ABSTRACT BOOK The combined Annual Scientific Meeting of the: 2018 Annual Scientific Meeting 21-24 October Brisbane Convention & Exhibition Centre www.blood2018.com
Coagulation and clotting in children: Medicine of the future, or the future of medicine
Apr 06, 2023
Understanding the coagulation system in humans and the effective use of anticoagulants has
been a major medical drive since the 1930s, when our rudimentary understanding of such things
really began. To this day disorders of coagulation are a major cause of morbidity and mortality in
our communities. The recognition and treatment of Vitamin K deficiency, then termed
“haemorrhagic disease of the newborn”, was one of the stunning early victories. But subsequently,
for decades, children were seen and not heard. However, in recent years there is renewed interest
in the coagulation system of children, in part brought about by the increased frequency of
thrombosis in children, coined as the “new epidemic” of tertiary paediatric care
Welcome message from author
This presentation will focus on our current understanding of the coagulation system in neonates and children, and the ramifications of this for the management of thrombosis, including the use of anticoagulants.
Transcript
2018 Annual Scientific Meeting 21-24 October Brisbane Convention & Exhibition Centre
www.blood2018.com
BMTSAA Poster Presentations P349 – P355
001. Coagulation and clotting in children: Medicine of the future, or the future of medicine
Monagle P1
1The Royal Children’s Hospital, Melbourne, Australia
Understanding the coagulation system in humans and the effective use of anticoagulants has been a major medical drive since the 1930s, when our rudimentary understanding of such things really began. To this day disorders of coagulation are a major cause of morbidity and mortality in our communities. The recognition and treatment of Vitamin K deficiency, then termed “haemorrhagic disease of the newborn”, was one of the stunning early victories. But subsequently, for decades, children were seen and not heard. However, in recent years there is renewed interest in the coagulation system of children, in part brought about by the increased frequency of thrombosis in children, coined as the “new epidemic” of tertiary paediatric care. This presentation will focus on our current understanding of the coagulation system in neonates and children, and the ramifications of this for the management of thrombosis, including the use of anticoagulants. There remains much to be learned, and truthfully a good understanding of paediatric coagulation physiology and pathophysiology is medicine of the future. However, in an aging population, where the major burden of disease is due to pathological processes that start in early life (potentially even in utero) then one can reasonably ask whether understanding coagulation physiology and pathophysiology of children, who appear protected against many clotting complications compared to adults, is in fact the future of medicine and we ignore it to the detriment of our entire population.
002. Sometimes it gets bloody – the challenges we face
Roxby D1 1SA Pathology Transfusion Medicine, Adelaide, Australia Transfusion of blood products is an essential aspect of resuscitation in critically bleeding patients, although at times empirical. In critical bleeding it is important to clearly identify surgical or coagulopathy associated haemorrhage and to restore the haemostatic defect through appropriate surgical interventions or guided blood product use. Hospitals have recognized the importance of providing blood products quickly to severely injured and bleeding patients by developing massive transfusion protocols (MTP) whereby a fixed quantity of products can be rapidly available. A number of observational studies and randomized clinical trials suggest that patients with severe trauma and coagulopathy have improved survival when the ratio of transfused red cells, plasma and platelets approaches 1:1:1. However this may not be directly applicable in non-trauma critical bleeding. Coagulation management in critical bleeding must be based on an understanding of the pathophysiological processes and functional assessment of the entire coagulation system leading to targeted replacement of platelets, fibrinogen, other clotting factors or use of anti-fibrinolytic agents. Standard coagulation tests may be unsuitable in such situations due to long turnaround times, being poor predictors of transfusion requirements and only providing an indirect correlation with the clinical picture. Ongoing studies examining the use of point of care testing in product replacement are underway providing more evidence that early and directed replacement of appropriate coagulation factors particularly fibrinogen and platelets may improve outcome. The use of fibrinogen concentrates rather than plasma-based replacement in trauma, obstetric and perioperative bleeding is now being proposed as the preferred approach. Although there have been recent significant changes in transfusion practice in critically bleeding patients, controversy continues to surround the use of a pre-defined massive transfusion response. Therefore, to be successful, it is important to consider ways to implement a patient specific response to critical bleeding to better guide timely and appropriate use of blood products directed at the patient’s own specific needs.
003. Haematology - the journey
Taylor K1 1Mater Medical Centre, Brisbane, Australia Kerry Taylor will take the audience on his path to Medicine and Haematology. He will tell of his beginnings in a small country town, the influence of family and experiences that made him choose medicine. He will relate what it was like to undertake Medicine and Haematology in the 70’s and 80’s and will detail life in a clinical school and hospital that Carl De Gruchy had made famous. He was fortunate to be a member of fellow clinicians making inroads in supportive care in the U.S. in the 80’s and then in Australia pioneering a new drug therapy in CML in Australia. He will elaborate on the many influential and colourful fellow clinicians who shaped his life as a haematologist, and he will detail the challenges on building a unit in Queensland and the later move to private practice. He will conclude by giving a personal opinion on what is good about life as a haematologist and what could be better.
