The Mean Fluorescence Intensities of Anti-HLA Antibodies Detected Using Micro-Bead Flow Cytometry Predict the Risk of Platelet Transfusion Refractoriness.

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 2285-2285
Author(s):  
Ashanka M Beligaswatte ◽  
Eleni Tsiopelas ◽  
Ian Humphreys ◽  
Greg Bennett ◽  
Kathryn Robinson ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
High Risk ◽  
Platelet Transfusion ◽  
Blood Product ◽  
Class I ◽  
Cell Transplant ◽  
Hla Antibodies ◽  
High Risk Patients ◽  
Risk Patients ◽  
Antibody Titers

Abstract Abstract 2285 Background: HLA allo-immunized patients often receive matched platelets only after demonstrating platelet transfusion refractoriness (PTR). If further risk stratification was possible, high risk patients could be considered for pre-emptive HLA-matched platelets, cryopreserved autologous platelets, or possibly thrombopoietin analogues. Micro-bead flow cytometry is widely used to detect anti-HLA antibodies, and mean fluorescence intensities (MFI) obtained from these assays correlate with antibody titers. We asked whether MFIs could be used to stratify the risk of PTR among allo-immunized patients. Study design: We retrospectively identified 387 patients who received an autologous stem cell transplant or induction therapy for acute leukemia, between January 2005 and March 2012. All patients had a serum sample taken for HLA antibody assay within 6 weeks of commencing cellular blood product transfusions. No patient was scheduled to receive prophylactic HLA matched platelets. The primary endpoint was the development of PTR. To minimize the influence of sensitization occurring after screening, only outcomes during the first 2 weeks from commencing cellular blood product transfusions were considered. PTR was defined as having received ≥ 2 consecutive RDPLT transfusions associated with an 18–24h corrected count increment of < 2.5 at 18 – 24 hours. Antibody testing was performed using a micro-bead flow cytometry assay (Lifecodes LifeScreen Deluxe, with positive results confirmed by Lifecodes Class I ID assay, Gen-Probe Transplant Diagnostics, Stamford, CT) either during the treatment period, or on serum samples stored at −30°C. Mean fluorescence intensities (MFI) were acquired using a Luminex 100 analyzer (Luminex Corporation, Austin, TX), and analyzed using Lifecodes Quicktype v2.5.5 (Gen-Probe Transplant Diagnostics, Stamford, CT). We defined the predictor variable avgMFI to be the average MFI of the 7 individual beads in the assay, weighted by whether the presence of antibodies was confirmed or not: where w = 1 if the presence of antibodies is confirmed, and 0 otherwise; and subscript i refers to the ith class I bead. Results: Antibodies were detected in 57 (14.7%) patients of whom 45 (78.9%) were female. A total of 1443 random donor platelet (RDPLT) transfusions (mean platelet count 2.4×1011/unit) were studied. Sixty six (17%) patients developed PTR, of whom 28 had detectable antibodies; 29 of 321 patients who did not develop PTR also tested positive. Among antibody positive patients, median avgMFI for refractory patients was 4589 versus 349 for patients who were not, Wilcoxon rank sum test P< 0.0001. (Figure 1). The area under the receiver operating characteristic curve for avgMFI as a predictor of PTR was 0.8633 (95% confidence interval: 0.7664 – 0.9602). Higher avgMFIs also correlated with a broader range of target antigens, likely due to increasingly avid binding to cross-reactive epitopes. (Spearman's r = 0.7736 for correlation between avgMFI and panel reactive antibody percentages (cPRA), calculated in reference to the general American population, and used here as a surrogate for the range of antibody specificities). cPRA was >80% in 25/27 patients with avgMFI>1000, suggesting poor ability to discriminate among patients with moderate to high antibody titers, and was not an independent predictor of PTR. Hence, while the increased probability of encountering a cognate antigen on a RDPLT may partly explain the correlation between avgMFI and PTR, the avidity of binding, represented in vitro by the MFIs, appears to be a more significant determinant of risk. In conclusion, we provide evidence for the concept that PTR risk due to HLA allo-immunization is usefully predicted by the MFIs of antibodies detected using micro-bead flow cytometry. Our model allows cut-offs for identifying high risk patients to be based on the degree of risk acceptable in a given clinical situation. This should enable hematology units to develop risk-adapted strategies for supporting allo-immunized thrombocytopenic patients. Disclosures: No relevant conflicts of interest to declare.

