Allogeneic hematopoietic stem cell transplantation remains a feasible approach for elderly with acute myeloid leukemia: a 10-year experience.

The incidence of AML increases with age. The implementation of reduced intensity conditioning and progress in supportive care enabled to perform allo-HSCT in elderly patients. The main objective of the study was to assess the safety and efficacy of allotransplantation in elderly AML.Forty nine patients (33 males) at median age of 68 years were identified. Data on patients' and transplant's related variables were retrieved from our local transplant registry. Most patients (65%) were transplanted from 10/10-HLA or 9/10-HLA matched unrelated donor, seven patients (14%) received stem cells from matched related donor and ten patients (20%) from haploidentical donor. All patients received reduced-intensity conditioning (RIC). Peripheral blood was a source of stem cells in all patients except one (98%). Acute GVHD developed in 22 patients (44%) with 5 individuals presenting grade III-IV. CMV reactivation was demonstrated in 19 patients (39%) till day + 100. In total, 22 patients (45%) have died. The main causes of death included infectious complications (n = 9), relapse with subsequent chemotherapy resistance (n = 7), steroid-resistant GvHD (n = 4) and other causes (n = 2). Twenty-seven patients (55%) were alive at the last contact, presented full donor chimerism and remained in the complete remission. The probability of OS and relapse-free survival (RFS) were 57% and 81% at 2 years, respectively. Older donor age showed negative impact on relapse. CMV reactivation, the severity of acute graft versus host disease and older donor age negatively influenced survival. Allo-HSCT remains a safe, feasible and effective procedure for elderly AML patients.

Allogeneic Hematopoietic Stem Cell Transplantation for Relapsed/Refractory Acute Myeloid Leukemia: A Single-Centre Experience.

INTRODUCTION: Patients with relapsed/refractory acute myeloid leukemia (r/r AML) are characterized as having a poor prognosis. The only viable option of treatment for these patients is allogenic stem cell transplantation (allo-HSCT). Therefore, we have attempted to analyse factors related to both the disease itself and the transplantation procedure that could have an influence on the improvement of outcomes in this group of patients. PATIENTS AND METHODS: Sixty-four patients with r/r AML underwent allo-HSCT at our center in 2012 to 2021. Fifty-two had active disease at the beginning of theallo-HSCT procedure, with amedian number of blasts in bone marrow (BM) of 18, and 12 had therapeutic aplasia after the last reinduction (blasts < 5% in BM). RESULTS: The probability of overall survival (OS) at 2 years was 25%. The median follow-up for survivors was 21.5 months. Progression-free survival (PFS) estimates were above 46%. The main cause of death was disease progression (49%). A statistically significant effect on premature death was reported for the diagnosis of secondary AML (sAML) and cytomelovirus (CMV) reactivation post allo-HSCT. On the other hand, chronic graft versus host disease (cGVHD) decreased the risk of disease progression. sAML and CMV reactivation were found to have opposite effects.

Room for Improvement: A 20-Year Single Center Experience with Allogeneic Stem Cell Transplantation for Myelodysplastic Syndromes.

Allogeneic stem cell transplantation (allo-SCT) remains the only curative therapeutic approach for patients with myelodysplastic syndromes (MDS). The aim of the study was to assess the efficacy/safety of allo-SCT as well as to identify factors influencing post-transplant survival. One hundred and two MDS patients (median age: 48 years; 57 males) who underwent allo-SCT were retrospectively evaluated. Twenty seven patients were transplanted from HLA-matched sibling and 75 patients received grafts from unrelated donors. Peripheral blood was a source of stem cell for 79 patients. Reduced intensity conditioning was used in 64 subjects. Acute and chronic graft versus host disease (GvHD) developed in 61 and 19 of patients, respectively. In total, 61 patients have died. The causes of deaths included infectious complications (n = 30), steroid-resistant GvHD (n = 17), MDS relapse (n = 9) and transformation to AML (n = 5). Non-relapse mortality and cumulative incidence of relapse at 2 years were 49.8% and 9%, respectively. 41 patients are alive at last contact and present full donor chimerism. 38 patients remain in complete hematological remission (CHR), 3 patients had CHR with incomplete platelet recovery. Median follow-up from diagnosis of MDS and transplantation are 27.1 months and 7 months respectively. Overall survival and relapse-free survival were 41% at 2 years. Increased serum ferritin level > 1000 ng/ml, presence of acute GvHD, grades III-IV acute GvHD and high hematopoietic cell transplantation-comorbidity index were found to negatively influenced survival. Allo-SCT for MDS is feasible procedure with a proportion of patients to be cured.