004. Donor-derived piggyBac transposon-generated CAR T-cells induce remission of relapsed/refractory B-cell malignancy post allogeneic haematopoietic stem cell transplant
Bishop D1,2,3,4, Blyth E1,2,3,4,5, Clancy L1,5, Burgess J1, Mathew G1, Atkins E3, Simms R1, Maddock K3, Stephen K6, O'Brien T7,8,9, Shaw P2,6, Gottlieb D1,2,3,4,5, Micklethwaite K1,2,3,4,5
1Westmead Institute For Medical Research, Sydney, Australia, 2Sydney Medical School, The University of Sydney, Sydney, Australia, 3Department of Haematology, Westmead Hospital, Sydney, Australia, 4Blood
and Marrow Transplant Unit, Westmead Hospital, Sydney, Australia, 5Sydney Cellular Therapies Laboratory, Westmead Hospital, Sydney, Australia, 6Cancer Centre for Children, Children’s Hospital at Westmead, Sydney, Australia, 7Children’s Cancer Institute, Sydney, Australia, 8Faculty of Medicine,
University of New South Wales, Sydney, Australia, 9Blood & Marrow Transplant Unit, Sydney Children’s
Hospital, Sydney, Australia
Aim CD19-specific chimeric antigen receptor (CAR19) T-cells effectively induce remissions of relapsed/refractory B-cell malignancy. However, their implementation is limited by costs associated with viral vectors used during production. Inexpensive CAR19 T-cells generated using the non-viral piggyBac transposon system demonstrated potent pre-clinical activity, so we now assess safety and activity in a first-in-human trial. Methods Patients with relapsed/refractory CD19+ malignancies post HLA-matched sibling HSCT were enrolled onto an ongoing phase I/II trial of donor-derived CAR19 T-cells. Donor T-cells genetically modified using piggyBac to express a second-generation CAR19 were expanded ex vivo over 15 days with CD19 stimulation and IL-15. Patients satisfying eligibility criteria immediately prior to first CAR19 T-cell infusion were included on trial. Up to 3 escalating doses of CAR19 T-cells (10- , 50- and 100x106/m2) were administered following lymphodepleting cyclophosphamide (and fludarabine for dose #1), according to response and CAR19 T-cell persistence at specified time- points. Results CAR19 T-cell products were successfully generated from 50x106 peripheral blood mononuclear cells for all patients (n=5), and comprised 1.5-2.5x109 cells with 61-93% CAR+ T-cells. Two patients were ineligible for trial analysis due to infection and poor performance status. Three eligible patients (DLBCL and 2 cases of ALL) have been followed for 2 to 5 months. Those with ALL achieved complete remission after dose #1, and with DLBCL after dose #2. Longest CAR19 T-cell persistence was 5 months. All 3 patients experienced CD19+-relapse associated with declining CAR19 T-cells, and are proceeding to dose escalation. Toxicity included: cytokine release syndrome (n=1), B-cell aplasia with hypogammaglobulinaemia (n=3), and prolonged neutropenia (n=2). No CAR T-cell-related encephalopathy syndrome or acute GVHD occurred. Conclusions Manufacture of piggyBac CAR19 T-cells for clinical use is feasible. Early trial results demonstrate similar safety and activity to that of virus-generated CAR19 T-cells. The optimal CAR19 T-cell dose and lymphodepletion strategy remain to be determined.
005. High, durable MRD negativity (MRD–) with venetoclax + rituximab (VenR) in relapsed/refractory (R/R) CLL: data from phase 3 MURANO study
Seymour J1, Hillmen P2, Langerak A3, Eichhorst B4, Owen C5, Assouline S6, Janssens A7, Marlton P8, Badoux X9, Mous R10, Chyla B11, Humerickhouse R11, Boyer M12, Humphrey K12, Punnoose E13, Wang J13, Wu J13, Jiang Y13, Mobasher M13, Kater A14
1Peter MacCallum Cancer Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia, 2St. James’s University Hospital, Leeds, UK, 3Dept of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands, 4University of Cologne, Cologne, Germany, 5Departments of Medicine and Oncology, University of
Calgary, Calgary, Canada, 6Segal Cancer Center, Lady Davis Institute, Jewish General Hospital, Montreal, Canada, 7Universitaire Ziekenhuizen Leuven, Leuven, Belgium, 8Princess Alexandra Hospital and University of Queensland, Brisbane, Australia, 9St George Hospital Department of Haematology NSW Health Pathology, Kogarah, Australia, 10UMC Utrecht Cancer Center, Utrecht, The Netherlands, 11AbbVie, North Chicago, USA, 12F. Hoffmann-La Roche, Welwyn Garden City, UK, 13Genentech, Inc., South San Francisco, USA, 14Academic Medical Center Amsterdam, on
behalf of Hovon CLL WG, Amsterdam, The Netherlands
Background: Survival with chemoimmunotherapy is associated with MRD–, but the importance of MRD with targeted agents and in the R/R setting remains unclear, mostly due to low MRD– rates. In MURANO (NCT02005471), VenR showed superior PFS (HR 0.17) and peripheral blood (PB) and bone marrow (BM) MRD– vs bendamustine + R (BR) in R/R CLL patients. We now report MRD kinetics. Methods: Randomization was to VenR for 6 months then single-agent Ven for 1.5 years maximum, or BR for 6 months. PB samples collected serially and BM samples at end of combination treatment (EOCT; Month 9) or at best response; MRD analyzed centrally by ASO-PCR and/or flow cytometry; MRD–: <1 CLL cell/104 leukocytes. Results: Higher concordance in MRD– between BM and PB in VenR (45/50 [90%]) vs BR (3/10 [30%]) in patients with paired samples. EOCT PB MRD– rates were higher with VenR (62% vs 13% with BR), and independent of high-risk factors: del(17p) and/or TP53mut, and unmutated IGVH (present vs non-present: 57% vs 66% and 61% vs 64%, respectively). PB MRD kinetics for VenR are shown in Figure. 121/194 (62%) patients on VenR were MRD– at EOCT: 100 (83%) maintained MRD– and were progression-free at median follow-up of 13.8 months; 2 developed PD; 2 died (unrelated); 2 developed Richter’s (1 immediately after MRD+); 15 (12%) converted to confirmed MRD+, 11 of whom remained progression-free at median MRD+ follow-up of 5.6 months. Conclusions: High concordance of PB and BM MRD with VenR confirms value of PB MRD for correlation with outcome. VenR achieves high, early, deep, durable PB MRD–regardless of risk features, unlike BR. Some reemergence of MRD+, mainly intermediate level (<1 CLL cell/102–104 leukocytes), was seen in a few patients, and rarely led to clinical PD within 6 months, consistent with the PFS benefit observed. Figure: MRD kinetics for VenR at various timepoints
