original article

Tuesday 29th April 2014 Free Communication John Goldman Memorial Symposium 1 SPIRIT 2: an NCRI randomised study comparing dasatinib with imatinib in patients with newly diagnosed CML SG O’Brien1, RE Clark2, C Hedgley1, J Apperley3, L Foroni3, C Pocock4, T Holyoake5, J Byrne6, C Hodgson1, W Osborne1, M Copland5, JM Goldman3 1 Newcastle University Medical School, Newcastle, UK; 2 Liverpool University, Liverpool, UK; 3Imperial College, University of London, London, UK; 4Kent & Canterbury Hospital, Kent, UK; 5Glasgow University, Glasgow, UK; 6 Nottingham City Hospital, Nottingham, UK SPIRIT 2 is a phase 3 prospective randomized open-label trial for patients with newly-diagnosed chronic phase CML. The trial compares imatinib 400 mg daily with dasatinib 100 mg daily: this is the first presentation of data comparing the two arms. Beginning in August 2008, 814 patients (407 in each arm) were recruited at 145 hospitals in the UK. The last patient joined the study in February 2013. The primary endpoint is event-free survival at 5 years. A key secondary endpoint is the rate of achievement of a BCR-ABL/ABL ratio of 14 cohorts and 4.4%, 12.8% and 18.8% from the equivalent DA cohorts. Thus the ability to tolerate treatment in the first 3 months predicts future adherence. 15/407 (3.7%) patients in the imatinib arm and 13/407 (3.2%) in the dasatinib arm have died (p = NS).

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

2 Equality of access to transplant for ethnic minority patients through improved provision of unrelated donors and use of cord blood and haploidentical transplant RN Lown1,2, SGE Marsh1, H Blake1, I Evseeva1, S MacKinnon3, A Pagliuca4, MN Potter2, NH Russell5, CF Craddock1,6, JA Madrigal1, BE Shaw1,2 1 Anthony Nolan Research Institute, University College London Cancer Institute, London, UK; 2Department of Haemato-Oncology, Royal Marsden Hospital NHS Foundation Trust, Surrey, UK; 3Department of Haematology, Royal Free Hospital, London, UK; 4Department of Haematology, King’s College Hospital, London, UK; 5 Department of Haematology, Nottingham University Hospitals, City Hospital Campus, Nottingham, UK; 6 Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK It is well accepted that patients of ethnic minorities who lack a sibling donor are poorly represented on the international unrelated donor panels. As recently as 2000, only 30% of such patients were able to find an unrelated donor suitable for transplantation. Continued expansion of the international donor inventory, and the advent of cord blood and haploidentical transplantation, have improved the prospects for transplantation for such patients. 332 patients referred by four UK transplant centres to the Anthony Nolan Graft Identification and Advisory Service (GIAS) for identification of an unrelated adult donor or cord blood unit were followed up. Of these, 84 (25.3%) were of non-White Northern European (WNE) descent. The underlying disease did not differ significantly between ethnicities. The median number of donors listed on the international search report was 127 (range 0–38,245) for WNE and 5.5 (0–380) for non-WNE respectively. 69.3% of WNE and 20.5% of non-WNE patients found a 10/10 HLA-matched donor at confirmatory typing (CT) (p < 0.001); 96.3% of WNE and 61.4% of non-WNE found at least a 9/10 HLA-matched donor (p < 0.001). Non-WNE patients had more cord blood transplants (21.3% vs. 3.8%, p < 0.001) and more haploidentical transplants (10.6% vs. 1.3%, p < 0.001). There was no significant difference in the number of patients reaching transplant (WNE 63.3%, non-WNE 56.0%, p = 0.185) when considering all of the graft sources. These data show that the chance of receiving a transplant for patients of a non-WNE descent has improved considerably compared to historical literature. The majority of non-WNE patients were able to find a 9 or 10/10 matched donor, and many of those who could not were afforded the option of a cord blood or haploidentical donor transplant within a similar timescale. However, whether survival following transplant is similar between ethnic groups remains to be seen.


Free Communication: John Goldman Memorial Symposium

3 Mature response data from a phase 2 study of PI3K-delta inhibitor idelalisib in patients with double (rituximab and alkylating agent)refractory indolent B-cell non-Hodgkin lymphoma (iNHL) A Davies1, AK Gopal2, BS Kahl3, S de Vos4, ND WagnerJohnston5, SJ Schuster6, WJ Jurczak7, IW Flinn8, CR Flowers9, R Dansey10, P Martin11, A Viardot12, KA Blum13, AH Goy14, J Gribben15, H-T Arkenau16, R Johnson17, K Linton18, PL Zinzani19, M Dreyling20, GA Salles21 1 Cancer Sciences Division, University of Southampton, Southampton, UK; 2Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; 3Hematology Clinic, University of Wisconsin Carbone Cancer Center, Madison, WI, USA; 4Division of Hematology/Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; 5 Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA; 6Lymphoma Program, Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA, USA; 7Department of Hematology, Jagiellonian University, Krakow, Poland; 8Hematologic Malignancies Research Program, Sarah Cannon Research Institute, Nashville, TN, USA; 9Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA; 10Clinical Development, Oncology Department, Gilead Sciences, Seattle, WA, USA; 11 Division of Hematology/Oncology, Weill Cornell Medical College, New York, NY, USA; 12Department of Internal Medicine, University Hospital of Ulm, Ulm, Germany; 13 Division of Hematology, Ohio State University Wexner Medical Center, Columbus, OH, USA; 14Division of Lymphoma, John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, NJ, USA; 15Centre Hemato-Oncology, St Bartholemews Hospital, London, UK; 16 Sarah Cannon Research Centre, Sarah Cannon Research Institute, London, UK; 17St James’ Institute of Oncology, Leeds, UK; 18The Christie Hospital, Manchester, UK; 19 Institute of Hematology and Oncology, University of Bologna, Bologna, Italy; 20Department of Internal Medicine, University Hospital Grosshadern, LMU Munich, Munich, Germany; 21Clinical Hematology Service, Centre Hospitalier Lyon Sud, Pierre Benite, France



mphadenopatthy response [Cheson 200 07] Criterion for lym e evaluation: 3 subjects no post baseline □ 2 subjects NE ■ 1 sub bject PD by Lymph L Node b biopsy

Figure 1. Waterfall plot of Best Nodal Response.

AST elevations have occurred in 13%. Grade ≥3 neutropenia occurred in 27%, thrombocytopenia in 6%, and anemia in 2%. Marrow function generally improved over time. 20% of pts have discontinued due to adverse events. Idelalisib was well tolerated, had an acceptable safety profile, and was highly effective in this double-refractory iNHL population with an ORR of 57%. Overall 90% of patients had some reduction in tumor burden. The ORR was consistent across all subgroups, regardless of disease subtype, number of prior regimens, refractoriness to bendamustine, or tumor bulk. Responses were durable beyond 1 year, substantially exceeding the median DOR for the last therapy. Data demonstrate that idelalisib can provide clinical benefit to patients with the unmet medical need of double-refractory iNHL.

Alkylating agent-rituximab combinations are a current standard of care for patients will iNHL. Most iNHL will eventually become refractory. PI3K-delta signaling is critical for activation, proliferation and survival of B cells, and is hyperactive in many B-cell malignancies. Idelalisib, a selective, oral inhibitor of PI3Kd, was evaluated in a phase 2 trial for patients with double-refractory iNHL. Eligible iNHL patients (pts, N = 125) included those with measurable disease who were refractory to both rituximab and an alkylating agent. Idelalisib was administered continuously until disease progression or intolerance. Responses were evaluated by an independent review committee. At 9.4 months, the overall response rate (ORR) is 57% (6% CRs, 50% PRs, and 1 MR). 90% of pts experienced some decrease in tumor burden (Fig. 1). Among responders, median DOR is 12.5 months. Median PFS and overall survival for all pts is 11.0 and 20.4 months, respectively. The most common adverse events are (total%/ ≥ G3%) diarrhea (43/13), fatigue (30/2), nausea (30/2), cough (29/0), pyrexia (28/2), dyspnea (18/3), rash (13/2), and pneumonia (11/7). Grade ≥3 ALT/


ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Free Communication: John Goldman Memorial Symposium

4 A phase 3, randomized, double-blind, placebocontrolled study evaluating the efficacy and safety of idelalisib and rituximab for previously treated patients with chronic lymphocytic leukaemia (CLL) (NCRN375) P Hillmen1, R Furman2, J Sharmann3, S Coutre4, B Cheson5, J Pagel6, JM Barrientos7, A Zelenetz8, T Kipps9, A Pettitt10, J Wallis11, A Duncombe12, C Dearden13, G Follows14, D MacDonald15, A Moosa16, N Panoskaltsis17, CDe Lord18, H McCarthy19, S O’Brien20 1 St. James’ University Hospital, Leeds, UK; 2Weill Cornell Medical College, New York, NY, USA; 3Willamette Valley Cancer Institute, Springfield, IL, USA; 4Stanford Cancer Center, Stanford University, Stanford, CA, USA; 5Lombardi Cancer Center, Georgetown University Medical Center, Washington, DC, USA; 6University of Washington School of Medicine, Seattle, WA, USA; 7Hofstra North Shore – LIJ School of Medicine, New Hyde Park, NY, USA; 8Memorial Sloan Kettering Cancer Center, New York, NY, USA; 9 Moores Cancer Center, University of California San Diego, La Jolla, CA, USA; 10Royal Liverpool University Hospital, Liverpool, UK; 11Freeman Hospital, Newcastle Upon Tyne, UK; 12Southampton General Hospital, Southampton, UK; 13 Royal Marsden Hospital, Sutton, UK; 14Addenbrooke’s Hospital, Cambridge, UK; 15Hammersmith Hospital, London, UK; 16Dorset County Hospital NHS Foundation Trust, Dorchester, UK; 17Northwick Park Hospital, Harrow, UK; 18 Princess Royal University Hospital, Orpington, UK; 19Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK; 20The University of Texas MD Anderson Cancer Center, Houston, TX, USA Idelalisib (IDELA) is a selective oral inhibitor of PI3Kd that reduces proliferation, enhances apoptosis, and inhibits homing and retention of malignant B cells in lymphoid tissues. This Phase 3 study evaluated the efficacy and safety of IDELA plus rituximab vs placebo plus rituximab in 220 patients with previously treated CLL. Eligibility included requiring treatment as per IWCLL, measurable lymphadenopathy, CLL progression 50 9 109/l in preference to interrupting therapeutic anticoagulation. 52% remove the CVL in line-associated thrombosis, usually after 48–72 hours anticoagulation. Therapeutic anticoagulation is commenced immediately for CSVT in the presence of intracranial haemorrhage in 56% while 39% withhold anticoagulation pending interval imaging. Duration of anticoagulation for line-associated thrombosis is 6 weeks in 43% and 3 months in 33% and for CSVT is 3 months in 71% and 6 months in 24%. 91% re-expose to asparaginase following a thrombotic event, 64% using LMWH as thromboprophylaxis. 36% screen those with thrombosis for thrombophilic abnormalities. This survey has identified significant variation in practice between centres. In the absence of high quality evidence consensus guidelines may be helpful and provide a basis for future research strategies.


Free Communication: Paediatrics

11 The natural course of childhood immune thrombocytopenia: results from the paediatric ITP registry EA Hannah1, JD Grainger1,2 1 University of Manchester, Manchester, UK; 2Department of Haematology, Royal Manchester Children’s Hospital, Manchester, UK Knowledge on the natural course of paediatric immune thrombocytopenia (ITP) has primarily been acquired from retrospective studies. The Intercontinental Cooperative ITP Study Group (ICIS) produced the first prospective study using the new definition of chronic ITP.

Duration of ITP Presentation 28 days 3 months 6 months 12 months 24 months 36 months 48 months


% Of patients with a platelet count 1 mg/l against HiB was considered to be an adequate response.


Patients with myeloma post ASCT responded significantly better to a conjugate vaccine HiB as compared to the polysaccharide vaccine PPV-23. (91% as compared to 5%) Response to pneumococcal antigens improved significantly after administration of a conjugate vaccine Prevenar (PCV-13) in 72% of the patients. In contrast, patients who had undergone splenectomy for immune cytopaenia responded well to both HiB and PPV-23 (82%) but the antibody titre to PPV-23 diminishes over time and was almost absent in the remaining 3 patients tested >8 years after spelenctomy. Covalent conjugation of polysaccharide antigen to a protein carrier protein in HiB and PCV-13 makes it more immunogenic and converts the immune response from being T-cell independent to T-cell dependent leading to a stronger and longer-lasting immune response. This explains the poor immunogenicity of PPV-23 and the poor response seen in our study in patients with myeloma when compared with PCV-13. However, PPV-23 offers a broader spectrum of serotype coverage. Therefore, PCV-13 and PPV-23 should be considered as complementary. We propose changes to the protocol for vaccination post ASCT, and suggest addition of PCV-13 at 6 and 8 m and continuing with PPV-23 at 18 m followed by a routine assessment of serological response at 24 m. We also propose that the serological response to pneumococcal antigens should be checked every 5 years post splenectomy.

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Free Communication: Myeloid Malignancy and Transplantation

Free Communication Myeloid Malignancy and Transplantation 28 Presence of acquired isodisomy on chromosome 13 results in impaired event-freesurvival survival in patients with FLT3-Itd positive acute myeloid leukaemia JCT Loke1, S Akiki2, J Borrow2, J Ewing3, SW Bokhari4, D Chandra5, J Arrazi1, P Hazlewood6, K Arthur7, J Walsh8, Y Membwange9, FA Wandroo9, A Watts10, A Borg11, C Craddock1, M Griffiths2, M Raghavan1 1 Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK; 2West Midlands Regional Genetics Laboratory, Birmingham, UK; 3Department of Haematology, Heartlands Hospital, Birmingham, UK; 4Department of Haematology, University Hospitals Coventry and Warwickshire NHS Trust, Warwickshire, UK; 5Department of Haematology, University Hospital of North Staffordshire, Staffordshire, UK; 6Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK; 7 Department of Haematology, Worcestershire Royal Hospital, Worcestershire, UK; 8Department of Haematology, New Cross Hospital, Wolverhampton, UK; 9Department of Haematology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK; 10Department of Haematology, Russells Hall Hospital, Dudley, UK; 11South Warwickshire NHS Foundation Trust, Warwickshire, UK In patients with Acute Myeloid Leukaemia, the FLT3-itd mutation is found in 25% of patients and is associated with an adverse outcome. Biological subgroups based on FLT3-itd mutation type exist, these include: clones with heterozygous FLT3-itd mutated/wildtype; homozygous mutated FLT3 allele; and clones with evidence of overexpression of FLT3-itd. These subgroups were identified by assessing the Allelic ratio (AR), expression ratio (ER) (mutation/wildtype ratio in genomic DNA and cDNA respectively) and the homozygosity of the FLT3-itd mutation (acquired isodisomy (AID)) (by analysis of microsatellite markers along chromosome 13). Overall survival (OS), event free survival (EFS) (time from diagnosis to induction failure, relapse or death) was calculated. Survival rates were estimated by the KaplanMeier method and differences compared with the log-rank test. 225 patients positive for the FLT3-itd mutation were identified. Median age of patients was 60 and the median follow-up for patients alive was 2.8 years. Outcomes of 173 intensively treated patients were analysed: those with lower AR (less than/equal to 0.3) as compared to higher AR (greater than 0.3) had an improvement in EFS (p = 0.04) but not OS (p = 0.09). AID also occurs at an AR of less than 1 because of the presence of normal cells or due to preferential amplification of the wildtype allele (in 7 patients). Thus AID provides true evidence of FLT3 mutant homozygosity and was detected in 24 (205 tested) patients. Presence of AID in patients had no impact on OS (p = 0.181) but significantly worsened EFS (p = 0.04). In contrast, patients stratified by ER (less than/equal vs. greater than 0.3) had no significant difference in OS (p = 0.37) and EFS (p = 0.14).

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Direct testing for AID is a more sensitive measure of FLT3 mutant homozygosity and the loss of wildtype FLT3 may have clinical and biological significance.

29 Genotypic and phenotypic heterogeneity of familial myeloproliferative neoplasms SE Langabeer1, J Linders2, E Conneally3, A Hayat4, B Hennessy5, M Leahy6, K Murphy7, M Murray4, F Ni Ainle8, P Thornton9, J Sarjent2 1 Cancer Molecular Diagnostics, St James’ Hospital, Dublin, Ireland; 2Department of Haematology, Our Lady of Lourdes Hospital, Drogheda, Ireland; 3Department of Haematology, St James’ Hospital, Dublin, Ireland; 4Department of Haematology, Galway University Hospital, Galway, Ireland; 5 Department of Haematology, Waterford Regional Hospital, Waterford, Ireland; 6Department of Haematology, University Hospital Limerick, Limerick, Ireland; 7Department of Haematology, St Vincent’s University Hospital, Dublin, Ireland; 8Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland; 9Department of Haematology, Beaumont Hospital, Dublin, Ireland The myeloproliferative neoplasms (MPN) are clonal haematopoietic disorders characterised by overproduction of mature myeloid cells. While the vast majority of MPN are sporadic in nature, familial clustering is evident with the incidence of familial MPN (FMPN) variably reported as between 1 and 10% of all MPN. FMPN manifests phenotypically as PV, ET or PMF, or less commonly, the related hereditary thrombocythaemia (HT) or hereditary erythrocytosis (HE). Clinical features, thrombotic complications, progression to myelofibrosis or acute leukaemia, and somatically acquired mutations associated with sporadic MPN such as the JAK2 V617F are also observed in FMPN. A series of FMPN kindreds is reported. Eleven kindreds with the index case having one or more first degree relative (parent/sibling/child) with an MPN have been identified: HT (n = 1), familial PV (n = 1), familial ET (n = 2) and familial mixed ET/PV (n = 7). All kindreds identified had a high level of penetrance with the MPN inherited in an autosomal dominant pattern. The index case with HT had no evidence of JAK2 exon 14, MPL or TPO mutations. Of the remaining ten FMPN index cases, 6 (67%) had evidence of the JAK2 V617F, all of which displayed a mother to son transmission of the MPN. Of 49 known first degree relatives, 18 (37%) had MPN of which nine (50%) harboured the JAK2 V617F. Of note, one patient from a mixed ET/PV kindred had classical PV without evidence of JAK2 exon 12 or 14 mutations or MPL exon 10 mutations. These FMPN kindreds display a significant phenotypic and genotypic diversity. Some studies estimate that a significant proportion of MPNs have a familial origin, it is proposed that the incidence of FMPN is not fully recognised in this population. Characterization of FMPN kindreds may allow the identification and assessment of candidate inherited predisposition events.


Free Communication: Myeloid Malignancy and Transplantation

30 Loss of imprinting at the 14q32 domain is associated with microRNA overexpression in acute promyelocytic leukaemia F Manodoro1, J Marzec2, T Chaplin1, F Miraki-Moud1, E Moravcsik3, JV Jovanovic3, J Wang2, S Iqbal1, D Taussig1, D Grimwade3, JG Gribben1, BD Young1, S Debernardi2 1 Centre for Haemato-Oncology, Queen Mary University of London, Barts Cancer Institute, London, UK; 2Centre for Molecular-Oncology, Queen Mary University of London, Barts Cancer Institute, London, UK; 3Department of Medical and Molecular Genetics, King’s College London School of Medicine, London, UK Distinct patterns of DNA methylation characterize the epigenetic landscape of PML-RARa associated acute promyelocytic leukaemia (APL). We previously reported that the microRNAs (miRNAs) clustered on chromosome 14q32 are overexpressed only in APL. Here, using high-throughput bisulfite sequencing with Roche 454 technology we identified an APL-associated hypermethylation at the differentially methylated region (DMR) located upstream, including also the binding site motifs for the enhancer blocking protein CTCF. Haplotype analysis of the DNA methylation changes in diagnostic/ remission paired patient samples, showed that hypermethylation was acquired in APL in a mono-allelic manner. The CpG status of the DMRs correlated with expression of the miRNAs following a characteristic position-dependent pattern. Moreover, a signature of hypermethylation was also detected in leukaemic cells from an established transgenic PML-RARA APL mouse model at the orthologous region on chromosome 12, including the CTCF binding site located upstream from the murine miRNA cluster. Deep sequencing in myeloid progenitor cells showed that the region does not undergo DNA methylation changes during myeloid differentiation, demonstrating that the observed epigenetic signature was leukaemic-specific. Altogether results indicate that 14q32 hypermethylation is implicated in the pathogenesis of APL. As the expression of the 14q32 miRNAs in the adult is normally restricted to the brain, we propose a model in which loss of imprinting (LOI) at the 14q32 domain leads to overexpression of the miRNAs in APL. This study provides novel insights into the epigenetic characterization of APL and mechanism underlying the deregulation of a specific cluster of miRNAs in this subtype of leukaemia. The 14q32 miRNAs include species with oncogene and tumour-suppressor activity and further investigations are required to determine the role they may play in the APL pathogenesis.

