Cyclosporin A as Immunosuppressive Treatment Option for Patients with Refractory Auto-Immune Thrombocytopenic Purpura.

Abstract The treatment of auto-immune thrombocytopenic purpura (AITP) remains unsatisfactory in patients refractory to first-line management such as corticosteroids and/or splenectomy. Those patients usually require unacceptably high doses of corticosteroids to maintain a safe platelet count and thus have refractory AITP. Relativelly new immunosupressive treatment modality is cyclosporin A (CsA) and no large studies involving these drug have been conducted. We treated 7 refractory AITP patients with CsA. Their platelet count were without any therapy below 20x109/L and mostly they had signs of subcutaneous and mucosal bleeding. In 6/7 patients splenectomy was performed earlier. In order to maintain »safe« platelet count, they all needed methylprednisolon (MP), at least 32 mg/daily. So at the time treatment with CsA began, all patients were on MP. During next months MP dosage was tapered or withdrew, according to patients platelet count and treatment efficacy. At the endpoint, in 4/7 patients complete remission (CR) was achieved and later CsA was slowly ceased. 3/7 patients are currently in partial remission (PR) of the disease. Also one of them who has more than 30 years history of the disease is in stable PR, on low dose CsA and low dose MP maintanance therapy. Her platelet count is well above 20x109/L. Among CsA treatment related side effects painful lower limb edema was most frequent. Based on our experience we suggest, that CsA should be recommended in refractory (chronic) AITP patients, because it shows long-term efficacy and good safety profile and is able to sustain remission at low doses or even after CsA discontinuation.</jats:p

Mobilization with cyclophosphamide reduces the number of lymphocyte subpopulations in the leukapheresis product and delays their reconstitution after autologous hematopoietic stem cell transplantation in patients with multiple myeloma

Autologous hematopoietic stem cell transplantation is considered the standard of care for younger patients with multiple myeloma. Several mobilization regimens are currently used, most commonly growth factors alone or in combination with chemotherapy. The aim of our study was to investigate the differences in lymphocyte subpopulation counts between three different mobilization regimens on collection day, in the leukapheresis product and on day 15 after autologous hematopoietic stem cell transplantation

Critical Serum-Selenium Levels in APL and MM Patients during ATO-Treatment (According to APL and MAC/DAC Schemes)

Abstract Introduction Arsenic trioxide (As2O3; ATO; Trisenox®) is an antineoplastic chemotherapeutic agent used for the treatment of acute promyelocytic leukemia (APL) and experimentally also for other malignancies including multiple myeloma (MM). As the therapeutic doses are rather high, and arsenic-selenium interactions well-known (arsenic complexation by selenium with subsequent excretion by bile), we assume that arsenic interferes in the selenium (Se) metabolism during the treatment. As selenium deficiency (&lt;40 ng Se/g) can be detrimental in many ways, the aim of our study was to follow serum-selenium levels in APL and MM patients during ATO treatment. Patients Over a period of 10 years, 20 patients (8 APL, 12 MM) were treated by ATO (administered as 2-h intravenous infusions). APL patients were previously treated according to a standard APL EORTC protocol. In 3 patients the ATO was started immediately after an interruption of treatment due to a differentiation syndrome and in the remaining 5 patients ATO was started due to relapse. ATO (0.15 mg/L) was administered for i) 50 consecutive days and prolonged for 25 days (5 days/week) after a 3-weeks break or for ii) 25 consecutive days repeated after a 1-week break. The majority of 12 MM patients was heavily pretreated, relapsed or refractory. ATO (0.25 mg/kg) infusion was followed by injection of ascorbic acid (1 g); Melphalan (0.1 mg/kg) and Dexamethasone (40 mg/kg) were added according to a MAC and DAC scheme, respectively. ATO was given in cycles (4 consecutive days followed by 3 weeks of 2 applications/week). Treatment efficacy was evaluated by measurement of a monoclonal spike, except for patients with a Bence-Jones type of MM who were only clinically evaluated. Sampling and analytical methods The urine and blood samples were taken before ATO infusion and total selenium was analyzed using inductively coupled plasma mass spectrometry (ICP-MS). Results All APL patients reached a stable molecular remission. In contrast, the efficacy of the ATO treatment in MM patients was difficult to evaluate due to the patients’ poor initial condition. In 3 MM patients the effect of ATO could not be evaluated since they deceased during the treatment. In 4 out of 9 remaining MM patients at least a partial remission occurred. Differences between both groups were also reflected in selenium-serum levels at the beginning and during the therapy. The average selenium-serum level of the APL group at the beginning of the treatment was in the range of the general population and almost two times higher than the average of the MM group (88.4 ± 17.8 ng/g, n = 5 vs. 54.6 ± 18.8 ng/g, n =10; Figure 1A). During the ATO treatment the serum-selenium levels fell significantly in both groups – final levels for APL patients were mostly around 50 ng/g and for MM patients below 40 ng/g (Figure 1B). In the urine of all patients a diminished selenium-excretion was observed during treatment. Conclusions Almost all APL patients receiving ATO daily responded well to the treatment while the positive treatment-response of MM patients was limited, possibly due to their pretreatment status and/or a suboptimal treatment protocol. Low serum-selenium levels (&lt;40 ng/ml) are frequently related to a compromised immune system. Hence, low initial selenium levels and even lower final selenium levels in MM patients may increase their vulnerability to infections and ATO side-effects. Figure 1: Selenium levels in serum of APL and MM patients before and during ATO treatment (A: 5APL and 10 MM patients; B: 7APL, 12 MM patients). Figure 1:. Selenium levels in serum of APL and MM patients before and during ATO treatment (A: 5APL and 10 MM patients; B: 7APL, 12 MM patients). Figure 2 Figure 2. Disclosures Off Label Use: Arsenic trioxide, drug with known antimyeloma activity. It was used as salvage options in multiple myeloma pts., in whom all other conventional treatment options were exhausted. Those patients would be otherwise treated only in a paliative way. They all wrote informed consent after we discussed the issue with them. </jats:sec

