The 44Th Annual Meeting of the European Society for Blood and Marrow Transplantation: Physicians Award Winners

Bone Marrow Transplantation (2019) 53:13–18 https://doi.org/10.1038/s41409-018-0317-z

ABSTRACT

The 44th Annual Meeting of the European Society for Blood and Marrow Transplantation: Physicians Award Winners

18–21 March 2018 ● Lisbon, Portugal

Published online: 24 September 2018 © Springer Nature Limited 2018

Sponsorship Statement: Publication of this supplement is sponsored by the European Society for Blood and Marrow Transplantation.

PHYSICIANS AWARD WINNERS in neurologic disability. We now report results on a randomized trial of non-myeloablative HSCT versus 1234567890();,: 1234567890();,: Van Bekkum Award continued treatment with standard DMTs.

O001 Methods: Patients on stable disease modifying therapy (DMT) with > 2 relapses in the previous 12 months Non-myeloablative haematopoietic stem cell were randomized (1:1) to treatment with either cyclopho- transplantation versus continued disease modifying sphamide and rabbit anti-thymocyte globulin followed therapies (DMT) in patients with highly active relapsing by hematopoietic stem cell infusion or to a control arm remitting multiple sclerosis (RRMS) with continued treatment with standard DMTs. Evaluating neurologists scoring the Expanded Disability Status Richard K Burt1, Roumen Balabanov2, John A Snowden3, Scale (EDSS) were blinded to treatment arms. Patients Basil Sharrack4, Maria Carolina Oliveira5, Flavia Nelson6, in the control arm who had 6 month confirmed EDSS Joachim Burman7 increase of > 1 point despite at least one year of treatment 1Northwestern University, Division of Immunotherapy for (defined as treatment failure) were allowed to crossover Autoimmune Diseases, Chicago, IL, United States; to HSCT. 2Northwestern University, Department of Neurology, Chi- cago, IL, United States; 3Sheffield Teaching Hospitals NHS Results: 110 patients were randomized, 55 to each arm. Foundation Trust, Department of Haematology, Sheffield, Three HSCT patients were withdrawn: two for failing United Kingdom; 4Sheffield Teaching Hospitals NHS enrollment criteria, one for recurrent infections occurring Foundation Trust, Department of Neurology, Sheffield, before transplant. Five control patients were withdrawn United Kingdom; 5University of São Paulo, Department of after soliciting transplants at other centers. All patients Internal Medicine, São Paulo, Brazil; 6University of Texas are at least one-year post enrollment. No deaths occurred Health Science Center at Houston, Department of Neurol- and no CTC grade 4 non-hematopoietic toxicities ogy, Houston, TX, United States; 7Uppsala University, occurred in the transplant arm. DMTs (number of patients) Department of Neuroscience, Uppsala, Sweden used in the control arm were: natalizumab (22), dimethyl fumarate (18), fingolimod (13) interferons (10), glatiramer Background: We previously reported (Journal of the acetate (8), mitoxantrone (5). During the first year American Medical Association, 2015) that non- after enrollment, one relapse occurred on the HSCT myeloablative haematopoietic stem cell transplantation arm versus 39 on the DMT arm (P< 0.001). Mean (HSCT) may be performed safely in patients with multiple EDSS improved from 3.5 to 2.4 after HSCT while it wor- sclerosis and is accompanied by long-term improvement sened from 3.3 to 3.9 on DMTs (P< 0.001). With a 14 mean follow up of 3 years (range 1 to 5 years), treatment (NTA). VEs stained with Vibrant Dil were incubated with failure was 60% (30 of 50) for the control arm and 6% CD34+ cells from cord blood for 24 hours. Then their (3 of 52) for HSCT (P < 0.001). For the 30 patients incorporation into HPC was analyzed by flow cytometry who failed the control arm and crossed over to HSCT, by and confocal microscopy. To study gene expression chan- one year after HSCT, the mean EDSS improved from 5.2 ges elicited in HPC after MSC-EVs incorporation, expres- to 2.6 (P< 0.001). sion arrays were performed using the Human Gene 2.0ST platform (Affymetrix), evaluating the functions of the Conclusions: HSCT was statistically superior to continued involved genes with the Webgestalt software. Apoptosis DMTs in patients with RRMS with > 2 relapses a year was evaluated by flow cytometry using annexinV/7AAD staining, whereas cell cycle was analyzed with BD Cycle- Clinical Trial Registry: NCT00273364, https://clinicaltria testPlus DNA Reagent kit. In addition, clonal growth of ls.gov/ct2/show/NCT00273364?term=NCT00273364&ra HPCs was compared by clonogenic assays in methylcellu- nk=1 lose. Finally, the functional in vivo changes induced by MSC-EV incorporation were studied in a xenotransplanta- Conflict of interest: All the authors have nothing to tion animal model. For this purpose, control HPC or HPC disclose previously co-cultured with MSC-VEs were administered into the BM of NOD-SCID mice. After four weeks, human hematopoietic engraftment was determined by flow Basic Science Award cytometry.

