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Abstract Background: Obesity is a prevalent health problem and significant heterogeneity is seen in the body weight and BMI among adult patients undergoing autologous stem cell transplantation (SCT). At least two critical steps of the SCT are influenced by the body weight. Stem cell collection targets are usually determined based on the actual body weight and conditioning chemotherapy doses are usually determined based on corrected ideal body weight. One could hypothesize that since the stem cells home to bone marrow, the ideal body weight (IBW) being based on the height may be a better indicator of the stem cell numbers required rather than the actual body weight (ABW). Since chemotherapy doses are calculated based on corrected ideal body weight, and the volume of distribution is higher in obese patients, these patients may have decreased drug exposure and hence a higher risk of progression. Methods: We retrospectively evaluated the engraftment kinetics and response outcome of 306 SCTs done at our institution between March 1998 and October 2001. These included patients who had undergone SCT for multiple myeloma (46%), NHL (34%), HD (6%) and AL amyloidosis (14%). Body weight, height, stem cell dose and engraftment data was obtained from medical records. The stem cell dose received was calculated based on their ABW as well as IBW and correlated with the time to white cell and platelet engraftment. We also evaluated the effect of BMI on the progression free survival after the stem cell transplant using various cut offs. Results: The mean (range) for the ABW, IBW and BMI were 46.6 kg to 189 Kg; 45.5 kg to 94 kg; and 17.5 to 55.8 respectively. Using logistic regression, we estimated the ability of CD34 cell dose by actual and ideal body weight to predict the likelihood of platelet engraftment (50,000) by day 21 post transplant. The coefficients using both the doses were very similar (.391 for ideal and 0.361 for actual). Using Receiver operating characteristic analysis (ROC analysis); we determined the stem cell dose cutoff that best predicted for failure to engraft neutrophils by 21 days post transplantation, median CD34 dose by ABW of 3.6 million/Kg and by IBW of 4.2 million/Kg. Similarly, for failure to engraft platelets by day 30 the cutoffs were 2.89 million/Kg by actual weight and 3.77 million/kg by ideal weight. Among the individuals with actual body weight more than 25% of ideal body weight (n=122, 40%), we calculated the optimal total CD34 dose required and compared to the actual dose infused using both the cutoff sets (286 million vs. 446 million, P < 0.001 using ANC cutoff and 251 million vs. 446 million using the platelet cutoff, P < 0.001). We then examined the effect of BMI on progression free and overall survival from transplant. The progression free and overall survival post transplant was similar for patients with BMI over 30 kg/m2 compared to those below this cutoff. There was no difference when patients with myeloma or lymphoma were studied separately. Conclusion: This study, as in previous studies, confirms that stem cell dose determined on the basis of ideal body weight is comparable to that by actual body weight in terms of engraftment kinetics. In patients significantly above the ideal body weight, it is reasonable to use a target based on ideal body weight which will allow for collection of less numbers of CD34 cells, thus conserving resources. Among patient undergoing stem cell transplant, the practice of using corrected ideal body weight does not appear to compromise the outcome of stem cell transplant.