31 Fev is required for self-renewal of fetal hematopoietic and leukemic stem cells T Liu1,2, F Zhang1,2, F Liu1,2, G Chen1,2, D Hong1,2 1 Department of Pathophysiology, Key Laboratory of Cell Differentiation, Apoptosis of National Ministry of Education, Shanghai Jiao Tong University, Shanghai, China; 2 Shanghai Children’s Medical Center, Shanghai Jiao Tong University, Shanghai, China Fev, also known as pet1 in mammals, is a recently identified ETS transcription factor belonging to the same subgroup as fli1 and erg. Our previous studies showed that fev is essential for hemogenic endothelium-based hematopoietic stem cell (HSC) development. It remains unknown however whether fev plays any role in maintenance of both fetal and adult HSC and is altered in leukemic stem cells (LSC). We have addressed these issues in the human context of normal and leukemic hematopoiesis. Fev is expressed in hematopoi-


etic cells of fetal liver and neonatal cord blood but not in that of post-natal bone marrow indicating that fev is a specific regulator of fetal hematopoiesis. Fev-knockdown in primitive hematopoietic cells of cord blood led to a marked reduction of primitive colony-forming cells (CFC), long term culture-initiating cells (LTC-IC), and SCIDrepopulating cells (SRC) in functional assays in vitro and in vivo, indicating fev is crucial for maintenance of fetal HSC. Assays of CFC-replating and SRC-retransplantation showed that fev is a regulator of self-renewal in fetal HSC. More interestingly, fev is detected in leukemic cells of some cell lines and patients, which is associated with complex karyotype and clinical high-risk. Moreover, knockdown of fev in the leukemic cells markedly compromised their capacity of leukemic reconstitution in xenograft recipients, indicating that fev is re-expressed and functions in LSC. Therefore, we have identified and characterized fev a candidate to distinguish LSC from normal adult HSC.

32 Lenalidomide potentiates human T cell alloresponses by selectively increasing proliferation of alloreactive CD8+ cells which exhibit a novel gene expression profile implications for IMiD therapy after allogeneic haematopoietic stem cell transplant C Besley, E Kotsiou, R Petty, A Sangaralingam, R LeDieu, J Gribben, J Davies Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK IMiDs like lenalidomide have immunostimulatory activity and therefore potential to reduce relapse after AHSCT by increasing GvT effects. However, early clinical experience using IMiDs after AHSCT has been limited by increased GvHD. Although lenalidomide has been shown to augment mitogen-stimulated T-cell responses in various ways, the effects of lenalidomide on T-cell alloresponses are not well defined. We determined the effects of lenalidomide on functional human T-cell alloresponses using a HLA-mismatched in-vitro model. We cocultured CFSE-labelled PBMCs from healthy donors with irradiated allogeneic PBMCs in the presence of 1uM lenalidomide. Functional alloresponses were quantified after 9 days of allococulture by flow cytometry. In addition, allo-coculture responders were flow-sorted into alloproliferative or non-proliferative fractions and extracted RNA used for gene expression profiling. Addition of lenalidomide to allo-cocultures (n = 12) led to a median 17% increase in the total number of responder cells (p < 0.001) due to an increase in proliferation of allospecific responder CD8 (alloCD8) T-cells (p < 0.001). Lenalidomide had no effect on proliferation of CD4 cells. Proliferation kinetic analysis showed that lenalidomide did not increase the number of cell divisions, but increased the CD8 allospecific precursor frequency (median 4–11%, p ≤ 0.001) consistent with lowering of the activation threshold of alloCD8 cells. Gene expression changes unique to Lenalidomide treatment included >8-fold increases in expression of genes reported to potentiate T-cell immune responses including PFKFB4, Pirin, and SOCS2 (part of the E3-ubiquitin ligase complex with cereblon), and >5-fold decreases in genes which suppress T-cell activation and differentiation including FAIM3 and PMCH. We have shown for the first time that lenalidomide potentiates human alloresponses by selectively increasing proliferation of alloreactive CD8 T-cells. Lenalidomide mediates this effect by increasing expression of genes common to the intrinsic CD8 alloproliferative response but also by modulating expression of additional genes ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Free Communication: Myeloid Malignancy and Transplantation important in control of T-cell activation and differentiation. These findings could be exploited to use lenalidomide more effectively to potentiate GvT without increasing GvHD after AHSCT.

33 Prophylactic single donor granulocyte transfusions improve the outcome of high risk paediatric patients undergoing stem cell transplantation with known bacterial and fungal infections: a 10-year single centre experience O Nikolajeva1, A Mijovic2, P Amrolia1, K Rao1, R Chiesa1, J Silva1, M Finch1, P Veys1 1 Great Ormond Street Hospital NHS Trust, London, UK; 2 Department of Haematology and Transfusion Medicine, King’s College Hospital, London, UK Bacterial and fungal infections remain a significant cause of TRM in allogeneic SCT setting. Granulocyte transfusions (GT) may reduce the neutropenic period post SCT and provide anti-fungal and antibacterial protection. A retrospective analysis was performed on consecutive paediatric SCT recipients at GOSH who received at least one prophylactic single donor GT between 3/2003 and 11/2013.Major ABO mismatch were deferred. CMV neg recipients were transfused from CMV neg donors, whenever practically possible. All producte

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were irradiated.All donors were conditioned with G-CSF+ Dexamethasone with harvest performed 12–18 hours later. 28 pts receievd 145 GT. Main indications for SCT were AL in 46% (13/28) and SAA in 21% (6/28). Cell sourse:7/28 MUD, 6/28 mMUD, 11/28 MSD+MFD and 4/28 haploidentical. Indications for prophulactic GT: (i) invasive fungal disease in 50% (ii) bacterial infection in 21% (iii)co-morbidities which might leed to decreased tolerance to sepsis in 18% (5/28): 2/5-cardiomyopathy; 2/5-haemorrhagic colitis;1/5- artificial mitral valve; (iv) 3/28 -prolonged neutropenia due to previous therapy. The median number of GT was 6 (range 2–6). Median dose was 3.56 9 1010 cells (range 0.5–8.36). There was a correlation between the increase in ANC and the granulocyte dose (rho = 0.466, pvalue < 0.01). Median days of ANC 1 site of extranodal disease in patients 6 and/or a CrCl 0.9) were observed between the manual and DM96 reclassified differentials for most cell classes. Blasts were present in the manual differentials of 118 smears and in the reclassified automated differential of 133 smears. In only one smear was a blast present in the manual differential but not in the DM96 pre- or reclassified differential. This study has shown that the CellaVision DM96TM can be used to obtain accurate leucocyte differentials for patients with haematological malignancy and reassuringly is reliable in identifying blast cells. However, considerably more operator re-classification is required to obtain an accurate count when the total leucocyte count is high (>50 9 109/l) and for smears from patients with CLL.

43 Haematology patients and the internet T Rider, T Chevassut Department of Haematology, The Royal Sussex County Hospital, Brighton and Sussex University Hospital Trust, UK Patients access on-line health information (OHI) to better understand their health. Our study aimed to determine which demographic factors influence OHI use. We also aimed to investigate how OHI is used by patients and subsequent implications on the patientdoctor relationship. We distributed a self-administered questionnaire to 202 outpatients. 62.3% of participants used the internet. Age (p < 0.001) and level of education (p < 0.001) were associated with internet use. 54.3% of participants used the internet to seek OHI. In addition 22 non-internet users had someone look up OHI on their behalf, therefore 68.9% of participants were exposed to OHI. Higher level of education (p < 0.001) and a household income of £15–25,000 (p = 0.023) were associated with OHI use following multivariate analysis. Age, gender and social deprivation were not associated with OHI use.


Only 17% of patients could recall which websites they used. 18% of patients had been recommended a particular website from a healthcare professional. 68.5% of patients asked more questions during consultations after reading OHI. Patients were more worried about their health after reading OHI (21% worried, 17.2% reassured, 61.7% unchanged). Those more reassured about their health after using OHI; had improved trust in their specialist (p < 0.001), improved confidence during consultations (p < 0.001) and were better shared decisions makers (p = 0.008). Those with increased trust in their haematologist after using OHI also had improved confidence (p < 0.001) and improved joint decision making ability (p < 0.001). 74.6% of patients did not share OHI with their haematologist. 83% of OHI users felt that OHI had no overall effect on their patientdoctor relationship. Haematologists could facilitate patients using OHI by recommending reliable high quality patient-friendly websites especially at the time of diagnosis or when discussing treatment options. Alternative health information resources should be provided where appropriate to non-internet users.

44 Clinical and haematological characteristics of patients with GATA2 deficiency W Tan1, SL Johnston2, DP Finnegan3, S Mansour4, JMM Cornish5, M Cummins5, JM Moppett5, P Sivaprakasam5, RE Protheroe5, CG Steward1,5 1 School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK; 2Department of Immunology, Southmead Hospital, Bristol, UK; 3Department of Haematology, Belfast City Hospital, Belfast, UK; 4SW Thames Regional Genetics Service, St George’s, University of London, London, UK; 5Bone Marrow Transplant Unit, Royal Hospital for Children, Bristol, UK Autosomal dominantly inherited mutations of the GATA2 transcriptional regulator gene have recently been identified as the cause of four clinical conditions: familial myelodysplastic syndrome (MDS)/ acute myeloid leukaemia (AML), MonoMAC syndrome (monocytopaenia, B/NK lymphopenia and susceptibility to mycobacterial/fungal/viral infections), Emberger syndrome (MDS/AML, primary lymphoedema usually involving lower limbs  congenital deafness) and dendritic cell, monocyte, B/NK lymphoid (DCML) deficiency. There is overlap in the clinical features described in these groups and patients are perhaps best described generically as having ‘GATA2 deficiency’. We have reviewed the presentations, serial blood counts and lymphocyte subset analysis and longitudinal history/treatment of 8 patients from 6 families diagnosed with GATA2 deficiency who have presented to either our haematology or bone marrow transplantation services. Their ages range from 50%. Five patients had no TS requested, and none had fasting TS. Only 3/78 was homozygous for the C282Y mutation while seven had C282Y/H63D compound heterozygosity. Those with mutations had average TS of 66.3% (range 33–87%). Patient with TS of 33% was identified following family testing. All ten patients had normal ultrasound scans. 24 patients(33%) in this study had liver disease/fatty liver with average ferritin of 1705 ng/ml, 13 patients(17%) had cancer with a ferritin 2844 ng/ml, 5 patients(6%) had rheumatological disorders with a ferritin of 703 ng/ml, and 26 patient(33%) had high ferritin due to infection/inflammatory conditions with ferritins of 635 ng/ml. HFE testing triggered by high ferritin is common, identifying only 10/78(13%) cases with GH. To avoid unnecessary genetic tests, high ferritin should be followed by TS estimation prior to genetic mutation analysis. When TS >50% is used as the screening method for HFE testing, there is a >90% sensitivity. Patients with haemochromatosis are presenting with biochemical evidence of iron overload but are otherwise asymptomatic. They have ferritins less than 1000 ng/ml at diagnosis. Patients with cancer had the highest ferritin levels but they were not biochemically iron overloaded.

46 The use of immunoplatelet counting for establishing an accurate platelet count during pregnancy B Velosa Ferreira, F Moita, SE Robinson Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK The aim of this study was to examine whether the use of immunoplatelet versus automated platelet count impacts upon treatment requirements in ITP in pregnancy and decision making regarding ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

epidural anaesthesia in ITP and Gestational thrombocytopenia (GT). A retrospective analysis of women referred to the Obstetric Haematology Clinic over 5 years with thrombocytopenia or known ITP was conducted. Automated platelet counts were performed on Beckman Coulter analyzers LH750. Immunoplatelet count was performed by flow cytometry. Thresholds for treatment of ITP and epidural anaesthesia were based on International Consensus Recommendations and local guidelines. 80 women (84 pregnancies) were referred. Immunoplatelet counts were performed in 62 pregnancies (170 samples) and compared to automated platelet counts. A diagnosis of ITP was established in 32 women and GT in 52 women. Using Wilcoxon matched pairs, signed rank test the difference between automated and immunoplatelet counts was significant for both ITP and gestational thrombocytopenia (p < 0.001). Applying the International Consensus recommendations for ITP, using automated platelet counts, 1 woman 95 fl, compared to 86% (12/14) women. After induction phase venesections, 45% (10/22) men and 36% (5/14) women had MCV >95 fl. One patient was homozygous for the H63D mutation and had a raised MCV of 100 fl but normal ferritin (32 lg/l). Of the 3 patients with compound heterozygosity C282Y/H63D, one had raised MCV (103 fl). Only one of three has required venesections to date. In comparison, 6 heterozygotes for the C282Y mutation had normal mean MCV of 91.5 fl with normal ferritin and TSAT. Similarly, 8 heterozygotes with the H63D mutation had a normal mean MCV of 92.5 fl (ferritin 432 lg/l, TSAT 30%). None of these patients required venesections to date. Only 1/54 patients had overt liver disease thus excluding it as a cause of macrocytosis. Our study confirms the presence of elevated MCV in the majority of HH individuals, especially women. The MCV did not decline after venesections despite ferritin normalisation, indicating that MCV is not a useful therapeutic guide in this phase. We propose that iron studies (ferritin, transferrin saturation) should be incorporated into routine screening for patients referred for investigation of raised MCV to haematology clinic.

Between 01/01/2009-31/12/2010, there were 585 episodes of admissions with FN, caused by 297 patients with a cancer diagnosis to EKUFHT (population 0.72 million). 122 patients (41.2%) had hematological malignancies [65(53.3%) with LymphoProliferativeNeoplasms and 57(46.7%) with MyeloProliferativeNeoplasms]. This is a follow-on sub-study from a large retrospective, single centre, hospital based, case-control study to assess the relationship


ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: General Haematology

57 Retrospective audit of incidence of deep vein thromboses in haem-oncology patients after peripherally inserted central venous catheters P Sriskandarajah, K Davis, N Pepper Department of Haem-Oncology, Royal Marsden Hospital NHS Trust, Sutton, UK The incidence of Deep Vein Thromboses (DVTs) in patients following peripherally-inserted central catheter (PICC) line insertion has not been investigated in haem-oncology patients. We sought to determine the incidence of DVTs in our patient cohort, as well as the characteristics and outcomes associated. Retrospective, single cohort analysis of patients with haematological malignancies and PICCS who developed a DVT were identified by electronic medical record database search. Between January 2010 and January 2013, 346 patients had a PICC inserted with ultrasound documented DVTs observed in 20 (6%) a median of 33 days after PICC placement. The majority of patients had AML (40%) and were male (60%), with only 10% having a history of previous thrombotic event. The most common complications included line removal (80%) and infection (45%) with no pulmonary emboli observed. The majority of patients were treated with 3 months anticoagulation with none requiring thrombectomy/thrombolysis and no haemorrhagic complications identified. Four patients presented prior to treatment at median of 18 days, and all had their therapy (including transplant) delayed up to maximum of 30 days. Following this audit, suggested recommendations included updating the hospital trust guidelines with standardized management of PICC line related DVT and a new risk assessment tool to consider patients for short-term thromboprophylaxis following line insertion.

58 A collective descriptive study of management of immune thrombocytopenic purpura (ITP) in three hospitals N Senadheera1, IS Wijesiriwardena2, YJ Costa3, D Gunawardena2 1 Department of Haematology, General Hospital, Ratnapura, Sri Lanka; 2Department of Haematology, Faculty of Medical Sciences, University of Sri Jayawardenapura, Gangodawila, Nugegoda, Sri Lanka; 3Department of Haematology, General Hospital, Gampaha, Sri Lanka Primary Immune thrombocytopenia (ITP) is an acquired autoimmune disorder which causes persistent lowering of the platelet count. Although very low platelet counts do not cause significant bleeding, treatment causes harmful effects to the patient rather than problems caused by the disease itself. This study was done to evaluate the behavioral pattern and response to standard therapy, and side effects to treatment in three centers in Sri Lanka. Retrospective data was collected from 72 patients with ITP and followed up for a minimum of 2 years from January 2007, at three tertiary care hospitals in Sri Lanka. The platelet count was below 10 9 109/l in 40(55%) at presentation.Skin bleeding was the commonest presentation and seen in 37 (51%). In 17(23.6%) it was an incidental finding. Out of the total of 72 patients, 69 were considered for treatment either due to the degree of thrombocytopaenia (1,000,000 copies/ml in the blood which necessitated treatment with intravenous ganciclovir. Her condition improved within a week but subsequently deteriorated again when she succumbed to multidrug resistant nosocomial infections, rapidly progressive CMV disease and multiorgan failure. This case highlights the challenges and difficulties involved in the diagnosis and management of pregnancy-related HLH whereby the patient’s clinical condition deteriorated despite delivery of the baby and conventional treatment for more common conditions associated with pregnancy. Immunosuppression as a result of treatment for HLH should also be highlighted as this can precipitate life-threatening infections such as CMV disease which needs to be promptly diagnosed (preferably with PCR) and treated.


Poster Session: General Haematology

60 Use of single agent low dose rituximab in primary immune thrombocytopenia and warm autoimmune haemolytic anaemia S Alhassan, SA Bennett, K Davies, G Evans Department of Haematological Medicine, East Kent Hospitals University Foundation Trust, UK The anti-CD20 monoclonal antibody, Rituximab, given weekly 375 mg/m2 9 4 is widely used as second-line therapy in patients with immune thrombocytopenia (ITP) and warm autoimmune haemolytic anaemia (AIHA). Due to potential toxicity and cost, a reduced dose of 100 mg weekly 9 4 has been used in ITP, although responses are variable. The optimal dosing in both conditions remains unknown. We sought to investigate retrospectively the outcomes of patients with primary ITP (n = 12) or AIHA (n = 10) who were treated with low dose rituximab in our trust between 2009 and 2013. Out of 13 treatment episodes for ITP, the overall response rate was 54% (7/13) with 31% (4/13) achieving a complete response (CR). Median follow-up duration was 14 months (range 8–35). Of those with CR, mean response duration was 8 months (SD  3.4). One patient relapsed at 6 months, but achieved a CR following a second course of treatment. There were no adverse events in this treatment group. Of 11 treatment episodes for AIHA, the overall response rate was 91% (10/11) with 55% (6/11) achieving a CR. Median follow-up duration was 18 months (range 8–52). Of those with CR, median response duration was 5.5 months (range 3–12). One patient relapsed at 9 months, and achieved a CR following a second course of treatment. Two patients died while in CR at a mean of 4 months following treatment, of causes unrelated to the rituximab. In conclusion, low dose rituximab 100 mg weekly 9 4 appears to be an effective treatment for warm AIHA with response rates of 91%, and should be considered as a second line therapy in this group of patients. In comparison, low dose rituximab was less effective in ITP (54% response rate) and the optimal dose for this condition is still to be established.

