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PURPOSE To present primary and final analyses from the randomized, double-blind, placebo-controlled, phase III iNTEGRATE study, which evaluated the safety and efficacy of ibrutinib with prednisone in previously untreated patients with chronic graft-versus-host disease (cGVHD). METHODS Patients (age ≥ 12 years) with newly diagnosed moderate or severe cGVHD, requiring systemic corticosteroid therapy, and with no prior systemic treatment for cGVHD were randomly assigned 1:1 to receive ibrutinib 420 mg once daily plus prednisone, starting at 1 mg/kg once daily or placebo plus prednisone. The primary end point was response rate at 48 weeks according to 2014 National Institutes of Health Consensus Development Project Criteria. Other end points included event-free survival, duration of response, time to withdrawal of immunosuppressants, improvement in Lee cGVHD Symptom Scale score, overall survival (OS), and safety. RESULTS Ninety-five and 98 patients enrolled in the ibrutinib-prednisone and placebo-prednisone arms, respectively. At 48 weeks, response rates were 41% (ibrutinib-prednisone) and 37% (placebo-prednisone; P = .54). At 33 months of follow-up, median duration of response was 19 months (ibrutinib-prednisone) and 10 months (placebo-prednisone; P = .10). Median event-free survival was 15 months (ibrutinib-prednisone) and 8 months (placebo-prednisone; hazard ratio, 0.76; 95% CI, 0.54 to 1.1; P = .11). Improvement in overall Lee cGVHD Symptom Scale was 43% (ibrutinib-prednisone) and 31% (placebo-ibrutinib; P = .07). Median OS was not reached in either arm. The 24-month Kaplan-Meier OS estimates were 80% for both arms (hazard ratio, 1.06; 95% CI, 0.59 to 1.90). Grade ≥ 3 serious adverse events occurred in 49% (ibrutinib-prednisone) and 47% (placebo-prednisone) of patients. CONCLUSION There was no statistical difference observed in the primary and secondary end points with ibrutinib-prednisone treatment. No new safety signals were observed with ibrutinib treatment in previously untreated patients with cGVHD. The primary end point of iNTEGRATE was not met.

Purpose:To develop a prognostic model and cytogenetic risk classification for previously treated patients with chronic lymphocytic leukemia (CLL) undergoing reduced intensity conditioning (RIC) allogeneic hematopoietic cell transplantation (HCT).Experimental Design:We performed a retrospective analysis of outcomes of 606 patients with CLL who underwent RIC allogeneic HCT between 2008 and 2014 reported to the Center for International Blood and Marrow Transplant Research.Results:On the basis of multivariable models, disease status, comorbidity index, lymphocyte count, and white blood cell count at HCT were selected for the development of prognostic model. Using the prognostic score, we stratified patients into low-, intermediate-, high-, and very-high-risk [4-year progression-free survival (PFS) 58%, 42%, 33%, and 25%, respectively, P < 0.0001; 4-year overall survival (OS) 70%, 57%, 54%, and 38%, respectively, P < 0.0001]. We also evaluated karyotypic abnormalities together with del(17p) and found that del(17p) or ≥5 abnormalities showed inferior PFS. Using a multivariable model, we classified cytogenetic risk into low, intermediate, and high (P < 0.0001). When the prognostic score and cytogenetic risk were combined, patients with low prognostic score and low cytogenetic risk had prolonged PFS (61% at 4 years) and OS (75% at 4 years).Conclusions:In this large cohort of patients with previously treated CLL who underwent RIC HCT, we developed a robust prognostic scoring system of HCT outcomes and a novel cytogenetic-based risk stratification system. These prognostic models can be used for counseling patients, comparing data across studies, and providing a benchmark for future interventions. For future study, we will further validate these models for patients receiving targeted therapies prior to HCT.

Supplementary Material

The relative efficacy of autologous hematopoietic cell transplant (auto-HCT) vs chimeric antigen receptor T-cell (CAR-T) therapy in patients with diffuse large B-cell lymphoma (DLBCL) who achieve a partial remission (PR) after salvage chemotherapy is not known. Using the Center for International Blood & Marrow Transplant Research registry database, we identified adult patients with DLBCL who received either an auto-HCT (2013-2019) or CAR-T treatment with axicabtagene ciloleucel (2018-2019) while in a PR by computed tomography or positron emission tomography scan. We compared the clinical outcomes between the 2 cohorts using univariable and multivariable regression models after adjustment for relevant baseline and clinical factors. In the univariable analysis, the 2-year progression-free survival (52% vs 42%; P = .1) and the rate of 100-day nonrelapse mortality (4% vs 2%; P = .3) were not different between the 2 cohorts, but consolidation with auto-HCT was associated with a lower rate of relapse/progression (40% vs 53%; P = .05) and a superior overall survival (OS) (69% vs 47%; P = .004) at 2 years. In the multivariable regression analysis, treatment with auto-HCT was associated with a significantly lower risk of relapse/progression rate (hazard ratio = 1.49; P = .01) and a superior OS (hazard ratio = 1.63; P = .008). In patients with DLBCL in a PR after salvage therapy, treatment with auto-HCT was associated with a lower incidence of relapse and a superior OS compared with CAR-T. These data support the role of auto-HCT as the standard of care in transplant-eligible patients with relapsed DLBCL in PR after salvage therapy.