Screening for Leptomeningeal Disease by High-Sensitivity Flow Cytometry in High Risk Patients with Aggressive Non-Hodgkin’s Lymphoma.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 4397-4397
Author(s):  
Joy Mangel ◽  
Jazmin Marlinga ◽  
Mike Keeney ◽  
Jan Popma ◽  
Anargyros Xenocostas ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
High Risk ◽  
High Sensitivity ◽  
B Cell Lymphoma ◽  
Leptomeningeal Disease ◽  
Cns Involvement ◽  
Lymphoma Cells ◽  
High Risk Patients ◽  
Csf Analysis ◽  
Risk Patients

Abstract Background: Central nervous system (CNS) involvement by non-Hodgkin’s lymphoma (NHL) portends a very poor prognosis. There is no consensus in the literature on the “high- risk” features that predict for leptomeningeal disease, and no standardized clinical guidelines exist regarding CNS surveillance, prophylaxis or treatment for patients at increased risk. 2–4 colour flow cytometry (FCM) has been reported to be more sensitive than standard cytology in detecting occult leptomeningeal disease (Blood 2005,105:496). The current study evaluates the utility of a high-sensitivity (5-colour) flow cytometry technique for detecting occult lymphoma cells in the cerebrospinal fluid (CSF) of high-risk patients with NHL. Method: Patients with a new diagnosis of histologically aggressive B or T cell NHL were included in this study if they displayed one or more “high-risk” features for CNS involvement. Patients suspected of CNS relapse of NHL were also eligible for participation. Patients underwent routine staging investigations, with the addition of a diagnostic lumbar puncture (LP) during initial assessment. CSF was tested by standard cytology, cell count and biochemistry, and an additional 5 ml was obtained for analysis by high-sensitivity FCM on a Beckman Coulter FC500. The antibody panel (5 antibodies per tube) was customized according to the phenotype of the lymphoma. The key markers for B cell lymphoma were CD19/kappa/lambda with CD5 or CD10. CD45 was used to identify all white blood cells in the sample. Results: Seventeen patients (8M/9F) with a median age of 59 (range 36–85) have been tested. Patients displayed anywhere from 2–6 “high-risk” features for CNS involvement. These included: HIV positivity (2), primary mediastinal B-cell lymphoma (4), bone marrow (5), multifocal bone (2), paraspinal (1), nasopharyngeal (2) or orbital (1) involvement, elevated serum LDH (12), multiple extranodal sites of disease (5), poor performance status (2), high IPI (3), B-symptoms (9), stage IV disease (11), and otherwise unexplained neurological symptoms (3). 14 patients underwent CSF analysis at time of initial diagnosis, one of whom had cranial nerve palsies secondary to a nasopharyngeal mass extending to the skull base. The other 3 were tested at relapse, transformation, and suspected CNS relapse ultimately diagnosed as a stroke. Despite the presence of these features, CSF analysis was negative for lymphoma cells by both cytology and FCM in all but one of the patients tested. However this patient had very high numbers of circulating lymphoma cells in the peripheral blood (PB), and the positive result was felt to be due to PB contamination of the CSF during a “bloody tap.” One patient with vague neurological symptoms had a negative LP at diagnosis, and later developed frank CNS involvement by lymphoma, but was too unwell to undergo a repeat LP. Conclusions: Given the limited number of patients enrolled thus far and the low prevalence of patients with NHL and CNS involvement (2/17), it is difficult to fully assess the utility of high-sensitivity FCM in the diagnosis of occult leptomeningeal disease. It is of interest that CSF analysis was negative even in the patient with cranial nerve palsies and in the patient who later developed multiple CNS lesions secondary to lymphoma, suggesting that this technique may have limited sensitivity in diagnosing leptomeningeal disease. The systematic screening of high-risk patients cannot yet be recommended as standard clinical practice.