O002 Results: MSC-VEs were positive for both MSC (CD44, CD90) and VEs (CD81, CD63) markers and negative The incorporation of extracellular vesicles from for hematopoietic markers (CD34, CD45), and exhibited mesenchymal stromal cells into hematopoetic progenitors their characteristic morphology by electron microcopy increase their clonogenic capacity and their engraftment and a regular size between 50 and 200nm by NTA. ability The incorporation of EVs into HPC was verified both by confocal microscopy and flow cytometry. In the Silvia Preciado, Sandra Muntión, Ana Rico, Luis Antonio gene expression array analysis we found that MSC- Corchete, Ana Gómez de la Torre, Teresa L Ramos, Con- EV incorporation induced an overexpression of some cepción Rodríguez, Rebeca Ortega, Jorge Diego Rufino, anti-apoptotic genes (BIRC2, BIRC3, NFKB) and a Miriam López-Parra, Alba Redondo, Lika Osugui, Fermín downregulation of pro-apoptotic genes (caspases) with Sánchez-Guijo an overexpression of genes involved in colony formation Hospital Universitario de Salamanca, Salamanca, Spain and hematopoetic cell proliferation (CD22, IL3RA, IL11), together with an activation of genes of the JAK-STAT Background: Treatment of graft failure after bone marrow pathway and an overexpression of CD44. All these (BM) transplantation with mesenchymal stromal cells findings were confirmed by other methods at the gene (MSC) is being evaluated clinically, since preclinical or protein level. A significant decrease in apoptosis evidence shows that MSC co-transplantation increases (p = 0.031), an increase of the percentage of cells in phase S hematopoietic progenitor cell (HPC) engraftment in xeno- (p = 0.065) and an increased CD44 expression (p = 0.03) trasplantation models. Since MSC exert their functions, were confirmed by flow cytometry in HPC that had in part, by the release of extracellular vesicles (EVs), in incorporated MSC-EVs compared to control HPCs. In the current study we wanted firstly to analyze multi- addition, these HPCs displayed a higher CFU-GM clono- parametrically changes induced in HPCs after the incor- genic potential. Finally, in the xenotransplantation poration of EVs released from MSC (MSC-EVs) and model, the engraftment ability of human HPC co-cultured secondly compare their capacity of engraftment in vivo to with MSC-EVs was significantly higher 4 weeks that of control HPC. after transplantation (10.26% (0.31%–71.06%) vs 1.22% (0.15%–55.97%); p = 0.0078). Methods: BM-MSC were isolated from 10 healthy donors following standard methods and characterized following Conclusions: The incorporation of EVs derived from MSC ISCT criteria. MSC-EVs were isolated by ultracentrifuga- induces genomic and functional changes in HPC, increasing tion and characterized by flow cytometry, Western blot, their clonogenic capacity in vitro and their engraftment electron microscopy and nanoparticle tracking analysis ability in vivo. The 44th Annual Meeting of the European Society for Blood and Marrow. . . 15