Secondary hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immune dysregulation disorder. Use of chimeric antigen receptor T-cell therapy (CAR-T) is associated with cytokine release syndrome (CRS), Immune Effector Cell Associated Neurotoxicity Syndrome (ICANS) and secondary HLH. However, application of HLH scoring systems (H-score, HLH-2004 criteria) are not validated in this setting. We analyzed the utility of applying the H-score and the HLH-2004 criteria to identify patients with possible HLH post-CAR-T for Relapsed/Refractory Diffuse Large B-cell Lymphoma. Only two of four patients with post CAR-T HLH met five or more of the diagnostic criteria for HLH by HLH 2004 criteria. In contrast all four post CAR-T HLH patients had a high H-score (169); however, an additional ten patients that did not have HLH also had a high H-score. Thus, in this patient population, both scoring systems were demonstrated to have low prognostic significance in differentiating between high grade CRS and HLH.

Aim: Characterize follicular lymphoma (FL) treatment patterns among elderly patients using a dataset with longer follow-up time. Materials & methods: Using the linked Surveillance, Epidemiology and End Results-Medicare data, we identified patients diagnosed with FL between 2000 and 2013 with claims data until 2014. We investigated the treatments received and assigned them to lines of treatment. Results: We identified 10,238 elderly patients. Over a 4.7-year median follow-up, 78% of the patients received at least first-line treatment. Fewer individuals received second-line (47%) and third-line (30%) treatments. RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone), RCVP (rituximab, cyclophosphamide, vincristine and prednisolone) and rituximab monotherapy were the most common treatment regimens. Conclusion: One in five elderly patients did not receive FL-directed therapy. The most common treatment regimens were limited to RCHOP, RCVP and rituximab monotherapy.

Introduction:Chimeric antigen receptor T-cell (CAR-T) therapy has become an important treatment modality for patients with relapsed/refractory (R/R) large B-cell lymphoma (LBCL). However, many of these patients have aggressive disease and require a form of bridging therapy (BT) for disease control during CAR-T manufacturing. There is limited data in the literature on the most appropriate form of BT and the impact of BT on clinical outcomes. Methods:We retrospectively analyzed data on 75 patients that received CAR-T therapy at our institution. BT was defined as therapy administered between apheresis and CAR-T infusion. 52 patients received bridging therapy (BT) and 23 did not receive BT (NBT). BT included 10 high dose (HD) steroids, 28 chemotherapy-based regimen (CT), and 14 radiation therapy (RT). CT included cytotoxic chemotherapy, immunotherapy, and targeted therapy. IRB approval was obtained for this study. Statistical analysis was conducted with SAS v9.4. Univariate analysis Cox proportional hazard model was used and p-values for response rate were generated from Fisher's exact test. The methods of generalized linear model and logistic regression were used to associate the toxicity grades and cytopenias with BT, respectively. Results:Many patient and disease characteristics between BT and NBT groups were similar, with minor, non-statistically significant differences (See Fig. 1a). Although while the incidence of stage III/IV patients in the BT and NBT group was comparable (p=0.79), in subgroup analysis, there were significantly more stage III/IV patients in the CT subgroup and NBT than in the RT and HD steroids subgroups (p=0.03). There was a higher incidence of bulky disease (≥10cm) in the BT and all BT subgroups versus (vs) NBT, although this was not significant (p=0.58 and p=0.92). The number of prior lines of therapy was comparable between the BT and NBT groups (p=0.99). However, in subgroup analysis there were significantly more patients in the CT subgroup and NBT that received ≥4 lines of therapy compared with RT and HD steroids subgroups (p=0.02). There was no significant difference in overall response rate (ORR) at last follow up between BT vs NBT and BT subgroups vs NBT with approximately 50% being in complete remission in all cases (p=0.48 and p=0.54). Progression free survival (PFS) and overall survival (OS) were similar in the BT vs NBT (one-year rates of 67% vs 64% and 83% vs 75%, respectively) and this was not statistically significant (p=0.52 and 0.89), see Fig. 1b and 1c. In subgroup analysis PFS was comparable in the BT subgroups (CT 69% and HD steroids 68%) vs NBT group (67%) while RT was lower (51%), although this was not statistically significant (p=0.54). In subgroup analysis OS was slightly worse in the BT subgroups (CT 77%, RT 76%, and HD steroids 72%) vs NBT group (83%) although was not statistically significant (p=0.93). The development of cytokine release syndrome (CRS) was comparable in the BT vs NBT group and in BT subgroups vs NBT (p=0.18 and p=0.53). The median grade of immune effector cell-associated neurotoxicity syndrome (ICANS) was higher in BT than NBT (grade 2 vs 0) and trended towards statistical significance (p=0.09). The development of cytopenias at day +180 following CAR-T therapy was significantly higher in BT (50%) vs NBT (13.3%) and was statistically significant (p= 0.038). Subgroup analysis also showed significantly increased cytopenias at day +180 in CT (58.3%) and RT (57.1%) subgroups (p= 0.04). Conclusion:In our single-institution experience, BT prior to CAR-T therapy is feasible and may preserve CAR-T candidacy in patients with rapidly progressive LBCL. BT does not appear to significantly affect ORR, PFS, and OS. The incidence of CRS was comparable, although there was a higher incidence of ICANS in BT, which trended towards significance, and could be contributed to higher tumor bulk in the BT group. BT patients receiving CT and RT for BT were more likely to experience prolonged cytopenias, likely due to the myelosuppressive impact of BT and previous lines of chemo-immunotherapy agents. In conclusion, in high-risk patients with advanced and/or aggressive disease, BT may provide disease stabilization to CAR-T with a similar toxicity profile compared to NBT patients, although BT patients are more likely to experience prolonged cytopenias after CAR-T therapy. Disclosures Kansagra: Alnylam Pharmaceuticals, Bristol Myers Squibb /Celgene, GlaxoSmithKline, Janssen, Pharmacyclics, Takeda Pharmaceuticals, Pfizer, Karyopharm Therpeutics:Other: Advisory Board.Hardy:Incyte Corporation:Other: Advisory Board Member;American Gene Technologies:Other: DSMB Member;Kite/Gilead:Other: Advisory Board Member.