ATO Metabolites in APL an MM Patients Treated According to APL and MAC/DAC Schemes

Abstract Introduction Arsenic trioxide (ATO) has been shown to be effective in the treatment of acute promyelocytic leukemia (APL) and towards multiple myeloma (MM) cells. Biologically active form of ATO is inorganic arsenic in its trivalent form (AsIII) which is metabolised in more or less active metabolites already in hours after infusion. The major arsenic excretion metabolites are methylated, namelly methylarsonic acid (MA) and dimethylarsinic acid (DMA). Despite that ATO already has an established role in APL treatment, there is still a lack of data on its metabolism especially when it is combined with other active compounds. The aim of our study was to get an insight into ATO metabolism through measurement of its metabolites in urine and total arsenic in blood during treatment according two different protocols. Patients and methods Patients (8 APL, 12 MM) were treated by ATO (administered as 2 h intravenous infusion) during the years 2004 - 2014. APL patients were previously treated according to a standard APL EORTC protocol. In three patients ATO was started immediately after an interruption of treatment due to a differentiation syndrome and in the remaining five patients ATO was started due to relapse. ATO (0.15 mg/L) was administered for i) 50 consecutive days and prolonged for 25 days (5 days/week) after 3 weeks break or for ii) 25 consecutive days repeated after one week break. Majority of 12 MM patients was heavily pretreated, relapsed or refractory. ATO (0.25 mg/kg) infusion was followed by injection of ascorbic acid (1g). Melphalan (0.1 mg/kg) or Dexamethasone (40 mg/kg) was added in MAC or DAC scheme respectively. ATO was given in cycles (4 consecutive days followed by 3 weeks of 2 applications/week). Treatment efficacy was evaluated by measurement of a monoclonal spike except for patients with Bence-Jones type of MM who were only clinically evaluated. The urine samples were taken before ATO infusion and analysed using HPLC separation combined on-line with hydride generation and atomic fluorescence spectrometry. Arsenic species As(III) and As(V) and both methylated metabolites MA and DMA were followed. Total arsenic concentrations in serum were analysed by ICP-MS. Results All APL patients have obtained a stable molecular remission. In contrast, efficacy of ATO treatment in MM patients is difficult to be evaluated due to the patients’ initial poor condition. In three MM patients effect of ATO cannot be evaluated since they deceased during the treatment. In four out of 9 remaining MM patients at least a partial remission was obtained. Differences between both groups, or better between both protocol regimens (consecutive APL or pulse DAC/MAC in MM), are also reflected in As serum levels and in the presence of ATO metabolites in urine. During the therapy the residual As serum levels in APL group were almost two times as big as those in MM group (72,33±16.79 ng/g vs. 45.13±7.2 ng/g). That means that lower daily doses of ATO preserve higher As concentrations in time than pulse therapy with higher doses. In the urine of MAC/DAC group the proportion of DMA was higher than in the patients treated according APL protocol (48.7 ± 14.6 % vs 63.2 ± 10.4%, Figure 1), while proportions of other three metabolites were lower. A higher proportion of the main active component, As(III), was present in the body of APL patients in comparison to MAC/DAC treated MM patiens (17.5 ± 7.4 % vs 8.6 ± 4.5 %; Figure 1). Differences in metabolites between both groups were statistically significant (MA: P = 0.0127; AsIII, DMA, AsIII: P &lt; 0.0001). Figure 1 Main active compound (AsIII) and main excretion ATO metabolite (DMA) in urine of APL and MM patients. Figure 1. Main active compound (AsIII) and main excretion ATO metabolite (DMA) in urine of APL and MM patients. Conclusions APL patients receiving ATO daily reached a sort of a steady state with a peak in As(III) concentration after i.v. infusion and gradual fall of As(III) concentration until the next day’s infusion while concentrations of other metabolites remained relatively stable. MM patients received higher ATO doses in pulses so that decrease of As(III) after initial peak ended in prolonged lower As(III) levels in between infusions. Poor response to ATO treatment in few MM patients can be attributed to their pretreatment status but also to suboptimal treatment protocol. Significantly lower residual serum As levels were observed during DAC/MAC in comparison to daily treatment according to APL protocol. Lower but more frequent doses of ATO, similar to those in APL, may be more effective in MM. Disclosures Off Label Use: Arsenic trioxide, drug with known antimyeloma activity. It was used as salvage options in multiple myeloma pts., in whom all other conventional treatment options were exhausted. Those patients would be otherwise treated only in a paliative way. They all wrote informed consent after we discussed the issue with them. </jats:sec