Funding: GRS1348/A/16, PI12/01775 (ISCIII, Spain). Results: WES yielded a uniform and consistent coverage of Santander-USAL grant to SP all samples, with an average depth-of-sequencing of 120x for purified AML samples and 60X for donor and patient Conflict of interest: There is no conflict of interest. The germline controls. A total of 249 protein-damaging somatic authors declare no competing financial interests. mutations in 220 genes were detected among all leukemic samples, averaging 15 somatic mutations per sample. Of all mutations, 54 were exclusive to relapses, with the muta- Presidential Symposium tional burden increasing significantly from pre- to post- alloHSCT samples (Wilcoxon test, pvalue = 0.02). This O003 was reflected also by patterns of clonal evolution observed in our cohort, with emergence in 8 patients of new clones at Abstract previously published relapse. Of notice, both number of post-transplantation relapse-specific mutations and appearance of new clones O004 had a tendency to increase proportionally with time to relapse. Relapse-specific mutations encompassed known Genomic and Transcriptional Profiling of Acute Myeloid AML driver genes, including WT1 and KRAS, but no gene Leukemia by Next-Generation Sequencing Unravels evidently related to immune function. Patient-Specific Patterns of Post-Transplantation Relapse By a linear model analysis of RNA-Seq data we found ~500 genes significantly deregulated in leukemic cells at Lucia Zanotti1, Gabriele Bucci1,2, Francesco Santaniello1,2, post-transplantation relapse and, in stark contrast to the Cristina Toffalori1, Donatella Biancolini2, Laura Zito1, genomic data, found that most of these genes belonged Matteo Giovanni Carrabba3, Friedrich Stölzel4, Martin to immune related categories, including transcripts belong- Bornhauser4, Massimo Bernardi3, Jacopo Peccatori3, ing to the antigen processing and presentation via HLA Chiara Bonini5, Davide Cittaro2, Dejan Lazarevic2, Class II and T cell costimulation pathways. Giovanni Tonon2, Fabio Ciceri3, Luca Vago1,3 Data from somatic mutations and patient-specificpoly- 1San Raffaele Scientific Institute, Unit of Immunogenetics, morphisms derived from WES were integrated with expres- Leukemia Genomics and Immunobiology, Milano, Italy; 2San sion data and used to predict neoantigens (NeoAgs) and Raffaele Scientific Institute, Center for Translational Geno- minor histocompatibility antigens (miHAgs) expressed by mics and Bioinformatics, Milano, Italy; 3San Raffaele Scien- leukemic cells respectively. NeoAgs predicted to bind to the tific Institute, Hematology and Bone Marrow Transplantation patient HLA Class I and Class II molecules were few, and Unit, Milano, Italy; 4Technical University Dresden, Depart- consistent with the observed accrual of new mutations, also ment of Hematology/Oncology, Medical Clinic and Policlinic their number increased at post-transplantation relapse (3.0 vs I, Dresden, Germany; 5San Raffaele Scientific Institute, 3.8 for HLA Class I NeoAgs, and 37 vs 49 for HLA Class II Experimental Hematology Unit, Milano, Italy NeoAgs). We predicted an average of 346 leukemia- expressed miHAgs per each case, and interestingly observed Background: Allogeneic hematopoietic stem cell trans- that in 9/14 patients most of the expressed miHAgs were plantation (allo-HSCT) represents the most effective treat- downregulated at post-transplantation relapse. ment available for many patients with high-risk Acute Finally, all this data were combined and modeled in Myeloid Leukemia (AML), but post-transplantation relap- "relapsograms", highlighting that patient-specific combina- ses remain frequent, warranting in-depth research on their tions of genomic and non genomic, immunological and biological bases. non-immunological mechanisms can explain mechanisms of relapse in the majority of patients from our cohorts. Methods: To identify changes occurring in leukemic cells at relapse after allo-HSCT, we combined Whole Exome Conclusions: Taken together, this comprehensive analysis Sequencing (WES) and RNA-Seq to analyze AML samples of the immunogenetic profile of post-transplantation relap- pairwise-collected and purified from 14 patients before and ses evidence that they originate upon a complex process, in after allo-HSCT. Nine of the patients had received trans- which leukemia clonal evolution combines with immune- plant from HLA-matched donor, either related (n = 3) or driven changes in patient-specific combinations. Thus, in a unrelated (n = 6), whereas five were transplanted from translational perspective, these observations warrant in- HLA-haploidentical relatives. Median time from allo-HSCT depth analysis of each case of post-transplantation relapse, to relapse was 140 days (range 33–574). to tailor personalized therapeutic approaches. 16