Waldenström macroglobulinemia/lymphoplasmacytic lymphoma (WM/LPL) is characterized by lymphoplasmacytic proliferation, lymph node and spleen enlargement, bone marrow involvement, and immunoglobulin M production. Treatment varies based on the extent and biology of disease. In some patients, the use of allogeneic hematopoietic cell transplantation (alloHCT) may have curative potential. We evaluated long-term outcomes of 144 patients that received adult alloHCT for WM/LPL. Data was obtained from the Center for International Blood and Marrow Transplant Research database (2001-2013). Patients received myeloablative (n=67) or reduced intensity conditioning (RIC; n=67). Median age at alloHCT was 53 years, and median time from diagnosis to transplantation was 41 months. Thirteen percent (n=18) failed prior autologous hematopoietic cell transplantation. About half (n=82, 57%) had chemo-sensitive disease at the time of transplantation, while 22% had progressive disease. Progression free survival, overall survival, rate of relapse, and non-relapse mortality at 5-years were 46%, 52%, 24%, and 30% respectively. Patients with chemo-sensitive disease and better pre-transplant disease status experienced significantly superior overall survival. There were no significant differences in progression-free survival based on conditioning (myeloablative 50% vs. RIC 41%) or graft source. Conditioning intensity did not impact treatment-related mortality or relapse. The most common causes of death were primary disease and graft-versus-host disease (GVHD). AlloHCT yielded durable survival in select patients with WM/LPL. Strategies to reduce mortality from GVHD and post-transplant relapse are necessary to improve this approach.

Background: Nonmyeloablative (NMA) and reduced-intensity conditioning (RIC) regimens are offered for patients with hematologic malignancies requiring allogeneic stem cell transplantation (HSCT) but are not candidates for myeloablative conditioning (MAC). The intensity of the conditioning regimen (CR) is important and contributes to the ability of HSCT to provide a cure. There is no consensus regarding the best RIC regimen and efficacy is not equal amongst RIC regimens. The combination of 2 days of intravenous Busulfan (total of 6.4 mg/Kg) and Fludarabine (total of 120-160 mg/m2) (Flu/Bu2) has been validated and widely adopted. While this regimen is well tolerated, relapses are common and remain the leading cause of death. Total body irradiation (TBI) has been widely used in the CR and provides the advantage of potent anti-cancer effect, immunosuppression and the ability to reach certain 'sanctuary sites' for chemotherapy (i.e. CNS). The 2 most commonly used TBI levels are 1200 cGy in MAC regimens and 200 cGy in NMA and RIC regimens. We hypothesize that the addition of 400 cGy (200 cGy two fractions per day, 6 hours apart) TBI to Flu/Bu2 will reduce the relapse rate without increasing its toxicity. In this retrospective study, we compared the safety and efficacy of Flu/Bu2/TBI400 with Flu/Bu2 CR amongst a diverse group of hematologic diseases. Methods: From 2006 to 2018, 137 adult patients with different hematological diseases were treated using one of two RIC regimens, either Flu/Bu2/TBI400 or Flu/Bu2 followed by HSCT from HLA-matched related or unrelated donors. The primary endpoint was OS defined as the time from the date of transplant to death from any cause. The secondary endpoints included PFS, relapse rate, cumulative incidence of relapse (CIR), non-relapse mortality (NRM), causes of death, aGVHD, cGVHD and engraftment. PFS was defined as the time from the date of transplant to disease progression as documented by the treating physician, based on pathological, imaging or clinical findings of the individual disease, or death from any cause. NRM was defined as time of death without evidence of progressive disease with relapse or progressive disease as a competing risk event (data not shown in the abstract). Relapse was defined as progression or disease relapse with NRM as a competing risk event. These endpoints were censored at the time of last follow-up. Results: A total of 137 patients were included in this study. 74 patients were treated with Flu/Bu2/TBI400 and 63 patients were treated with Flu/Bu2. The 2 groups were comparable in terms of patient-, disease- and transplant-related characteristics; however, Flu/Bu2/TBI400 patients had a higher HCT-CI score and a lower KPS. CNI-MTX GVHD prophylaxis was used in a higher proportion in Flu/Bu2/TBI400. Most of the Flu/Bu2 transplants occurred from 2006 to 2012. The median age was 62 in both groups and patients had comparable disease type distribution and DRI (Table 1). The median follow-up time was 4.62 years. Flu/Bu2/TBI400 showed improvement of PFS over Flu/Bu2; the 5-year PFS was 50% in the TBI arm vs. 34% in the no-TBI arm (p=0.06 of marginal statistical significance). There was a numerical improvement of OS in favor of the TBI arm but this was not statistically significant; The 5-year OS was 53% with TBI vs. 39% without TBI (p=0.13). Cumulative incidence of relapse was not different between the 2 groups (p=0.29), see figures 1, 2 and 3. There was no difference in aGVHD incidence between the 2 groups (p=0.21). The TBI arm had significantly lower incidence of cGVHD compared to no-TBI arm (29% vs. 54%, p=0.005). Advanced DRI, grade III-IV aGVHD, cGVHD, use of ATG and MUD were associated with worse OS (univariate analysis). The same factors, with the exception of cGVHD, were associated with worse PFS. Multivariable Cox regression model revealed that grade III-IV aGVHD was associated with worse OS (p=0.001) while advanced DRI was associated with marginally inferior OS (p=0.07) (Table 2). Conclusion: This is the largest retrospective study of RIC Flu/Bu2/TBI400 regimen for HSCT with a median follow-up approaching 5 years. Our data suggests that RIC Flu/Bu2/TBI400 is safe and efficacious for different hematological malignancies. When compared to Bu/Flu2 without TBI, Flu/Bu2/TBI400 had lower incidence of cGVHD and showed a strong trend towards improved PFS and OS though not statistically significant at this time. Grade III-IV aGVHD was associated with poor OS in both groups. Disclosures Hardy: Incyte Corporation: Other: Advisory Board Member; Kite/Gilead: Other: Advisory Board Member; American Gene Technologies: Other: DSMB Member.