61 Intrathoracic extramedullary haemopoiesis in a patient with hereditary spherocytosis S Lawless, P Kettle Department of Haematology, Belfast City Hospital, Belfast, UK We present a case of extramedullary haemopoiesis presenting with an incidental intrathoracic paravertebral mass on MRI scan, in a patient previously undiagnosed with hereditary spherocytosis. Case History: A previously well 71 year old gentleman undergoing a MRI pelvis to investigate prostatic symptoms was found to have an intrathoracic paravertebral mass. The spleen appeared bulky and the bone marrow signal appeared abnormal. He had undergone a cholecystectomy 40 years ago. There was no significant family history. On examination he was mildly icteric. There was no hepatosplenomegaly or lymphadenopathy. Further investigations revealed a normocytic anaemia. His reticulocyte count and bilirubin were elevated at 291 9 109/l and 37 lM respectively. His blood film revealed anisocytosis, polychromasia, frequent spherocytes and basophilic stippling. His bone marrow biopsy revealed a hypercellular aspirate with erythroid hyperplasia and minor dyserythropoeitic features. Spherocytes were noted. EMA binding assay confirmed hereditary spherocytosis. The biopsy of his paravertebral mass revealed extramedullary haemopoiesis.


Discussion: Extramedullary haemopoiesis is a rare finding. It may occur in hereditary spherocytosis as a compensatory response to insufficient bone marrow red cell production. Usual sites are the spleen, liver and lymph nodes. Intrathoracic extramedullary haemopoiesis is less common. It shows a male predominance and the median age of presentation in hereditary spherocytosis is 57 years, which reflects the prolonged haemopoietic stimulation needed for extramedullary haemopoiesis to develop. We present images of the blood film, bone marrow and the intrathoracic mass along with MRI and CT images. The pathogenesis of extramedullary haemopoiesis and the management of hereditary spherocytosis are discussed.

62 An audit of the effect of introduction of antibiotic monotherapy guidance on the management of febrile neutropenia, in a tertiary centre D Swan, R Radia The Bristol Haematology and Oncology Centre, Bristol, UK Neutropenic febrile illness in the major cause of mortality for patients on chemotherapy, with reported mortality rates of 2–21%. A report from the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) in 2008 highlighted several problems in its management, including failure of diagnosis, and delays in resuscitation, prescribing and administering antibiotics. In September 2012 NICE updated their guidelines, recommending beta-lactam monotherapy, unless there are patient or microbiological contra-indications, instead of dual therapy with an aminoglycoside. They also suggested fluoroquinolone prophylaxis in certain groups. Updated guidelines were adopted in May 2013 at the Bristol Haematology and Oncology Centre. We conducted a retrospective audit of patients admitted under haematology over a 3 month period from May to July 2013, identifying 35 cases, using diagnostic criteria defined by NICE (neutrophil count of ≤0.5 9 109/l, with a temperature ≥38 degrees, or signs/ symptoms consistent with sepsis), undertaking a full review of notes for each case. Correct diagnosis occurred in 91.4% (n = 32) of patients, 80% (n = 28) received empirical first line antibiotics, 40% (n = 14) had positive blood cultures, and half of these resulted in changes to antibiotics. During this period, mortality was 8.57% and the mean length of stay was 13.8 days (range 4–52 days). 42.9% of patients received ciprofloxacin, none of whom developed C. difficile. The mean time from recognition to antibiotic administration was 179 minutes (range 60 to 1820 minutes), almost 3 times longer than the hour recommended in the 2012 Surviving Sepsis Guidelines. The audit concluded that antibiotic monotherapy has not significantly impacted mortality, length of stay or C. difficile rates, when compared to the previous 5 months, but a re-audit with a larger patient group would be useful. The time to antibiotic administration needs urgent attention.

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: General Haematology

63 TeamHaem: engaging and educating in haematology using social media AK McGregor1, EA Graves1, J Young1, CW Tiplady2 1 The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK; 2Northumbria Healthcare NHS Foundation Trust, UK Social media (SoMe) is gaining popularity as a platform for informal, user-directed learning; the ease with which educational material and discussion can be accessed from multiple devices is key to this. We aimed to develop a haematology-oriented presence within SoMe to promote educational dialogue and haematology as a specialty. We chose Twitter, a free, widely used SoMe microblogging website as it allows instant dissemination and discussion of educational material. Our Twitter profile (@TeamHaem) contains a short biography of who we are and our objectives. @TeamHaem established a Twitter presence by ‘following’ education and medical professionals, enabling us to see their status updates. We subsequently asked them to ‘tweet’ about us; therefore gaining our own followers. We created case-led discussions, which evolve over time and are designed to be topical and relevant to our followers, targeting their various skill sets and levels of expertise. We used the website Wordpress to create the backbone of our case and Twitter to lead the discussion. Images, such as blood films, can be posted in addition to links from journal articles. Any follower can contribute or can simply watch the case developing. We react to followers’ suggestions and encourage evidence-based discussion, closing each case with a summary. We moderate discussion and explicitly refrain from offering medical advice. Technological literacy, compliance with confidentiality and SoMe guidelines, time management and promotion of the service to nonTwitter users have all provided challenges. These obstacles have been overcome by following General Medical Council guidelines, seeking advice from senior colleagues, presenting at local meetings and publishing in trainee newsletters. @TeamHaem has been operational since 2012 and we currently have 555 followers around the world, including doctors, nurses, pharmacists and biomedical scientists. We have published 17 cases so far. As our community grows and develops so will the strength of discussion and debate.

64 Treatment of neutropaenic sepsis: impact of an acute oncology service E Chernucha, C Boyes, M Hemstock, F Wadelin Department of Haematology, Nottingham City Hospital, Nottingham, UK Neutropaenic sepsis is a recognised complication of chemotherapy and is a common cause of admission and morbidity for haematology patients. It is a potentially fatal condition and patients can deteriorate rapidly. Early recognition of the condition and prompt treatment with intravenous antibiotics is vital. National guidelines recommend that appropriate antibiotics should be delivered within 1 hour of admission, and that all Trusts should have a protocol for the management of patients with neutropaenic sepsis. A retrospective audit was performed to review the timeliness of the administration of antibiotics for haematology patients admitted to a Level 4 Haematology Unit with signs of neutropaenic sepsis, or developing these signs whilst an in-patient, over a 7 month period (January–July 2013). This audit also reviewed compliance with current Trust antibiotic guidelines for the management of this group of patients. ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

The Acute Oncology Service (AOS) was established in the Trust in August 2013 and implemented a series of training for nurses working in acute admission areas focussing on the treatment of neutropaenic sepsis and the need for prompt identification and treatment. A prospective audit was commenced in August 2013 to evaluate the impact of the training and compliance with the peer review measures, using the same audit criteria. Results of these audits show an improvement in prompt and appropriate treatment for patients with neutropaenic sepsis following changes implemented by the Acute Oncology Service. Overall this has led to better service delivery and improved patient safety. Our recommendation is to continue regular nurse based training to reinforce previous learning, and continued promotion of the Acute Oncology Service website to facilitate access to Trust guidelines.

65 An audit of the management of primary immune thrombocytopenia (ITP) in adults EMR Watts, S Marshall Department of Haematology, Sunderland Royal Hospital, UK International consensus guidelines exist on the management of ITP (Provan,D, et al,[2010] Blood,115:168–186). There is no current BCSH guideline. We performed a retrospective audit of 45 adult ITP patients from Sunderland Royal Hospital, to assess compliance with the International Consensus Report Guidelines. The Royal College of Pathologists Haematology audit template was utilized. 100% of patients had a full blood count, 96% a film, and 96% of those over 60 years had marrow investigations. 88.9% had immunoglobulin quantification, 84.4% had Hepatitis C and 75.5% had HIV antibody investigations. 100% of patients treated met indications for treatment as outlined by Provan et al, and of those 94% received first line therapies of either steroids or intravenous immunoglobulin. 100% of those failing first line therapy received appropriate second line drugs. 68% received Rituximab either as a single agent or in combination. The remainder received treatments in line with the International Consensus Report. Five patients received Romiplostim after failing to respond to two or more therapies. Three had a good response. We demonstrated good compliance with international recommendations in the investigation and management of ITP. Some recommended investigations, such as direct antiglobulin test (DAT) and flow cytometry were little used (37% and 0% respectively), but we would dispute the inclusion of these tests as ‘essential’. We would suggest that these investigations are only of value in those where diagnostic uncertainty remains. One of the patients in our cohort did have Evan’s Syndrome but this was evident from other clinical and laboratory features. Although few patients received a thrombopoietin agonist, the evidence and efficacy experienced supports greater use of these agents, particularly as an oral formulation has now been approved by NICE. This audit forms a baseline from which to improve current practice at our centre, and will be repeated in 12–18 months.


Poster Session: General Haematology

66 Sickle cell and thalassemia service innovation to improve social care outcomes for patients: a 12 month review CE Matthews, G Davies, D Tsitsikas, R Amos Homerton University NHS FoundationTrust, UK The Social liaison post is part of a service innovation programme, in collaboration with psychology, for sickle cell disease (SCD) and Thalassemia patients in City and Hackney. The aim of this review is to assess the efficacy of the programme during its first year of implementation. High readmission rates in SCD are closely linked with social deprivation and low socio-economic conditions influenced by the wider determinants of health including housing, unemployment, social care needs and poverty. During this 12 month period the service received 62 referrals, 50 were from City and Hackney and 12 from out of the area. Referrals received were mainly from the haematology consultants, clinical psychologists and the nursing team. 35 referrals (56%) were regarding support with poor housing conditions; from these, a total of 11 clients had measurable outcomes which included successful rehousing of a client within a month, rehousing after an eviction, an elderly client rehoused into a ground floor property and repairs done promptly after receipt of a supporting letter. 12 referrals (19%) were regarding employment retention; one client was promoted after I attended a formal meeting to address her sickness absence. 7 referrals (11%) for childcare support especially mothers with sickle cell needing childcare when in crisis; this proves to remain a difficult ongoing need. The remaining 14% included supporting patients with immigration issues; in addition, one client was assisted to clear overpayment arrears and supported another with the reinstatement of a benefit payment and reduction in council tax bill. It is still too early to assess the overall impact on readmission rates but evidence so far suggests that patients engaging with the service find it helpful and some of their social needs are successfully addressed.

67 A novel objective measure of sample quality can provide training feedback to improve expertise at bone marrow aspirate procedures P Kalkur, S Patel, A Zaidi, T Butler Department of Clinical Haematology, Barts Health NHS Trust, London, UK Poor quality bone marrow (BM) aspirates may lead to diagnostic inaccuracy. Dry taps have been associated with BM fibrosis, but a more prevalent sign of poor quality BM aspirates is the aparticulate, haemodilute or bloody tap. Due to local concerns we sought to determine factors associated with high numbers of aparticulate BM aspirates. To determine historical controls, 1000 BM reports (initial 200 each from 2007 to 2011) were analysed. 1.2% were dry taps, 26% aparticulate. Common indications included diagnosis (23%), staging (18%) and response assessment (56%), with no association between indication and aparticulate BMs. The recognised association between BM reticulin grade (0–4) and aparticulate proportion was confirmed (spearman 0.89, p = 0.007), as well as diseases such as myelofibrosis. However, a high aparticulate proportion (22%) still occurred with reticulin grade 200. There was reduced Factor II, VII, IX and X levels. A 50:50 mix showed normalisation of the clotting profile. Vitamin K 10 mg and 3000 Units prothrombin complex concentrate (PCC) was administered. The INR normalised briefly but increased again to greater than 10 with recurrence of the haematuria. A further 3000units of PCC was administered and vitamin K 30 mg daily was given. The haematuria resolved and the INR normalised after 3 months. Difenacoum was detected using normal-phase HPLC with diode array detection. The difenacoum concentration was 1.44 mg/l. Vitamin K1 2,3-epoxide and K1 were quantified using reversed phase


HPLC. ELISA was used to measure undercarboxylated prothrombin (PIVKA-II). There was an elevated PIVKA-II concentration at presentation with levels >100au/ml. The K10 level to K1 was also elevated at presentation thereby confirming difenacoum action. The INR, PIVKA-II levels and K10 to K1 were elevated for 3 months demonstrating the prolonged effects of Difenacoum. This case highlights the importance of confirming the diagnosis of Difenacoum ingestion as the cause for the deranged clotting profile. The PIVKA-II assay demonstrated prolonged vitamin K antagonism for greater than 3 months. Patients with a history of superwarfarin ingestion require prolonged vitamin K administration to normalise the INR.

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Haemostasis and Thrombosis

87 Increased plasma levels of procoagulant microparticle activity and P-selectin in patients with myeloproliferative disorders compared with healthy controls JS Laird1, S Rhodes2, O Jones3, M Hair4, EA Brown5, M McColl3 1 Department of Haematology, Glasgow Royal Infirmary, UK; 2 Paul O’Gorman Leukaemia Research Centre, Gartnavel General Hospital, Glasgow, UK; 3Department of Haematology, University Hospital, Crosshouse, Kilmarnock, UK; 4Department of Obstetric Research Laboratory, University of Glasgow, Western Infirmary, UK; 5Department of Statistics, University of the West of Scotland, UK Increased levels of tissue factor-bearing microparticles have been associated with an elevated risk of venous thrombo-embolism in patients with malignancy (Zwicker et al [2012] British Journal of Haematology, 160, 530–537). Similarly, elevated levels of the adhesion molecule P-selectin have been found to be associated with a number of pro-thrombotic conditions and malignancies (Katayama

M et al [1993] British Journal of Haematology, 84(4), 702–710; Chong BH et al [1994] Blood, 83(6), 1535–1541). In this study, we sought to investigate the mechanisms underlying the procoagulant state in a number of haematological malignancies by measuring plasma levels of P-selectin and procoagulant microparticle (PMP) activity in patients with myeloproliferative disorders [polycythaemia rubra vera (PRV) and essential thrombocythaemia (ET)], lymphoproliferative disorders [Chronic Lymphocytic Leukaemia (CLL) and low grade Non Hodgkins Lymphoma (NHL)] and healthy controls, using ELISA techniques. We found that P-selectin levels were significantly increased in the myeloproliferative disorders group, compared with the lymphoproliferative disorders group (Mann–Whitney U = 17.5, Z = 4.05, p < 0.01) and the healthy controls (U = 10.0, Z = 4.62, p < 0.01). Furthermore, we found that PMP activity levels were significantly higher in the plasma of patients with myeloproliferative disorders compared with healthy controls (U = 37.5, Z = 3.68, p < 0.01) (Table 1). Our findings provide further insight into the pro-thrombotic mechanisms in patients with myeloproliferative disorders.

Table 1. Subject characteristics and results

Study group (Results)

Myeloproliferative disorders, N = 16 (10 PRV, 6 ET)

Lymphoproliferative disorders, N = 15 (9 CLL, 6 NHL)

Mean Age (years) Range (years) Gender M/F Median Procoagulant Microparticle activity level (nM) Range (nM) Median plasma level of P-selectin (ng/ml) Range (ng/ml)

61.69 (28–87) 7/9 9.25 (6.0–42.9) 61.95 (34.7–663.0)

69.47 (53–85) 10/5 7.7 (2.7–25.8) 26.9 (11.3–59.6)

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Controls, N = 18 57.89 (31–80) 8/10 5.7 (2.6–11.0) 33.05 (21.1–43.0)


Poster Session: Haemostasis and Thrombosis

88 A single centre experience of treating immune thrombocytopenia with romiplostim – sustained response after treatment discontinuation K Pallavi, L Taylor, R Nandigam, U Doobaree, D Provan, AC Newland Department of Haematology, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK Romiplostim is a thrombopoietin peptide mimetic agent recently approved for the treatment of adults with chronic immune thrombocytopenia (ITP). In randomized controlled studies, this agent has demonstrated an increase in the platelet count in the majority of patients with ITP, both in splenectomized and non-splenectomized patients.Transient rebound thrombocytopenia after discontinuation of romiplostim is well recognised, possibly resulting from enhanced clearance of endogenous thrombopoietin by the increased number of megakaryocytes. However, recent data show that durable responses after treatment discontinuation are achievable in a proportion of patients. We report the Royal London Hospital experience of treating patients with immune thrombocytopenia with romiplostim. Data were collected retrospectively for patients started on treatment with romiplostim between June 2008 and December 2013. Twenty one patients (10 male) were treated; median age of 39 years (range 23–75). Seven patients had undergone splenectomy prior to starting romiplostim. Median platelet count at the time of starting romiplostim was 13 9 109/l (Range 2–48 9 109/l). Treatment was administered on a weekly regime with dose adjustment according to response. Median dose of romiplostim was 5 lg per kilograms of body weight. Median duration of therapy was 26 months (Range 7–60). Nineteen patients (90.4%) responded (platelet count >50 9 109/l without concomitant ITP therapy). In five patients (26.3%) remission was sustained for longer than 6 months after discontinuing romiplostim therapy. These patients had received romiplostim for a median duration of 32 months (range 17–60) before discontinuation of therapy. Treatment was discontinued in one patient due to side effects (fatigue and sinus congestion). Two patients were switched to alternative treatment – eltrombopag due to lack of response to romiplostim. One patient died due to causes unrelated to ITP and romiplostim. Romiplostim is effective treatment for ITP and may induce a lasting response in some patients even after treatment discontinuation.

89 The impact of dietary vitamin K on the pharmacological activity of FXa inhibitor rivaroxaban in man S Abohelaika1, T Biss1, P Murphy2, J Coulson1, H Wynne3, F Kamali1 1 Institute of Cellular Medicine, Newcastle University, UK; 2 Department of Haematology, Freeman Hospital, Newcastle Upon Tyne, UK; 3Care of the Elderly, Freeman Hospital, Newcastle Upon Tyne, UK The impact of dietary vitamin K intake on anticoagulation response to warfarin is well established. However, the effect of dietary vitamin K on the activity of the novel oral anticoagulants is less well known.


We examined the influence of dietary vitamin K intake on the pharmacological activity of rivaroxaban in man ex-vivo. 31 medically stable elderly inpatients (mean age 87  6 years) with a poor dietary intake and 28 healthy subjects (mean age 36  10 years) with adequate diets were studied. Each subject completed a validated dietary questionnaire for quantification of vitamin K content of foods eaten in the past week and provided a blood sample. The plasma samples were incubated with rivaroxaban (100– 500 ng/ml). Normal prothrombin time (PT), modified prothrombin time (mPT), and vitamin K dependent clotting factors activity were measured according to established in-house methods. Rivaroxaban produced a greater prolongation of both PT (p = 0.01) and mPT (p = 0.02) in the plasma of elderly subjects than the younger healthy subjects over the drug concentration range studied. The mean difference in PT between the two groups ranged from 1.8s to 5.0s at 100 and 500 ng/ml plasma rivaroxaban concentrations respectively. The mean difference in m-PT between the two groups ranged from 10.0s to 34.0s at 100 and 500 ng/ml plasma rivaroxaban concentrations respectively. There was also a greater inhibition of factor Xa (p = 0.005) activity by rivaroxaban in the elderly subjects compared to the healthy subjects, whereas factor IXa (p = 0.03) activity was significantly inhibited in the healthy subjects compared to the elderly subjects. The analysis of dietary questionnaires showed that the healthy subjects consumed significantly higher amounts of vitamin K than the elderly ones (mean difference 150 lg; p < 0.0001). The present study findings demonstrated that the anticoagulation response to rivaroxaban may be influenced by poor dietary vitamin K intake.