Platelet Functions and Risk Prognosis in Myelodysplastic Syndromes,

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 3806-3806
Author(s):  
Nora V. Butta ◽  
Mónica Martín Salces ◽  
Raquel de Paz ◽  
Elena G. Arias Salgado ◽  
Ihosvany Fernández Bello ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
High Risk ◽  
Myelodysplastic Syndromes ◽  
Surface Expression ◽  
Low Risk ◽  
Control Group ◽  
Platelet Surface ◽  
High Risk Patients ◽  
Fibrinogen Receptor ◽  
Risk Patients

Abstract Abstract 3806 The myelodysplastic syndromes (MDS) are a heterogenous group of clonal stem cell disorders with peripheral cytopenias and increased incidence of leukemic transformation. The prognosis of MDS is determined by several factors, including the presence of specific cytogenetic abnormalities, the percentage of blastoid cells in bone marrow and peripheral blood, the number of affected cell lineages, and transfusion dependency. The most commonly used risk stratification system is the International Prognostic Scoring System (IPSS). This score divides patients into a lower risk subset (low and intermediate-1) and a higher risk subset (intermediate-2 and high). Patients with MDS may have hemorrhagic complications with serious outcomes that are among the major causes of death in this population. These bleeding episodes that are often related to thrombocytopenia also occur in MDS patients with normal platelet count. The aim of this work was to study functional characteristics of platelets in MDS patients and their relationship to risk evaluated as indicated by IPSS. Eighty diagnosed MDS patients risk-stratified according to IPSS were included: 40 with low-risk, 29 with intermediate-1-risk (I-1), 8 with intermediate-2-risk (I-2) and 3 with high-risk. Eighty healthy donors were included as control group. Platelet-related primary haemostasis was evaluated with an automated platelet function analyzer (PFA-100®, Siemens Healthcare Diagnostics). Samples of citrated blood were aspirated under a shear rate of 4,000–5,000/s through a 150-μm aperture cut into a collagen-ADP (COL-ADP) or collagen-epinephrine (COL-EPI) coated membrane. The platelet haemostatic capacity is indicated by the time required for the platelet plug to occlude the aperture (closure time, CT), which is expressed in seconds. Platelet activation was determined through FITC-PAC-1 (a mAb that recognizes activated conformation of fibrinogen receptor) and FITC-P-selectin mAb binding to quiescent and 100 μM TRAP activated platelets by flow cytometry. Surface expression of fibrinogen receptor (αIIb and β3 subunits) was determined by flow cytometry with specific mAbs. Apoptosis was determined by flow cytometry analysis through FITC-annexin V binding to platelet membrane phosphatidylserine (PS) exposed in basal conditions. I-2 and high-risk patients were gathered together in a high-risk group in order to analyze experimental results. Statistical analysis was performed with one-way ANOVA and Tukey test. CTs obtained with COL-EPI and COL-ADP cartridges in controls and low risk patients were similar and significantly shorter than CTs observed in I-1-risk and high-risk MDS patients (p<0.05). Platelets from all MDS patients showed a reduced capability for being activated by 100 μM TRAP. This impairment was more evident in I-1-risk and high-risk patients: PAC-1 binding, in arbitrary units (AU), was 11368±1017 in controls; 7849±789 in low-risk MDS (p<0.05); 4161±591 in I-1-risk MDS (p<0.01 versus control and p<0.05 versus low-risk) and 492±184 in high-risk MDS (p<0.01 versus control and p<0.05 versus low-risk). The platelet surface expression of P-selectin induced by 100 μM TRAP was also reduced: 5102±340 AU in controls, 3318±400 AU in low-risk MDS (p<0.05); 1880 ±197 AU in I-1-risk MDS (p<0.05 versus control and versus low-risk), and 1211±130 AU in high-risk MDS (p<0.05 versus control and versus low-risk). Diminished responses to TRAP were not due to a reduction in surface expression of fibrinogen receptor in platelets from MDS patients. Platelets from MDS patients expressed more PS than controls under basal conditions. Mean fluorescence values for FITC-annexin binding were: 383±16 in controls; 444±21 in low-risk (p<0.05); 575±52 in I-1-risk MDS (p<0.05 versus control and versus low-risk); 611±17 in high-risk MDS (p<0.05 versus control and versus low-risk). Our results indicated that platelets from MDS patients had less ability to be activated and were more apoptotic than control ones. These dysfunctions were more pronounced when the risk of the disease was higher according to IPSS. Disclosures: No relevant conflicts of interest to declare.