Introduction: Secondary hemophagocytic lymphohistiocytosis (HLH) is an aggressive life-threatening activation of the immune system triggered by an underlying condition. Use of chimeric antigen receptor therapy (CAR-T) to treat relapsed/refractory diffuse large B-cell lymphoma (R/R DLBCL) is associated with cytokine release syndrome (CRS), Immune Effector Cell Associated Neurotoxicity Syndrome (ICANS) and development of secondary HLH. Application of HLH scoring systems such as the H-score or HLH-2004 criteria to identify CAR-T triggered HLH is not validated in this setting. Inability to promptly recognize the development of secondary HLH in CAR-T patients and to distinguish it from CRS may lead to delay in HLH specific therapy and increased mortality. We analyzed the utility of applying the H-score and the HLH-2004 criteria to identify possible patients with HLH post-CAR-T for R/R DLBCL. Methods: A single center retrospective analysis of 75 patients with R/R DLBCL following CAR-T was performed. Using a peak ferritin of 500 mcg/L or higher within 30 days of CAR-T administration, 43 out of 75 patients were identified at risk for HLH. The H-score and HLH-2004 criteria were applied retrospectively. Measurement of NK activity was not available for any patients and soluble IL2 was collected intermittently. The mean H-score was calculated, and two sample t-test performed to evaluate for a difference in the mean H-score between low versus high grade CRS, low versus high grade ICANS, as well as presence versus absence of cytopenias at days 30, 90 and 180. Low grade CRS/ICANS was defined as 1, and high grade as 2 or higher. CRS was graded per Lee 2014 criteria and ICANS per CTCAEv.4. The 43 patients were then subdivided by H-score threshold of 169 into H-score Low (< 169) and H-score High (≥ 169). The threshold of 169 was used given a prior validation study showing optimal sensitivity and specificity for identifying acquired HLH in adult patients with an H-score equal to or higher than 169. Both Progression Free Survival (PFS) and Overall Survival (OS) were defined as time from CAR-T infusion until an event of last follow up. Kaplan-Meier curves were produced to describe the distribution of PFS and OS between two subpopulations of low and high H-Score. Results: Median peak ferritin was 1571.8 mcg/L (range: 375 mcg/L - >50,000 mcg/L, table 1). Median H-score was 135 (range 61 -250). Four patients were treated with HLH directed therapy receiving steroids with either tocilizumab, siltuximab and/or anakinra. Of these 4 patients, only 2 met five HLH-2004 criteria. All 4 patients had H-scores above 169 (209, 211, 228 and 250). Of these 4 patients, one died from complications thought secondary to HLH. Fourteen patients (14/43, 32%) had an H-score >169. Ten patients did not require any HLH directed therapy and had no clinical evidence of HLH. The mean H-score was not different between patients with low vs high grade CRS (148.2 vs 141.8, p=0.7) or low vs high grade ICANS (145.9 vs 142.6, p=0.8). No statistical correlation was seen between H-score and cytopenias at any time point. There was no significant difference in PFS or OS between the H-score low vs high subgroups (p=0.7, p=0.1 respectively, figure 1 and 2). Patients with higher H-score tended to have longer length of hospitalization for CAR-T (Pearson correlation coefficient 0.289). Conclusions: In patients with R/R DLBCL post CAR-T, the use of either the H-score or application of HLH-2004 criteria had low utility in identifying possible HLH in patients who screened in based on peak ferritin within 30 days of CAR-T administration. While apparent differences between the H-score high and low categories may not reach statistical significance due to the small number of patients, our exploratory analysis does not support the use of H-Score to evaluate for HLH post-CAR-T. The immediate post-CAR-T period is characterized by a high inflammatory state, which likely results in high H-scores. Results from our study suggest a need for further characterization of HLH following CAR-T and the role for a CAR-T specific HLH scoring system to distinguish secondary HLH from CAR-T related inflammation in this specific patient population. Disclosures Hardy: American Gene Technologies: Other: DSMB Member; Kite/Gilead: Other: Advisory Board Member; Incyte Corporation: Other: Advisory Board Member.

There is limited information on the cost burden associated with follicular lymphoma (FL) and how it compares to other non-Hodgkin lymphoma (NHL) subtypes. We examined the direct medical costs associated with FL and estimated the incremental 3-year cost of FL compared to other NHL subtypes. Using the linked Surveillance, Epidemiology and End Results-Medicare dataset, we identified 16,691 NHL patients aged 66 years or older who were diagnosed with NHL between 2007 and 2013. The mean 3-year cost among the full NHL sample was $120,120 (standard error (SE) 839). The mean 3-year cost per patient was $114,443 (SE 1738) for FL and $121,402 (SE 950) for non-FL subtypes. The incremental 3-year cost of FL compared to non-FL was US$-5458 (95% confidence interval: US$-9325 to US$-1590). Longitudinally, FL was less costly than other NHL subtypes in the first year only, and became more expensive in the second and third years.