90 Impaired fibrinolysis in angiographically documented patients with coronary artery disease AB Fernandes1, LM Lima1, MO Sousa1, VP Toledo1, RS Kazmi2, BA Lwaleed3, MG Carvalho1 1 Faculty of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; 2Department of Haematology, University Hospital Southampton NHS Foundation Trust, Southampton, UK; 3Faculty of Health Sciences, University of Southampton, Southampton, UK Impaired fibrinolysis may predispose to coronary artery disease (CAD). Hypo-fibrinolysis due to high levels of plasminogen activator inhibitor-1 (PAI-1) has been reported in CAD. A novel regulator of fibrinolytic activity, thrombin activatable fibrinolysis inhibitor (TAFI) has attracted attention in recent years. It acts by blocking the formation of a ternary complex of plasminogen, fibrin and tissue plasminogen activator (t-PA). Previously ambiguous results regarding TAFI levels have been reported in CAD. We measured plasma levels of PAI-1 and TAFI in patients with age ranging from 40 to 65 years, who had been submitted to coronary angiography and assessed the association of these markers with the extent of stenosis in three groups: angiographically normal artery (NAn), mild to moderate atheromatosis (MA) and severe atheromatosis (SA). Plasma levels of PAI-1 were increased in patients with severe atheromatosis compared to mild/moderate atheromatosis (p < 0.001) or to normal angiographically patients. For TAFI no difference was found between different groups. When patients were grouped in only two groups based on clinical cut-off point for intervention (stenosis less than or above 70%) we found increased plasma levels for PAI-1 (p < 0.001) and decreased plasma levels for TAFI (p = 0.04) in patients with stenosis above 70%. No difference was found in PAI-1 or TAFI levels ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Haemostasis and Thrombosis comparing the number of affected vessels. In conclusion: Impaired fibrinolysis as evidenced by a raised level of PAI-1 is found in stable CAD. There appears to be an association with the extent of degree of atheromatosis, although there is no correlation with the number of affected vessels.

91 Experience of romiplostin use in the management of ITP in a district general hospital setting - can fixed doses be used during stable phase to reduce wastage? B Van Staden, A Mahmood, HN Ahmad Department of Haematology, Burton Hospitals NHS Foundation Trust, Burton, UK The thrombopoetin receptor agonist, Romiplostim is indicated in chronic ITP patients with refractory ITP. We reviewed and analysed the data from two refractory ITP patients managed with Romiplostim. Using current manufacturer guidelines, we started with weekly dosing adjustments aiming for the recommended baseline platelet count of at least 50 9 109. Guidelines recommend an initiating dose of 1mcg/kg per week with increase in 1mcg increments to a maximum of 10 mcg/kg weekly until platelet count is stabilized above mentioned baseline. Hereafter, monthly blood tests are recommended and readjustment made if platelet count exceeds 200 9 109. Our patients commenced on 1mcg/kg, though once the platelet count was consistently above baseline, after a few dose adjustments, we found in both patients that during the stable phase, 250 mcg hence between 3 and 4 mcg/kg per patient respectively was an ideal maintenance dose that consistently kept the platelet count above 50 9 109 without requiring need for regular dose adjustment. Therefore these two patients have now been continued on this fixed dose and have shown an excellent response. Though our experience is limited, we have found a standard dose of 250 mcg to be an effective in maintenance of safe platelet counts. Also, as Romiplostim is available only in 250 and 500 mcg vials, variable doses will invariably lead to some wastage of this expensive drug. Given the economic climate and to simplify self-administration we propose further studies are required to assess whether a fixed dose of Romiplostim can be established for stable phase management of chronic ITP.

92 Identifying patients with non-valvular atrial fibrillation & poorly controlled INR on warfarin who are suitable to be switched to NOACs HN Ahmad, B Van Staden, A Haque, A Khan, A Gul Department of Haematology, Burton Hospitals NHS Foundation Trust, Burton, UK

form of an audit of Percent time in therapeutic INR range (TTR) amongst AF patients attending our Warfarin Dosing Service. Using our electronic patient records a total of 797 patients were identified as non-valvular AF patients on Warfarin at our dosing service. We found that 79% of these patients had a TTR of more than 60% and 53% above 70%. The 21% patients who did not meet the TTR target were arguably still at a higher risk of stroke. Moreover the fluctuation in their INRs also put them at a higher risk of bleeding. We went on to check the records for abnormalities of renal (eGFR) and liver blood tests (LFTs) in this cohort. Our results showed that 94% of these patients had normal LFTs, 97% had eGFRs of >30 and 59% had eGFRs of >60. Thus majority of the patients in this cohort were eligible for switching to NOACs. Although our data is limited to a single center, it suggests that approximately 20% of the AF patients on Warfarin may require switching to a NOAC due to poor INR control.

93 A retrospective analysis of hospital acquired thrombosis reporting EL Wyatt-Haines, S Black, M Faughnan, WJN Uprichard, MS Shannon Hospital Thrombosis Group, St George’s Hospital, London, UK The 2013 Dr Foster Intelligence report on post-operative pulmonary embolism and deep vein thrombosis for St George’s Hospital, identified 3.68 episodes of hospital acquired thrombosis (HAT) per 1000 people. This figure is higher than the expected rate of 2.78. HAT is defined as a thrombotic event occurring during an inpatient episode or within 90 days of discharge. HATs result in considerable morbidity and mortality, as well as influencing CQUIN (Commissioning for Quality and Innovation payment framework) targets. A retrospective analysis was performed to establish if these were true cases of HAT. All 113 cases of HAT in the Dr Foster report were investigated by examination of electronic discharge summaries and radiology reports to determine whether they were true cases of post-operative HAT. Only 40 of the 113 cases were genuine HAT. Of the remaining 73, 24 had no history of thrombosis, 16 had a past history of venous thromboembolism, 31 had a pre-existing venous thrombosis on admission and two had arterial thrombosis (not included in HAT criteria). This results in a rate of 1.3 per 1000. In addition, nine of the 40 cases were not post-operative. HAT is being reported incorrectly, resulting in incorrect statistics as well as CQUIN-associated financial consequences. The list of cases reported to Dr Foster is generated by administrative staff coding discharge summaries; we suggest that the discharge summaries are unclear in their description of thrombosis and are being misinterpreted by the coding staff. Doctors and clinical coders need to work together to review miscoded episodes and to ensure future coding is correct. This will reduce clinical risk and potential financial penalties.

There are quite a significant number of patients of non valvular Atrial Fibrillation (AF) who are on Warfarin for stroke prevention but fail to achieve stable INR control and hence remain at risk. In recent years at least three different New Oral Anticoagulants (NOACs) have been shown to be effective as well as non inferior to Warfarin for stroke prevention in AF. These drugs despite not having effective antidotes yet are considered to have lesser risk of serious bleeding than Warfarin. Although work may be in progress, no clear guidelines have yet been established to decide which patients require switching to NOACs and when. We decided to address this in the ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103


Poster Session: Haemostasis and Thrombosis

94 Indications and outcomes of patients receiving prothrombin complex concentrate at the University Hospital of South Manchester during 2011 RA Salisbury1, S Elhanash2 1 John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK; 2Department of Haematology, University Hospital of South Manchester, Manchester, UK Background: Prothrombin Complex Concentrate (PCC) is an infusion of human clotting factors used to rapidly reverse warfarin. It has the advantage over fresh frozen plasma of containing less volume and being faster acting. BCSH guidelines advocate its use for the reversal of warfarin in the event of a limb or life-threatening haemorrhage where reversal is required within 6–8 hours. Methods: Retrospective case series of all patients receiving PCC at the University Hospital of South Manchester during 2011. Data were collected from case notes, blood result reporting software, blood bank database and copies of blood request forms. Results: Twenty-two cases were identified using the blood bank database of which 2 were excluded. One did not receive PCC and one was lost to follow up. 15/20 (75%) were male with mean age 72 (64–81; 95% CI). 18/20 (90%) cases were taking warfarin. 11/20 (55%) had active bleeding and 9/20 (45%) required an emergency procedure/surgery. Mean INR prior to PCC administration was 3.81 (2.33–5.27; 95% CI). Mean INR after PCC administration was 1.36 (1.23–1.49; 95% CI). 16/20(80%) received vitamin K in addition to PCC. Time from prescription to infusion, in the cases where it was recorded, ranged from 0:00 to 7:25 hours. 6/20 (30%) of cases died during the episode where they required PCC. 3/20 (15%) had further bleeding after receiving PCC. 2/20 (10%) had a thromboembolic event within 28 days of receiving PCC. Discussion: In this case series we provide a summary of how PCC is used within a large teaching hospital. We demonstrate that PCC is used in patients not taking warfarin and in patients undergoing emergency procedures/surgery. PCC was effective in correcting INR but did not prevent further bleeding in all cases. It was associated with significant thromboembolic events but outcomes could not be attributed to PCC administration alone.

95 Novel tandem red cell exchange transfusion and ultrafiltration programme for congestive cardiac failure complicating sickle cell disease intolerant of pharmacological agents V Mathew1, P Greaves1, M Dwornik2, T Bowker2, DA Tsitsikas1, RJ Amos1 1 Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK; 2Department of Cardiology, Homerton University Hospital NHS Foundation Trust, London, UK A 48-year-old man with HbSS disease, complicated by avascular necrosis and frequent painful crises, initially successfully managed with hydroxycarbamide, was admitted with a history of exertional dyspnoea and bilateral leg swelling, developing 6 weeks after a prior admission for an acute chest syndrome, which had responded to exchange transfusion. At that time treatment with hydroxycarbamide was stopped because of reduced effectiveness. After extensive investigation (including a CTPA), a non-ischaemic, dilated cardiomyopathy (DCM) was diagnosed and furosemide 40 mg, ramipril 1.25 mg and


bisoprolol 2.5 mg daily were started, 96 hours later his creatinine was 429lM with a metabolic acidosis. This resolved following i.v. fluids and withdrawal of nephrotoxins, and without renal replacement therapy. Given his intolerance of pharmacological agents and ongoing marked fluid overload, a trial of ultrafiltration (UF) was initiated. The first 72 hours UF session, during which the haematocrit was continuously monitored and maintained between 0.24 and 0.25, removed 12 litres of fluid. There was no significant deterioration in sickle-related pain. Despite subsequent cautious fluid restriction, fluid retention and weight gain returned within weeks and, at the same time, his sickle-related pain deteriorated, most likely due to fluid restriction and withdrawal of hydroxycarbamide. Therefore we instituted an 8-weekly programme of automated red cell exchange transfusion (ARCET) with a target HbS of 1 cycle of CHOP/CNOP chemotherapy plus Rituximab. Scoring of antibody positivity was assessed as a percentage of total malignant cells by consensus opinion of specialist haematopathologists. Staining of p53 greater than 50% was defined as positive and any p21 staining was defined as positive in line with other published works. This cohort included a range of ages [21–91 years], stages, IPI groups [Low 37%, low-intermediate 18%, high-intermediate 30% and high 15%] and Hans ABC or GC-like DLBCL cases [ABC-like 37% GC-like 63%.]. Neither p53 nor p21 expression alone significantly predicted for outcome [p = 0.9 and p = 0.93 respectively]. However, p53+/ p21 [n = 25] cases had a significantly worse overall survival [p = 0.039]. When cases were divided into GC- and ABC-like the significance of p53+/p21 was persistent only in the GC-like group but not in the ABC-like group [p = 0.03 and p = 0.624 respectively]. This poorer prognosis in p53+/p21 GC-like DLBCL patients may reflect an underlying TP53 mutation. The p53+/p21 phenotype is not significant in the ABC-like DLBCL patients as mechanisms other than TP53 mutations may be contributing to their poorer outcomes.

110 Initial experience and clinical utility of a high resolution melting curve assay to detect the MYD88 L265P mutation in peripheral blood and bone marrow aspirates in patients with lymphoplasmacytic lymphoma and related disorders J Kothari1, S Adams2, H Kempski2, S D’Sa1, P Blombery1 1 Department of Haematology, University College Hospital, London, UK; 2Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK The gain of function mutation MYD88 L265P is present in approximately 90% of patients with Waldenstroms Macroglobulinaemia


(WM). We aimed to validate and implement a qualitative assay for detection of the MYD88 L265P for diagnostic use in patients with WM and related disorders. A high resolution melting (HRM) curve assay was designed with primers targeting the c.794 T>C mutation. Peripheral blood (PB) samples and bone marrow aspirate (BM) samples were used. During validation, magnetic cell sorting (MACS) by CD19 was implemented on PB to improve sensitivity. After validation, the assay was implemented into diagnostic use. Thirty samples have been analysed (20 PB and 10 BM). 25 samples were from patients with a diagnosis of WM. 5 patients had the assay performed as part of the characterisation of an IgM paraprotein. On PB samples, the mutation was detected in 7 patients [median lymphocyte count 2.1 9 109/l (range 1 – 9.32)]. Of the 13 patients where the mutation was not detected, 10 patients had an established diagnosis of WM and 3 were performed as part of a work up of a lymphoproliferative disorder. On BM samples, the mutation was detected in 7/10 patients – all of whom had a diagnosis of WM (morphological involvement 17-90%). Of the negative BM samples, two patients had IgM myeloma and one was from a haemodilute aspirate from a patient with WM. Aspirate samples were assayed without enrichment. All positive samples by HRM had the L265P mutation confirmed on subsequent sequencing. Our HRM assay detects the MYD88 L265P mutation in BM samples with a sensitivity of approximately 10% mutant allele burden. Moreover, using CD19 enrichment, the mutation was also detectable in PB. Detection of the MYD88 L265P mutation with this assay is therefore feasible with routine diagnostic samples and is a useful investigation in patients with WM and related disorders.

111 In patients with chronic lymphocytic leukaemia an IgG1 and a HCT CI > 2 were significantly associated with inferior survival. Moreover patients with both a poor performance status (ECOG >1) and HCT CI >2 had a significantly worse outcome than those with either poor performance status or HCT-CI >2 alone. Our findings suggest that the combination of co-morbidity and performance status may be a better prognostic indicator of outcome in high IPI diffuse large B cell lymphoma than age alone.

126 Results of the randomised phase II NCRI arctic (attenuated dose rituximab with chemotherapy in CLL) trial of low dose rituximab in previously untreated CLL T Munir1, D Cohen2, D Milligan3, A Schuh4, L McParland2, A Chalmers2, A Varghese1, A Rawstron5, D Allsup6, S Marshall7, A Smith2, C Collett2, W Gregory2, A Duncombe8, P Hillmen1 1 Department of Haematology, St James’ University Hospital, Leeds, UK; 2Clinical Trials Research Unit, University of Leeds, UK; 3Centre for Haematology and Stem Cell Transplantation, Heartlands Hospital, Birmingham, UK; 4 MRC Haematology Unit, University of Oxford, UK; 5 Haematological Malignancy Diagnostic Service, St James’ University Hospital, Leeds, UK; 6Department of Haematology, Hull & East Yorkshire NHS Trust, UK; 7City Hospitals Sunderland, UK; 8Department of Haematology, Southampton University Hospital, UK Non randomised-phase II trials suggest adding mitoxantrone (M) to FCR improves outcomes in CLL. Standard rituximab dose has been extrapolated from lymphoma trials but lower doses of rituximab (miniR) may be effective in CLL. ARCTIC is a phase IIB, randomised, multicentre trial comparing FCR to FCM-miniR to assess non-inferiority of the investigational arm. Fludarabine 24 mg/m2/day and Cyclophosphamide 150 mg/m2/day were administered orally for 5 days in both arms (q28d). IV rituximab 500 mg/m2 (cycle 1) followed by 375 mg/m2 (cycle 2–6) on day 1 was administered in FCR arm. IV rituximab 100 mg and mitoxantrone 6 mg/m2 were given on day 1 (cycles 1–6) in FCM-miniR arm. 100 patients were recruited to each arm. The median age was 63 years (range 36–80). Binet stage was progressive stage A (17%), stage B (48%), stage C (36%). 59% (95/160) had unmutated Ig genes, 4% (7/185) 17p deletion and 16% (13/188) 11q deletion. Dose modification (FCR 63%; FCM-miniR 66%), premature treatment discontinuation (FCR 30%; FCM-miniR 35%) and G-CSF requirement (FCR 42%; FCM-miniR 51%) were more common following FCM-miniR. 96 patients (49%) were hospitalised due to an SAE (FCR 46%; FCM-miniR 52%). A planned interim analysis after 103 patients indicated the CR rate to FCM-miniR was not non-inferior to FCR. As a consequence, 21 patients still receiving treatment with FCM-miniR crossed over to FCR. The 179 intention-to-treat patients who did not cross-over reported a 95% ORR, with 68% achieving a CR (FCR 77%; FCMminiR 57%). Undetectable MRD by flow cytometry (sensitivity 10 4) in marrow 3 months post treatment was 51% (FCR 55%; FCM-miniR 45%).

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Lymphoid Malignancy - Clinical ARCTIC was stopped prematurely as it was clear that the trial would not show non-inferiority for FCM-miniR. Both arms performed well and low dose of rituximab with FCM appeared to be effective but there was more toxicity associated with the addition of mitoxantrone confounding the comparison of rituximab doses.

127 Hepatitis B screening for patients receiving rituximab: addition of virology screening box to chemotherapy prescription card could improve clinical practice J Connor1, G Harris1, D Galvani1, R Dasgupta1, S Purcell2, R Allen2, B Hammer1 1 Department of Haematology, Wirral University Teaching Hospital, UK; 2Pharmacy and Aseptics, Wirral University Teaching Hospital, UK Rituximab was approved in 1997 and is now used routinely in the treatment of Non-Hodgkin’s lymphoma. One of the recognised complications is hepatitis B virus (HBV) reactivation and there have been reports of reactivation leading to fulminant hepatitis, liver failure and death.As a consequence recent guidance from the Medical and Healthcare Products Regulatory Agency (MRHA) in November 2013 has advised that all patients should be screened for HBV prior to commencing Rituximab.In order to adequately screen for HBV, heptatis B surface antigen (HBsAg) and hepatitis B core antibody (antiHBc) are advised.We have assessed the HBV screening rates for all Haematology patients receiving Rituximab in 2013 to identify a) the total number of patients screened and b)the number of patients with incomplete or incorrect testing.91 patients who had received Rituximab in 2013 were identified via pharmacy coding.37% of patients (n = 34) had correct HBV screening prior to treatment.Of those who were screened, no patients were found to have previous or current HBV infection.7% of patients (n = 6) were incompletely screened for HBV with only anti-HBc being tested for.The remaining 51 patients (56%) had no evidence of HBV screening prior to commencing Rituximab.In light of the low screening rates we have made changes to our local chemotherapy prescription card to which a new viral screen completion box has been added which prompts clinicians to confirm the patient’s HBV status.Aseptics have been instructed to issue Rituximab only if this box has been completed.We have also made changes to electronic virology requests to ensure the correct tests are performed.We are planning to reassess our hepatitis screening rates in due course but predict that the chemotherapy card alteration will increase screening rates significantly which will result in improved clinical practice.

128 Efficacy and tolerability of lenalidomide for the treatment of multiple myeloma: a ‘real world’ single centre experience JA Chadwick1,2, E Tholouli1, A Sinacola1, E Thornton1, SDJ Gibbs1 1 Manchester Royal Infirmary, UK; 2North West Deanery, UK Lenalidomide has been reported as effective treatment for relapsed/ refractory myeloma. It is being evaluated in the Myeloma XI trial as first-line and maintenance therapy. We retrospectively audited our ‘real world’ experience of lenalidomide at Manchester Royal Infirmary. We identified 64 patients treated with lenalidomide from June 2009 to November 2012. 21 patients were treated first-line, 3 as ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

maintenance and 40 for relapsed/refractory disease. Maintenance patients have had 1–31 treatment cycles. Analysis focused on relapsed/refractory disease. Patients received a median of 4 prior therapies (range 1–7); 100% received steroids, 93% thalidomide, 90% bortezomib and 50% autologous stem cell transplantation (ASCT). Median number of lenalidomide treatment cycles is 6 (range 1–26). 12 (30%) patients remain on treatment. Partial responses were achieved in 62.5%, VGPR in 23% CR in 13%. This compares favorably with phase 3 trial results of 60.2%, 15.9% and 8.5% respectively. Grade 3–4 cytopenias were common: 55% neutropenia, 58% anaemia and 35% thrombocytopenia. Most patients continued treatment with dose modifications. 45% received G-CSF support. Worsening renal impairment occurred in 17%, however this resolved with dose reductions/interruptions in 70%. Grade 1–2 peripheral neuropathy occurred in five patients (13%), venous thromboembolism in two (5%). Overall, dose reductions occurred in 13 patients (33%) and doses postponed in 17 (43%). The median number of cycles was higher with dose reductions (9 vs. 4 cycles). Treatment cessation was due to progressive disease in 12 (44%) and toxicity in 14 (52%), including renal failure (4), bowel disturbance (3), cytopenias (2), infections (2), hypocalcaemia (2), and liver dysfunction (1). One patient ceased to proceed to second ASCT. In conclusion, lenalidomide is effective and relatively well tolerated treatment. Clonal responses in our analysis were similar to those of clinical trials. Cytopenias were common, but usually can be managed with G-CSF support and dose modifications can allow continued treatment for most toxicities.