Comorbidity and Outcomes for Patients Over Age 65 Years Treated with Allogeneic Stem Cell Transplantation for Acute Myelogenous Leukemia and Myelodysplastic Syndrome

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 2032-2032 ◽  
Author(s):  
Henry J. Conter ◽  
Nhu-Nhu Nguyen ◽  
Gabriela Rondon ◽  
Julianne Chen ◽  
Elizabeth J Shpall ◽  
...  
Keyword(s):  
Stem Cell ◽  
High Risk ◽  
Cumulative Incidence ◽  
Stem Cell Transplant ◽  
Myelogenous Leukemia ◽  
Cell Transplant ◽  
High Risk Patients ◽  
Risk Patients ◽  
Acute Myelogenous ◽  
Related Mortality

Abstract Abstract 2032 Background: Acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS) preferentially afflict patients 65 years of age and older. Patients in this age group are likely to have underlying comorbid conditions. These comorbidities affect treatment planning decisions and clinical outcomes. Here we report comorbidity-stratified outcomes of patients older than 64 treated at MD Anderson Cancer Center from 1996 until 2011, inclusive, treated with allogeneic stem cell transplant (ASCT). Methods: 182 patients older than 64 received an ASCT for AML (n=143) or MDS (n=39). Patient charts were reviewed and comorbidity data abstracted using a standardized form. Burden of comorbidity was assessed using the Hematopoetic Stem Cell Transplant-Specific Comorbidity Index (HSCT-CI). Low-risk, intermediate-risk, and high-risk patients were categorised at 0, 1–2, and >=3 points as per the HSCT-CI. 157 patients were evaluable for pre-transplant comorbidity. Outcomes of interest were cumulative incidence of transplant-related mortality (TRM), cumulative incidence of relapse-related mortality (RRM), incidence of acute and chronic graft-versus-host disease (GVHD), and overall survival (OS). These were estimated from the date of transplantation. Results: The median age of transplanted patients was 67 (range 65–79), and 37 patients age 70 and older were treated. The majority of patients were intermediate-risk and high-risk patients (table), 9 patients had HSCT-CI scores of >=5. Median follow-up for alive patients was 12.6 months (n=63; range 0–118). Cumulative incidence of TRM was 6% at 100 days, 14% at 1 year, 23% at 2 years, and 36% at 5 years (figure). Cumulative incidence of RRM was 36% at 1 year, 42% at 2 years, and 47% at 5 years. HSCT-CI did not independently predict for either TRM or RRM (log-rank test p=0.95). The incidence of grade III and IV acute GVHD was 10% of all patients. The cumulative incidence of chronic GVHD was 25% at 1 year, 27% at 2 years, and 30% at 5 years, with no association between GVHD and HSCT-CI comorbidity. Conclusion: ASCT is a curative option for selected patients over age 64. HSCT-CI did not predict TRM or survival on this cohort of high-risk patients. Disease relapse was of greater concern than TRM, and so novel approaches to relapse prevention are needed. Disclosures: No relevant conflicts of interest to declare.

Screening Efectiveness with SERUM Galactomannan in High and Low Risk Patients for Fungal Infection in the Post ALLO-HTC

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 5452-5452
Author(s):  
Fabio Augusto Ruiz Gómez ◽  
Valentin García Gutierrez ◽  
Elia Gomez ◽  
Pilar Herrera Puente ◽  
Isabel Page Herráez ◽  
...  
Keyword(s):  
High Risk ◽  
Fungal Infection ◽  
Hodgkin Lymphoma ◽  
Risk Group ◽  
False Positives ◽  
Low Risk ◽  
Cell Transplant ◽  
Aspergillus Infection ◽  
High Risk Patients ◽  
Risk Patients