006. Daratumumab plus bortezomib-melphalan-prednisone (D-VMP) in elderly (≥75 y) patients with newly diagnosed multiple myeloma (NDMM) ineligible for transplantation (ALCYONE)
Campbell P1, San-Miguel J2, Iida S3, Blade J4, Mateos M5, Lee J6, Garg M7, Hungria V8, Beksac M9, Spicka I10, Knop S11, Pour L12, Jakubowiak A13, Bauer M14, Wang J15, Wroblewski S16, Kobos R15, Qi M16, Cavo M17
1Andrew Love Cancer Centre, Geelong , Australia, 2Clínica Universidad de Navarra-CIMA, IDISNA, CIBERONC,
Pamplona , Spain, 3Nagoya City University Graduate School of Medical Sciences , Nagoya, Japan, 4Servei d'Hematologia, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain, 5University Hospital of Salamanca/IBSAL, Salamanca, Spain, 6Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, South Korea, 7Leicester Royal Infirmary – Haematology, Leicester, United Kingdom, 8Irmandade Da Santa Casa De Misericordia De São Paulo, São
Paulo, Brazil, 9Ankara University School of Medicine Department of Hematology, Ankara, Turkey, 10Clinical Department of Haematology, 1st Medical Department, Charles University in Prague, Prague, Czech Republic, 11Wuerzburg University Medical Center, Würzburg, Germany, 12University Hospital Brno, Brno, Czech Republic, 13University of Chicago Medical Center, Chicago, USA, 14Genmab A/S, Copenhagen, Denmark, 15Janssen Research & Development, Raritan, USA, 16Janssen Research & Development, Spring House, USA, 17"Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
Aim: We examined the efficacy and safety profiles of D-VMP vs VMP in elderly (≥75 y) and non-elderly (<75 y) NDMM patients in ALCYONE. Methods: Patients received ≤nine 6-week VMP cycles (V: 1.3 mg/m2 SC twice weekly during Cycle 1 and QW during Cycles 2-9; M 9 mg/m2 PO and P 60 mg/m2 PO on Days 1-4 during Cycles 1-9) ± daratumumab (16 mg/kg IV QW during Cycle 1, Q3W during Cycles 2-9, and Q4W during Cycles 10+). Results: The study included 211 ≥75 y (104 D-VMP; 107 VMP) and 495 <75 y (246 D-VMP; 249 VMP) patients. After median follow-up of 16.5 months, PFS was prolonged with D-VMP vs VMP in both the ≥75 y (median not reached [NR] vs 20.4 months; HR 0.53; 95% CI 0.32-0.85) and <75 y (median NR vs 17.9 months; HR 0.49; 95% CI 0.36-0.68) patients. ORR and ≥CR rates were consistently higher for D-VMP vs VMP in ≥75 y (ORR: 88% vs 70%; ≥CR: 41% vs 24%) and <75 y (ORR: 92% vs 76%; ≥CR: 43% vs 25%) patients. Minimal residual disease–negative rates (10–5 threshold) also increased with D-VMP vs VMP in ≥75 y (24% vs 8%) and <75 y (22% vs 6%) patients. Rates of the most common (≥10%) grade 3/4 TEAEs, peripheral sensory neuropathy, and infections are listed (Table). Conclusions: Efficacy and safety of D-VMP vs VMP in patients ≥75 y of age were consistent with the overall study population.
≥75 y <75 y
Grade 3/4, % D-VMP VMP D-VMP VMP
Most common TEAEs Neutropenia 52 42 35 38 Thrombocytopenia 51 43 28 35 Anemia 24 23 13 19 Leukopenia 13 9 6 9 Lymphopenia 10 10 7 4 Pneumonia 18 9 9 2 Peripheral sensory neuropathy 0 6 2 3
Infections 28 20 21 13
007. Overall survival with carfilzomib/dexamethasone (Kd56) versus bortezomib/dexamethasone (Vd) by prior line of therapy and previous exposure to bortezomib
Ho P1, Weisel K2, Siegel D3, San Miguel J4, Hajek R5, Gaidano G6, Orlowski R7, Zhou L8, Kimball A8, Moreau P9
1Institute of Haematology Royal Prince Alfred Hospital, Camperdown, Australia, 2Universitatsklinikum Tubingen, Tubingen, Germany, 3John Theurer Cancer Center, Hackensack University Medical Center , Hackensack, USA, 4Clinica Universidad de Navarra, University of Navarra , Pamplona, Spain, 5Department of Haematooncology, University Hospital Ostrava , Ostrava, Czech Republic, 6Division of Hematology, University of Eastern Piedmont , Novara, Italy, 7The University of Texas MD Anderson Cancer Center, The University of Texas, Houston, USA, 8Amgen Inc., Thousand Oaks, USA, 9Hematology Department, University of Nantes , Nantes, France
Background: In the ENDEAVOR overall survival (OS) analysis, median OS was significantly longer with Kd56 versus Vd. Here, we present OS and safety analyses comparing Kd56 with Vd according to prior lines of therapy and previous exposure to bortezomib. Methods: Full details of the study design have been presented elsewhere. The Kaplan-Meier OS rate and median OS time were estimated up to the time point where there were ≤10 patients (Kd56 and Vd combined) in the risk set. The study was not powered to detect differences in OS between subgroups. Adverse events (AEs) are presented as preferred terms and were not adjusted for exposure. Results: Patients were randomized to receive Kd56 (n=464) or Vd (n=465). The proportion of patients with 1 (Kd56, 49.8%; Vd, 49.2%) or 2-3 (Kd56, 50.2%; Vd, 50.8%) prior lines of therapy was balanced between the treatment arms. The proportion of patients with prior exposure to bortezomib was also balanced between the Kd56 and Vd arms (54% in each arm) and within the subgroups of patients with 1 prior line (Kd56, 42.0%; Vd, 42.8%) and 2–3 prior lines of therapy (Kd56, 65.7%; Vd, 65.3%). Survival outcomes and rates of grade ≥ 3 adverse events of interest by prior treatment are shown (Table). Conclusions: Treatment with Kd56 showed a survival benefit compared with Vd in patients with RRMM irrespective of the number of prior lines of therapy and previous exposure to bortezomib. Kd56 reduced the risk of death by 17% (1 prior line) and 24% (2–3 prior lines). Kd56 prolonged PFS by 7.5 months and OS by 14.8 months vs retreatment with bortezomib in proteasome inhibitor-sensitive patients. The rate of AEs in this subgroup analysis was consistent with that reported in the overall population. Moreover, no unexpected safety events occurred during longer follow-up.