129 Dose-adjusted R-EPOCH for the treatment of primary mediastinal B-cell lymphoma: the West Anglia experience NF Grigoropoulos1, S Nagumantree2, A Hodson3, L Cooke4, M Karanth5, HK Cheow6, AS Shaw6, CR Crawley1, R Bulusu7, MV Williams7, GA Follows1 1 Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, UK; 2Department of Haematology, Peterborough City Hospital, UK; 3Department of Pathology, Ipswich Hospital, UK; 4Department of Haematology, Queen Elizabeth Hospital, King’s Lynn, UK; 5 Department of Haematology, West Suffolk Hospital, Bury St. Edmunds, UK; 6Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, UK; 7Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, UK Primary mediastinal B-cell lymphoma (PMBL) is an aggressive lymphoma mainly affecting young people. Although most patients treated with R-CHOP will be cured, approximately a quarter will progress or relapse, and the majority of these will die of lymphoma. Mediastinal radiotherapy may increase cure rates, but long term cardiac, pulmonary, and oncogenic toxicities are important caveats in this young cohort. Chemotherapy intensification with dose-adjusted R-EPOCH may obviate the need for RT, and excellent results have been published recently. Following earlier data, we adopted R-DA-EPOCH as first-line therapy for PMBL in our network in mid-2010. To examine the relevance of recent trial results to routine practice, we performed a service analysis of PMBL patients treated with R-DA-EPOCH in our network. All PMBL patients treated with R-DA-EPOCH in West Anglia were identified through a lymphoma database search. Response rates were assessed, and PFS/OS analyses were performed using the Kaplan-Meier method.


Poster Session: Lymphoid Malignancy - Clinical 27 patients with PMBL were treated in our region with R-DAEPOCH. Median age was 30. 32% had stage IV disease. At the cutoff date of 31/10/2013 median follow-up was 18 months. 3/27 (11%) had R-CHOP for the first treatment cycle. 6/27 (22%) received RT in first remission. 24/27 (89%) achieved PET negative remission (Deauville ≤3). 4/27 (15%) had biopsy-proven progression/relapse despite appropriate dose escalations as per protocol. Of these, 2 were salvaged and transplanted. 2/27 (7.4%) died, 1 with CNS relapse post-RT, and 1 with disease refractory to salvage chemotherapy, RT, and brentuximab vedotin. Median PFS and OS have not been reached. Updated 2-year follow up will be presented. Encouraging results were achieved in our region with R-DA-EPOCH. RT was avoided in the majority of patients. Salvage with chemo-radiotherapy and transplant is feasible after R-DA-EPOCH. It remains unclear whether R-DA-EPOCH is superior to R-CHOP with RT.

130 Fixed dose rituximab for diffuse large B cell lymphoma treated with R-CHOP – a retrospective audit MV Furtado1,2, NK Shah1,2, SAJ Rule1,2 1 Department of Haematology, Derriford Hospital, Plymouth, UK; 2University of Plymouth, UK For diffuse large B cell lymphoma (DLBCL) adding rituximab to CHOP chemotherapy has been shown to improve overall survival however the pharmacodynamic rationale for the standard dosage of 375 mg/m2 rituximab per cycle has never been established. Consequently, since 2006, approximately 280 patients with DLBCL treated with R-CHOP at Derriford Hospital, Plymouth, have received a capped dose of 500 mg rituximab per cycle. To determine long term outcomes we audited patients treated pre and post this dosage policy change. In total, 84 patients (46 male, 38 female) were included who received R-CHOP for de novo stage I-IV DLBCL (n = 77) or grade 3 follicular lymphoma (n = 7) between April 2004 and 2007. Median age at first treatment, 67.1 (range 28.8– 84.6), was comparable between a cohort of 48 patients who received an ‘uncapped’ rituximab dose of 375 mg/m2 each cycle, and a cohort of 36 patients who received a ‘capped’ dose of 500 mg per cycle. Both groups received a median of 6 cycles of RCHOP (range 1–8). Overall response rate to RCHOP was similar in each cohort (88.9% capped, 89.6% uncapped). Median followup for all patients was 58.7 months. The five year overall survival was also comparable, [61.1% capped, 68.7% uncapped, median survival 52.5 months (capped arm) and not yet reached (uncapped arm), p = 0.17] indicating no significant difference between survival curves at 5 years. The uncapped cohort received a median increased dose of 1000 mg of rituximab per patient per total treatment schedule, compared to the capped group. Our centre treats approximately 41 new DLBCL patients a year (2005–2009), equating to a saving of £72000 p.a. with this dose reduction. In summary this data demonstrates an equivalent five year overall survival in a cohort of patients with DLBCL treated with a fixed dose of 500 mg rituximab RCHOP regime, compared to a cohort receiving standard rituximab dosing.


131 Lenalidomide in practice: clinical audit of practice and outcomes at a district general hospital P Garland, C De Lord, B Vadher, M Ceesay, P Dighe, A Lakhani, S Bowcock Department of Haematology, Princess Royal University Hospital, King’s College Hospital NHS Foundation Trust, Kent, UK Lenalidomide is recommended in England as an option for myeloma patients who have received at least 2 prior therapies. Under the Treatment Continuation Scheme, NHS costs are limited to 26 cycles. We report an audit of clinical practice/outcomes at our centre, based in South East London. Pharmacy prescriptions since 2009 were cross-checked with patient records to derive individual ‘myeloma timelines’ from diagnosis, and demographic data and detailed treatment histories/outcomes were obtained. Over the 4 years, 24 patients received lenalidomide (median age 77.7 years); 13 patients died. All received dexamethasone and cyclophosphamide was subsequently combined for appropriate patients. Dosage was attenuated in 17/24 patients, principally for renal impairment and cytopenias. Aspirin was used for venous thrombosis prophylaxis and no thromboembolic events were seen. 13 patients had a meaningful response beyond 4 months therapy. Of the 10/11 patients who stopped lenalidomide within 4 cycles, all had heavily pre-treated myeloma and/or were over 80 years old and succumbed to acute events. The longest duration of therapy was 17 cycles. During this period, no patients were funded under the Treatment Continuation Scheme, although 6 remain on treatment with good responses. In the rapidly evolving field of myeloma treatment, the practical translation of new approaches into an unselected DGH population, within NICE restrictions, is challenging. Predictably, our cohort is older, with more co-morbidity than original trials. The importance of proactive dose escalation where renal function/performance status improves whilst on therapy, and GCSF to avoid neutropenia, were highlighted in our results. Data collation with ongoing audit has facilitated review of local practice/outcomes and provided the opportunity for future comparison with similar demographically placed centres. Additional analysis of the 2013 data will allow presentation of 5 years practice since lenalidomide approval by NICE.

132 Reflective testing in diagnosis of paraproteinaemias: what is its role? N Flaum1,2, S Watt2, AM Kelly1 1 Department of Biochemistry, University Hospitals of South Manchester, UK; 2Department of Haematology, University Hospitals of South Manchester, UK Reflective testing is a divisive issue. Laboratory clinicians and clinical scientists use their judgement to perform relevant additional tests on samples sent by physicians to assist in a diagnosis. No studies to date have been published to investigate reflective testing in haematological or oncological conditions. In UHSM serum electrophoresis and immunoglobulins may be added by the Duty Biochemist, if they consider other biochemical results potentially suspicious for myeloma or paraproteinaemia; globulin over 42 g/l was considered suspicious. To assess the impact of this we analysed all positive electrophoresis results over one year where the electrophoresis request was made by the Duty Biochemist. The history of each patient with paraproteinaemia was ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Lymphoid Malignancy - Clinical reviewed by casenotes, previous blood tests, contacting GP surgeries and clinical haematology departments to confirm if a diagnosis was reached, and whether the diagnosis was new or previously known. Over this time there were 54 positive results from approximately 1950 tests (2.7%) of which six were new diagnoses: three MGUS, one Waldenstrom’s macroglobulinaemia, and two of myeloma. Of the myeloma patients, one died shortly after diagnosis and one underwent treatment. 69% of patients had a previously confirmed or likely MGUS diagnosis. 325 add-on tests were performed for every new diagnosis, approximately 975 tests for each diagnosis of myeloma. Financial costs in this time of limited NHS resources are relevant: the tests in this study cost >£33,000, approximately £17,000 per new myeloma diagnosis. Practical and ethical issues such as consent and autonomy relating to serum electrophoresis as an add-on test need to be considered, including possible disadvantages of MGUS diagnosis such as risk of psychological distress, physician time, further investigations, and that no clinical benefit of monitoring of MGUS patients have been shown. Overall this study shows no clear benefit of reflective testing for paraproteinaemia, and its use needs greater analysis.

133 Outcome of diffuse large B cell lymphoma: a United Kingdom district general hospital experience F Seymour, A Barkhuizen, A MacWhannell, S Basu, S Francis, A Jacob Department of Haematology, Royal Wolverhampton Hospital NHS Trust, UK Incidence of Diffuse Large B Cell Lymphoma (DLBCL) has steadily increased in recent decades. It has been demonstrated that the addition of Rituximab to CHOP chemotherapy improved outcome and is generally well tolerated with complete response (CR) rates of 75% and 2 year survival of 70%, (Coiffier et al [2002] NEJM 346, 235) however, stringent clinical trial inclusion criteria mean that the results may not be reproduced in patients seen in routine clinical practice. All patients diagnosed with DLBCL at out haematology centre between 2007 and 2011 were identified in the haematological malignancy database and a retrospective review of medical records was performed. Where clinical scores were not documented in medical records they were retrospectively calculated based on pathology and radiology reports. In total 111 patients were identified and included in this analysis. Our unselected cohort of patients achieved CR rates of 65% with 2 year survival of 61%. In those patients considered fit enough to undergo full intensity treatment (defined as 6–8 cycles of R-CHOP) CR rates were 80% with 2 year survival of 85%. In contrast those patients treated with reduced intensity chemotherapy achieved a CR rate of 45% and 2 year survival of 50%. Interestingly, in patients aged over 70, those who received reduced intensity chemotherapy achieved a CR and 2 year survival rate of 75% compared to 52% in those receiving full dose treatment. This real world experience demonstrates that it is possible to achieve response rates comparable to the published data in those patients considered fit enough to undergo full intensity treatment. Outcome in those under the age of 70 treated with reduced dose chemotherapy is disappointing; this is likely to reflect a cohort with significant co-morbidity. In contrast the improved outcome seen in those aged over 70 treated with reduced intensity chemotherapy reflects a reduction in toxicity.

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

134 Single centre outcome of mantle cell lymphoma over the past decade NK Shah1,2, M Furtado1,2, N Crosbie2, S Rule1,2 1 Peninsula Schools of Medicine and Dentistry, University of Plymouth, UK; 2Derriford Hospital, Plymouth Hospitals NHS Trust, UK Mantle Cell lymphoma (MCL) accounts for 6–8% of all non-Hodgkin lymphomas. It has a heterogeneous clinical course with poor prognosis and a challenge to treat. We retrospectively analysed 51 MCL patients diagnosed and managed in Plymouth between 2000 and 2010. 45/51 patients were included. Patient characteristics, therapies and biological markers were evaluated with regards to overall survival rate (OS). Up-front treatment regimens were categorised into treatment within clinical trials or physician’s choice. The median age was 68 years (range: 40–88) and 58% (26/45) of the patients were older than 65 years (45% and 95% OS at 3 years in patients >65 and 1 extranodal site and raised LDH level. BCSH guidelines recommend that (1) all patients requiring CNS-directed therapy should receive 3–6 doses of intrathecal (IT) methotrexate (MTX), (2) consideration can be given to the addition of systemic high dose MTX (HDMTX) (3) and if HDMTX alone is to be used then it is essential that this practice is audited. We decided to review the incidence of CNS disease in patients with DLBCL, deemed to be at high risk of CNS occurrence, who were treated with R-CHOP-like chemotherapy at our centre and who received IT chemotherapy as the sole form of prophylaxis. Electronic chemotherapy records and clinical notes were used to identify patients and record demographics, disease-related data, chemotherapy details and clinical outcome. Thirty-eight such patients were identified between 2004–12. With a median follow-up of 50 months 15 patients have died. Only 1 patient has developed CNS involvement. This isolated parenchymal relapse occurred 4 months after completion of 8xR-CHOP and 6 9 12.5 mg ITMTX in a man presenting with testicular involvement-giving an incidence of CNS relapse of 2.6%. Our data does not support the need for additional systemic prophylaxis in addition to ITMTX in high risk patients, though we acknowledge the sample size is small and that confidence intervals will be wide. A national audit of the effectiveness of various CNS chemoprophylaxis strategies would be desirable.

139 The management of early stage chronic lymphocytic leukaemia within primary care is safe and effective: an observational retrospective cohort study HM Parry1, S Damery2, N Mudondo3, P Hazlewood4, T McSkeane4, S Aung5, J Murray4, G Pratt1, P Moss1, D Milligan5 1 Department of Cancer Sciences, University of Birmingham, UK; 2Department of Primary Care Clinical Sciences, University of Birmingham, UK; 3Birmingham Medical and Dental School, University of Birmingham, UK; 4Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK; 5Centre for Haematology and Stem Cell Transplantation, Heart of England NHS Foundation Trust, Birmingham, UK

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Objectives: To investigate the safety and effectiveness of discharging patients with stage A0 Chronic Lymphocytic Leukaemia (CLL) to primary care follow up and the associated impact on disease progression and patient survival. Design: Observational Retrospective Cohort Study. Setting: Outpatient Haematology clinics in two large teaching hospitals with contrasting management practices for patients with stage A0 CLL, and primary care practices in West Midlands, UK. Participants: All patients aged 18 and over diagnosed by a haematologist with stable stage A0 Chronic Lymphocytic Leukaemia since 2002. Main outcome measures: Evidence of disease progression, need for treatment and overall mortality. Results: 314 Stage A0 CLL patients were identified in the two Haematology units, of which 146 patients (46.5%) were discharged to primary care, whilst 168 patients (53.3%) were followed up in Haematology outpatient clinics. No difference in mortality or need for treatment was found between the two groups. Of those discharged to primary care, 49 (33.6%) were subsequently re-referred to secondary care whilst 97 remained in primary care. Conclusion: The management of stable stage A0 CLL with an annual appointment within primary care or in secondary care leads to equivalent clinical outcomes. Two thirds of patients who are managed in primary care do not need re-referral. The prevalence of early stage CLL is expected to increase in line with the ageing population and management within primary care should be considered as a potentially cost effective approach.

140 Use of serum free light chain assay in patients with plasma cell disorders – a re-audit

F Ng Kee Kwong1, R Popat2, A Rismani2 1 University College London, UK; 2Department of Haematology, UCL Cancer Institute & University College Hospital, London, UK

An audit in October 2011 assessed the appropriateness of the use of Serum Free Light Chain (SFLC) assays at University College London Hospital (UCLH) compared with the International Myeloma Working Group (IMWG) guidelines. An analysis of 161 notes showed that 39% (63) met the criteria. Tests were inappropriately being requested to monitor response and progression in patients with myeloma (94) and had been ordered for non-myeloma patients on four occasions. It was proposed that local guidelines should be developed and that the blood form stamp should be redesigned to reduce the rate of indiscriminate testing. The re-audit in October 2012 was to establish the effectiveness of these changes. In October 2012, a list of all requests was acquired and the patient data was accessed through CDR. The data collected included the patients’ demographics, diagnosis, prior therapies, disease measurement, and number of bands, serotype, light chain and stage. The context for each test was identified that is, diagnosis, response to therapy, monitoring for disease progression and assessment of complete remission. The concomitant use of serum electrophoresis or urine Bence-Jones proteins was noted. Adherence was thereafter assessed. 232 tests were requested in October 2012. Only 33.2% (77) were compliant. High volumes of tests were still inappropriately being requested for patients with multiple myeloma who were not in complete remission (141) and for non-myeloma patients (14).The increase in test turnover inevitably entailed heavier expenses.


Poster Session: Lymphoid Malignancy - Clinical The minor difference may reflect a lack of implementation of the action plan from the first audit. A locally adapted guideline is essential as there is a strong emphasis on monitoring for disease progression through the detection of light chain escape, especially at UCLH. There is also a perceived additional benefit from SFLC tests, which could potentially be included in further research undertaken at the Cancer Institute.

141 High-dose methotrexate in treating primary testicular lymphoma MAV Reinius1, SS Ahmad1, C Crawley2, MV Williams1, J Wimperis3, GA Follows4 1 Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, UK; 2Department of Clinical Haematology, Addenbrooke’s Hospital, Cambridge, UK; 3 Department of Haematology, Norfolk and Norwich University NHS Foundation Trust, UK; 4Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, UK Primary testicular lymphoma [PTL] has a propensity for CNS spread. Treatment commonly involves orchidectomy, R-CHOP, intrathecal methotrexate [IT-MTX] and prophylactic contralateral testicular radiotherapy. Systemically-administered high-dose MTX [HD-MTX] at 3 g/m2 may potentially enhance CNS parenchymal penetration and obviate scrotal irradiation. HD-MTX was incorporated into the Anglia Cancer Network PTL treatment protocol in 2005. Outcomes, since 2005, from the Network’s largest lymphoma centres, based in Cambridge and Norwich [CUH, NNUH], were retrospectively reviewed. 10 patients were identified (CUH = 6, NNUH = 4). All presented with scrotal swelling. Median age at diagnosis: 61.5 (49–71). Median IPI-score: 1. ECOG-PS: 0 (90%); 1 (10%). 80% had stage IE disease and 20% stage IIE (paraaortic). Standard protocol included R-CHOP21 (6 cycles) plus IT-MTX (3–6 cycles) with HD-MTX (3 cycles) administered between or after R-CHOP21. NNUH also offered contralateral testicular radiotherapy (30 Gy/15#) +/ nodal irradiation if stage IIE. No grade 3/4 toxicities were recorded. 8 patients remain in remission at median follow-up of 4.27 years. One patient relapsed within bone marrow, but without CNS metastasis and died of systemic disease. Another died of unrelated causes. No CNS or testicular relapse was noted in our 10 patients, including the six who did not receive scrotal irradiation. One patient with bilateral disease on biopsy underwent unilateral orchidectomy after completing systemic treatment with complete response. He remains relapse-free at 5.91 years follow-up having declined irradiation and bilateral orchidectomy. Treatment of PTL with HD-MTX has shown encouraging clinical outcomes with regard to tolerability and disease-free survival. Accepting the low numbers, absence of CNS relapse with median follow-up of 4.27 years suggests prophylactic efficacy of HD-MTX. Elimination of disease in an in-situ testis following treatment is of interest, given currently practiced contralateral testicular irradiation. Our results highlight the need for further more extensive prospective research to determine the role of HD-MTX in treating PTL.


142 Does pregnancy influence remission rate in lymphoid malignancies MA Vinogradova1, RG Shmakov2, ES Polushkina2 1 Department of Haematology, Federal Research Centre for Obstetrics and Gynaecology, Moscow, Russia; 2Department of Obstetrics, Federal Research Centre for Obstetrics and Gynaecology, Moscow, Russia In recent years survival of patients with several lymphoid malignancies (LM) has improved considerably due to implementation of new medicines and optimization of supportive treatment. For this reason the issues of reproductive health in these patients are becoming very important. Pregnancy planning, evaluation of the disease prognosis and possibility of childbearing in patients with LM are crucial for their quality of life. We have been developing the optimal strategy for management of pregnant patients with LM. From 1986 to 2013, we have analyzed 171 pregnancies in 159 women remaining in remission after LM, including 131 patients with Hodgkin lymphoma (HL), 24 patients with non-Hodgkin lymphomas (NHL). All of them underwent the standard treatment of disease to achieve remission. The median time from the moment of achieving remission to the onset of pregnancy was 6.3 years in patients with HL, 3.5 years- in NHL. In pregnant women with full LM remission the progression of the disease was registered in 2 (1.5%) patients with HL and in 1 (4.2%) with NHL. All patients with diagnosed disease relapse needed the resumption of chemotherapy. 163 (95.3%) of pregnancies ended up with a birth of full-term healthy infants without birth defects. Premature birth occurred in 6 (3.5%) cases. Neonatal mortality occurred in 1 (0.6%) newborn with anencephaly. In 1 (0.6%) patient pregnancy was terminated for medical reasons in the 2nd trimester. The mode of delivery was determined by the obstetrician in all cases. No thrombotic or hemorrhagic complications during labor or postpartum period have been observed. We conclude that pregnancy does not influence progression of LM in patients with long-lasting remission. We recommend patients with LM to plan a pregnancy 3 years after achieving the remission. There is no difference in health between infants born by mothers in LM remission and the newborns from general population.