Abstract Background and aims: Serum galactomannan (GM) is used as a screening test for the early diagnosis of Aspergillus infection in high risk patients for fungal invasive infection. Serial GM levels analysis have proven to be useful in the high risk clinical setting patients, specially when neutropenic and not receiving anti-mold agents prophylaxis. There is a lack of information regarding the benefit of GM in patients undergoing allogeneic hematopoietic cell transplant (HCT). The aim of this work is to measure the real clinical benefit of the serial periodic determination of GM in the post allo-HCT period. Material and methods: 139 consecutive patients who receivedan allo-HCT (59% related family member donorsand 41% unrelated donors) in our centre for five years (since January 2010 to February 2015) were included in the study. Median age was 46 years. Baseline characteristics of these patients are shown in figure 1. Patients were monitored with GM weekly and received primary prophylaxis with fluconazole since the admission until the immunosuppression was tapered. In order to find a population that could benefit the most for AGA monitoring, we classified our population in low risk patients for invasive fungal infection (IFI) versus high risk patients (those with previous proven or probable IFI or those suffering from GVHD; high risk patients received anti-mold prophyllaxis, mainly with voriconazole or posaconazole). Patients considered as low risk who suffered from Graft versus Host Disease (GVHD) in the ulterior outcome, were censored for low risk and considered as high risk since the development of GVHD, and therefore anti-mold agent prophylaxis was started. GM positivity was determined according standard criteria. When GM positivity was detected, radiological and clinical studies (chest/sinus CT scans, cultures, etc.) to discard Aspegillosis were done as soon as possible. Every patient was followed up prospectively until the last medical consultation or decease. Results: Global overall survival (OS) for the entire cohort was 55.39% and cumulative incidence for severe GVHD grade III/IV was 49.5%. During the follow up, GM became positive in 31/139 (22%) cases. With this approach, the global false positive and false negative rate was 31% and 6% respectively.110/139 (79.14%) patients were identificated as low risk cases. We observed GM positivization in 1.81% (2/110) and 37.18% (29/78) for low and high group respectively. All 2 positive GM in the low risk group were false positives. Regarding the high risk group, 34.48% (10/29) were false positives while in the rest 19 patients (65.52%), subsequent radiological and clinical findings allowed us to diagnose Aspergillus infection (besides they received anti-mold agent prophylaxis). Conclusions: In our experience there is not enough evidence for supporting making serial monitoring with GM in low risk patients for IFI in the post allo-HCT period. However it may be an useful tool in high risk patients. Table 1. N (%) Age (years) Mean 46.18 Median 48.01 Sex (man vs woman) 91 vs 48 (65 vs 35%) Hematology disease Acute Mieloid Leukemia Acute Limphoblastic Leukemia Multiple Myeloma Chronic Mieloid Leukemia Non Hodgkin Lymphoma Hodgkin Lymphoma Others diseases 79 (56.8%) 18 (12.9%) 9 (6.5%) 3 (2.2%) 13 (9.4%) 9 (6.5%) 8 (5.6%) Pre allo-HSCT IFI 17 (12.2%) Aconditioning Myeloablative Reduced Intensity 95 (68.3%) 44 (31.7%) Source of progenitors Peripherical blood Bone marrow 132 (95.0%) 7 (5.0%) Type of donor Related Non-related 82 (59.0%) 57 (41.0%) Graft time (days) Neutrophils (>500 in two consecutive determinations) Platelets (>30.000 in two consecutive determinations) 15.52 17.75 Post-transplant CMV viremia (number of patients with >600 copies in the post-HSCT period) 48 (34.5%) Disclosures No relevant conflicts of interest to declare.

Abstract 13513: MitraClip ® for Functional Mitral Regurgitation: Outcomes in Over 600 Patients

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Gorav Ailawadi ◽  
D. Scott Lim ◽  
Irving L Kron ◽  
Alfredo Trento ◽  
Saibal Kar ◽  
...  
Keyword(s):  
Coronary Artery ◽  
High Risk ◽  
Mitral Regurgitation ◽  
Nyha Class ◽  
Class I ◽  
Symptom Improvement ◽  
Surgical Risk ◽  
High Risk Patients ◽  
High Surgical Risk ◽  
Risk Patients