Abstract Introduction L-asparaginase therapy results in systemic depletion of antithrombin (AT) and fibrinogen (FG), resulting in thrombotic (TE) and hemorrhagic events (HE). Prophylactic correction of coagulation disturbances have been inconclusive with regard to cost effectiveness, and specifically cost effectiveness of antithrombin concentrate (ATC) replacement has not been evaluated. (Abbott et al, 2009, Mitchell et al, 2003). Currently, AT repletion is recommended for levels less than 60%. (Stock et al, 2012) Several treatment protocols with distinctly different L-asparaginase (LAS) or pegaspargase (PEG) doses complicate the frequency and intensity of ATC replacement. We carried out this study to evaluate the cost effectiveness of ATC replacement, based on our institutional practice. Methods This single center, retrospective, observational study was approved by the Institutional Review Board and conducted at Mayo Clinic, Rochester, MN. Consecutive adult patients with a confirmed diagnosis of ALL receiving LAS or PEG between January 2000 and October 2012 were evaluated. Patients with hereditary or acquired thrombophilias or pre-existing TE or HE, were excluded. Per institutional guidelines, ATC was administered if levels were less than 70%. The Centers for Medicare & Medicaid (CMS) single drug historical pricing guide was utilized for 2000-2004. ATC cost beginning January 1, 2005, was derived from the CMS average sales price, reported quarterly. To adjust for price differences due to regimen utilization trends, each dose was also calculated at the final 2012 cost of 3.05/unit. ATC repletion practices and estimated expenditures were compared between regimens. Results Fifty four patients were treated with LAS or PEG containing regimens. Of these, 47 (87%) received ATC. Twenty-eight patients received LASP, 22 received PEGASP and 4 received both. Distribution across protocols was; CALGB 9111 (n=20, Larson et al, 1998), E2993 (n=13, Goldstone et al, 2008), C10403 (n=9, NLM: NCT00558519), CCG 1941 (n=7, Gaynon et al, 2006) and Augmented HyperCVAD (n=5, Faderl et al, 2005). PEG and LAS dosing schemes are outlined in table 1 . LAS doses were converted to PEG upon specific protocol revision or at discontinuation of LAS availability in 2012. Regimens specified a dose cap with the exception of C10403. A total of 399 LAS and PEG doses resulted in 378 instances of ATC repletion. The reimbursement price of ATC in 2000 was estimated at 1.50/unit U.S. dollars (USD) and 3.04/unit USD by the fourth quarter of 2012. The total estimated average sales price was 2,471,745 USD over the study period. C10403 resulted in the highest median number of PEG doses per patient (n = 5) and a median of 17 ATC doses per dose of PEG. This resulted in C10403 being the most expensive regimen with the median expense for ATC replacement being 118,064 USD (chart 1). This conclusion was also seen after comparing different regimens using the most recent 2012 cost estimates. The overall incidence of TE or HE was 17% and equally distributed between regimens (please see accompanying abstract). Conclusions Repletion of ATC in patients receiving asparaginase containing chemotherapy regimens is very expensive and continues to add to costs at many centers, without clear benefit, especially with regards to TE and HE. A prospective, randomized, multicenter clinical trial looking to answer this question is the need of the hour. Disclosures: No relevant conflicts of interest to declare.

Abstract Background Chronic myelomonocytic leukemia (CMML) is a clonal hematologic disorder that was classified by the World Health Organization (WHO) as a myelodysplastic/ myeloproliferative overlap disease. Cytogenetic abnormalities have a significant prognostic role in many hematologic neoplasms, but their prognostic value in CMML has been debatable. Recently, monosomal karyotype (MK) has been reported to be a marker of poor prognosis in patients with myelodysplastic syndromes (MDS) and primary myelofibrosis, but its value in CMML is unknown. Aim To study MK effect on clinical outcome for patients diagnosed with CMML Method A retrospective study of all cases diagnosed with CMML at Mayo Clinic Rochester between 1994 to 2011 was performed. Only pts with complete cytogenetic analysis at presentation to our institution were included. MK was defined as the presence of ≥ 2 autosomal monosomies or one autosomal monosomy with at least one structural abnormality (Breems et al, JCO 2008). CK was defined as the presence of at least 3 chromosomal abnormalities. Appropriate IRB approval was obtained in accordance with Helsinki declaration. Comparison between groups’ medians was done using Wilcoxon test, while survival estimates were calculated using Kaplan-Meier curves using JMP V9. Results A total of 262 pts diagnosed with CMML had available cytogenetic data at diagnosis. Median age was 72 years, 176 (67%) were male. Median hemoglobin 10.5 g/dL, white blood cells (wbc) 12 x109/L, platelet 89 x109/L, peripheral blood (PB) blast 0, and bone marrow (BM) blast 4%. CMML2 was seen in 9% while 47% were proliferative (wbc >13). Leukemic transformation was documented in 34 pts (13%). Median overall survival was 513 days. Cytogenetic (CG) analysis was diploid in 167 pts (64%). Trisomy 8 was the most frequent cytogenetic abnormality at 8% (22), followed by complex karyotype (CK) 5% (14), then -7 at 4% (10) and MK 3% (7, six of which were also CK). Comparing pts with diploid CG to other categories indicates: to abnormal CG pts had lower wbc (0.001), PB blasts (p<0.0001), and BM blasts (p=0.0001); to CK pts had lower PB blasts (p=0.003) and higher platelets (p=0.03); to -7 pts had lower wbc (p=0.005), PB blast (p=0.0004), BM blasts (p=0.03) and higher platelets (p=0.03); to +8 pts had lower PB blast (p=0.02) and BM blasts (p= 0.01); no difference was noted when compared to MK. Median OS was statistically significantly worse in MK+ vs MK- (24 vs 527 days, p= 0.002), but not in other comparisons: -7 vs others (250 vs 527 days, p=0.2), CK+ vs CK- (256 vs 527 days, p=0.05), diploid vs others (570 vs 365 days, p=0.1), +8 vs others (312 vs 527 days, p=0.1). Pts with MK+ only or MK+CK+ did worse than CK+ only or other groups (4, 63, 304, 527 days, respectively, p<0.0001). On a multivariate analysis, MK+ (in addition to platelet, BM blast, hemoglobin, and wbc) did have an impact on OS (p=0.0004), while CK+, -7, +8, diploid CG, age, PB blast did not. Conclusion Cytogenetic abnormalities were not frequent findings in pts diagnosed with CMML (36%), but did affect wbc, PB and BM blasts. The most common cytogenetic abnormality was +8 while MK was present at 3% (less than published data in MDS). Only MK predicted statistically significant shorter mOS between all other cytogenetic categories on both univariate and multivariate analysis. This finding needs to be validated by larger cohorts of pts due to its rare occurrence in CMML. Disclosures: No relevant conflicts of interest to declare.