008. ACTN1-related macrothrombocytopenia: an Australian experience using NGS and diagnostic biomarker to confirm pathogenicity
Takagi Y1, Chen Q1,2, Rabbolini D1,2, Zhu Y1, Joseph J3, Crispin P4, Bennett A5, Stevenson W1,2, Ward C1,2, Morel-Kopp M1,2
1The University of Sydney, St Leonards, Australia, 2Royal North Shore Hospital, Sydney, Australia, 3St Vincent Hospital, Sydney, Australia, 4Canberra Hospital, Canberra, Australia, 5Monash Pathology, Melbourne, Australia
Introduction: Autosomal dominant macrothrombocytopenia due to abnormality of α-actinin-1 (ACTN1) has recently been described; but confirming the pathogenicity of a genetic change remains a diagnostic challenge.
Aim: To assess the pathogenicity of ACTN1 genetic variants in Australian macrothrombocytopenic patients using an in vitro cytoskeletal model. Informed consent was obtained and the study was approved by relevant ethics committee.
Methods: Targeted gene sequencing of 47 genes important for platelet formation and function was performed in 221 individuals from 162 families; 47 (21.3%) had macrothrombocytopenia. To determine the pathogenetic role of identified ACTN1 variants, CHO cells were transfected with Myc-tagged wild-type or “mutant” ACTN1 and spread onto fibronectin coated slides before being fixed, permeabilized, and stained with fluorescent anti-c-Myc antibody, phalloidin and DAPI for imaging.
Results: Three novel heterozygous ACTN1 missense variants were identified by targeted sequencing and confirmed by Sanger sequencing. Two variants (c.127T>A,p.Ser43Thr; c.384G>T,p.Trp128Cys) were located within the actin-binding domain (ABD), and one variant (c.2108A>G,p.Asn703Ser) was located in the spectrin-like repeats region. By immunofluorescence, CHO cells transfected with wild-type ACTN1 or 703Ser variant showed well-organized, finely stretched actin filaments with high level of ACTN1 colocalisation. By contrast, CHO cells expressing ACTN1 ABD variants (43Thr and 128Cys) showed shorter and thicker filaments consistent with disorganisation of the actin filament network by the abnormal ACTN1 molecules.
Conclusion: Using immunofluorescence in an in vitro model as a diagnostic biomarker, we concluded that the 703Ser variant, located outside of the functional domains of ACTN1, was likely benign. By contrast, the two variants in the ACTN1-ABD domain impaired the actin filament organization, suggesting those variants are likely pathogenic and responsible for the macrothrombocytopenia. The individuals carrying those two variants are the first cases of ACTN1- related macrothrombocytopenia identified in an Australian population.