Abstract 18925: The Serum Level of Mir-30a-3p And Mir-31-5p Can Discriminate Responders From Non-responders to CD34 + Cell Therapy in Patients With Dilated Cardiomyopathy

Introduction: The potential predictive value of specific, circulating miRNAs in blood in patiens with non-ischemic dilated cardiomyopathy (DCM) undergoind CD34+ cell therapy remains undefined. Hypothesis: We assessed the hypothesis that the relative level of specific miRNAs in serum obtained at baseline will discriminate responders from non-responders to stem cell therapy in patients with DCM. Methods: We enrolled 10 consecutive patients with DCM who underwent transendocardial CD34+ cell transplantation between January and December 2013. All patients received 5-day stimulation with G-CSF; CD34+ cells were selected with apheresis and injected transendocardially guided by electroantomical mapping. Patients were followed for 6 months and good clinical response was defined as an increase of left ventricular ejection fraction (LVEF) ≥5%. Before cell therapy, total RNA was isolated from serum with the miRCURY RNA Isolation Biofluids Kit. cDNA synthesis and real-time qPCR were performed using the miRCURY Locked Nucleic Acid and Universal RT microRNA PCR system with The qPCRs were run on a ViiA7 thermocycler. Results: At 6 months after therapy, good clinical response was found in 5 patients (Group A), and 5 patients failed to respond to cell therapy (Group B). The two groups did not differ with regards to age (55±9 years in Group A vs. 57±3 years in Group B; P=0.58), male gender (87% vs. 100%; P=0.34), baseline LVEF (33±5% vs. 28±8%; P=0,28), LVEDD (6.6±0.4 cm vs. 6.9±0.7 cm; P=0.33) or NTproBNP levels (1460±932 pg/mL vs. 4540±3808 pg/mL; P=0.15). When analyzing the pool of miRNAs we found the serum level of miR-30a-3p and miR- 31-5p to be significantly different between two study groups (both had adjusted P values of 0.031). The serum level of miR- 31-5p was higher in the group of responders (log2 fold change of 6.78) while the serum level of miR-30a-3p was higher in the group of non-responders (log2 fold change of 4.98). Conclusions: In patients with DCM undergoing CD34+ cell therapy specific serum miRNAs appear to discriminate clinical responders from non-responders. Therefore, they could be used as a tool when selecting appropriate patients for stem cell therapy. </jats:p