Abstract Abstract 1178 Poster Board I-200 Background: High-dose chemotherapy with autologous peripheral blood stem cell transplantation (PBSCT) has been shown to be of value in selected patients with malignant lymphoma and multiple myeloma (MM). Both granulocyte macrophage colony stimulating factor (GMCSF) and granulocyte colony stimulating factor (GCSF) are widely used following stem cell transplantation to support accelerated myeloid recovery and potentially shorten hospital stay. In the recent years, PBSCT is increasingly done in an ambulatory care setting and it is not clear if routine growth factor use has any potential benefit. We undertook this study to compare engraftment kinetics, incidence of febrile episodes, hospitalization duration and other outcomes among transplants done with or without growth factor support Patients and Methods: We included adult patients undergoing PBSCT for myeloma and lymphoma between May 2007 and June 2009 in an ambulatory care setting. Prior to April 2008 (Group-1) all patients received GMCSF 500 mcg/ day starting on day 6 routinely. Since April 2008, there was a shift in clinical practice and routine use of GMCSF was discontinued due to lack of clear evidence regarding benefit. Patients transplanted between April 2008 and June 2009 did not routinely receive GMCSF (Group-2). Typical conditioning regimen for lymphoma was BEAM (BCNU, Etoposide, Cytosine Arabinose, Melphalan) and for multiple myeloma was melphalan 200mg/m2. Patients' demographics details, indication for PBSCT, duration of neutropenic fever, hospital stay, and neutrophil and platelet engraftment were collected from electronic medical records. Neutrophil engraftment is defined as the first day of 2 consecutive days when ANC was > 0.5 × 109/L and platelet engraftment is defined as first of 7 consecutive days on which patient's unsupported platelet count was greater than 20× 109/L. Results: A total of 309 were included in this study, 126 (40%) patients in group-1 (69 with MM, 57 with lymphoma) and 183 (60%) in group-2 (100 with MM, 83 with lymphoma). In group-1, 73 (58%) and in group-2 130 (71%) were male patients. Median age was 59 (29-74) years in group 1 and 58 (24-76) years in group-2. Patients in group 1 received a median of 3.65 (1.1-8.7) versus 4.37 (1.1-9.54) CD34+ x106/kg in group 2 (P =0.005). Median time to neutrophil engraftment was 12 (95% CI 12, 12) for group-1 and 14 (95% CI; 13-14) for group-2 (Kaplan Meier analysis; log rank P < 0.0001). Median estimated time to platelet engraftment was 14 days (95% CI; 13, 15) for group 1 and 13 days (95% CI; 13-13) for group 2 (Kaplan Meier analysis; log rank P 0.007). In group-1 98 (78%) patients developed febrile episodes compared to 117(64%) in group-2 (P = 0.009). Median duration of fever was 2 days (range, 1-8) in group-1 compared to 1 day (range, 1-8) in group-2 (P = 0.0003). The median (range) duration of hospital stay was 7 (1-40) days for group-1 compared to 8 (2-56) days for group-2 (P=NS). There was no significant difference in mortality between these two groups. Conclusion: Routine use of granulocyte growth factors is associated with a shorter time to neutrophil engraftment, but associated with a delay in platelet engraftment. The longer time to neutrophil engraftment without growth factor use does not translate into any increase in frequency of febrile episodes. On the contrary, higher number of febrile days is seen with use of growth factors, likely explained on the basis of drug fever. No difference in the frequency of engraftment syndrome or treatment related mortality was seen. Disclosures: No relevant conflicts of interest to declare.