Background: The treatment options for degenerative or primary mitral regurgitation (DMR) include mitral surgery and transcatheter edge-to-edge repair (MitraClip). However, the optimal therapy for patients with functional or secondary MR (FMR) remains unclear. The purpose of this study was to evaluate the 1 year outcomes of all patients with FMR undergoing MitraClip in the United States as part of the EVEREST (Endovascular Valve Edge-to-Edge Repair STudy) II study. Methods: Patients treated in the EVEREST II trial (randomized trial and continued access registries) with severe FMR were evaluated. Outcomes at 30 days and 1 year were analyzed and adjudicated by an independent core laboratory. Patients were further stratified by surgical risk (High risk= STS mortality score ≥12% or pre-specified risk factors). Results: A total of 619 patients (mean age=73.4 years) with FMR were treated with MitraClip. Comorbidities were common including coronary artery disease (81.1%), NYHA functional class III/IV (80.3%), and previous coronary artery bypass grafting (55.7%). Device implantation was achieved in 96.4% with a mean hospital stay of 3.3 days and an 87.2% discharge to home. At 30 days, mortality was 3.6% with a major adverse event rate of 9.2%. At 1 year, the survival was 78.3%, while the majority of survivors had MR≤2+ (84.5%) and significantly improved symptoms (83.2% NYHA Class I/II). The left ventricular end diastolic volume (LVEDV) improved from 162.5ml to 152.6ml (P<.001). When comparing high surgical risk patients (n=485; mean STS score=10.6±6.9%) to non-high risk patients (n=134), the 30 day mortality was similar (4.1% vs. 1.5%, P=.19), but the 1 year mortality was worse (22.7% vs. 13.4%, P=.02). Nevertheless, at 1 year, there were similar rates of MR reduction (MR≤2+: 83.9% vs. 87.3%) and improvement in LVEDV (-9.0ml vs -12.6ml). The non-high risk cases had greater symptom improvement (NYHA Class I/II: 91.2% vs. 80.2%, P=.001). Conclusions: MitraClip in patients with severe FMR is associated with excellent safety, positive ventricular remodeling, symptom improvement, and stable MR reduction at 1 year independent of surgical risk. Compared to high surgical risk patients, non-high risk patients may derive the greatest survival and symptom benefit.

Reduced Intensity Conditioning (RIC) with Fludarabine, Busulfan and Cyclophosphamide for High Risk Patients with Thalassemia Major Undergoing Allogeneic Bone Marrow Transplantation Results in High Rejection Rates.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 1998-1998 ◽  
Author(s):  
Mammen Chandy ◽  
Vikram Mathews ◽  
Biju George ◽  
Auro Vishwabandya ◽  
Salamun Desire ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Bone Marrow Transplantation ◽  
High Risk ◽  
Graft Rejection ◽  
Thalassemia Major ◽  
Class I ◽  
Class Iii ◽  
High Risk Patients ◽  
Allogeneic Bmt ◽  
Risk Patients