Conflict of interest: This study was supported by the CMV seropositivity and hypoalbuminemia were also European Commission (ERA-NET TRANSCAN assessed. The hazard associated with individual comor- JTC2012 Cancer12-045-HLALOSS) to LV; by the Italian bidities was assessed using a cause-specificCoxregres- Ministry of Health RF-2011-02351998 to FC, LV and sion for non-relapse mortality (NRM) in a multivariable GB, and RF-2011-02348034 to LV; by the Associazione analysis adjusted for age, disease risk and donor type. Italiana per la Ricerca sul Cancro Start-Up Grant #14162 Cumulative incidence for NRM was plotted and compared to LV; and by the DKMS Mechtild Harf Research usingtheFineandGraytest. Grant to LV. All the authors declare no relevant conflicts of interest to disclose. Results: A total of 884 patients were included in the analysis. The median age was 55 years (IQR: 41–63). Trans- O005 plant indications reflected a typical distribution of patients treated with allogeneic transplantation. Flu/Treo was the Comorbidities Exert Regimen-Specific Effects on Non- most frequently used conditioning regimen (32%), followed Relapse Mortality in Allogeneic Stem Cell Transplantation by Flu/Bu2 (17%), BuCy (15%), Flu/Bu4 (13%), Flu/Mel (13%) and Cy/TBI (10%). The most prevalent comorbid- Joshua Fein1,2, Myriam Labopin3, Noga Shem-Tov1, Ronit ities were mild hepatic disease (47%), hypertension (23%) Yerushalmi1, Ivetta Danylesko1, Furie Nadav4, Avichai and obesity (22%). In an analysis of the entire cohort, renal Shimoni1, Arnon Nagler1, Roni Shouval1 dysfunction (eGFR ≤ 60 mL/min/1.73 m2), hypoalbumine- 1Chaim Sheba Medical Center Tel Hashomer, and Sackler mia and severe hepatic disease were associated with the Faculty of Medicine, Tel Aviv University, Division of highest risk of NRM (Figure A). The risk associated with Hematology and Bone Marrow Transplantation, Ramat certain comorbidities differed between regimens. In Flu/ Gan, Israel; 2Tel Aviv University, Sackler School of Medi- Bu4, the hazard of NRM was significantly increased among cine, Tel Aviv, Israel; 3European Society for Blood and patients with cardiac disease, diabetes mellitus and hyper- Marrow Transplantation, Acute Leukemia Working Party, tension (HR: 5.8 [95% CI: 2.2–15.5], 4.7 [1.6–13.4] and 3.8 Paris, France; 4Chaim Sheba Medical Center Tel Hasho- [1.3–11.3], respectively). Comorbidities associated with mer, and Sackler Faculty of Medicine, Tel Aviv University, increased risk among patients treated with Flu/Treo were Internal Medicine F, Ramat Gan, Israel ongoing infection at transplantation (HR: 3.5 [1.8–7.0]), hypoalbuminemia (2.6 [1.5–4.7]) and severe hepatic disease Background: Prospective trials studying the selection of (HR: 2.2 [1.1–4.3]). Additional risk-modifying comorbid- a preparative regimen best suited to an individual ities were identified in the settings of Flu/Bu2 and Flu/Mel. transplant recipient are lacking. We hypothesized that In Bu/Cy and Cy/TBI, patients were younger and had fewer regimen-associated toxicity is driven in a comorbidity- comorbidities, limiting the power of their respective sub- specific manner. analyses. The cumulative incidence of NRM echoed these findings. Among Flu/Bu4-treated patients, those without Methods: This retrospective study included adult patients cardiac disease experienced a 3-year incidence of NRM of receiving allogeneic transplantation for all indications 9.8% (95% CI: 5.3–18.3) versus 34.8% (19.5–61.9, p = between 2006 and 2015 at a single large academic med- 0.0003) for those with cardiac disease (Figure B). Similarly, ical center. Patients were treated with the following con- in Flu/Treo, patients without ongoing infection had 3-year ditioning regimens: Fludarabine plus two days of NRM of 26.9% (21.7–33.3) versus 62.5% (41.2–94.9, p = Busulfan (Flu/Bu2); Fludarabine plus four days of 0.0008) for patients with infection (Figure C). Busulfan (Flu/Bu4); Fludarabine plus Melphalan (Flu/ Conclusions: It is common practice to group Mel); Fludarabine plus Treosulfan (Flu/Treo); Busulfan preparative regimens by intensity. However, this analysis plus Cyclophosphamide (Bu/Cy); or Cyclophosphamide demonstrates that individual comorbidities may exert effects and total body irradiation (Cy/TBI). Patient comorbidity unique to a particular conditioning regimen. Our findings status was determined using the definitions of the suggest that the selection of regimen should be driven in Hematopoietic Cell Transplantation Comorbidity Index part by specific comorbidities, rather than by their cumu- (HCT-CI, Sorror et al., 2005) with more permissive lative burden. definitions of obesity and renal disease. Additional con- ditions not included in the HCT-CI, such as hypertension, Conflict of interest: The authors have nothing to disclose. The 44th Annual Meeting of the European Society for Blood and Marrow. . . 17

[[O005 Figure] Figures A–C] Charlotte Jubert9, Corinne Pondarré10, Gérard Socié4, Sylvie Chevret11 1CHIC Créteil, Pediatrics Referral Center for Sickle Cell Disease, Nogent sur Marne, France; 2CHIC Centre Hos- pitalier Intercommunal de Créteil, Medical Imagery Referral Center for Sickle Cell Disease, Créteil, France; 3Debré Hospital, Hemato-Pediatrics BMT Unit, Paris, France; 4St-Louis Hospital, SCT Unit, Paris, France; 5Strasbourg University Hospital, Hemato-Pediatrics, Strasbourg, France; 6La Timone, Hemato-Pediatrics, Marseille, France; 7Necker Hospital, Hemato-Pediatrics, Paris, France; 8La Timone, SCT Unit, Marseille, France; 9Bordeaux Hospital, SCT Unit, Bordeaux, France; 10CHIC Créteil, Pediatrics Referral Center for Sickle Cell Disease, Créteil, France; 11St-Louis Hospital, Statistics, Paris, France

Background: DREPAGREFFE is the ﬁrst trial pro- spectively comparing SCT and standard care for patients with Sickle-Cell-Anemia (SCA).