009. Fibrinolysis and Innate Immunity at play: Complement C5a receptor inhibition reduces tissue plasminogen activator (t-PA) and plasminogen (Plg)-induced blood brain barrier (BBB) opening in vitro
Keragala C1, Woodruff T2, Niego B3, McQuilten Z4, Medcalf R1
1Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia, 2School of Biomedical Sciences, University of Queensland, Brisbane, Australia, 3NanoBiotechnology
Research Group, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia, 4Transfusion Research Unit and Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
Aim The relationship between fibrinolysis and innate immunity is evident in the increased BBB permeability induced by t-PA and Plg, which can trigger CNS infiltration by immune cells. Although Rho-Kinase 2 (ROCK-2) signalling plays an important role here, the pro-inflammatory properties of plasmin, including C3 and C5 convertase activity, led us to hypothesise that plasmin mediated BBB permeation may in part be driven by complement activation. We aimed to characterise the effects of targeted complement inhibition on this phenomenon using in vitro BBB models. Synergy experiments evaluated added effects of antifibrinolytic, Tranexamic acid (TXA), and selective ROCK-2 inhibitor (KD025). Methods In vitro models of the BBB were assembled on porous membranes of Transwell inserts either as a monolayer of human brain endothelial cells (hBECs) (Model 1) or in co-culture with SVG human immortalised astrocytes (on abluminal membrane surface; Model 2) (Fig. 1). The in vitro BBB was stimulated with t-PA+Plg in the presence or absence of complement fragment 5a receptor 1 inhibitor (PMX205). BBB permeability was assessed 4hr post- stimulation by evaluating fluorescent tracer passage from luminal to abluminal chambers over 1hr. Permeability changes were calculated relative to a control model without stimulation. Results PMX205 blocked permeability increases in stimulated hBECs monocultures, most notably at 100μM (p<0.01). PMX205 effect was comparable to KD025, which served as a positive inhibition control (p<0.01) (Fig. 2). Greater BBB protection by PMX205 and synergistic action with…
www.blood2018.com
BMTSAA Poster Presentations P349 – P355
001. Coagulation and clotting in children: Medicine of the future, or the future of medicine
Monagle P1
1The Royal Children’s Hospital, Melbourne, Australia
Understanding the coagulation system in humans and the effective use of anticoagulants has been a major medical drive since the 1930s, when our rudimentary understanding of such things really began. To this day disorders of coagulation are a major cause of morbidity and mortality in our communities. The recognition and treatment of Vitamin K deficiency, then termed “haemorrhagic disease of the newborn”, was one of the stunning early victories. But subsequently, for decades, children were seen and not heard. However, in recent years there is renewed interest in the coagulation system of children, in part brought about by the increased frequency of thrombosis in children, coined as the “new epidemic” of tertiary paediatric care. This presentation will focus on our current understanding of the coagulation system in neonates and children, and the ramifications of this for the management of thrombosis, including the use of anticoagulants. There remains much to be learned, and truthfully a good understanding of paediatric coagulation physiology and pathophysiology is medicine of the future. However, in an aging population, where the major burden of disease is due to pathological processes that start in early life (potentially even in utero) then one can reasonably ask whether understanding coagulation physiology and pathophysiology of children, who appear protected against many clotting complications compared to adults, is in fact the future of medicine and we ignore it to the detriment of our entire population.
002. Sometimes it gets bloody – the challenges we face
Roxby D1 1SA Pathology Transfusion Medicine, Adelaide, Australia Transfusion of blood products is an essential aspect of resuscitation in critically bleeding patients, although at times empirical. In critical bleeding it is important to clearly identify surgical or coagulopathy associated haemorrhage and to restore the haemostatic defect through appropriate surgical interventions or guided blood product use. Hospitals have recognized the importance of providing blood products quickly to severely injured and bleeding patients by developing massive transfusion protocols (MTP) whereby a fixed quantity of products can be rapidly available. A number of observational studies and randomized clinical trials suggest that patients with severe trauma and coagulopathy have improved survival when the ratio of transfused red cells, plasma and platelets approaches 1:1:1. However this may not be directly applicable in non-trauma critical bleeding. Coagulation management in critical bleeding must be based on an understanding of the pathophysiological processes and functional assessment of the entire coagulation system leading to targeted replacement of platelets, fibrinogen, other clotting factors or use of anti-fibrinolytic agents. Standard coagulation tests may be unsuitable in such situations due to long turnaround times, being poor predictors of transfusion requirements and only providing an indirect correlation with the clinical picture. Ongoing studies examining the use of point of care testing in product replacement are underway providing more evidence that early and directed replacement of appropriate coagulation factors particularly fibrinogen and platelets may improve outcome. The use of fibrinogen concentrates rather than plasma-based replacement in trauma, obstetric and perioperative bleeding is now being proposed as the preferred approach. Although there have been recent significant changes in transfusion practice in critically bleeding patients, controversy continues to surround the use of a pre-defined massive transfusion response. Therefore, to be successful, it is important to consider ways to implement a patient specific response to critical bleeding to better guide timely and appropriate use of blood products directed at the patient’s own specific needs.
003. Haematology - the journey
Taylor K1 1Mater Medical Centre, Brisbane, Australia Kerry Taylor will take the audience on his path to Medicine and Haematology. He will tell of his beginnings in a small country town, the influence of family and experiences that made him choose medicine. He will relate what it was like to undertake Medicine and Haematology in the 70’s and 80’s and will detail life in a clinical school and hospital that Carl De Gruchy had made famous. He was fortunate to be a member of fellow clinicians making inroads in supportive care in the U.S. in the 80’s and then in Australia pioneering a new drug therapy in CML in Australia. He will elaborate on the many influential and colourful fellow clinicians who shaped his life as a haematologist, and he will detail the challenges on building a unit in Queensland and the later move to private practice. He will conclude by giving a personal opinion on what is good about life as a haematologist and what could be better.