Abstract BACKGROUND: We have previously reported on the therapeutic value of low-dose thalidomide in combination with prednisone (THAL-PRED) for the treatment of both anemia and thrombocytopenia in MMM (Blood2003;101:2534), with response rates of 62% and 75% for each cytopenia respectively. Alkylators have long been shown to have palliative benefit in MMM, however are used judiciously as long-term use could increase likelihood of leukemic transformation. Additionally, oral cyclophosphamide has been shown to synergize with thalidomide and steroids in the treatment of myeloma (Garcia-Sanz et. al. Leukemia2004;18:856–863). In the current study, we investigated the value of adding oral cyclophosphamide to THAL-PRED for MMM (TPC). METHODS: Study eligibility criteria included a histologically confirmed diagnosis of MMM and either severe anemia (hemoglobin < 10 g/dL) or symptomatic splenomegaly. Protocol treatment was initiated with 50 mg of oral thalidomide (THAL) daily, oral cyclophosphamide (CTX) 25 mg daily for three months, and a three month prednisone taper starting at 0.5 mg/kg/day for the first month followed by a 50% reduction for the second months and a further 50% reduction for the third and final month of treatment with prednisone. Patients with a demonstrable clinical response after three months were able to remain on thalidomide alone as maintenance. Responses were assessed by the International Working Group for Myelofibrosis Research and Treatment (IWG-MRT) criteria for MMM clinical responses (Tefferi et. al. Blood 2006; epub May 2006). RESULTS: 13 patients were enrolled to the trial (median age 73 years, range, 46–80; 7 males). Six patients (46%) completed the planned three cycles (i.e. 12 weeks) of treatment, the remaining seven patients discontinued treatment early for the following reasons: progression (n=3), patient choice (n=2), other medical problem (n=1) and died on study (n=1). After the initial 3 months of treatment, 3/13 (23%) patients evidenced a response (n = 1) or stable disease (n = 2) and continued on an additional three months of THAL alone. At enrollment, nine patients (69%) were anemic (8 of whom (62%) were red cell transfusion dependent). Ten patients (77%) were at least moderately thrombocytopenic (platelet count < 100 x 109//L). Eight patients (62%) had palpable hepatomegaly/splenomegaly, and five patients (38%) had severe constitutional symptoms (night sweats). According to IWG-MRT criteria for MMM the best responses observed from therapy was a CI (clinical improvement) in 2 individuals (one each for anemia (1/9 patients (11%); and thrombocytopenia (1/10 patients (10%)). No clear responses in organomegaly or constitutional symptoms were observed. The regimen overall was well tolerated with toxicities in excess of grade 2 all being related to myelosuppression (anemia (n=2), neutropenia (n=2), and thrombocytopenia (n=3)). CONCLUSIONS: This phase II study of combination therapy with thalidomide-prednisone-cyclophosphamide in patients with MMM strongly suggests that the addition of the alkylator cyclophosphamide largely negates the clinical benefits of THAL-PRED. This observation supports the potential immunologic mechanism of THAL-PRED benefit in MMM, and cautions against potential combinations of immunological and cytotoxic therapy in this disorder.