Methods: DREPAGREFFE is a French Mendelian randomized trial with 2 arms (transfusions/transplantation) deﬁned by random-availability of a HLA-matched sibling. It enrolled SCA-children younger than 15, transfused for history of abnormal-TCD (TAMV≥200cm/sec), with at least one non-SCA sibling, and parents agreeing to HLA-typing and transplantation when available MSD or chronic transfusion pursuing for at least one year. Conditioning consisted of intravenous busulfan, cyclophosphamide 200mg/kg and rabbit anti-thymocyte globulin (20mg/kg). Cell source was BM (n = 24), CB (n = 8). HbS was maintained below 30% when transfused. Between 12/2010 and 6/2013, 67 SCA- children (7 with stroke history) were enrolled. Thirty-two with a MSD were transplanted, while 35 (no donor) were included in the transfusion arm. The primary outcome measures were at 1 year the TAMV and percent of patients with normalized-TCD (<170cm/sec). The secondary outcome measures were the outcome of stenoses and ischemic O006 lesions, cognitive performances, iron overload, and Health- Related-Quality of Life (HRQL). An amendment in Feb- Abstract previously published 2013 extended the patient participation to 3 years as a cohort-study. O007 Results: All patients were alive at 1 and 3-years. In the Drepagreffe Trial comparing Transfusions for at least 1 year transfusion arm, 12 patients had been switched to hydro- to Transplantation in Children with Sickle Cell Anemia and xyurea between 1 and 3-years. No new stroke was observed a History of Abnormal-TCD: results at 3-years during the 3-years follow-up. All transplanted patients successfully engrafted; Cumulative incidence of acute- Francoise Bernaudin1, Suzanne Verlhac2, Jean-Hugues GvHD ≥ grade 2 was 9.4% (95%CI: 0–19.8%). No Dalle3, Régis Peffault de Latour4, Catherine Paillard5, chronic-GvHD was observed. Median [Q1-Q3] donor chi- Isabelle Thuret6, Bénédicte Neven7, Claire Galambrun8, merism at 1-year was: 92.0% [80.2–97.5%], range 61%– 18

100% and at 3-years: 90.2% [78.9–97.4%], range 30%– higher energy p = 0.021 and lower numbers of days missed 100%. All transplanted patients had the same hemoglobin in school (p = 0.001) than transfused children. At 3 years, electrophoresis as their donor. At 3-years, median [Q1-Q3] not only parents of transplanted children, but also children hemoglobin, HbS% and ferritin were in transplanted vs non- themselves reported higher scores of quality of life in all transplanted 12.1g/dL [11.4–13.2] vs 9.2g/dL [8.2–9.9], p< domains than those in the non-transplanted arm. 0.001;0%[0–38] vs 35.8% [25.0–67.4], p< 0.001; and 347mg/L [154–571] vs 1731 [792–3744], p< 0.001, Conclusions: These results should encourage providers to respectively. Median [Q1-Q3] velocities (TAMV) were recommend SCT to children with available MSD and a significantly lower in transplanted: 109.5 cm/s [92.0–119.5] history of abnormal-TCD, even to those with normalized than in non-transplanted 149.0 cm/s [130–180], p< 0.001 velocities on chronic transfusion and the percent of patients with normalized TCD was higher in transplanted (27/32) than in non-transplanted children Clinical Trial Registry: NCT 01340404 (19/35), p = 0.02. TAMV increased between 1 and 3 years only in 5 patients of the transfusion arm after switch to Conflict of interest: no relevant conflict of interest to hydroxyurea (n = 4) or despite transfusions (n = 1). New disclose ischemic lesions were only observed in the transfusion arm (n = 3). No significant difference in cognitive performance was observed between the 2 arms at 1and 3-years. However Jian-Jian Luan Award at 1 year, parents reported in all domains (physical, p< 0.001, emotional, p< 0.001, social p = 0.006 and school p< O008 0.001 functioning) significantly higher scores in transplanted than in transfused children whereas transplanted Abstract previously published children reported significant lower pain rate, p = 0.006