004. Donor-derived piggyBac transposon-generated CAR T-cells induce remission of relapsed/refractory B-cell malignancy post allogeneic haematopoietic stem cell transplant
Bishop D1,2,3,4, Blyth E1,2,3,4,5, Clancy L1,5, Burgess J1, Mathew G1, Atkins E3, Simms R1, Maddock K3, Stephen K6, O'Brien T7,8,9, Shaw P2,6, Gottlieb D1,2,3,4,5, Micklethwaite K1,2,3,4,5
1Westmead Institute For Medical Research, Sydney, Australia, 2Sydney Medical School, The University of Sydney, Sydney, Australia, 3Department of Haematology, Westmead Hospital, Sydney, Australia, 4Blood
and Marrow Transplant Unit, Westmead Hospital, Sydney, Australia, 5Sydney Cellular Therapies Laboratory, Westmead Hospital, Sydney, Australia, 6Cancer Centre for Children, Children’s Hospital at Westmead, Sydney, Australia, 7Children’s Cancer Institute, Sydney, Australia, 8Faculty of Medicine,
University of New South Wales, Sydney, Australia, 9Blood & Marrow Transplant Unit, Sydney Children’s
Hospital, Sydney, Australia
Aim CD19-specific chimeric antigen receptor (CAR19) T-cells effectively induce remissions of relapsed/refractory B-cell malignancy. However, their implementation is limited by costs associated with viral vectors used during production. Inexpensive CAR19 T-cells generated using the non-viral piggyBac transposon system demonstrated potent pre-clinical activity, so we now assess safety and activity in a first-in-human trial. Methods Patients with relapsed/refractory CD19+ malignancies post HLA-matched sibling HSCT were enrolled onto an ongoing phase I/II trial of donor-derived CAR19 T-cells. Donor T-cells genetically modified using piggyBac to express a second-generation CAR19 were expanded ex vivo over 15 days with CD19 stimulation and IL-15. Patients satisfying eligibility criteria immediately prior to first CAR19 T-cell infusion were included on trial. Up to 3 escalating doses of CAR19 T-cells (10- , 50- and 100x106/m2) were administered following lymphodepleting cyclophosphamide (and fludarabine for dose #1), according to response and CAR19 T-cell persistence at specified time- points. Results CAR19 T-cell products were successfully generated from 50x106 peripheral blood mononuclear cells for all patients (n=5), and comprised 1.5-2.5x109 cells with 61-93% CAR+ T-cells. Two patients were ineligible for trial analysis due to infection and poor performance status. Three eligible patients (DLBCL and 2 cases of ALL) have been followed for 2 to 5 months. Those with ALL achieved complete remission after dose #1, and with DLBCL after dose #2. Longest CAR19 T-cell persistence was 5 months. All 3 patients experienced CD19+-relapse associated with declining CAR19 T-cells, and are proceeding to dose escalation. Toxicity included: cytokine release syndrome (n=1), B-cell aplasia with hypogammaglobulinaemia (n=3), and prolonged neutropenia (n=2). No CAR T-cell-related encephalopathy syndrome or acute GVHD occurred. Conclusions Manufacture of piggyBac CAR19 T-cells for clinical use is feasible. Early trial results demonstrate similar safety and activity to that of virus-generated CAR19 T-cells. The optimal CAR19 T-cell dose and lymphodepletion strategy remain to be determined.
005. High, durable MRD negativity (MRD–) with venetoclax + rituximab (VenR) in relapsed/refractory (R/R) CLL: data from phase 3 MURANO study
Seymour J1, Hillmen P2, Langerak A3, Eichhorst B4, Owen C5, Assouline S6, Janssens A7, Marlton P8, Badoux X9, Mous R10, Chyla B11, Humerickhouse R11, Boyer M12, Humphrey K12, Punnoose E13, Wang J13, Wu J13, Jiang Y13, Mobasher M13, Kater A14
1Peter MacCallum Cancer Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia, 2St. James’s University Hospital, Leeds, UK, 3Dept of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands, 4University of Cologne, Cologne, Germany, 5Departments of Medicine and Oncology, University of
Calgary, Calgary, Canada, 6Segal Cancer Center, Lady Davis Institute, Jewish General Hospital, Montreal, Canada, 7Universitaire Ziekenhuizen Leuven, Leuven, Belgium, 8Princess Alexandra Hospital and University of Queensland, Brisbane, Australia, 9St George Hospital Department of Haematology NSW Health Pathology, Kogarah, Australia, 10UMC Utrecht Cancer Center, Utrecht, The Netherlands, 11AbbVie, North Chicago, USA, 12F. Hoffmann-La Roche, Welwyn Garden City, UK, 13Genentech, Inc., South San Francisco, USA, 14Academic Medical Center Amsterdam, on
behalf of Hovon CLL WG, Amsterdam, The Netherlands
Background: Survival with chemoimmunotherapy is associated with MRD–, but the importance of MRD with targeted agents and in the R/R setting remains unclear, mostly due to low MRD– rates. In MURANO (NCT02005471), VenR showed superior PFS (HR 0.17) and peripheral blood (PB) and bone marrow (BM) MRD– vs bendamustine + R (BR) in R/R CLL patients. We now report MRD kinetics. Methods: Randomization was to VenR for 6 months then single-agent Ven for 1.5 years maximum, or BR for 6 months. PB samples collected serially and BM samples at end of combination treatment (EOCT; Month 9) or at best response; MRD analyzed centrally by ASO-PCR and/or flow cytometry; MRD–: <1 CLL cell/104 leukocytes. Results: Higher concordance in MRD– between BM and PB in VenR (45/50 [90%]) vs BR (3/10 [30%]) in patients with paired samples. EOCT PB MRD– rates were higher with VenR (62% vs 13% with BR), and independent of high-risk factors: del(17p) and/or TP53mut, and unmutated IGVH (present vs non-present: 57% vs 66% and 61% vs 64%, respectively). PB MRD kinetics for VenR are shown in Figure. 121/194 (62%) patients on VenR were MRD– at EOCT: 100 (83%) maintained MRD– and were progression-free at median follow-up of 13.8 months; 2 developed PD; 2 died (unrelated); 2 developed Richter’s (1 immediately after MRD+); 15 (12%) converted to confirmed MRD+, 11 of whom remained progression-free at median MRD+ follow-up of 5.6 months. Conclusions: High concordance of PB and BM MRD with VenR confirms value of PB MRD for correlation with outcome. VenR achieves high, early, deep, durable PB MRD–regardless of risk features, unlike BR. Some reemergence of MRD+, mainly intermediate level (<1 CLL cell/102–104 leukocytes), was seen in a few patients, and rarely led to clinical PD within 6 months, consistent with the PFS benefit observed. Figure: MRD kinetics for VenR at various timepoints