Abstract Background: Treatment-related AML (t-AML) accounts for 10 to 20% of all AML cases and carries an especially poor prognosis (Kayser et al. 2011, Godley et al. 2008). Patients diagnosed with t-AML are likely to have abnormal cytogenetic profiles with chromosome changes that are predictive of an aggressive malignancy, poor response to therapy, and decreased overall survival(Smith et al. 2003). The simultaneous use of multiple chemotherapeutic agents of different classes makes it increasingly difficult to predict risk for developing t-AML and determining disease course. An updated analysis of predictive factors for t-AML is needed so clinicians can more accurately inform patients of their prognosis. The aim of this study was to classify t-AML according to primary malignancy, previous chemotherapy exposure, and cytogenetic profile. Methods: A retrospective chart review of patients that were diagnosed with AML at Mayo Clinic from 7/1/1990 to 5/13/2015 was performed following IRB approval. AML patients found to have a previous malignancy treated with chemotherapy were classified as t-AML. Chemotherapeutics were classified as alkylating agents, antimetabolites, anti-tubulin agents, and topoisomerase II inhibitors. Patients diagnosed with a myelodysplastic or myeloproliferative disorder prior to development of AML were excluded from this study. Previous chemotherapy exposures, duration of chemotherapy exposure, complete blood count, chromosome abnormalities, and survival data were collected for t-AML cases. Cytogenetic changes were classified as favorable, intermediate, and adverse according to the system used by Kayser et al. 2011. JMP 10.0 was used for statistical analysis. Results: Out of 584 patients, 64 patients (11%) had a primary malignancy that was treated with chemotherapy prior to being diagnosed with AML. The most common primary malignancies were breast cancer (31%), non-Hodgkin lymphoma (27%), colorectal cancer (8%), and Hodgkin lymphoma (8%). Laboratory findings showed median hemoglobin 9.6 g/dL (4.7-13.8), median white blood cells 3.2 x109 (0.6-126), median platelets 50x109 (3-320), median peripheral blood blasts of 8% (0-91), and median bone marrow blasts 38% (1-94). 95% of patients diagnosed with t-AML had been previously treated with an alkylating agent. Additional exposure to an anti-metabolite trended towards a more adverse cytogenetic profile (χ2=5.0, p=0.08) but there was not a statistically significant decrease in overall survival (KM analysis, p=0.31). The median overall survival for patients diagnosed with t-AML was 10.2 months compared to 19.2 months for patients with de-novo AML (KM analysis, p=0.04). Adverse cytogenetic profiles were associated with decreased survival (KM analysis, p <0.0001). However, there was no difference in overall survival between patients with t-AML that had intermediate cytogenetics and those with de-novo AML (KM analysis, p=0.36). None of the chemotherapy classes other than antimetabolites were associated with poor cytogenetics or survival when combined with an alkylating agent. Conclusion: Over half of all patients classified as having t-AML in this study received prior chemotherapy for breast cancer or non-Hodgkin lymphoma. Cytogenetic classification of t-AML into favorable, intermediate and adverse groups is useful in predicting disease course. Interestingly, t-AML patients with intermediate risk cytogenetics had similar overall survival to patients with de-novo AML. This suggests that the poor outcomes observed in patients with t-AML is predominantly due to the subset with adverse cytogenetics. Thus, cytogenetic analysis remains the best indicator of overall survival regardless of chemotherapy exposure. Additional work is needed to delineate the risk associated with the aforementioned chemotherapy classes. Disclosures Al-Kali: Celgene: Research Funding.

Abstract Introduction: Disease relapse remains one of the major causes of treatment failure in hematopoietic stem cell transplant (HSCT) following reduced-intensity conditioning (RIC) regimens. Donor chimerism assessment early after HSCT may help identify patients at risk for relapse who may benefit from additional therapeutic interventions but its precise role in this setting is unclear. In addition, the differential impact of conditioning regimen is not well studied. Aim: 1. Study the impact of early full T-lymphocyte chimerism (T-lymphocyte chimerism ≥ 90% on day 30 to 60) on relapse incidence (RI) and acute graft versus host disease (aGVHD) in patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) following RIC-HSCT. 2. Looking at the tempo of achievement of complete donor T-lymphocyte chimerism based on the two most common RIC regimens, Fludarabine/Melphalan (FM) and Fludarabine/Busulfan (FB). Method: After IRB approval, patients with AML or MDS who underwent RIC-HSCT with FB or FM between 2008 and 2014 at our institution were identified. Post-transplantation CD3 (lymphocyte) and CD33 (myeloid) donor chimerism were measured per protocol using PCR-based analysis of short tandem repeats. Categorical and continuous variables were analyzed using Pearson's chi-squared and Wilcoxon / Kruskal-Wallis, respectively. Survival estimates were calculated using the Kaplan-Meier and log-rank test. RI was estimated accounting NRM on a competing event analysis using Grey's model. Cox