143 The combination of the NCCN-IPI and CR status is highly predictive of outcome following R-CHOP in de novo diffuse large B-cell lymphoma MJ Bishton1, AP Haynes1,2, AK McMillan1, E James3, EM Bessell3, CP Fox1 1 Department of Haematology, Nottingham University Hospital, UK; 2Faculty of Medicine & Health Sciences, Nottingham University, UK; 3Department of Oncology, Nottingham University Hospital, UK This study was a retrospective analysis of patients with de-novo DLBCL treated with R-CHOP between January 2005 and December 2011 at Nottingham City Hospital. Patients identified in the Nottingham lymphoma registry over 16 years planned to receive R-CHOP were included by intention-to-treat analysis. Transformed disease, historical, contemporaneous or subsequent was excluded, as was relapse. Patients had Revised International Prognostic Index (R-IPI) and NCCN International Prognostic Index (NCCN-IPI) calculated at diagnosis. Responses pre-2007 were assessed using CT, and from 2007 using PET-CT with images undergoing routine central review. ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Lymphoid Malignancy - Clinical 204 patients, median age 65 years (17–96) were treated with ≥1 R-CHOP. Another 12 patients who received intensification with R-CoDoxM/IVAC were identified and not included in the analysis. 178 patients (87.3%) received 6–8 cycles of R-CHOP and 50 patients (24.5%) radiotherapy.


No. patients (%)

PET-CR rate (%)

0 1–2 3–5 NCCN-IPI 0–1 2–3 4–5 6+

24 (11.8) 91 (44.6) 89 (43.6)

86.7 96.6 78.9

28 79 61 36

89.5 96.1 82.9 73.7

(13.7) (38.7) (29.9) (17.6)

As expected, the R-IPI and NCCN-IPI predicted overall survival (OS) and progression free survival (PFS), as did CR by CT-PET or CT. OS and PFS of patients achieving PET-CT or CT-CR continued to be influenced by both R-IPI and NCCN-IPI. However, R-IPI 3–5 patients achieving PET-CR had OS and PFS of 61.4% (log rank test p = 0.0014) and 72.8% (p = 0.0045) at 5 years, while NCCN-IPI 1–5 patients achieving PET-CR had OS of 76.3–94.1% and PFS of 84.6–100%, and NCCN 6+ patients OS and PFS of 23.8% and 41.7% (Both p < 0.0001). Our data suggests patients ICCN-IPI 1–5 in CR post R-CHOP have excellent outcomes, and may merit reduced follow up frequency. In contrast, NCCN-IPI 6+ have dismal outcomes regardless of response. This group consists of older patients with poor performance status ineligible for intensification or salvage therapy, and should be considered for alternative therapies.

144 A single centre clinical experience of the efficacy and safety profile of subcutneous versus intravenous bortezomib KL Randall, SW Bokhari, I Qureshi Department of Haematology, University Hospitals Coventry and Warwickshire NHS Trust, UK Bortezomib plays a key role in the management of multiple myeloma. The European Medicines Agency approved its subcutaneous use in 2012 with a study by Moreau et al demonstrating similar efficacy to intravenous administration with an improved safety profile. However, there is little published data on its use in clinical practice. Our Trust switched to subcutaneous use in 2012 and this study aimed to review our clinical experience. 38 patients were treated with Bortezomib between January 2011 and February 2013; 20 by subcutaneous and 18 by intravenous administration. Baseline characteristics were similar between the 2 groups. The median age was 70 and the majority of patients had received 1 prior line of treatment (90% subcutaneous, 78% intravenous) with 85% and 72% having received a previous iMiD. Patients received a median of 5.5 cycles in the intravenous group and 5 cycles in subcutaneous group. The overall response rate (CR + PR) was similar between the subcutaneous and intravenous groups (75% vs. 78% respectively) with a median time to best response of 4 cycles in both groups. There was no significant difference in relapse-free survival (median 10.5 vs. ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

6.5 months) or 1 year overall survival (80% vs. 78%, p = 0.79) with subcutaneous compared to intravenous administration. Grade 3–4 adverse events were seen in 8 patients (40%) in subcutaneous group compared to 3 (17%) in intravenous group with 20% and 17% discontinuing treatment and 30% and 11% needing dose reductions due to adverse events, respectively. 55% and 50% developed peripheral neuropathy in the subcutaneous and intravenous groups, with 15% and 17% suffering Grade 3 or more. There were more Grade 3–4 haematological toxicities in the subcutaneous group (25% vs. 0%) however 4 of the 5 patients were being treated with VCD or PAD. We found no significance difference in outcomes or side effects between subcutaneous and intravenous Bortezomib.

145 The use of rasburicase and laboratory screens in the management of tumour lysis syndrome: a clinical audit V Anand, C Millar Royal Derby Hospital, UK Rasburicase is a recombinant urate oxidase used in the prevention of tumour lysis syndrome (TLS). It is cost-effective when used in highrisk patients. In clinical practice, stratifying patients into risk groups is not always straight-forward and clinical judgement is often used when deciding when to give Rasburicase. Monitoring of renal function and electrolytes using laboratory screens is essential in the management of TLS. We carried out a retrospective review of electronic patient records. Local TLS guidelines were used to draw appropriate standards as follows:

1. Rasburicase to be given when: – High risk of TLS – Intermediate risk of TLS with additional risk factors 2. TLS laboratory screen (U&E, Phosphate, Calcium, Urate, LDH) in all patients at: – Baseline – +4 hours post chemotherapy – The following day Rasburicase was issued to 93 patients over a 12 month period between May 2012 and May 2013. We included a total of 40 patients in the analysis, who had been given their first dose of Rasburicase. Rasburicase was used correctly in 65% (26⁄40) of cases. Of the remaining patients, 2 were in a low risk group but both had an LDH greater than 1000. Ten patients in the intermediate risk group did not have any additional risk factors. However, 5 of these died within 5 months. Eighty-three percent of patients had a baseline laboratory TLS screen, 88% had a screen at +4 hours and 61% had a screen the following day. Although according to local guidelines Rasburicase was given correctly in only two-thirds of cases, clinical judgement used in most other cases was probably justified. TLS guidelines should perhaps take into account clinical judgement for intermediate risk group patients. There is scope to improve on performing TLS laboratory screens, especially the following day. An electronic order set for the TLS screen may help to improve uptake.


Poster Session: Lymphoid Malignancy - Clinical

146 PET/CT imaging for lymphoma patients at St Barts Hospital, Barts Health NHS Trust J Marway, A Theodoulou, R Auer Department of Haematology-Oncology, St Barts Hospital/ Barts Health NHS Trust, London, UK The British Committee for Standards in Haematology (BCSH) guidelines advocate the use of Positron Emission Tomography (PET) in high-grade Non-Hodgkin’s and Hodgkin’s lymphoma. The role of PET is less well recognized in low-grade lymphomas. The guidelines for Lymphoma diagnosis, Follicular and Mantle cell Lymphomas, state that the role of PET/CT remains uncertain and that CT scan is the established staging imaging. PET scanning is readily available at our institute and it is often the default choice of imaging to assess staging, outcome and long-term follow-up. This study aims to assess our utilization of PET imaging in lymphoma patients. We performed a retrospective study of lymphoma patients who underwent PET imaging (November 2012–April 2013). We collected data for the indication and results of the scan, any prior or subsequent imaging and whether the patients were on a clinical trial. There were 150 lymphoma patients who had PET/CT scans over the 6-month study period. 68 had Diffuse Large B-Cell Lymphoma (DLBCL), 34 had Hodgkin’s Lymphoma (HD) and 48 had ‘other’ types of Lymphoma. The commonest indication was outcomes scan (50–60%), followed by staging scans (19–20%) and then other indications (20–30%). 19% of patients with low-grade lymphomas required further investigations, as PET was inadequate (i.e. patients needing MRI scans or special CT scans), compared to 8% with DLBCL and only 5% with Hodgkin’s. PET/CT imaging is a sensitive tool when used in DLBCL and HD and we have shown that it is being correctly utilized in these patients. For low-grade lymphomas, we are not strictly following BCSH guidelines, and a proportion of patients are receiving PET/CT instead of CT scans. A significant number of patients require further investigations, due to a degree of uncertainty in PET/CT interpretation in this patient group. Therefore, further studies are required to establish the most appropriate imaging.

147 Isolated, extranodal anaplastic large cell lymphoma, ALK-positive of the bladder treated initially with resection alone SG Williams, SA Kelly, JAT Nicholson Department of Haematology, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK We report the case of a 29 year old woman with a previous history of depression, recurrent urinary tract infections and urethral dilatation who presented with terminal haematuria and dysuria with no growth on urine culture. Flexible cystoscopy showed a 2 cm polypoid lesion on the left side of the bladder and the patient was listed for transurethral resection. By the time of that procedure, she had discovered that she was 6 weeks pregnant, later found to be a twin pregnancy. The tumour was completely resected via the transurethral route and histology showed it to be anaplastic large cell lymphoma, ALK-positive (ALCL, ALK+ve). Staging with complete magnetic resonance imaging (MRI) scan and bone marrow biopsy showed no evidence of lymphoma, confirming this to be isolated, extranodal ALCL, ALK+ve of the bladder; repeat cystoscopy confirmed complete resection. The patient was counselled about the benefits and risks of chemotherapy during pregnancy, decided against this and so was


managed with observation alone. Healthy twin girls were delivered by Caesarean section at 34 weeks for obstetric reasons. Post-partum, the offer of chemotherapy was once again declined. Four years later an isolated bladder recurrence of the ALCL, ALK+ve was discovered on routine surveillance cystoscopy at a different endothelial site. It was resected and, this time, she was treated with standard cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) chemotherapy. Complete remission continues 2 years later. This is only the second reported case of truly isolated, extranodal ALCL, ALK+ve of the bladder and is unique in being initially treated with resection alone. Although relapse occurred, the remission was 4 years and the relapse localised suggesting that resection alone might be a valid initial strategy in this rare lymphoma.

148 Stem cells harvested after bortezomib-based re-induction for multiple myeloma relapsing after autologous stem cell transplant (ASCT) and those stored from first induction yield equal outcomes: results from the BSBMT/UKMF Myeloma X (Intensive) Trial C Parrish1, TCM Morris2, C Williams3, DA Cairns4, J Cavenagh5, JA Snowden6, J Ashcroft7, J Cavet8, H Hunter9, JM Bird10, A Chalmers4, J Brown4, K Yong11, S Schey12, S Chown13, G Cook1 1 St James’ Institute of Oncology, Leeds Teaching Hospitals Trust & University of Leeds, UK; 2Queen’s University, Belfast, UK; 3Department of Haematology, Centre for Clinical Haematology, Nottingham City Hospitals, UK; 4Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, UK; 5Department of Haematology, Barts & The London NHS Trust, UK; 6Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, UK; 7 Mid-Yorks NHS Trust, Wakefield, UK; 8Department of Haematology, The Christie NHS Foundation Trust, Manchester, UK; 9Department of Haematology, Plymouth Hospitals Trust, UK; 10Department of Haematology, United Bristol Hospitals NHS Trust, UK; 11University College London Hospitals, UK; 12King’s College Hospital, London, UK; 13 Gloucester Royal Hospital, Gloucester, UK The multi-centre phase III BSBMT/UKMF Myeloma X Trial demonstrated the clinical utility of second ASCT (ASCT2) for relapsed MM. However, many patients have insufficient stored PBSC for ASCT2 and remobilisation after ASCT1 lacks robust evidence. The feasibility, safety and efficacy of remobilisation for ASCT2, were therefore examined. Eligible patients with MM relapsing post-ASCT1 received 2–4 cycles of PAD (bortezomib, doxorubicin, dexamethasone), then either ASCT2 or weekly cyclophosphamide. Those with inadequate stored PBSC1, and others at clinician discretion, attempted remobilisation. 297 patients were enrolled (median age 61, range 38–75); 73.6% relapsed >24 months post-ASCT1. 170 (57.2%) had PBSC1 stored (median: 3.3 9 106 CD34+ cells/kg, range: 0.6–13). 110 underwent remobilization: progressive disease, death or withdrawal precluded harvesting in 32 (10.7%). 1 attempt was made in 71 (64.5%), 2 in 32 (29.1%), 3 in 4 (1.3%); 3 unknown. Regimens used (first attempt) were cyclophosphamide + G-CSF (70%), G-CSF (8.2%), Plerixafor + G-CSF (6.4%), other (15.5%). Median yield was 2.3 9 106 CD34+/kg (range 0–39). Toxicities were consistent with published data. 174 patients were randomized, (ASCT2 n = 89, ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Lymphoid Malignancy - Clinical cyclophosphamide n = 85). 42 received PBSC1, 29 PBSC2 and 11 a mixture (PBSCMix). Median CD34+ dose was: PBSC1: 3.2 (range 1.6–13.6), PBSC2: 2.9 (1.4–7), PBSCMix: 2.6 (2.1–6.6). Median times to engraftment and discharge were similar: PBSC1: neutrophils >0.5 9 109/l: 12d, platelets >50 9 109/l: 18d, discharge: 16d; PBSC2: 12d, 21d & 16d; PBSCMix: 12d, 24d & 18d. Median TTP (ASCT arm) was 19 m; PBSC sources were not significantly different: PBSC1: 18 m, PBSC2: 24 m, PBSCMix: 33 m. TTP hazard ratios (vs. PBSC1) were 0.85 for PBSC2 and 0.49 for PBSCMix; p = 0.3553. PBSC harvesting after bortezomib-based re-induction for myeloma relapsing after ASCT is feasible and safe, permitting ASCT2 for patients without stored stem cells. Although follow-up is short, outcomes were unaffected by stem cell source. Impact on overall survival and quality of life remain to be clarified.

149 Re-audit of bortezomib use in a district general hospital: further insights into toxicity S Horton, J Stokes, A Johny, R Frewin, S Chown Department of Haematology, Edward Jenner Unit, Gloucestershire Royal Hospital, UK Previous audit in Gloucestershire in 2009 identified a significant rate of toxicity from the use of intravenous Velcade (bortezomib) in multiple myeloma. Subcutaneous administration of the drug has been reported to be associated a more favourable side effect profile and therefore a re-audit of bortezomib use was initiated following conversion to subcutaneous administration protocols. 15 patients were identified as having received Velcade for multiple myeloma between January and June 2013 (mean age 69, range 54–82). The mean number of cycles given was 4 (range 1–6). Suboptimal response or toxicity precluded Velcade use beyond cycle 6 in all patients audited. 6/10 patients that received 4 or more cycles had at least a partial response (PR) with 1/10 gaining a complete remission (CR) (vs. 9/9 PR and 1/9 CR in 2009). 12/15 patients reported one or more toxicities (vs. 13/15 in 2009). Neuropathy remained a significant problem, affecting 10/15 patients (including 3 at Grade 3 or higher). Diarrhoea affected 3/15. Of concern was the fact that 3/15 patients were affected by development of cardiac failure, two of whom required hospital admission. Whilst concomitant dexamethasone may have contributed to the condition, these patients had received similar doses of dexamethasone previously without evidence of cardiac failure. Treatment was terminated in 5/15 patients following the development of cardiac failure or neuropathy. This re-audit demonstrated the significant toxicity associated with bortezomib, which persisted despite conversion to subcutaneous administration. Notably, it identified the risk of rapid and unavoidable development of cardiac failure. Greater caution may be required when patients receiving bortezomib present with early signs of neuropathy or cardiac failure, due to the risk of morbidity and negative impact on quality of life.

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

150 Is an aspirate for morphology and flow cytometry really necessary when a trephine is also being performed in the diagnosis and staging of lymphoma? RW Whitmill, MC Crowther Worcester Royal Hospital, UK In many centres the standard practice when staging lymphoma is to take an aspirate for slides and flow cytometry plus a trephine. We undertook a review of all the staging marrows over the last 2 years in order to seek evidence for eliminating one these tests from our practice thereby potentially saving money, time and discomfort to the patient. 141 of 168 patients with proven lymphoma who passed through our MDT had a marrow biopsy. Of those 53 had evidence of lymphoma infiltration, including 16% of DLBCL, 35% of follicular and 33% of transformed follicular. For 23 patients, over 10% of total patients, the marrow was the sole histology sample to diagnose their lymphoma this included 16 Waldenstr€ oms. Of the 53 patients, 3 did not have a trephine and one was insufficient. For 47 out of 49 patients the trephine alone was sufficient to positively stage their marrow disease. This compares to the 27 patients that had lymphoma demonstrated by flow cytometry. The 1 patient where this upstaging that would have been missed on trephine alone had intrathecals as a consequence, the other patient had a low level low grade clone picked up in flow which was not felt to be clinically significant. This suggests trephines have a sensitivity and negative predictive value of 98 and 99% respectively, compared to flow cytometry’s 55%. It could therefore be argued that if these findings are confirmed then a trephine alone could be used for lymphoma staging, and that cases where a trephine is not taken or is insufficient then this should be repeated as an aspirate alone is not sufficient for excluding marrow involvement.

151 Monoclonal immunological deposition disease (MIDD): experience at the North West Amyloidosis Clinic, Manchester, UK C Wall1, E Tholouli1, L McWilliams2, A Sinacola1, SDJ Gibbs1 1 Department of Clinical Haematology, Central Manchester University Hospitals NHS Foundation Trust, UK; 2Department of Histopathology, Central Manchester University Hospitals NHS Foundation Trust, UK Monoclonal immunoglobulin deposition disease (MIDD) is a rare complication of plasma cell dyscrasiae, similar to systemic AL amyloidosis. MIDD is characterised by non-fibrillar monoclonal light and/or heavy chain deposits in various organs, typically kidneys, presenting with renal impairment, proteinuria and hypertension. Reports of this disease in the literature are scant, but this disorder is considered one of the ‘monoclonal gammopathies of renal signifcance’. We retrospectively reviewed our experience of this disorder at the North West Amyloidosis Clinic, Manchester Royal Infirmary, between 2009 and 2013 inclusive. Nine patients were identified with MIDD. All diagnoses were made on renal biopsy, eight as light chain deposition disease (LCDD) and one probable heavy chain deposition disease (HCDD).


Poster Session: Lymphoid Malignancy - Clinical Median age at diagnosis was 58 (range 51–73). All but one presented with ≤15% plasma cells on bone marrow biopsy. All patients presented with renal dysfunction, proteinuria (three within the nephrotic range) and microscopic haematuria. All but one with significant hypertension. Extra renal involvement was not confirmed in any patient. Eight patients received chemotherapy, four containing bortezomib, two with lenalidomide and two with thalidomide and all achieved at least partial clonal responses. Three patients received autologous stem cell transplants (ASCT) and all observed stabilisation or improvement in renal function. Three patients progressed to end-stage renal failure, two at the time of relapsed clonal disease, and none of these patients had undergone ASCT. We have confirmed recent observations regarding MIDD in our small series, namely, that most patients have renal presentation disease with hypertension and a low level plasmacytosis, that ASCT is effective treatment and that unlike AL amyloidosis, renal function can improve with good clonal responses. MIDD should be considered in any patient with a plasma cell dyscrasia and significant proteinuria who renal biopsy is Congo red negative. Electron microscopy or immunoflorescence needs to be performed to confirm the diagnosis.