006. Daratumumab plus bortezomib-melphalan-prednisone (D-VMP) in elderly (≥75 y) patients with newly diagnosed multiple myeloma (NDMM) ineligible for transplantation (ALCYONE)
Campbell P1, San-Miguel J2, Iida S3, Blade J4, Mateos M5, Lee J6, Garg M7, Hungria V8, Beksac M9, Spicka I10, Knop S11, Pour L12, Jakubowiak A13, Bauer M14, Wang J15, Wroblewski S16, Kobos R15, Qi M16, Cavo M17
1Andrew Love Cancer Centre, Geelong , Australia, 2Clínica Universidad de Navarra-CIMA, IDISNA, CIBERONC,
Pamplona , Spain, 3Nagoya City University Graduate School of Medical Sciences , Nagoya, Japan, 4Servei d'Hematologia, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain, 5University Hospital of Salamanca/IBSAL, Salamanca, Spain, 6Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, South Korea, 7Leicester Royal Infirmary – Haematology, Leicester, United Kingdom, 8Irmandade Da Santa Casa De Misericordia De São Paulo, São
Paulo, Brazil, 9Ankara University School of Medicine Department of Hematology, Ankara, Turkey, 10Clinical Department of Haematology, 1st Medical Department, Charles University in Prague, Prague, Czech Republic, 11Wuerzburg University Medical Center, Würzburg, Germany, 12University Hospital Brno, Brno, Czech Republic, 13University of Chicago Medical Center, Chicago, USA, 14Genmab A/S, Copenhagen, Denmark, 15Janssen Research & Development, Raritan, USA, 16Janssen Research & Development, Spring House, USA, 17"Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
Aim: We examined the efficacy and safety profiles of D-VMP vs VMP in elderly (≥75 y) and non-elderly (<75 y) NDMM patients in ALCYONE. Methods: Patients received ≤nine 6-week VMP cycles (V: 1.3 mg/m2 SC twice weekly during Cycle 1 and QW during Cycles 2-9; M 9 mg/m2 PO and P 60 mg/m2 PO on Days 1-4 during Cycles 1-9) ± daratumumab (16 mg/kg IV QW during Cycle 1, Q3W during Cycles 2-9, and Q4W during Cycles 10+). Results: The study included 211 ≥75 y (104 D-VMP; 107 VMP) and 495 <75 y (246 D-VMP; 249 VMP) patients. After median follow-up of 16.5 months, PFS was prolonged with D-VMP vs VMP in both the ≥75 y (median not reached [NR] vs 20.4 months; HR 0.53; 95% CI 0.32-0.85) and <75 y (median NR vs 17.9 months; HR 0.49; 95% CI 0.36-0.68) patients. ORR and ≥CR rates were consistently higher for D-VMP vs VMP in ≥75 y (ORR: 88% vs 70%; ≥CR: 41% vs 24%) and <75 y (ORR: 92% vs 76%; ≥CR: 43% vs 25%) patients. Minimal residual disease–negative rates (10–5 threshold) also increased with D-VMP vs VMP in ≥75 y (24% vs 8%) and <75 y (22% vs 6%) patients. Rates of the most common (≥10%) grade 3/4 TEAEs, peripheral sensory neuropathy, and infections are listed (Table). Conclusions: Efficacy and safety of D-VMP vs VMP in patients ≥75 y of age were consistent with the overall study population.
≥75 y <75 y
Grade 3/4, % D-VMP VMP D-VMP VMP
Most common TEAEs Neutropenia 52 42 35 38 Thrombocytopenia 51 43 28 35 Anemia 24 23 13 19 Leukopenia 13 9 6 9 Lymphopenia 10 10 7 4 Pneumonia 18 9 9 2 Peripheral sensory neuropathy 0 6 2 3
Infections 28 20 21 13
007. Overall survival with carfilzomib/dexamethasone (Kd56) versus bortezomib/dexamethasone (Vd) by prior line of therapy and previous exposure to bortezomib
Ho P1, Weisel K2, Siegel D3, San Miguel J4, Hajek R5, Gaidano G6, Orlowski R7, Zhou L8, Kimball A8, Moreau P9
1Institute of Haematology Royal Prince Alfred Hospital, Camperdown, Australia, 2Universitatsklinikum Tubingen, Tubingen, Germany, 3John Theurer Cancer Center, Hackensack University Medical Center , Hackensack, USA, 4Clinica Universidad de Navarra, University of Navarra , Pamplona, Spain, 5Department of Haematooncology, University Hospital Ostrava , Ostrava, Czech Republic, 6Division of Hematology, University of Eastern Piedmont , Novara, Italy, 7The University of Texas MD Anderson Cancer Center, The University of Texas, Houston, USA, 8Amgen Inc., Thousand Oaks, USA, 9Hematology Department, University of Nantes , Nantes, France
Background: In the ENDEAVOR overall survival (OS) analysis, median OS was significantly longer with Kd56 versus Vd. Here, we present OS and safety analyses comparing Kd56 with Vd according to prior lines of therapy and previous exposure to bortezomib. Methods: Full details of the study design have been presented elsewhere. The Kaplan-Meier OS rate and median OS time were estimated up to the time point where there were ≤10 patients (Kd56 and Vd combined) in the risk set. The study was not powered to detect differences in OS between subgroups. Adverse events (AEs) are presented as preferred terms and were not adjusted for exposure. Results: Patients were randomized to receive Kd56 (n=464) or Vd (n=465). The proportion of patients with 1 (Kd56, 49.8%; Vd, 49.2%) or 2-3 (Kd56, 50.2%; Vd, 50.8%) prior lines of therapy was balanced between the treatment arms. The proportion of patients with prior exposure to bortezomib was also balanced between the Kd56 and Vd arms (54% in each arm) and within the subgroups of patients with 1 prior line (Kd56, 42.0%; Vd, 42.8%) and 2–3 prior lines of therapy (Kd56, 65.7%; Vd, 65.3%). Survival outcomes and rates of grade ≥ 3 adverse events of interest by prior treatment are shown (Table). Conclusions: Treatment with Kd56 showed a survival benefit compared with Vd in patients with RRMM irrespective of the number of prior lines of therapy and previous exposure to bortezomib. Kd56 reduced the risk of death by 17% (1 prior line) and 24% (2–3 prior lines). Kd56 prolonged PFS by 7.5 months and OS by 14.8 months vs retreatment with bortezomib in proteasome inhibitor-sensitive patients. The rate of AEs in this subgroup analysis was consistent with that reported in the overall population. Moreover, no unexpected safety events occurred during longer follow-up.