Real-world experience with ruxolitinib for steroid-refractory acute graft-versus-host disease: a single center experience.

Steroid-refractory acute graft-versus-host disease (SR-aGVHD) remains a major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Ruxolitinib (RUX), an oral JAK1 and JAK2 inhibitor, has recently been approved for patients with SR-aGVHD. The aim of this study was to evaluate RUX efficacy and toxicity in a real-world setting. Eighteen patients received RUX at 5 mg or 10 mg twice a day after a median 3 lines of prior unsuccessful immunosuppressive therapy. Median time on RUX therapy was 28 days (range 7-129). Five patients (28%) responded to RUX, including 4 complete responses and 1 partial response. Response to RUX was irrespective of aGVHD grade and the number of involved organs. One-year overall survival (OS) was 60% for RUX-responders versus 31% for non-responders (p = ns). Treatment duration greater than 29.5 days was found to have a positive impact on OS (p < 0.007). Major adverse events during RUX treatment were grade 3-4 thrombocytopenia (61% of patients) and cytomegalovirus reactivation (50%). After median follow-up of 55 days (range 29-706), 14 patients (78%) died, mainly due to further progression of GVHD. RUX may represent a valuable therapeutic option for some patients with advanced SR-aGVHD, but more studies are warranted.

Pre-transplant FLT3/ITD status predicts outcome in FLT3-mutated acute myeloid leukemia following allogeneic stem cell transplantation.

Acute myeloid leukemia (AML) with fetal liver tyrosine kinase 3 (FLT3) internal tandem duplication (ITD) is associated with poor prognosis, and allogeneic stem cell transplantation (Allo-SCT) seems to be the preferred therapeutic approach. However, the predictors of post-transplant outcomes were not well-defined. The aim of the study was to evaluate the significance of FLT3/ITD mutation by polymerase chain reaction as minimal residual disease (MRD) marker of outcomes after transplantation. We identified 43 patients (28 females and 15 males) with FLT3-mutated AML at the median age of 45 years who were allografted between 2009 and 2019. Hematological status at transplant was as follows: the first complete remission (CR1) in 29 patients, CR2 in 5, and 9 patients were transplanted in marrow aplasia (MA). Twenty-seven patients were FLT3 MRD negative at transplant. Median time from diagnosis to transplant was 16.7 months. Post-allograft CR rate was 88%. The relapse incidence (RI) was lower for patients who were FLT3 MRD negative at transplant when compared with those with FLT3 MRD positivity (41% vs 59%; p = 0.01). The patients who eradicated FLT3/ITD at day + 30 after transplant had lower RI than those with detectable FLT3/ITD (23% vs 76%; p = <0.001). The 2-year LFS and OS were 53% and 54%, with the median OS and LFS of 28 months and 27 months, respectively. Patients with CR1/2 and FLT3 MRD(-) had a 2-year OS of 80%. The FLT3 MRD negativity at transplant prolonged LFS in multivariate analysis (HR 5.3 95%CI 1.97-14.2); p < 0.001), whereas FLT3 MRD negativity and unrelated donor predicted favorable OS.

Allogeneic transplantation for high-risk chronic lymphocytic leukemia-a summary of a 16-year experience.

In the pathway inhibitor era, the number of allogeneic stem cell transplantation (ASCT) for chronic lymphocytic leukemia (CLL) continues to decrease and this approach should be offered only after careful risk-benefit assessment. Nevertheless, ASCT still remains only curative therapeutic modality for CLL, especially in countries with limited access to novel agents. Thirty patients with CLL at median age of 42 years at diagnosis (range 29-64) underwent ASCT between years 2002 and 2018. Thirteen patients were transplanted in complete remission (CR), ten patients achieved partial response (PR), and seven had stable disease. The median time from diagnosis to transplant was 4 years (range 0.5-12). Twenty-three patients received HLA-matched related donor stem cell grafts, and seven patients received either matched unrelated donor or HLA-mismatched grafts. Reduced intensity conditioning (RIC) and myeloablative regimen (MAC) were used in 24 and 6 patients, respectively. Mortality to day + 100 after transplant was 16% (8% for RIC only). Acute and chronic graft versus host disease (GVHD) developed in 40% and 63% of patients, respectively. Fifteen patients relapsed or progressed after transplant. Thirteen patients (43%) are alive at last follow-up and 10 (77%) remain in clinical CR. Median follow-up for survivors was 6.8 years (range 0.4-15.2). Three-year progression-free and overall survivals were 56% and 60%, respectively. These outcomes were better for patients who received RIC conditioning: 64% and 72%, respectively. CR at transplant was found to have favorable impact on post-allograft survival. RIC should be preferred over MAC. ASCT may remain a valuable option for some CLL patients.