152 The burden of care: healthcare resource utilisation in a tertiary referral centre in the era of novel myeloma therapies WKW Wong1, C Parrish1, C Overvoorde1, RG Owen1, S Feyler1,2, AJ Ashcroft1,3, C Kallmeyer1, G Cook1 1 St James’ Institute of Oncology, Leeds Teaching Hospitals Trust & University of Leeds, UK; 2Calderdale & Huddersfield NHS Foundation Trust, UK; 3Mid-Yorks NHS Trust, Wakefield, UK The adoption of immunomodulatory drugs (IMiDs) and proteasome inhibitors (PI) has undoubtedly transformed the therapeutic landscape in myeloma, but the associated healthcare resource utilisation of readmissions and inpatient care has not been well documented; we present a detailed examination from a UK regional centre. In this retrospective case-note review, details and duration (LoS) of admissions (FCE) were examined for patients admitted for MM therapy-related complications or symptoms subsequently resulting in a diagnosis of MM. Between August 2011 and July 2013, 331 FCEwere recorded in 285 patients: 239 (72.2%) resulting from emergency admissions. Reasons for admission were: infection (43.1%), AKI 12.5%, bone pain 5%, spinal cord compression 2%, hypercalcaemia 2.5%, new symptomatic MM 13.8% (n = 33, 38% of new diagnoses in the study period). 156 patients (46.1%) were on therapy at admission: IMiD-based n = 111, PI-based n = 45. 4.5% of emergency admissions subsequently received ICU/HDU care (median stay 6 days, range 5–11). The median LoS for all patients was 10d (range 1–91); significantly longer LoS was seen in patients admitted whilst on PI-based therapy vs. IMiDs (12d 95% CI 11.6–21 vs. 8d 95% CI 3.9–11.5, p < 0.007). The median number of readmissions in the 12 m after diagnosis was 1 (95% CI 0.46–1.0); median cumulative LoS over 12 m was 31d (95% CI 26.5–49.7). No significant difference in either re-admission rate or cumulative LoS between those who presented with AKI as opposed to neurosurgical complications at diagnosis. With a median FU of 17.8 m (range 0.2–139.3) 24% of newly diagnosed patients have died: 43% of those diagnosed as an inpatient, 12% of those diagnosed as an outpatient (HR 3.66, 95% CI 1.24, 11.65; p = 0.02).


In this era of novel therapies, acute admissions for new diagnoses and complications of therapy continue to require significant hospital resources in secondary care.

153 Ibrutinib associated lymphocytosis corresponds to bone marrow involvement in mantle cell lymphoma MV Furtado1,2, B Munneke3, M Wang4, D Beaupre3, J McGreivy3, S Rule1,2 1 Department of Haematology, Derriford Hospital, Plymouth, UK; 2University of Plymouth, UK; 3Pharmacyclics Inc, California, USA; 4MD Anderson Cancer Centre, Texas, USA Brutons Tyrosine Kinase (BTK) is a tyrosine kinase that is involved in the signalling pathway of the B cell receptor which is critical for the maturation and functioning of normal B cells and malignant B cells of varied non hodgkins lymphoma subtypes. Ibrutinib is an inhibitor of the BTK protein which covalently binds to cysteine-481 in the active site of BTK. Peripheral blood lymphocytosis has been a significant feature of ibrutinib therapy for MCL – 33% of the 111 MCL patients enrolled in a phase 2 study of single agent ibrutinib (PCYC-1104-CA; NCT01236391) developed a transient increase in the peripheral absolute lymphocyte count. Further analysis of this patient cohort has found a significant association between bone marrow involvement with MCL and the development of peripheral blood lymphocytosis during ibrutinib therapy. Of the 111 patients there was a significantly different change in mean maximum absolute lymphocyte count (ALC) in those with disease involving the bone marrow (n = 53) and in those with no bone marrow disease (n = 57) (25.08 vs. 3.08 respectively; p value 0.0001) For those patients with disease within the bone marrow, the degree of marrow involvement significantly correlated with mean maximum ALC change – 9.64 in those with ≤30% marrow involvement versus 39.47 for those with >30% marrow involvement (p = 0.0078). Changes in tumour volume did not correlate with involvement of bone marrow with disease (reduction in SPD 49 vs. 47.5 (marrow involved vs. not involved) p = 0.54. The lymphocytosis that occurs in MCL during ibrutinib treatment can be striking (≥50% from baseline and >5000 cells/mm3) and appears to be associated with bone marrow disease involvement. This may help clinicians predict which patients may potentially develop lymphocytosis during ibrutinib therapy and thereby alleviate concerns when it occurs.

154 VMP using weekly and subcutaneous bortezomib is well tolerated and efficacious for newly diagnosed and relapsed myeloma patients JM O’ Sullivan, S Kumar, C Yeomans, G Milner, S Schey, M Kazmi, MJ Streetly Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK VMP (Bortezomib/Melphalan/Prednisolone) is the standard of care for treating newly diagnosed transplant ineligible symptomatic myeloma. However when administered twice weekly and intravenously toxicity may result in premature discontinuation of treatment. Both weekly and subcutaneous administration of bortezomib are reportedly ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Lymphoid Malignancy - Clinical better tolerated yet maintain efficacy. We report our experience of using a weekly subcutaneous bortezomib based VMP approach. This was a retrospective single centre review of all newly diagnosed or relapsed patients treated with weekly subcutaneous Bortezomib (1.3 mg/m2 Day 1, 8, 15 and 22), Melphalan (7 mg/m2 Days 1–4) and Prednisolone (60 mg/m2 Days 1–4) every 35 days (VMP). 22 patients commenced treatment (January 2012–October 2013). The median age was 76 years. 81.8% (18/22) were newly diagnosed cases and 18.2% (4/22) relapsed cases. Patients received a median of 5 cycles. 31.8% (7/22) are still on treatment. The overall response rate (ORR, ≥ partial response) for the whole group was 68.1% (15/22). In newly diagnosed patients, the ORR was 61.1% (11/18) with 16.7% (3/18) complete responses/very good partial responses and 44.4% (8/18) partial responses. One patient progressed on therapy. In the relapsed group, the ORR was 100% (1 CR, 4 PR). Median time to best response was 4.5 months. Bortezomib was dose reduced to 1 mg/m2 in 22.7% (5/22) of patients. There were no dose modifications or delays for haematological toxicities. With a median follow-up of 8.5 months in the newly diagnosed group, the overall survival was 83.3% (15/18) and progression free survival was 72.2% (13/18). With a median follow up of 18.5 months in the relapsed group, there was an overall survival of 75% (3/4) and a median progression free survival of 11.5 months. In this review, weekly subcutaneous Bortezomib is well tolerated with an excellent safety profile and remains efficacious. It is a suggested treatment approach for this patient population.

155 Flow cytometric assays of plasma cell phenotypes may obviate the need for the majority of trephine biopsy investigations in myeloma S Patel1, T Farren2, M Macey2, M Calaminici3, H Oakervee4, JD Cavenagh4, T Butler1 1 Department of Clinical Haematology, Barts Health NHS Trust, London, UK; 2Immunophenotyping, Barts Health NHS Trust, London, UK; 3Department of Cellular Pathology, Barts Health NHS Trust, London, UK; 4Department of HaematoOncology, Barts Health NHS Trust, London, UK The diagnosis of myeloma requires bone marrow (BM) plasma cell (PC) percentage and clonality to be established, typically by light chain (LC) restriction. We examined 5 years of flow cytometry (FC) samples (n = 306) in myeloma. BM aspirate/trephine reports were available in 156. Whilst FC generally underestimated PC percentage compared to BM aspirate morphology (mean 15% lower) and aspirate less than trephine (mean 19%), in 67% there was no change in diagnosis if the 10% PC threshold for myeloma was considered. In 84 cases with trephine LC restriction, 76% had already been established as clonal by FC. In 2 cases, clonality was established by FC, not by trephine, and in 14 cases FC was the only clonality investigation performed. Cytoplasmic LC evaluation by FC is sometimes inconclusive. Malignant PCs are reported to differ from polyclonal PCs by aberrant expression of CD56 and CD117, and CD19 negativity. We considered the use of these markers for malignant PCs as surrogates when FC LC assays failed.

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In 167 cases clonal by FC LC restriction: 93% were CD19 negative, 69% CD56 positive and 51% CD117 positive. When markers are combined into a ‘myeloma score’ of 0–3, 40% of cases had a score of 3. In cases with inconclusive FC LC but clonality on trephine, 45% had a score of 3. Conversely, 2/14 cases that appeared to be polyclonal by flow or trephine had a score of 3, but both had clonality established on repeat sampling or cytogenetics. We suggest a myeloma score incorporating CD19/56/117 may be a helpful adjunct or alternative to FC LC assay. Ongoing work to validate this scoring system is evaluating a greater number of cases. FC assays of PC phenotypes in myeloma may obviate the need for slower and expensive immunohistochemistry performed on trephines, in an adaptive Bayesian approach to diagnosis.

156 The utility of minimal residual disease (MRD) assessment in post-first relapse re-induction: results from the BSBMT/UKMF Myeloma X (intensive) Trial RG Owen1, DM DeTute1, AJ Ashcroft2, DA Cairns3, M Fletcher3, C Williams4, JD Cavenagh5, JA Snowden6, AC Rawstron1, C Parrish7, TC Morris8, JMB Brown3, G Cook7 1 HMDS, St James’ Institute of Oncology, Leeds, UK; 2 Department of Haematology, Mid Yorkshire NHS Trust, Wakefield, UK; 3Clinical Trials Research Unit, University of Leeds, UK; 4Department of Haematology, Nottingham City Hospital, UK; 5Department of Haematology, Barts and the London NHS Trust, UK; 6Department of Haematology, Sheffield Teaching Hospitals, UK; 7Department of Haematology, St James’ Institute of Oncology, Leeds, UK; 8 Department of Haematology, Queens University, Belfast, UK Introduction: MRD assessment by multicolour flow cytometry (MFC) is a powerful prognostic tool in multiple myeloma. There is however no published data assessing its use in relapsed MM in a phase III RCT setting. Our aim was to test the utility of MFC in the setting of the Myeloma X trial in predicting TTP. Methods: Patients received 2–4 cycles of PAD (Bortezomib, Doxorubicin, Dexamethasone) before randomization between second autologous transplant (ASCT2) and weekly cyclophosphamide (C-weekly). The primary endpoint was TTP; secondary endpoints included OS and ORR (to PAD and randomized intervention). Bone marrow was analysed by standardised MFC at entry & specified subsequent timepoints. IMWG response was assessed after re-induction, 100d postASCT2/30d post-C-weekly & at progression. Unfavourable genetic abnormalities were defined as FGFR3/IGH, IGH/MAF & del TP53 by interphase FISH. Results: 297 patients (median age 61, range 38–75) were entered; 174 were randomised: ASCT2 = 89, C-weekly = 85. MFC was available in: 224 at presentation, 162 after induction, 46/89 at D100 post-ASCT2 & 50/85 D30 post-C-weekly. In an ITT analysis of randomized patients, MRD negativity was highly predictive of improved TTP: all patients: logrank p = 0.0003 HR 0.34 [0.19, 0.62], ASCT arm: logrank p = 0.0227, C-weekly arm: logrank p = 0.0107. CR/sCR was achieved in 39% post-ASCT2 & 22% post-C-weekly; MRD status was predictive of TTP in both arms regardless of IMWG response, and indeed was more predictive of TTP than conventional remission status: logrank p < 0.0001. Adverse cytogenetics were present in 19% of patients; MRD status was predictive of TTP regardless of cytogenetic risk (logrank p = 0.0124). Discussion: These data show MRD assessment by MFC is a sensitive predictor of TTP at first relapse, irrespective of subsequent therapy.


Poster Session: Lymphoid Malignancy - Clinical The data also imply MRD is a stronger prognostic factor than achieving sCR/CR or favourable cytogenetics. These results require confirmation and could potentially be the focus of trials to tailor post transplant maintenance.

157 Clinical and biological heterogeneity of M-CLL is associated with differential CXCR4 and CD49d expression CJ Pepper1, AGS Buggins2, CH Jones1, EJ Walsby1, F Forconi3, G Pratt4, S Devereux2, F Stevenson3, CD Fegan1 1 Cardiff CLL Research Group, Institute of Cancer & Genetics, School of Medicine, UK; 2Department of Haematology, King’s College London, UK; 3Cancer Sciences Unit, CRUK Clinical Centre, University of Southampton, UK; 4CRUK Institute for Cancer Studies, University of Birmingham, UK Two major subsets of chronic lymphocytic leukaemia (CLL) with clearly different clinical behaviour are those with unmutated (U-CLL) or mutated (M-CLL) IGHV genes. While these broad divisions are prognostically useful, there is significant intra-subset variability in survival especially within M-CLL. The causes of this heterogeneity remain incompletely resolved but there is growing evidence that differential trafficking to tissue sites plays a major role. Here we show that CXCR4 expression and migratory capacity toward CXCL12 are consistently high within U-CLL, but vary widely in M-CLL. Probing the heterogeneity within M-CLL revealed that patients showing ≥median CXCR4 expression had inferior clinical outcomes (p < 0.0001; HR = 3.5), which was not explained by preferential usage of IGHV3-21 or by the presence of high-risk cytogenetic lesions. Levels of CXCR4 correlated with expression of the a4b1 integrin, CD49d (r2 = 0.35), and patients with concordant CXCR4hi/CD49dhi had the shortest survival (p < 0.0001; HR=5.2). In contrast, CD38 and ZAP-70 expression provided weaker prognostic value within M-CLL; multivariate analysis confirmed CXCR4 as the dominant co-variable followed by age at diagnosis, Binet stage and CD49d expression. These findings reveal biological variability within M-CLL cases affecting molecules which appear to influence clinical behaviour and which are potentially druggable using agents aimed at signaling pathways.

158 Systemic treatment of relapsed mantle cell lymphoma after initial treatment with fludarabine and cyclophosphamide with or without rituximab: long-term follow-up of a large randomised trial W Townsend1, A Kirkwood1, A Patel1, P Smith1, S Rule2 1 UCL CRUK Cancer Trials Centre, University College London, UK; 2Department of Haematology, Plymouth Hospitals NHS Trust and Plymouth University Peninsula School of Medicine, UK Between 2002 and 2010, 370 patients with untreated Mantle Cell Lymphoma (MCL) were randomised to receive Fludarabine and Cyclophosphamide (FC) alone or in combination with rituximab (FCR). Progression free survival (PFS) and overall survival (OS) were significantly longer in the FCR arm and rituximab plus chemotherapy is now the standard-of-care for first-line treatment. However, optimal treatment of relapsed disease and response to subsequent therapy remain unknown. Here we report on the subsequent


treatment of patients in the FC versus FCR trial and their response to re-treatment. Data on subsequent treatment is available for 70% of patients. Of these, 141 (55%) received subsequent systemic treatment. 26 different therapies were used as the second-line of therapy after initial FC or FCR. 109 (77%) patients received intensive treatment, most commonly CHOPR (n = 62, 44%), ESHAPR (n = 9, 6%), Bortezomib-containing regimens (n = 10, 7%), or Nordic-protocol (n = 8, 6%). 32(23%) patients received palliative therapy. Rituximab was given as part of the second-line of therapy in 50% of patients. Patients in the FC-arm were significantly more likely to receive rituximab at relapse than patients who received FCR (58.6% vs. 35.2%, p = 0.007). The overall response rate (ORR) to the second-line of treatment was 58% for patients receiving intensive therapies; 62% (re-treatment including rituximab), 53% (without rituximab). FCR-arm patients had an ORR to rituximab-containing intensive re-treatment of 56% (n = 18). The median survival for patients receiving intensive re-treatment was 15.8 months from start of re-treatment (16.6 months FC-arm, 13.9 months FCR-arm). The median survival for patients receiving less intensive therapies was 5 months. This study demonstrates the lack of consensus on treatment for relapsed MCL and the poor outcome for patients in this setting.

159 The initial diagnosis and management of newly diagnosed follicular lymphoma in Scotland in 2012 IC Lentell, FM Scott Department of Haematology, Western General Hospital, Edinburgh, UK The British Committee for Standards in Haematology has published guidelines on the initial diagnosis and management of follicular lymphoma, highlighting the importance of obtaining prognostic information to identify those patients at risk of transformation to high grade disease. We audited the initial management of patients diagnosed with follicular lymphoma in Scotland in 2012 against BCSH guidelines. Clinical data were also gathered on performance status, co-morbidities and factors leading to choice of treatment. Data on 142 newly diagnosed patients were collected from 10 centres in Scotland for the year 2012. Three participating centres offer clinical trials; 98% of cases were presented at a lymphoma multidisciplinary meeting; 125 cases (88%) had a biopsy confirming disease grade and 141 (99%) completed full staging investigations. A FLIPI score was calculated on 94% of patients at diagnosis. The largest group had symptomatic stage 2–4 disease. Of these 66 patients (46%), 66% were treated with R-CVP, 14% were treated with R-CHOP and 9% were treated within a clinical trial. For these 66 patients, 66% received maintenance Rituximab. Forty-three patients (30%) had asymptomatic stage 2–4 disease and 36 (84%) were managed on a ‘watch and wait’ strategy. Twenty patients (14%) had stage 1A disease (or 2A where nodes are contiguous) of whom 8 (40%) received radiotherapy, 6 (30%) were ‘watch and wait’, 5 (25%) had an alternative management plan and 1 was upstaged on PET scanning. There were 13 cases of grade 3B disease and all were treated as diffuse large B cell lymphoma. Although the results confirm that in the majority of cases the appropriate treatment strategies are being implemented in accordance with BCSH guidance in Scotland, a significant percentage lack accurate grading information which may compromise treatment. Improved collaboration with surgical and pathology colleagues is ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Lymphoid Malignancy - Clinical required in order to obtain tissue suitable for accurate diagnosis and determining prognosis.

160 Interim PET-CT scanning in lymphoma management – a retrospective audit EJ Renaudon-Smith, A Zaidi, U Hossain Whipps Cross Hospital, Leytonstone, UK Positron emission tomography–computed tomography (PET-CT) is the modality of choice for determining both disease stage and response to treatment in patients with lymphoma. An interim scan after 2–4 cycles of chemotherapy is common practice to identify (i) patients likely to progress through treatment, so alternative regimes can be considered and (ii) patients who have responded well, allowing for reduced intensity chemotherapy to minimise treatment related toxicities (RATHL trial). Variability in interpretation methods and potential for subjectivity may present difficulties in identifying positive interim scans. Moreover, how a clinician uses this information to change treatment depends upon relevant clinical trials, patient factors and personal experience. Our retrospective audit of thirty-two haemato-oncology patients undergoing chemotherapy over a five-month period in a district general hospital considers these issues. We examine not only practical issues in the timing, reporting and communication of PET-CT’s, but also how clinical decisionmaking and patient outcomes were affected by a positive interim scan. The two commonest chemotherapy regimes were R-CHOP (67%) followed by ABVD (13%). We found that 54% of our patients had a complete metabolic response at interim scan, 38% had a partial response and 8% had stable or progressive disease. Those patients with stable or progressive disease at interim in our cohort were Non-Hodgkin’s Lymphoma patients and they went on to have further cycles of R-CHOP chemotherapy before re-scanning. Response at interim was favourable for all our Hodgkin’s Lymphoma (HL) patients and we are currently looking at a larger cohort of patients to analyse the predictive value of interim PET scanning specifically in HL. We recommend standardisation of PET reporting with clear definition of what constitutes a positive interim scan. We also recommend that positive interim scans are discussed in MDT meetings attended by both the radiologist and clinician to guide subsequent treatment decisions.