proportional regression was used to compute hazard ratios (HR). Results: Baseline characteristics: Out of 134 patients who received FM or FB, 75 patients had evaluable early sorted chimerism data. 42 and 33 patients received FB and FM, respectively. Patient, disease and transplant variables were balanced in both FM and FB (Table 1). The median follow up of the cohort was 37 months (2.4-43) and at last follow up 29.1% of patients relapsed and 59% died. All patients achieved early complete myeloid chimerism whereas T-lymphocyte chimerism was complete in 50 patients and mixed in 25 patients. Characteristics of early lymphocyte chimerism by status are shown in table 1. Notably, likelihood of achieving complete T-lymphocyte chimerism ≥ 90% at 60 days was 100% versus 47% in FM and FB respectively (p <0.0001). Acute graft versus host disease: There was no significant difference in incidence of grade II-IV aGVHD between patients with full early donor T-lymphocyte chimerism in comparison to those with early mixed donor chimerism (46% vs. 48%, p =0.87). Impact of full chimerism and conditioning regimen on RI and overall survival (OS): Among the entire cohort, patients achieving early full T-lymphocyte chimerism had a significantly lower RI compared to those with mixed chimerism with a HR of 0.38 (CI 0.14-0.97; p=0.044) but OS was not significantly different with HR 0.69 (CI 0.33-1.51; p=0.34). In patients conditioned with FB, there was no difference in 2-year RI between complete or mixed early T-lymphocyte chimerism at 38.2% and 40.7% respectively (p = 0.9). After FM conditioning, all patients achieved early T-lymphocyte chimerism and the 2-year RI was 6.9%. Achievement of early complete lymphocyte chimerism post FB in comparison to FM was associated with significantly higher risk of relapse (HR 8.6 CI 2.07-57, p=0.0025). Furthermore, there was a trend towards worse OS with FB vs. FM with a median of 23 vs. 44 months, respectively (p = 0.058). Conclusion: Similar to prior reports, we observed that full T-lymphocyte chimerism is associated with decreased relapse risk without an increase in aGVHD. Our findings also suggest that RIC with FM yields a higher incidence of early complete T-lymphocyte chimerism and is significantly associated with decreased risk of relapse compared to FB. There was a greater risk of relapse in the FB group, even among those achieving early complete donor lymphoid chimerism. This needs further validation given the small sample size. Figure 1. Figure 1. Disclosures No relevant conflicts of interest to declare.

Abstract Background: Haploinsufficiency of GATA2 results in familial immunodeficiency and MDS/ AML. We identified a family with a novel c1339A>C, pS447R germline GATA2 mutation. Unlike most other disease-causing GATA2 mutations, this mutation occurred in the non-zinc finger domain. Methods: After due IRB approval, clinical and laboratory data were retrospectively abstracted. Results: Seven family members with the mutation are being followed at our institution. (Table 1), of whom two have MDS, one MDS/AML and one with isolated neutropenia. At the time of diagnosis 5/7(71%) pt had decreased monocyte count. 4/7(57%) patients had decreased NK cell count and/or function. Only 1/7(14%) patient had decreased CD4 count. 3/7(42%) patients had reduced B cell numbers and 5/7(71%) patients had persistent HPV warts. Other infections include invasive Absidia sinusitis, infectious mononucleosis, pertussis, and blood stream infections with S. maltophilia and S.aureus. One patient had the Emberger's syndrome presenting with lymphedema and congenital pulmonary stenosis. Pulmonary manifestation included a patient each with decreased DCLO and hyperreactive airway disease. Genitourinary manifestations included pelvic kidney/dysplastic kidney, posterior urethral valve, dermoid cyst and hydrocele. Two female patients developed primary infertility. One patient had a history of appendicular carcinoid. 4/7(57%) patients have successfully undergone allogenic stem-cell transplantation. Conclusion: Germline GATA2 mutations are associated with a high frequency of MDS/AML. We describe a family with a non-zinc finger GATA2 mutation causing MDS/AML, with a spectrum of hematological and non-hematological manifestations, once again, highlighting the heterogeneity of this syndrome and expanding the genotype-phenotype correlation in this disease. Abstract 5614. Table#Age/sexHemDAbso . MonoCount Abso. CD4 TCellNK cyto-toxicityAbso. NK CountAbso.B cell CountInfectiousDermCoag/VascularCVS/LungOthersNo.137/MAMLSeverely DecreasedNormalAbsentSeverely DecreasedAbsentAbsidia S.maltop- hilia S.aureusHPV WartsITP -Hydrocele 10 hyperparathyroidismNo.231/FMDSDecreasedNormalAbsentDecreasedNormalInfectious MonoHPV Warts-Hyper- reactive airwayInfertilityNo.317/FMDSSeverely DecreasedNormalUnknownDecreasedDecreasedHerpes stomatitisHPV Warts-Dec-DCLOPosterior urethral valveNo.49/MNeutropeniaSeverely DecreasedNormalNormalNormalNormalHSV-1HPV Warts Embergers syndrome Pul. Stenosis Congenital dysplastic Rt. Kidney Pelvic Lt. KidneyNo.531/F-DecreasedNormalDecreasedNormalNormal- -Qualitative platelet defectNoneInfertilityNo.635/F-NormalNormalDecreasedDecreasedDecreasedPertussisHPV Warts--Dermoid appendicular carcinoid No.756/F-NormalNormalNormalNormalNormalFrequent PNA---- Disclosures No relevant conflicts of interest to declare.