Splenic irradiation before allogeneic stem cell transplantation for myelofibrosis.

Splenectomy before allogeneic stem cell transplantation (ASCT) for patients with myelofibrosis (MF) remains a matter of debate, and conflicting results have been reported to date. The procedure seems to fasten post-transplant hematological recovery, but it does not have an impact on survival. The role of pre-transplant splenic irradiation (SI) is much more difficult to evaluate. Forty-four patients (25 males and 19 females) with MF at median age of 49 years at diagnosis (range 14-67) underwent ASCT. The post-transplant outcome was compared between irradiated and non-irradiated patients. Eleven patients received irradiation before transplantation. Median dose of radiation was 1000 cGy (range 600-2400). There was no difference in median time to engraftment between patients with and without previous radiotherapy. Acute and chronic graft versus host disease (GVHD) occurred in 47% and 36% of patients, respectively. There was no difference in GVHD incidence between groups. Eight patients relapsed/progressed in irradiated group versus 17 in non-irradiated (70% vs. 51%; p = 0.3). Transformation to acute myeloid leukemia was observed in 3 patients: 2 in irradiated and 1 in non-irradiated group. In total, 22 patients died with no statistical difference in death rate between irradiated and non-irradiated subjects. The probability of overall survival after transplant for the entire cohort at 2 years was 54% (72% for irradiated and 48% for non-irradiated patients; p = 0.25). Splenic irradiation prior to ASCT for myelofibrosis has not beneficial effect on post-transplant outcome.

Real Life Data on Efficacy and Safety of Azacitidine Therapy for Myelodysplastic Syndrome, Chronic Myelomonocytic Leukemia and Acute Myeloid Leukemia.

The administration of azacitidine (AZA) was found to be more effective than conventional care regimen (CCR) in patients with higher-risk myelodysplastic syndromes (MDS), chronic myelomonocytic leukemia (CMML) and acute myeloid leukemia (AML) with lower blast count. We designed a study to determine efficacy and safety of AZA therapy in "real life" patients with MDS, CMML and AML. The study included 83 patients (65% male) with a median age at diagnosis of 68 years. 43 patients were diagnosed with higher-risk MDS, 30 had AML and 10-CMML. Median AZA dose was comparable between treated groups. AZA dose reduction was required for 44% of MDS, 17% of AML and 25% of CMML patients. Complete remission (CR) was achieved in 14% of MDS, 7% of AML and 10% of CMML patients. Overall response rate was following: 27% for MDS, 20% for AML and 20% for CMML. Estimated OS at 12 months was 75% for MDS, 60% for AML and 75% for CMML. Median follow-up for MDS/AML/CMML from AZA initiation to last follow-up was 9.0, 9.4 and 9.4 months, respectively. The most common toxicity of AZA therapy was myelosuppression and infections. AZA treatment was effective in a limited number of patients with acceptable safety profile.

Long-Term Outcome of Autologous Hematopoietic Stem Cell Transplantation (AHSCT) for Acute Myeloid Leukemia (AML)- Single Center Retrospective Analysis.

For patients with acute myeloid leukemia (AML) in complete remission without an acceptable HLA donor, the autologous hematopoietic stem cell transplantation (AHSCT) may remain a therapeutic option as remission consolidation, however its role is still a subject of continued debate. One hundred and twenty patients who underwent AHSCT for AML were included in this retrospective single center analysis. The procedure was performed over a 19 years period and transplanted patients were in first complete remission (CR1; n = 109) or in second CR (CR2; n = 11). The median age at transplant was 37 years (range 18-64). The source of stem cells was bone marrow (n = 61; 50.8%), peripheral blood (n = 36; 30%) and bone marrow with peripheral blood (n = 23; 19.2%). The median time from AML diagnosis to AHSCT was 0.8 year (range 0.3-4.4) and the median follow-up after AHSCT for surviving patients was 12.8 years (range 3.1-20.5). The median LFS was 1.1 year. The probability of LFS calculated at 5 years and 10 years after transplantation was 28% (95%CI, 22%-32%) and 21% (95%CI, 18%-24%), respectively. The last relapse occurred 14.8 years after AHSCT and among patients who survived >2 years, 28.4% (27/95) had leukemia recurrence. The median OS was 1.7 years. The probability of OS after 5 years and 10 years was 29% and 22%, respectively. There was a tendency for increased LFS for patients younger than 50 years at transplant if compared to older population. AHSCT for AML was safe with acceptable toxicity profile. Leukemia recurrence remained the leading cause of death.