008. ACTN1-related macrothrombocytopenia: an Australian experience using NGS and diagnostic biomarker to confirm pathogenicity
Takagi Y1, Chen Q1,2, Rabbolini D1,2, Zhu Y1, Joseph J3, Crispin P4, Bennett A5, Stevenson W1,2, Ward C1,2, Morel-Kopp M1,2
1The University of Sydney, St Leonards, Australia, 2Royal North Shore Hospital, Sydney, Australia, 3St Vincent Hospital, Sydney, Australia, 4Canberra Hospital, Canberra, Australia, 5Monash Pathology, Melbourne, Australia
Introduction: Autosomal dominant macrothrombocytopenia due to abnormality of α-actinin-1 (ACTN1) has recently been described; but confirming the pathogenicity of a genetic change remains a diagnostic challenge.
Aim: To assess the pathogenicity of ACTN1 genetic variants in Australian macrothrombocytopenic patients using an in vitro cytoskeletal model. Informed consent was obtained and the study was approved by relevant ethics committee.
Methods: Targeted gene sequencing of 47 genes important for platelet formation and function was performed in 221 individuals from 162 families; 47 (21.3%) had macrothrombocytopenia. To determine the pathogenetic role of identified ACTN1 variants, CHO cells were transfected with Myc-tagged wild-type or “mutant” ACTN1 and spread onto fibronectin coated slides before being fixed, permeabilized, and stained with fluorescent anti-c-Myc antibody, phalloidin and DAPI for imaging.
Results: Three novel heterozygous ACTN1 missense variants were identified by targeted sequencing and confirmed by Sanger sequencing. Two variants (c.127T>A,p.Ser43Thr; c.384G>T,p.Trp128Cys) were located within the actin-binding domain (ABD), and one variant (c.2108A>G,p.Asn703Ser) was located in the spectrin-like repeats region. By immunofluorescence, CHO cells transfected with wild-type ACTN1 or 703Ser variant showed well-organized, finely stretched actin filaments with high level of ACTN1 colocalisation. By contrast, CHO cells expressing ACTN1 ABD variants (43Thr and 128Cys) showed shorter and thicker filaments consistent with disorganisation of the actin filament network by the abnormal ACTN1 molecules.
Conclusion: Using immunofluorescence in an in vitro model as a diagnostic biomarker, we concluded that the 703Ser variant, located outside of the functional domains of ACTN1, was likely benign. By contrast, the two variants in the ACTN1-ABD domain impaired the actin filament organization, suggesting those variants are likely pathogenic and responsible for the macrothrombocytopenia. The individuals carrying those two variants are the first cases of ACTN1- related macrothrombocytopenia identified in an Australian population.
009. Fibrinolysis and Innate Immunity at play: Complement C5a receptor inhibition reduces tissue plasminogen activator (t-PA) and plasminogen (Plg)-induced blood brain barrier (BBB) opening in vitro
Keragala C1, Woodruff T2, Niego B3, McQuilten Z4, Medcalf R1
1Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia, 2School of Biomedical Sciences, University of Queensland, Brisbane, Australia, 3NanoBiotechnology
Research Group, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia, 4Transfusion Research Unit and Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
Aim The relationship between fibrinolysis and innate immunity is evident in the increased BBB permeability induced by t-PA and Plg, which can trigger CNS infiltration by immune cells. Although Rho-Kinase 2 (ROCK-2) signalling plays an important role here, the pro-inflammatory properties of plasmin, including C3 and C5 convertase activity, led us to hypothesise that plasmin mediated BBB permeation may in part be driven by complement activation. We aimed to characterise the effects of targeted complement inhibition on this phenomenon using in vitro BBB models. Synergy experiments evaluated added effects of antifibrinolytic, Tranexamic acid (TXA), and selective ROCK-2 inhibitor (KD025). Methods In vitro models of the BBB were assembled on porous membranes of Transwell inserts either as a monolayer of human brain endothelial cells (hBECs) (Model 1) or in co-culture with SVG human immortalised astrocytes (on abluminal membrane surface; Model 2) (Fig. 1). The in vitro BBB was stimulated with t-PA+Plg in the presence or absence of complement fragment 5a receptor 1 inhibitor (PMX205). BBB permeability was assessed 4hr post- stimulation by evaluating fluorescent tracer passage from luminal to abluminal chambers over 1hr. Permeability changes were calculated relative to a control model without stimulation. Results PMX205 blocked permeability increases in stimulated hBECs monocultures, most notably at 100μM (p<0.01). PMX205 effect was comparable to KD025, which served as a positive inhibition control (p<0.01) (Fig. 2). Greater BBB protection by PMX205 and synergistic action with…
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