Abstract BACKGROUND: Complement-mediated thrombotic microangiopathies (TMAs) are a subset of TMAs in which the thrombocytopenia, microangiopathic hemolytic anemia, and end organ damage are caused by mutations in genes encoding the alternative complement pathway. Numerous complement genes have been implicated in complement-mediated TMAs including complement factor H (CFH), CD46 (MCP), complement factor I (CFI), complement component 3 (C3), complement factor B (CFB), factor H related 5 (CFHR5), and thrombomodulin (THBD) among others. Genetic analysis typically yields a mutation in 60% of patients whose TMA is presumed to be mediated by complement dysregulation. However, the description of novel disease-associated variants may increase this proportion. METHODS: A retrospective study of patients with TMAs diagnosed between 2000 and 2014 was performed. TMA diagnosis was made based on thrombocytopenia and evidence of microangiopathic hemolytic anemia. Analysis was performed with Alamut¨ software with additional in silico prediction tools (SIFT, MutationTaster, and Polyphen) for classification of gene variants. Variants of unknown significance (VUS) and likely pathogenic variants were further assessed using several mutation databases, including HGMD, ClinVar, and Factor H database RESULTS: Of patients diagnosed with a TMA, genetic analysis was performed in only a 10% of patients. Of the 29 patients with genetic studies performed, mutations were identified in 18 patients (62%). The majority of the mutations had been described previously in the literature, but four novel variants were identified: three missense and one splice-site. The table below summarizes these variants as well as laboratory findings on presentation. These were two variants of CFH, one variant of CFHR5, and one variant of CFI. In silico modeling of these variants revealed two polymorphisms likely to be pathogenic, one polymorphism likely benign given the lack of predicted splicing changes, and one VUS. Table 1. Protein Mutation Classification Age Sex Hemoglobin (g/dL) Platelets (thousands) Creatinine (mg/dL) CFH c.245-10_245-9dup Likely benign 61 F 11.6 51 6.7 CFH c.476G>A, p.Ser159Asn Likely pathogenic 43 F 9.1 101 9.1 CFHR5 c.1412G>A p.Gly471Glu Likely pathogenic 30 F 9.8 129 4.9 CFI c.1190T>A p.Val397Glu Unknown significance 51 M 9.4 125 6.1 DISCUSSION: With therapy available to target the alternative complement pathway, genetic analysis to identify genetic variants capable of causing complement mediated TMAs is an essential part of the evaluation. This genetic data must be interpreted and correlated with functional analysis and clinical phenotype. The reporting of novel variants in clinical databases, with inclusion of relevant clinical findings, is necessary to accurately classify and verify variants as pathologic mutations or benign polymorphisms. The full understanding of this diverse disease requires a more complete understanding of its genetics. While complement pathway-directed therapies are available, their rational use requires thorough interpretation of laboratory data, including genetic analysis. Disclosures Murray: Mayo Clinic: Patents & Royalties: Patent Application Filed.