Total body irradiation (TBI) has been included in standard conditioning for acute lymphoblastic leukemia (ALL) before hematopoietic cell transplantation (HCT). Non-TBI regimens have incorporated busulfan (Bu) to decrease toxicity. This retrospective study analyzed TBI and Bu on outcomes of ALL patients 18–60 years old, in first or second complete remission (CR), undergoing HLA-compatible sibling, related, or unrelated donor HCT, who reported to the Center for International Blood and Marrow Transplant Research from 2005 to 2014. TBI plus etoposide (25%) or cyclophosphamide (75%) was used in 819 patients, and intravenous Bu plus fludarabine (41%), clofarabine (30%), cyclophosphamide (15%), or melphalan (13%) was used in 299 patients. Bu-containing regimens were analyzed together, since no significant differences for patient outcomes were noted between them. Bu patients were older, with better performance status; took longer to achieve first CR and receive HCT; were treated more recently; and were more likely to receive peripheral blood grafts, antithymocyte globulin, or tyrosine kinase inhibitors. With median follow-up of 3.6 years for Bu and 5.3 years for TBI, adjusted 3-year outcomes showed treatment-related mortality Bu 19% versus TBI 25% (P = .04); relapse Bu 37% versus TBI 28% (P = .007); disease-free survival (DFS) Bu 45% versus TBI 48% (P = .35); and overall survival (OS) Bu 57% versus TBI 53% (P = .35). In multivariate analysis, Bu patients had higher risk of relapse (relative risk, 1.46; 95% confidence interval, 1.15 to 1.85; P = .002) compared with TBI patients. Despite the higher relapse, Bu-containing conditioning led to similar OS and DFS following HCT for ALL.

[Figure][1] A 34-year-old man with myelofibrosis underwent HLA-matched unrelated donor hematopoietic stem cell transplantation (HSCT) with major ABO incompatibility, complicated by pure red cell aplasia requiring red blood cell transfusion for several months, and by graft-versus-host disease

Background: Cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) are known complications of chimeric antigen receptor T-cell (CAR-T) therapy. These clinical syndromes develop as a result of CAR-T activation, proliferation, and tumor lysis with resultant cytokine secretion. In prior reports of CD19 CAR-T therapy patients, those who developed ICANS showed evidence of endothelial activation and disruption of the blood-brain barrier as a result of cytokine release while only approximately one-third demonstrated changes on Brain MRI (Gust et al. Cancer Discov 2017). As such, further predictive markers and studies are needed to identify patients at risk for ICANS to allow for expedited management and improved outcomes. Herein we report a single-center analysis exploring glycolytic activity on PET/CT and the association with clinical outcomes for patients with relapsed/refractory diffuse large B-cell lymphoma (R/R DLBCL) after CAR-T therapy. Methods: An organ-based evaluation of uninvolved sites was conducted in R/R DLBCL patients (n=32) who underwent CD19 CAR-T therapy with evaluable PET/CT imaging at baseline immediately prior to CAR-T therapy and at 30 days post-infusion (D+30). All patients in this analysis were treated with axicabtagene ciloleucel as standard of care therapy after 2 or more lines of therapy. Tumor metabolic volume (TMV) and mean standard uptake value (SUVmean) of various organs were quantified using ROVER [Region of interest (ROI) visualization, evolution, and image registration] software (ABX advanced biochemical compounds GmbH, Radeberg, Germany). Statistical analysis was completed using STATA 14 (StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP). All tests were performed after testing the normality distribution assumption. Temporal changes were assessed using paired t-tests, and between-group analyses were completed with two-sample t-tests. Results: SUVmean increased significantly after CAR-T therapy in the following organs (D+30 v baseline pre-CAR-T PET/CT): cerebral cortex (8.23 v 7.09, p=0.036), cerebellum (6.26 v 5.56, p=0.024), basal ganglia (9.22 v 7.61, p=0.005), parotid gland (1.61 v 1.42, p=0.004), liver (2.47 v 2.17, p=0.002), spleen (2.08 v 1.84, p=0.043), and pancreas (1.76 v 1.48, p Conclusion: For patients with R/R DLBCL undergoing CD19 CAR-T therapy, significantly increased CNS glycolytic activity is seen on PET/CT at D+30 post-infusion when compared to baseline. Interestingly, these changes do not correlate with development of ICANS or lymphoma response; however, changes in cortical activity were associated with CRS grade ≥2. Overall, our findings illustrate a functional and radiographic link between cytokine release and subsequent disruption of the blood-brain barrier as quantified by increased cortical glycolysis 30 days post-CAR-T therapy. While findings are limited by small sample size, further validation in a larger data set is warranted. Disclosures Hutnick: Kite/Gilead: Other: Yescarta Speakers Bureau, Speakers Bureau. Badros:Celgene Corporation: Consultancy; Amgen: Consultancy.

Background We examined the impact of vancomycin-resistant Enterococcus (VRE) bloodstream infection (BSI) on outcomes of allogeneic hematopoietic cell transplantation (HCT) utilizing the Center for International Blood and Marrow Transplant Research database. Methods Adult and pediatric patients (N = 7128) who underwent first HCT for acute leukemia or myelodysplastic syndrome from 2008 through 2012 were analyzed as 3 groups—VRE BSI, non-VRE BSI, without BSI—according to BSI status at 100 days (D100) after allogeneic HCT. Multivariable models examined the effect of VRE BSI for overall survival (OS) and nonrelapse mortality (NRM) at 1 year. Results Of 7128 patients, 258 (3.2%) had VRE BSI, 2398 (33.6%) had non-VRE BSI, and 4472 (63%) had no BSI. The median time to VRE BSI and non-VRE BSI were D11 and D15, respectively. Compared with non-VRE BSI patients, VRE BSI patients were older, had advanced-stage acute leukemia, and received umbilical cord blood (UCB) allografts. In multivariable models, VRE BSI was associated with lower OS (relative risk [RR], 2.9;(99% confidence interval [CI], 2.2–3.7) and increased NRM (RR, 4.7; 99% CI, 3.6–6.2) (P < .0001) for both. Other predictors for worse OS and increased NRM were non-VRE BSI, older age, advanced disease stage, UCB allograft, – mismatch, comorbidity index ≥3, and cytomegalovirus seropositivity (P < .001 for all variables). Conclusions VRE BSI is associated with lowest OS and highest NRM compared with patients without BSI or non-VRE BSI. Novel interventions that address the pathophysiology of VRE BSI have the potential of improving survival after HCT.