The sudden onset of mastocytosis in the course of venom-induced anaphylactic reaction in a patient with myelodysplastic syndrome.

Mastocytosis is a disease resulting from a proliferation of clonal, abnormal mast cells in tissues and organs, defined as Philadelphia-negative myeloproliferative neoplasm. We present a male patient with clinically, morphologically and immunohistochemically confirmed mastocytosis with preceding myelodysplastic syndrome, occurred after wasp bite in the course of anaphylactic reaction. The propensity to hymenoptera venom-induced anaphylaxis and the presence of an increased population of atypical mast cells in bone marrow found after anaphylactic shock may suggest the possible relationship between hymenoptera venom allergy and anaphylaxis and the development of mastocytosis of unusual course in a predisposed person.

Clinical relevance of mutant NPM1 and CEBPA in patients with acute myeloid leukaemia - preliminary report.

AIM OF THE STUDY: Mutant NPM1 and CEBPA have been reported in patients with acute myeloid leukaemia (AML) and intermediate cytogenetic risk, and they appear to be associated with characteristic demographic and laboratory data, as well as clinical outcome. The objective of the study was to assess the clinical relevance of NPM1 and CEBPA mutations in AML. MATERIAL AND METHODS: This retrospective analysis was based on 60 newly diagnosed patients with AML and normal/no metaphases karyotype and known mutation status, who were treated in our centre between 2008 and 2011 according to the PALG (Polish Adult Leukaemia Group) study protocol. Pretreatment bone marrow samples were studied by G-banding analysis, and NPM1, CEBPA, and FLT3-ITD mutations were detected by polymerase chain reaction (PCR). RESULTS: NPM1 mutations were detected in 21 AML patients (35%). In the NPM1-positive subgroup, the FLT3-ITD mutation was observed in 3 cases (14%), which was significantly less frequent than in the NPM1-negative patients, where FLT3-ITD was detected in 16 cases (41%; p = 0.04). Among the CEBPA-positive population (n = 11; 18%), none of the studied patients had FLT3-ITD mutation, whereas it was detected in 19 CEBPA-negative patients (0% vs. 38%; p = 0.01). The highest complete remission rate was reported for the NPM1-positive/FLT3-ITD-negative group (n = 18; 88%) and the CEBPA-positive/FLT3-ITD-negative group (n = 8; 73%). For OS, multivariable analysis revealed NPM1-positive/FLT3-ITD-negative (HR: 0.18, 95% CI: 0.19-0.63) and CEBPA-positive/FLT3-ITD-negative (HR: 0.35, 95% CI: 0.19-0.63) as favourable prognostic factors. The presence of the NPM1-negative/FLT3-ITD-positivecombination predicted adverse overall survival (HR: 2.03, 95% CI: 1.13-3.66). CONCLUSIONS: NPM1 and CEBPA mutations are associated with clinical outcome in AML patients.

The JAK2V617F tyrosine kinase mutation has no impact on overall survival and the risk of leukemic transformation in myelofibrosis.

