 HLA match and graft source marrow. The median of the neutrophil engraftment was D+ 25 and the platelets engraftment was in D+60. Two patient died, one by intestinal and liver GVHD on D+120, and another with sagittal sinus thrombosis and hemorrhagic stroke on D+3. Other two patients showed PRES syndrome related to cyclosporine use. The patients showed generalized seizures with tomographic neurological alteration. After the imunossupressor change to tacrolimus and the change of Phenytoin to Lamotrigine, the patient had total resolution of neurological complications without development of neurological sequelae. Patients who used Lamotrigine since the beginning of the conditioning have not shown neurological alterations. Conclusion: The PRES Syndrome and Stroke are two of the main causes of mortality related to the use of calcineurin inhibitors. Patients with sickle disease have shown endothelial and cerebral microcirculation changes, which made them highly susceptible to neurological complication. The control of blood pressure, maintenance of 50.000 platelets level and the use of Lamotrigine as prophylaxis of seizures seems to decrease the risk of neurological complications. Prospective studies with lamotrigine as primary prevention of PRES Syndrome must be performed. Patients with severe neurological alteration as vessels stenosis more than 90% and Moya-Moya Syndrome must be better evaluated before the conditioning because of high TRM risk. Disclosures No relevant conflicts of interest to declare.

Mycobacterium tuberculosis infection: a rare late complication after cord blood hematopoietic SCT