7560 Background: Axicabtagene Ciloleucel (Axi-cel), an anti-CD19 CART cell therapy, achieved 58% complete response (CR) rate, in patients with relapsed refractory (r/r) LBCL on the ZUMA-1 study (Neelapu, NEJM 2017). Early response assessment (PET-CT) at day 30 is a common clinical practice. Patients with partial response (PR) at day 30 pose a therapeutic dilemma. ZUMA-1 analysis showed 1/3rd PR patients would convert to a CR. No biomarkers exist to predict eventual response. We report comprehensive PET-CT biomarker analysis on patients with PR at day 30 treated with Axi-cel for r/r LBCL. Methods: Ten patients with PR based on PET-CT imaging at day 30 were retrospectively assessed. Day 30 PET-CT was compared to baseline and a day 90 PET-CT. Global burden of disease of each patient at every time-point were quantified using Total Tumor Glycolysis (TTG) methodology as the imaging biomarker. Using adaptive-thresholding method, each lesion on FDG PET image was segmented and the following parameters were quantified: metabolic-volume (MV), SUVmax, SUVpeak, Partial-Volume-Corrected SUVmean and five other imaging biomarkers. To evaluate the effect of baseline and early imaging biomarkers to predict the subsequent burden of disease multiple regression analysis was performed (STATA 15). Results: Day 90 PET-CT assessment revealed, 4 patients had progressive disease (PD), 4 had CR, and 2 had PR. TTG of patients with PD at day 90 was 900 vs. 29 in patients with non-PD (CR, PR). The Global-SUVmean of the patients with PD at day 90 was 725 vs. 86 in patient with non-PD. Regression analysis showed early-TTG as a significant predictor of subsequent-TTG (beta-coefficient = 1.26 (0.39-2.13); P-value = 0.02; adjusted-R-squared = 0.97), while the baseline-TTG didn’t have any effect on subsequent-TTG (P-value = 0.3). Additionally, the regression analysis didn’t show any significant predictive value in SUVmean and SUVmax of baseline and day 30 scans to predict subsequent burden of disease (TTG or Global-SUVmean) with P-values > 0.8. Conclusions: Early post-axi-cel TTG, rather than baseline, can predict subsequent response to treatment. None of the SUV indices, commonly used in daily practice, were predictive of eventual response.

Introduction The PRIMA (Primary Rituximab and Maintenance) study established 2 years of maintenance rituximab (MR) as a standard of care for follicular lymphoma (FL) patients who achieve an objective response after induction chemotherapy. A 17% improvement in progression-free survival (PFS) compared with those who did not receive MR was observed. However, the decision to stop MR after 2 years was arbitrary, and the PRIMA study reports only short-term follow-up of 3 years. Longer series on FL outcomes describe ubiquitous relapse and death following recurrence. The optimal duration of MR is under investigation. Herein, we report our experience with prolonged MR in FL. Patients and Methods In this retrospective analysis, the outcome of 25 consecutive, unselected, previously untreated patients with low-grade high tumor burden FL in need for treatment is described. All patients achieved a partial or complete response to induction immunochemotherapy and received ongoing MR therapy. Results With a median follow-up of 5.0 years and 5.2 years mean duration of MR, there are no relapses. Five deaths have occurred, unrelated to lymphoma or therapy. Prolonged MR treatment has been well-tolerated. Hypogammaglobulinemia is the only observed adverse event, with only one patient requiring monthly intravenous gamma globulin infusions due to recurrent pneumonia. There has been no discontinuation of MR or refusal to remain on MR. Conclusion These provocative long-term results suggest that continuous MR beyond 2 years is safe and may be associated with prolonged PFS in patients with FL who achieve an objective response after immunochemotherapy.