The prevalence of JAK2V617F tyrosine kinase mutation differs between various variants of myelofibrosis with the higher detection rate for patients with post-polycythemia vera myelofibrosis (post-PV MF; 91%) if compared to primary myelofibrosis (PMF; 45%) and post-essential thrombocythemia myelofibrosis (post-ET MF; 39%). The impact of V617F point mutation and its allele burden on overall survival (OS) and the risk of leukemic transformation (LT) has been the subject of several studies, but the results were ambiguous. Our study included 77 patients with the following variants: 42 patients with PMF (55%), 16 with post-ET MF (21%) and 19 with post-PV MF (24%). Median age at diagnosis for the entire cohort was 61 years (range 19-81), with 53% of female. A total of 42 patients were JAK2V617F positive, giving an overall frequency of 55%; the median allele burden was 22% (range 2-96%). The JAK2V617F point mutation was detected in 21 patients with PMF (50%), 14 with post-PV MF (88%) and 7 with post-ET MF (37%). Lower JAK2V617F allele burden was more frequently detected in PMF patients, whereas higher allele burden was predominantly seen in post-PV/ET MF group. There was no significant difference between V617F-positive and V617F-negative patients in terms of studied parameters in PMF as well as in post-PV/ET MF subgroup. No significant difference was also demonstrated when the above-mentioned subpopulations were analyzed according to JAK2V617F allele burden, except higher leukocyte count in post-PV/ET MF patients with higher allele burden (14.3×10(9)/L vs. 6.2×10(9)/L; p=.03). Median follow-ups for V617F-positive and V617F-negative patients were 16.6 months (range 3.6-206.4) and 36.4 months (range 2.5-142.1), respectively. The presence of JAK2V617F mutation did not affect OS and the risk of LT development.

Irreversible marrow aplasia after single course of 2-chlorodeoxyadenosine for hairy cell leukaemia preceding by A pandemic 2009-H1N1-associated pneumonia.

Hairy cell leukaemia (HCL) is a rare, indolent lymphoproliferative disorder characterized by varying degrees of cytopenias and the presence of malignant B cells with cytoplasmic projections. Cladribine (2-chlorodeoxyadenosine, 2-CdA) is an adenosine deaminase-resistant purine analogue and has been shown to be very effective as a first-line therapeutic option for HCL. The therapy with 2-CdA is found to be well tolerated with a paucity of toxicity. The common side effects include immunosuppression and reversible myelosuppression. We report a HCL patient with A pandemic 2009-H1N1-associated pneumonia who fully recovered after oseltamivir and antibiotics. The subsequent treatment with single 5-day course of 2-CdA resulted in persistent marrow aplasia with fatal systemic aspergillosis.

The incidence and risk factors for chronic graft-versus-host-disease.

OBJECTIVES: Chronic graft-versus-host-disease (cGVHD) deteriorates survival and quality of life after allogeneic hematopoietic cell transplantation (alloHCT). We evaluated the incidence and risk factors for this complication based on a single-center experience. METHODS: 255 consecutive patients, aged 29 (10-56) years, who survived without disease progression after alloHCT performed between 1992-2003 were included in the analysis. The preparative regimen was myeloablative, donors were either related (n=177) or unrelated volunteers (URD-HCT) (n=78). RESULTS: Cumulative incidence of the overall and extensive cGVHD equaled 48% and 22%, respectively. In a multivariate analysis the following factors were associated with increased risk of cGVHD: preceding grade II-IV acute GVHD, recipient age > or =40 years, URD-HCT, the diagnosis of chronic myeloid leukemia (CML) or myelodysplastic syndrome, and CD3 cell dose 50 x 10(6)/kg. Similar factors, excluding recipient age contributed to increased risk of extensive cGVHD, however, the cut-point for CD3 cell dose was 100 x l0(6)/kg and the use of steroids for acute GVHD prophylaxis was found an additional risk factor. In a CML subgroup the risk of cGVHD was increased for patients previously treated with interferon. CONCLUSIONS: Various recipient-, donor-, and procedure-related factors are related to the risk of cGVHD. Individualized treatment and modification of risk factors may contribute to improved outcome.

First two successful unrelated donor bone marrow transplantations for paroxysmal nocturnal hemoglobinuria in Poland.

OBJECTIVES: The experience with bone marrow transplantation (BMT) from matched unrelated donors (MUD) for paroxysmal nocturnal hemoglobinuria (PNH) is limited and optimal preparative regimen has been not established. METHODS: We report first two MUD BMTs for patients with PNH in Poland. Preparative regimen consisted of Treosulfan, Fludarabine and Thymoglobulin. We also present the review of published reports on allogeneic transplantations for PNH and discuss important transplant-related issues. RESULTS: Both patients are alive and are doing well over 12 and over 4 months following BMT. Regeneration is complete with full 100% donor chimerism and the eradication of PNH clone. CONCLUSIONS: MUD BMT is an effective treatment for PNH. Treosulfan, Fludarabine and Thymoglobulin treatment can be safely and effectively used for conditioning in PNH.