Abstract Background The impact of cytomegalovirus (CMV) infection on the risk of relapse after Hematopoietic Cell Transplantation (HCT) remains controversial, with some studies demonstrating lower risk (Green et al, Blood 2013), while others demonstrating no impact (Schmidt-Hieber et al, Blood 2013), or lower relapse risk only in myeloablative (MA) (Manjappa et al, BBMT, 2014) or in reduced intensity conditioning (RIC) (Cichocki et al, ASH 2014) HCT. Furthermore, the majority of studies have used antigenemia for CMV monitoring, while there is limited data with the use of Quantitative Nucleic Acid Testing (QNAT). Aim To determine the impact of CMV infection, as detected by QNAT, on transplant-related outcomes for patients with acute myeloid leukemia (AML), stratified by MA or RIC HCT. Methods After IRB approval, consecutive adults with AML who underwent allogenic HCT from HLA-matched peripheral blood (PB) grafts at our institution between 2006 and 2014 were retrospectively reviewed. All grafts were T-cell replete. Early CMV infection was defined as any positive CMV result by PCR assay during the first 100 days post HCT. Relapse incidence (RI), non-relapse mortality (NRM), disease-free survival (DFS), and overall survival (OS) were compared between patients with and without CMV infection, and stratified according to MA or RIC. DFS and OS were estimated using the Kaplan-Meier method, and compared with log-rank test. Cumulative incidence of relapse and NRM were analyzed as competing events, using Gray's test. Multivariable analyses adjusting for patient's age, disease status at transplant, cytogenetic risk, and ABO incompatibility were performed using Cox's proportional hazards regression, and the Fine and Gray approach. Results A total of 190 consecutive patients, including 94 (49%) MA and 96 (51%) RIC HCT were analyzed. Patients, disease, and transplant characteristics are shown in table 1. Of the 94 MA HCT (median age 45 y, 50% male), 66 (70%) received total body irradiation. After a median follow up of 18 m, 36 (38%) CMV infection, 16 (17%) relapses, 22 (23%) NRM and 35 (37%) deaths occurred in the MA group. Median time to CMV infection and to relapse in this group was 38 (range 8-241) and 140 (29-1690) days, respectively. Among the recipients of MA HCT, patients with early CMV infection showed no difference in the RI (figure 1), but had a significant trend towards higher NRM and significantly lower DFS and OS in both univariate and multivariable analysis (figure 2) (P values shown in table 2). Among 96 RIC HCT (median age 59 y, 56% male), fludarabine plus melphalan was used in 62 (65%) and fludarabine plus busulfan in 34 (35%) patients. In this group, early CMV infection occurred in 33 (34%), relapse in 25 (26%), NRM in 25 (26%), and deaths in 46 (48%) patients after a median follow up of 21 m (1-91 m). Among the recipients of RIC HCT, median time to CMV infection and to relapse was 40 (17-175) and 291 (19-1971) days, respectively. In the RIC group, early CMV infection was associated with a significant trend towards lower RI (figure 1) and higher NRM in both univariable and multivariable analysis, but no difference in DFS and OS (figure 2). Conclusion Our study of a large homogenous group of AML patients who underwent a uniform HLA-matched PB HCT demonstrates a significantly lower risk of relapse associated with early CMV infection detected by QNAT following RIC, but not MA HCT. Early CMV infection in MA HCT is associated with higher NRM and therefore inferior survival, whereas in the RIC HCT, there is no impact on survival as the benefit of lower relapse is offset by the higher NRM. Table 1. Patients, disease and transplant characteristics according to CMV infection All Patients Patients with CMV Viremia Patients without CMV Viremia P value Patients, no (%) 190 (100) 69 (36) 121 (64) - Median age, y (range) 54 (18-72) 54 (26-70) 54 (18-72) 0.75 Male Patients, no (%) 104 (55) 30 (43) 74 (61) 0.02 D/R CMV Serostatus, no (%) <0.0001 -/- 29 (15) 1 (1) 28 (23) +/+ 64 (34) 35 (51) 29 (24) +/- 13 (7) 1 (1) 12 (10) -/+ 84 (44) 32 (47) 52 (43) Conditioning 0.65 MA 96 (51) 33 (48) 63 (52) RIC 94 (49) 36 (52) 58 (48) Disease status at Transplant 0.96 CR1 129 (68) 46 (67) 83 (69) CR2 34 (18) 13 (19) 21 (17) Other 27 (14) 10 (14) 17 (14) Cytogenetic 0.65 Favorable 8 (4) 2 (3) 6 (5) Intermediate 130 (68) 46 (67) 84 (69) Unfavorable 52 (28) 21 (30) 31 (26) Disclosures Al-Kali: Novartis: Research Funding.