Introduction: Approximately 1.5% of population will be diagnosed with leukemia in their lifetime (SEER Cancer Statistics Review). Diagnosis of acute leukemia has an overwhelming effect on the patient and their families. Besides the diagnosis, effect of chemotherapeutic agents and agony over the ultimate outcome can also affect emotional-behavioral wellbeing. Evolution of depression as a disorder, along the course of acute leukemia has been reported in the past (David et al Procedia Soc & Behav Sci 2014). We investigated the prevalence of mental health disorders in hospitalized patients admitted with acute leukemia diagnosis utilizing Healthcare Utilization Project National Inpatient Sample (HCUP NIS), 2002-2014. HCUP-NIS is the largest publicly available all-payer inpatient health care database in the United States, and is a 20% stratified sample of all hospital discharges. Methods: We identified hospitalizations for acute leukemia using ICD-9 codes (203.XX, 204.XX, 205.XX, 206.XX, 207.XX and 208.XX) in the NIS database. We included patients with a primary diagnosis of acute leukemia (myeloid, lymphoid and plasma cell leukemia) including admissions for inpatient chemotherapy and/or complications requiring hospitalization. Similarly, ICD-9 codes were used to identify patients with mental health disorders of interest (ADHD, adjustment disorder, alcohol abuse, anxiety disorder, mood disorders, personality disorders, schizophrenia, substance abuse, childhood disorders). "Surveyfreq" was used to calculate proportions while "Surveymeans" was used to calculate median length of stay and hospital charges. Cochran-Armitage test was used to analyze trends; Kruskal-Wallis test was used for non-parametric data. We used chi-square for categorical data frequency, P value of < 0.05 was considered statistically significant. All analysis was performed using SAS 9.4. Results: We identified a total of 59,223 patients with mental health disorders (18.4%) out of a total of 321223 hospitalizations for acute leukemia (table 1). Median age for patients with mental health disorders is 56 years. Mood disorder was most prevalent at 8% followed by anxiety disorder at 6%. Within all mental disorders, mood disorders comprised 44% of all cases followed by anxiety disorder at 32% (figure 1). Over 60% of mental health disorders were in patient age group above 50 years (figure 2). Prevalence of mental health disorders has increased from 10% to 28% between 2002 and 2014 (figure 3). Prevalence of anxiety disorder has increased 6 fold between 2002 (2%) and 2014 (12%). It is unclear if this change is due to an actual increase in the prevalence of this condition or better recognition of mental health disorders leading to better coding. Median length of stay (LOS) is significantly longer in patients with mental health disorders compared to those without (18 days vs 9 days respectively). Median charges for hospitalization are also significantly increased in patients with mental health disorders than those without ($119,245 vs $62,132 respectively). Conclusion: Mental health disorders are common in patients with acute leukemia. One in four patients (28%) in 2014 had a mental health disorder compared to 9% in 2002. Given the retrospective nature of our study, it is difficult to determine if this is an actual increase in the incidence and prevalence of mental health disorders or if better recognition and medical coding contributes to this finding. Our study shows a disproportionate burden of mental health disorders in patients above the age 50, which constitutes the majority of the patients diagnosed with acute leukemia. Use of mental health screening tools in this population could provide an avenue for recognition and possible early intervention. Given the retrospective nature of our study, these findings need to be validated in a prospective patient population. Disclosures No relevant conflicts of interest to declare.

Background: Chimeric antigen receptor T-cell (CAR-T) therapy is an FDA-approved therapy for relapsed or refractory diffuse large B-cell lymphoma (DLBCL) and acute lymphoblastic leukemia (ALL). A common side effect of CAR-T therapy is cytokine release syndrome (CRS), and its severity ranges from mild to severe, and occasionally resulting in death. Patients at particularly high risk for severe CRS may benefit from earlier supportive care and rescue therapies, such as tocilizumab. Although the median onset of CRS has been reported as two days, no existing prognostic tools adequately assist the bedside clinician with triaging which patients will decompensate and warrant escalation of care. For example, biomarkers such as CRP and ferritin are ineffective in predicting CRS severity. Evaluation of the sublingual microcirculation of patients receiving CAR-T therapy may serve as a valuable surveillance tool. The sublingual microcirculation (defined as blood vessels Methods: Video images are collected in real time. Prior to interpretation, all video clips were assessed for quality based on the current microcirculation consensus document. Each acceptable clip was then analyzed by using two point-of-care (POC) scoring systems: 1) the microvascular flow index (MFI) and 2) the point-of-care microcirculation (POEM) score. The MFI is determined by dividing the video monitor into four equal quadrants and grading the overall flow of each quadrant with a score from 0-3 (0 = no flow; 1 = intermittent flow; 2 = sluggish flow; 3 = normal flow). The POEM score utilizes an ordinal 1-5 scale (1 = critically impaired; 2 = impaired; 3 = normal with marked heterogeneity; 4 = normal with mild heterogeneity; 5 = normal) that is a composite of four measurements assessing flow impairment and heterogeneity. For each enrolled patient, a baseline measurement was made immediately prior to CAR-T cell infusion with follow up measurements occurring every six hours beginning at hour 18 after cell infusion until hour 72. After hour 72, measurements were made daily until they were deemed no longer at risk for CRS. Results: At this time there is mature data on 7 patients. All patients received Axicabtagene Ciloleucel- a CD19 directed CAR-T cell therapy (Yescarta, Kite Pharma). All patients had normal baseline microcirculation (MFI > 2.6, POEM=5) and normal or near-normal microcirculation at the end of the study period. No patients developed severe CRS (grade 3 and above). Three patients developed grade 2 CRS that required tocilizumab. Patients #1 and #2 both had significant microcirculatory impairments ≥12 hours prior to developing symptoms severe enough to warrant tocilizumab. Patient #3 had normal microcirculation through the first four days of therapy and developed hypotension on day six. We captured a subtle change from a normal MFI and POEM score to mild impairment with both scoring algorithms on day five, one day prior to clinical manifestations of decompensation. For logistical reasons, subsequent data were unable to be obtained. MFI and POEM scores for all patients are listed below in Table 1. The remaining four patients developed grade 1 CRS with associated mild microcirculatory changes. Conclusions: In this pilot study, POC microcirculatory assessments were successfully used to monitor patients undergoing CAR-T therapy. Patients with more severe CRS manifested lower MFI and POEM scores and maintained their nadir longer than those with milder CRS. Our data suggest that CAR-T patients developing CRS manifest early signs of sublingual microcirculatory dysfunction. Moreover, these microcirculatory defects present prior to the development of standard clinical abnormalities, such as macrocirculatory derangements. While further investigation is ongoing, this tool could be used for earlier identification of patients at risk for CRS in order to deliver earlier appropriate therapies, and ultimately to improve patient outcomes. Disclosures No relevant conflicts of interest to declare.