Abstract Usual cytoreductive therapy for bone marrow transplantation (BMT) for thalassemia major consists of busulfan (Bu) 14–16mg/kg and cyclophosphamide(Cy) 160–200mg/kg +/− anti-thymocyte globulin (ATG). In high risk patients, this is associated with significant regimen related toxicity and graft rejection. Fludarabine (Flu) containing conditioning has been used effectively by adding immunosuppression in RIC with reduced doses of myelosuppressive drugs to lower regimen related toxicities and graft rejection. There is also data to suggest that a 24-hour gap between Bu and Cy doses could reduce toxicities associated with this combination. We therefore treated 25 patients (median age: 7 years, range: 3–14), 12 males and 13 females, with beta thalassemia major with a regime of Flu 150mg/m2 (day-15 to -11), Bu 14mg/kg (day-10 to -7) and Cy 160mg/kg (day-5 to day-2). Most of these patients were heavily transfused (median red cell units:100, range: 21–250) and poorly chelated (median serum ferritin: 2510 ng/ml, range: 1039–6740). Their risk stratification (Lucarelli class) was as follows: Class I: 4 (16%), Class II: 8 (32%) Class III: 13 (52%). Allogeneic BMT was performed using a 6/6 matched related donor and bone marrow as the graft. Graft versus host disease (GVHD) prophylaxis consisted of cyclosporine A and mini-methotrexate. The median cell dose was 4.56 × 108 TNC/kg (range: 2.5–14.1). Three (20%) of 20 assessable patients developed grade I-II acute GVHD, 2 (10%) each had hemorrhagic cystitis and veno-occlusive disease. Mortality within the first 100 days were due to graft failure/rejection in 4 patients (16%) and one each of diffuse alveolar hemorrhage, intracranial hemorrhage and sepsis (4% each). With a mean follow-up of 8 months (range 0–11), 18 (72%) of 25 patients are alive. Among the 13 patients in class III, 5 (38.5%) rejected the graft (3 had primary failure and 2 after initial engraftment). In a historical cohort of 47 patients conditioned with Bu16, Cy200 and ATG, the rejection rate was only 8%. The regimen was very well tolerated by all patients and patients in class I had no rejection. Pharmacokinetic data was available on Bu and Cy from 14 of the 25 patients treated with this protocol. The mean values for Bu kinetics were: Cmax-1 (ng/ml): 1069.2±265.8, Cmin-1(ng/ml): 186.8±73.2, Cl-F-1 (l/h/kg): 0.281±0.081, AUC-1 (ng*h/ml): 3648±918 and Css-1 (ng/ml): 608±153. They are not significantly different from patients conditioned Bu16mg/kg without Flu (data not shown). The Cy kinetic data are as follows: Cmax-1(ng/ml): 441.4±188, AUC-1(ng*h/ml): 1431±791, Cl-F-1(l/h/kg): 0.0378±0.027. The Cmax-1 and AUC-1 were significantly lower compared to patients receiving 200mg/kg and dosed without a 24-hour gap between the Bu and Cy. Overall, these data suggest that Flu does not provide adequate immunosuppression for sustained engraftment after allogeneic BMT even when combined with Bu 14 and Cy160 (with a 24-hour gap between Bu and Cy) in high risk patients with thalassemia major (Lucarelli class III) but could be useful in the others (Class I and II). OUTCOME OF ALLOGENEIC BMT CLASS NUMBER (%) OVER ALL SURVIVAL (months) EVENT FREE SURVIVAL (months) REJECTION (%) MORTALITY (%) ALL PATIENTS 25 69±9.8 62.6±10.0 6 (24) 7 (28) CLASS I 4 (16%) 75±21.7 75±21.7 0 1 (25) CLASS II 8 (32%) 83.3±15.2 83.3±15.2 1 (12.5) 1 (12.5) CLASS III 13 (52%) 57.7±14.7 44.9±14.1 5(38.5) 5 (38.5)

Voided Urine Flow Cytometry in Screening High-Risk Patients for the Presence of Bladder Cancer

1990 ◽  
Vol 32 (9) ◽  
pp. 894-897 ◽  
Author(s):  
Dane K. Hermansen ◽  
Robert A. Badalament ◽  
Paul R. Bretton ◽  
Marek Kimmel ◽  
Catherina M. Aswad ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
Bladder Cancer ◽  
High Risk ◽  
Urine Flow ◽  
High Risk Patients ◽  
Risk Patients ◽  
Urine Flow Cytometry

The Relationship of Acute Gvhd and Pre- and Post-Transplant Flow-MRD to the Incidence and Timing of Relapse in Children Undergoing Allogeneic Transplantation for High Risk ALL: Defining a Target Population and Window for Immunological Intervention to Prevent Relapse

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 470-470 ◽  
Author(s):  
Michael A. Pulsipher ◽  
Bryan Langholz ◽  
Donna A. Wall ◽  
Kirk R. Schultz ◽  
Nancy Bunin ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
High Risk ◽  
Detection Threshold ◽  
Phase Iii ◽  
Unrelated Donor ◽  
Reference Laboratory ◽  
Relapse Risk ◽  
High Risk Patients ◽  
Risk Patients ◽  
Grade Ii