Background: Sickle cell disease (SCD) is a common hemoglobinopathy, characterized by vaso-occlusive crises and affects over 100,000 people in United States. It afflicts long-lasting organ damage with a spectrum of clinical severity. Median survival for SCD is shortened to the 6th decade of life despite advances in medical care (Elmariah et al Am J Hematol 2014). Allogeneic stem cell transplant (SCT) is a potentially curative option and is increasingly considered in patients with severe symptomatic SCD. The use of SCT is limited by donor availability and treatment related complications. Several advancements in conditioning regimen and use of alternate donor source have favorably impacted the feasibility of this approach. We identified SCT performed for sickle cell disease in the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) from 2002-2014 in an attempt to identify hospitalization outcomes, factors affecting length of stay and healthcare utilization. Methods: HCUP-NIS is a 20% stratified sample of all discharges from hospitals across 46 states in the United States and incorporates weighting algorithms to predict nationwide estimates. We used International Classification of Diseases, Ninth Revision (ICD-9) procedure codes to identify HCT hospitalizations {Bone marrow (BM):41.02, 41.03, Peripheral blood (PB): 41.05, 41.08 and Cord blood (CB): 41.06} for sickle cell disease (282.5,282.6X -282.6X). We excluded patients who underwent SCT for indications other than SCD. Surveyfreq was used to calculate proportions and surveymeans was used to calculate median length of stay and hospital charges. Kruskal-Wallis test was used for non-parametric data. Chi-square for categorical data frequency, P value of < 0.05 was statistically significant. All analysis was performed using SAS 9.4. Results: Outcomes were analyzed from a total of 742 hospitalizations for SCT from 2002-2014 (table 1). Median age for stem cell transplant was 9 years. GVHD occurred in 14% of stem cell transplants. Overall, in-hospital mortality was low at 2.6% while mortality in patients who developed GVHD was 14%. Bacterial infections (including C.difficile) occurred more commonly than viral or fungal infections (table 2). Patients who developed graft vs host disease (GVHD) were also more likely to have bacterial, viral and fungal infections than those without. Pain crisis was noted in 9% of total admissions while stroke occurred in 6%. Median length of stay (LOS) was 35 days and median charges were $359,646. If GVHD developed, median LOS increased to 54 days while median charges increased to $712,324. Similarly, bacterial sepsis was associated with a longer median LOS of 63 days while median charges increased to $626,986 (table 3). Conclusions: The rate of inpatient mortality with SCT in sickle cell disease is lower than the overall inpatient mortality rate for allogeneic SCT (7%; Godara et al bbmt 2018), indicating a favorable outcome for these patients. Infections do occur commonly during the course of hospitalization, especially in association with GVHD. Length of stay is adversely impacted by occurrence of GVHD, bacterial sepsis, C.difficile infection and viral infections. While we are limited by duration of follow up in our study, these patterns suggest some essential modifiers for inpatient morbidity and mortality, therefore require validation in a large prospective study. Disclosures No relevant conflicts of interest to declare.

7563 Background: There are multiple treatment regimens approved for the management of follicular lymphoma (FL). However, there is limited information available to describe the course of therapy (COT) that patients receive following FL diagnosis. Methods: Using the linked Surveillance, Epidemiology, and End Results (SEER) registry & Medicare claims dataset, we analyzed patients 66 years and older diagnosed with FL from 2000 to 2011. In order to characterize FL treatments, we identified first, second and subsequent-lines of therapy listed in the National Comprehensive Cancer Network guidelines 2.2016. We identified the first COT (COT1) as the first regimen that a patient receives after diagnosis. We identified the second and third COT (COT2 and COT3) as new treatment received following/interrupting COT1 or COT2, respectively. Using visual analytics software, we investigated and reported the proportion of patients receiving each COT, the top three regimens within each COT, and the median time to starting a COT from diagnosis or end of a previous COT. Results: 10,836 FL patients were identified after applying the inclusion/exclusion criteria. Sixty-two percent (N=6,756) of the patients received FL-directed treatment. Among patients receiving COT1, 65% received COT2. Among patients receiving COT2, 79% received COT3. The table below provides additional information on the COT received. Conclusions: Analysis of real-world data indicates that almost 4 out of 10 elderly FL patients do not receive the listed FL-directed treatments. In contrast to rituximab, there was limited use of RCHOP and RCVP after COT1 during the study period. Additional research is needed to understand the differences across demographic groups and associated health outcomes. [Table: see text]

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Peripheral T-cell lymphoma (PTCL) is a heterogeneous group of non-Hodgkin's lymphoma that carries, except for ALK-positive anaplastic large cell lymphoma, a poor prognosis. Only a third of patients live 5years past diagnosis. The incidence of PTCL has been increasing during the last two decades. In recent years, there was a rising interest in PTCL manifested by the abundance of publications dedicated exclusively to this disease. The international T-cell lymphoma project was formed with an aim of unifying efforts towards a better understanding of the diagnosis and management of this disease. Given the poor outcomes of PTCL patients, high-dose chemotherapy and autologous stem-cell transplantation (HDT/ASCT) have been used in the up-front and salvage settings, with different success rates. However, there are no prospective randomized controlled trials addressing the role of HDT/ASCT in a PTCL-restricted population. This article critically reviews the data available from the retrospective and prospective studies addressing this topic. We will emphasize the favorable prognostic factors of HDT/ASCT such as a solid remission at the time of transplantation, a chemotherapy sensitive disease and a low prognostic index score. As novel agents and new therapeutic strategies are introduced, there is a continued need for prospective randomized trials to define the optimal use of HDT/ASCT in managing PTCL.