Abstract Abstract 470 We previously reported lower rates of grade II-IV aGVHD, but no improvement in survival with the addition of sirolimus to tacrolimus/methotrexate GVHD prophylaxis in a randomized phase III Children's Oncology Group/Pediatric Blood and Marrow Transplant Consortium trial, ASCT 0431. We performed further analysis of this cohort to test whether the presence or absence of aGVHD combined with detection of pre- and/or post-HCT minimal residual disease (MRD) would allow definition of high-risk populations amenable to early intervention to prevent relapse. MRD was measured on patient bone marrow samples with multi-channel flow cytometry at a single reference laboratory (detection threshold 0.01%). The trial included children ages 1–21yrs with high-risk CR1 and CR2 ALL receiving related and unrelated donor TBI-based allogeneic HCT. The analysis included 144 eligible patients with an estimated median follow up of 757d (interquartile range 558–1022d). Both the absence of grade II-IV aGVHD at day 100 and positive MRD pre-and/or post-HCT were correlated with relapse. To illustrate the effect of aGVHD on relapse, Table 1 shows the cumulative incidence of TRM, relapse, and EFS at 100 days, 1 yr, and 2 yrs after HCT in patients with or without aGVHD. Table 1. Effect of grade II-IV aGVHD by day 100 on TRM, Relapse, and EFS Time post-HCT # of Pts at Risk TRM Relapse EFS yes aGVHD no aGVHD yes aGVHD no aGVHD yes aGVHD no aGVHD yes aGVHD no aGVHD Day 100 69 44 3.0% 6.6% 0.8% 3.7% 35% 51% 1 year 32 55 4.6% 7.4% 5.0% 24% 31% 28% 2 years 17 19 7.0% 7.4% 6.4% 30% 27% 22% Thirty eight percent of patients developed grade II-IV aGVHD (most (89%) by day +50). Analysis of patients who did or did not experience aGVHD by day 100 showed that patients who developed aGVHD rarely experienced TRM or relapse from that time forward (7.0 and 6.4% with TRM and relapse at 2 yrs post-HCT, respectively). Conversely, patients who did not develop aGVHD had a small risk of early relapse (3.7% at d100) but a steadily increasing rate of relapse starting day 200 post-HCT. Patients who did not develop grade II-IV aGVHD relapsed nearly 5 times more than those with aGVHD (30% vs. 6.4 at 2 yrs), with the result that EFS at 2 years was 19% (17/89) in those with no aGVHD vs. 35% (19/55) in those with aGVHD (p=0.001). It is important to note that the occurrence of aGVHD did not impact the rate of TRM. To assess the effect of the MRD status on relapse, we measured MRD by flow cytometry of BM pre-HCT, within 2 wks of engraftment, and at 3, 6, 9, or 12m after HCT and correlated the presence of MRD in these samples with relapse rates. More than 400 samples were analyzed. For patients positive for pre-HCT MRD, the rate ratio (RR) for relapse was 3.7 (1.6–8.2) with an estimated two-year relapse risk of 27.4% (17.4–43.1) and 70.8% (50.4–99.4) in pre-HCT MRD negative and positive patients, respectively. For patients positive for post-HCT MRD, we constructed a Cox regression model to assess the effect of positive post-HCT MRD in the context of other transplant-related variables. In the post-HCT period, an MRD positive result was associated with a 14-fold increase in relapse rate over an MRD negative result (RR=14.3, 95% CI:6.1–33.6). These findings did not change after controlling for risk group, immunophenotype, donor type and pre-HCT MRD status. Finally, we did an analysis of the combined effect of aGVHD and MRD status. Patients who developed grade II-IV aGVHD had low rates of post-HCT MRD and relapse, and a combined predictive effect of MRD status in patients with aGVHD could not be assessed. However, among patients who did not develop aGVHD, pre- and post-HCT MRD statuses were found to be independent risk factors for relapse (Table 2). Table 2. Effect of Pre- and Post-HCT MRD on Relapse risk of Patients without aGHVD Pre-HCT MRD Post HCT MRD RR for Relaspe (CI) - - 1 (reference) + - 2.5 (1.0-5.8) - + 12.7 (4.2-38.2) + + 31.2 (7.5-129.3) In summary, measurement of flow MRD on BM samples pre- and early post-HCT is feasible and positive results along with absence of grade II-IV aGVHD is highly predictive of relapse. There is a brief “window of opportunity” after day 50 and before day 200 post-HCT when most patients who will get aGVHD have experienced it, and the large majority of high-risk patients identified by MRD and aGHVD status have yet to relapse. It is imperative that novel post-HCT interventions be developed and given during this window in order to decrease relapse in the very high-risk patients we have defined. Disclosures: No relevant conflicts of interest to declare.

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