161 Establishment and operation of a bank of blood donor derived Epstein-Barr virus specific cytotoxic T cell lines for treatment of posttransplant lymphoproliferative disease MA Vickers1, N Robinson1, G Wilkie1, N Rivera1, J Russell1, D Clark1, N Fraser1, J Barry2, D Turner2, V Robertson2, H Newlands2, P Flanagan3, J Campbell2, T Haque4, M Turner2 1 Aberdeen & NE Scotland Blood Transfusion Centre, Scottish National Blood Transfusion Service, UK; 2Scottish National Blood Transfusion Service, Edinburgh, UK; 3New Zealand Blood Service, Auckland, New Zealand; 4Department of Virology, Royal Free Hospital, London, UK Epstein-Barr virus (EBV) driven lymphomas associated with immunosuppression are a significant problem, particularly after transplantation. Conventional treatment (reduction of immunosuppressive

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drugs, administration of rituximab/chemotherapy) is often effective but risks organ rejection and causes significant side effects. We have established a bank of anti-EBV CTLs derived from 25 blood donors for issuing ‘off the shelf’ to partially human leucocyte antigen (HLA) matched patients. EBV positive donors were from New Zealand to reduce the risk of Creutzfeldt-Jakob disease. The panel was chosen to maximise the probability of HLA class I and II matches, and minimise mismatches, so providing a partial match at ≥3 (HLA-A, -B, -DRB1) loci for ~80% of Caucasian patients. In the two years since the bank was granted a ‘Specials’ license by the MHRA for this Advanced Therapy Medicinal Product, there have been enquiries about 32 patients. Eleven died before any cells could be issued. Nine patients did not proceed to infusions, five of whom did not have post-transplant lymphoproliferative disorder (PTLD) and four improved with conventional therapy. Twelve cell lines have been issued and eleven administered. Only one patient has died of refractory disease, representing good outcomes compared to contemporaneous and historical controls. The indications for issue have been: nine cases of post-transplant lymphoproliferative disorder (one CD20- rituximab resistant, one with concomitant graft versus host disease precluding reduction of immunosuppression, one unfit for chemotherapy, six used as consolidation), two cases with congenital immunosuppression as a bridge to allogeneic hematopoietic stem cell transplant and one case of EBVassociated leiomyosarcoma post-cardiac transplant (related donor). A third party donor-derived anti-EBV CTL cell bank can be operated under current legislation and is a valuable addition to existing therapies for selected patients. The bank should be contacted before the disease becomes pre-terminal.

162 Extending subcutaneous rituximab maintenance therapy from 2 years until progression versus observation in patients with indolent non-Hodgkin’s lymphoma: interim safety data from the MABCUTE study S Rule1, J Briones2, AM Carella3, O Casasnovas4, WG Barreto5, C Pocock6, S Osborne7, R Smith7, F Zaja8 1 Department of Haematology, Derriford Hospital, Plymouth, UK; 2Department of Haematology, Santa Creu i Sant Pau Hospital, Barcelona, Spain; 3IRCCS AOU San Martino, IST, Genoa, Italy; 4Haematology Clinic, CHU Le Bocage, Dijon, France; 5Department of Haematology, Santa Marcelina Hospital, Sao Paulo, Brazil; 6Department of Haematology, East Kent Hospitals, Canterbury, UK; 7F. Hoffmann-La Roche Ltd., Basel, Switzerland; 8Haematology Clinic, AOUD S. M. Misericordia, Udine, Italy MABCUTE (NCT01461928) is an ongoing multicentre, phase IIIb study evaluating subcutaneous (SC) rituximab maintenance in indolent non-Hodgkin’s lymphoma (iNHL). Adult patients with histologically-confirmed relapsed/refractory CD20 + iNHL and ≥1 line of immunotherapy chemotherapy radiotherapy, plus a CR/PR to induction (rituximab every 3– 4 weeks x8 cycles [IV 375 mg/m2 c1, SC 1400 mg, c2–8]) and 6–8 cycles’ standard chemotherapy followed by standard maintenance (rituximab SC 1400 mg/8 weeks for 24 months), were randomised to further maintenance rituximab (SC 1400 mg/8 weeks) until PD, or observation. At January 16, 2013, the safety population comprised 216 patients with ≥1 dose SC rituximab: 70 (32%) had completed induction (24 [11%] discontinued), 58 (27%) had entered standard maintenance (2 discontinued), and the remainder were mid-induction. Median age


Poster Session: Lymphoid Malignancy - Clinical was 64.5 years (range 20–90). Most patients had follicular NHL (n = 131 [61%]) and the most common chemotherapy regimen was bendamustine (n = 137 [63%]). Administration-related reactions (ARRs) occurred in 61 (28%) patients after 1 dose of rituximab IV and 89 (41%) patients after a median (range) 5 (1–11) doses of rituximab SC. Most common AEs were neutropenia (n = 44 [20%]), nausea (n = 41 [19%]) and pyrexia (n = 35 [16%]). Grade ≥3 AEs occurred in 70 patients (32%). SAEs occurred in 44 patients (20%). Grade 4 haematological events (n = 25 [12%]) were mostly neutropenia (n = 22 [10%]). One non-haematological grade 4 event (thrombosis and pulmonary embolism) resolved after 12 days. Reasons for discontinuation (n = 26): AEs (n = 8), patient/investigator request (n = 6), PD (n = 5), death (n = 2), other (n = 5). There were two deaths; neither was considered study drug-related. Rituximab SC is associated with transient and mainly mild/moderate ARRs which were expected given the change in administration route; other toxicities were of expected incidence and intensity with no new safety signals identified, as confirmed by the Independent Data Monitoring Committee. Rituximab SC appears to be well tolerated and the study continues.

163 Clinical review of overall survival for myeloma patients progressing after both bortezomib and lenalidomide based therapy MJ Streetly1,2, M Kazmi1,2, T Campbell2,3, SA Schey2,3 1 Department of Clinical Haematology, Guys and St Thomas’ NHS Trust, London, UK; 2Department of Haematology, King’s Health Partners, London, UK; 3Department of Clinical Haematology, King’s College Hospital NHS Trust, London, UK Several recent reports have demonstrated improved survival for myeloma patients since the introduction of thalidomide, bortezomib and lenalidomide. However, patients continue to relapse and develop eventual drug resistance. The outcome for patients who have failed both bortezomib and immunomodulatory therapy (thalidomide or lenalidomide) has recently been described with median overall survival of 9 months in a study including only patients entered into clinical trials (median age of 58 years at diagnosis). We sought to define outcomes for patients in an unselected population who had failed both bortezomib and lenalidomide therapy. This was a retrospective clinical review of patients whose last bortezomib or lenalidomide exposure had occurred between Jan 2011 and Dec 2013. Patients were included if they had previously received and relapsed after bortezomib based therapy (regardless of response) and were also relapsed and/or refractory to lenalidomide. 29 patients with a median age of 65.1 years (range 34.8–76.9) were identified as fulfilling the criteria. Bortezomib had been received at a median of 2nd line therapy (1–5) and lenalidomide received at a median of 3rd line therapy (2–6). Bortezomib treatment preceded lenalidomide treatment in 27/29 patients. 12/29 (41%) patients were considered to be refractory to bortezomib whereas 27/29 (93%) were considered refractory to lenalidomide. The median time from diagnosis to dual bortezomib / lenalidomide failure was 3.5 years. 19/29 patients have died with a median overall survival following failure of both bortezomib and lenalidomide of 5.9 months. 11/29 patients received at least one further line of treatment post dual failure although response rates were poor with 29 longer as the time from last therapy to randomization. Median OS for PIX patients with a CR/CRu was not reached.

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Achievement of a CR/CRu with single-agent PIX in patients with 2 or more prior regimens for aNHL was associated with prolonged survival. The only demographic factor predictive of achieving a CR/ CRu was receiving 3 prior lines of therapy or less.

167 Weekly bortezomib/cyclophosphamide/ dexamethasone for relapsed myeloma: a retrospective review MJ Streetly1,2, J O’Sullivan1,2, G Milner1,2, C Yeomans1,2, D Gunning2,3, S Deppe2,3, T Campbell2,3, M Kazmi2,3, S Schey2,3 1 Department of Clinical Haematology, Guys and St Thomas’ NHS Trust, London, UK; 2Department of Academic Haematology, King’s Health Partners, London, UK; 3 Department of Clinical Haematology, King’s College Hospital NHS Trust, London, UK Bortezomib admininstered twice weekly and intravenously is licensed and approved by NICE for the treatment of relapsed myeloma. However, this approach is associated with response rates 8 months and again experienced symptomatic IRR and cytokine release on day 1 of re-treatment, however peak values were generally lower than those seen on initial exposure. Both patients completed planned infusions of 1000 mg. No further IRR or significant cytokine release occurred throughout the remainder of cycle 1 or cycles 2–8. These results provide further evidence that pro-inflammatory cytokines, rather than complement activation, likely mediate the symptoms of IRRs and that obinutuzumab administration triggers cytokine release in association with rapid destruction of circulating B cells.

169 Outcomes including CNS relapse for high grade B cell lymphoma treated with rituximabcontaining regimens at two district general hospitals A Hastings1, T Sugai2, M Al-Obaidi1, A Babb1 1 West Middlesex University Hospital, UK; 2Hillingdon Hospital, UK We present a retrospective review of patients with high grade B cell lymphoma treatedwith rituximab-containing regimens across two District General Hospitals in West London from 2004–2013. 94/111 patients had a diagnosis of diffuse large B cell lymphoma (DLBCL), 17 had high-grade transformations of low-grade lymphoma. The


median age at treatment was 68 (21–92). 95 treated initially with at least one cycle of full dose R-CHOP regimen. 16 patients were treated with RCVP or R-GCVP. Kaplan–Meier estimate of survival revealed an overall 1-year survival of 0.84, with three year survival at 0.66. Progression-free survival was 0.78 and 0.56 at the same intervals respectively. For the RCHOP group one and three year overall survival rates were 0.85 and 0.67 respectively. The cohort of patients receiving other regimes had an overall survival of 0.81 and 0.40 at one and three years. 39 patients received methotrexate (MTX) as CNS prophylaxis (37 had intrathecal MTX and 2 had intravenous MTX). In total, 6 patients had CNS disease, either at presentation (1) or relapse (5), at a median of 8 months from start of treatment. No patient with testicular or breast involvement had CNS relapse (n = 6). No patient with IPI4-5 had a CNS relapse (19). This reflects the difficulty in targeting CNS prophylaxis in high-grade lymphoma.

170 Managing the risk of cardiotoxicity: an audit of lymphoma patients receiving doxorubicinbased chemotherapy at Musgrove Park Hospital, Taunton K Burley, S Allford Department of Haematology, Musgrove Park Hospital, Taunton & Somerset NHS Foundation Trust, UK Anthracyclines are widely evidenced to be associated with cardiotoxicity. Monitoring of cardiac function is required, however there is no clear consensus on who should undergo echocardiograms and when. The risk is, in part, dose dependant but it is also suggested that pretreatment cardiac screening can be stratified on factors such as age, pre-existing heart disease and hypertension. Our aim was to audit the service provided to non-Hodgkins lymphoma (NHL) patients receiving doxorubicin-based chemotherapy at Musgrove Park Hospital (MPH), focussing on the pre-treatment cardiac assessment and echocardiogram monitoring of patients throughout chemotherapy. We performed an electronic search of the departmental patient database for patients with a diagnosis of NHL who had received R-CHOP or CHOP chemotherapy within the last four years. Data collection from clinic and discharge letters, Mosaiq for chemotherapy prescriptions and Tomcat (the electronic echocardiogram system) was undertaken. 93 patients fulfilled the inclusion criteria; 47% male with a mean age of 63 years at diagnosis. 73% of patients had a diagnosis of diffuse large B-cell lymphoma and 12% follicular lymphoma. 100% of patients had a cardiac history documented, however only 55% had a cardiac examination documented and none of our patients had a documented ECG review prior to starting chemotherapy. Following risk stratification, we found that 43% of patients with significant risk factors for cardiotoxicity underwent baseline echocardiogram. No patients with a known ejection fraction less than 30% received doxorubicin. Of the 14 patients who received a cumulative doxorubicin dose over 300 mg/m2, none underwent echocardiogram monitoring before receiving further treatment. Our service complied with recommendations for doxorubicin discontinuation from the FDA in 50% of relevant cases. Following local dissemination of these findings an action plan for improvements to the service is in progress including the design of a clinician checklist to prompt appropriate assessment and re-audit.

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Myeloid Malignancy – Clinical

Poster Session Myeloid Malignancy – Cellular and Molecular Biology 171 GATA1 is overexpressed in patients with essential thrombocythemia and it is normalized by anagrelide treatment L Brown1, C Graham1, CR Rinaldi1,2 1 School of Life Science, MPN-LAB, University of Lincoln, UK; 2 Department of Haematology, United Lincolnshire Hospitals NHS Trust, UK GATA1 is essential for cell maturation and differentiation within the erythroid and megakaryocytic lineages. Several studies have suggested a connection between GATA1 and myeloproliferative neoplasia (MPN). As we previously reported, high GATA1 RNA levels are found in bone marrow of patients with ET and PV, independently from the JAK2 V617F mutation. Anagrelide (ANA) has been proven to be an active drug in reducing platelet count in ET and PMF patients, however, the mechanisms by which this drug induces its effect is still unclear. Erusalimsky reported on down-modulation of the expression of GATA1 and its co-factor FOG1 in MK during the in vitro differentiation in the presence of ANA in culture media. In this study we analyse the expression of GATA1 in peripheral blood (PB) samples from 30 patients with ET and we compared the levels of expression before and after treatment with common cytoreductive agents such as Hydroxyhurea (HU) and ANA. We confirmed the data obtained in BM with a significant up-regulation of GATA1 in ET. When we measured the expression of GATA1 before and during treatment with ANA, there was a significant reduction of the RNA at 3 and 6 months of therapy, concomitantly with reduction in PLT counts. Interestingly this was not equally observed in patients treated with HU, despite normalization of PLT. Furthermore, when we analyse patients on combination treatment ANA + HU, GATA1 RNA reduction was observed only when patients were taking ANA. Those data suggest a direct effect of ANA on GATA1 expression. GATA1 could represent a generic molecular marker in ET and a possible diagnostic criteria in thrombocytosis. GATA1 overexpression is independent from JAK2 mutations, and responds specifically to ANA therapy suggesting a role in monitoring therapy response.

172 Validating the use of combination treatments with the demethylating agent decitabine in acute myeloid leukaemia CS Young, JF Hay, RN Armstrong, KI Mills Centre for Cancer Research and Cell Biology, Queen’s University Belfast, UK Epigenetic modifications have been associated with gene silencing and play an important role in the development of cancer. In particular aberrant patterns of DNA methylation and recruitment of histone deacetylases (HDACs) have been reported in Acute Myeloid Leukaemia (AML). A number of epigenetic therapies such as Decitabine have been developed with the aim of reactivating these genes. A link between demethylation and acetylation in reactivating silenced genes has made the combination of demethylating agents and histone deacetylase inhibitors a particular area of interest for AML. ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

This study has identified and assessed the molecular, cellular and functional consequences of the synergistic combinations of Decitabine with Vorinostat. Myeloid leukaemia cell lines were treated with sequential dose combinations of Decitabine and Vorinostat (covering a range of doses less than the IC50 for each agent). Combination treatments were found to be synergistic at inhibiting the proliferation of cell lines in vitro and affect the ability of leukaemic bone marrow cells to form colonies in methyl cellulose assays. Combination treatment significantly increased caspase 3/7, 8 and 9 activity and enhanced levels of acetylated H4 above that of single treatments. Vorinostat alone decreases mRNA levels of DNA methyltransferase 1 (DNMT1). This is further decreased in combination treatments however following LINE-1 pyrosequencing analysis we did not observe further demethylation in single agent Vorinostat treated cells compared to control cells or in combination treatments compared to Decitabine treatment alone. This suggests compensation for the loss of DNMT1 from other DNA methyltransferase enzymes. Expression arrays have also identified key genes such as those involved in immune system processes being induced in the combination treatments only. This study suggests that combining epigenetic therapies can result in synergistic effects which may lead to improved treatment for AML; whilst the identification of key pathways could lead to more targeted therapeutic combinations.

173 NPM1 mutated AML masquerading as APL: resolving a diagnostic conundrum K Wall1, R Evans1, J Mason1, A Ivey2, D Grimwade2, R Lovell3, H Hussein3, S Akiki1, M Griffiths1 1 West Midlands Regional Genetics Laboratory, Birmingham Women’s NHS Foundation Trust, UK; 2Department of Medical and Molecular Genetics, King’s College London School of Medicine, UK; 3Department of Haematology, Heart of England NHS Trust, Birmingham, UK Acute Promyelocytic Leukaemia (APL) is a medical emergency; any clinical suspicion of APL is an indication to treat immediately with the targeted therapy All Trans-Retinoic Acid (ATRA) and await genetic exclusion of the PML-RARA gene fusion before halting ATRA and commencing conventional AML therapy. Promyelocytes demonstrating nuclear invagination are a characteristic hallmark of APL, however NPM1 mutated AML (with or without FLT3 internal tandem duplication) has also been associated with nuclear invaginations. Furthermore, there is substantial overlap in the immunophenotype of APL and a proportion of NPM1 mutated AML. This has resulted in a series of cases referred for diagnostic PML-RARA analysis on the basis of morphology and immunophenotyping, which have subsequently proven to be NPM1 mutated with no evidence of PMLRARA translocation or alternative RARA gene rearrangement. We present a series of such cases referred over an 18 month period. Of 34 cases assessed for RARA gene rearrangements, 67% had PMLRARA gene fusion by RT-PCR, 21% had NPM1 mutation (without PML-RARA) and 12% had neither PML-RARA nor NPM1 mutation. G-band and/or FISH analysis confirmed a t(15;17) in all PML-RARA positive cases but not in the other cases. These results emphasise the


Poster Session: Myeloid Malignancy – Clinical need for rapid genetic testing of all clinically suspected APL cases in order to enable cessation of ATRA and commencement of appropriate AML chemotherapy for those patients lacking a PML-RARA gene rearrangement.

174 Genetic analysis of PRC2 and Jumonji genes in MDS S Shinde, A Mohamedali, S Mian, G Mufti, on behalf of the National Cancer Research Institute Haemato-Oncology Clinical Studies Group Department of Haematological Medicine, King’s College London, Rayne Institute, UK Polycomb group (PcG) gene complex associated mutations have been implicated in the pathogenesis of myeloid neoplasms. The detection of microdeletion or areas of acquired copy neutral LOH (CN-LOH) at 7q36.1 in myelodysplastic syndrome (MDS), led to the identification of mutations in the SET domain of EZH2. EZH2 is a methyltransferase which trimethylates lysine 27 of histone 3 (H3K27) and is part of the PRC2 complex that includes EED, SUZ12, and EZH1. To study the involvement of these PRC2 components in MDS, we sequenced the full length genes of EED, SUZ12, EZH1 in 61 patients and found no mutations, indicating the importance of mutations of EZH2 in the context of the PcG genes in MDS. These results suggest that gene expression modulated by changes in H3K27me3 would play a role in the pathogenesis of the disease. In addition to the genes in PRC2, we also investigated the involvement of Jumonji demethylases. We specifically analysed 13 Jumonji genes (JARID1A, JARID1B, JARID1C, JARID1D, JMJD1B, JMJD1C, JMJD2A, JMJD2C, JMJD2D, JMJD3, JMJD4, UTX) by SNP_A karyotyping in 124 patients with MDS. 23% of patients showed a genomic abnormality at one or more gene locus, specifically, deletions (n = 24) were more frequent than CN-LOH (n = 12) or amplifications (n = 11).Patients with genomic aberrations at the respective gene locus were sequenced using 454 DNA sequencing but, interestingly, no mutations were identified, suggesting the involvement of additional genetic factors in the development of myeloid malignancies.

176 Salinomycin induces cell death and impairs colony formation in murine models of acute leukaemia and human cell lines CL Burt, NM Mulgrew, LMJ Kettyle, HL Keenan, KI Mills, A Thompson Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Northern Ireland, UK Acute leukaemia is a heterogeneous group of hematopoietic disorders primarily diagnosed by the accumulation and clonal expansion of hematopoietic stem and progenitor cells (HSPCs) due to a blockage in differentiation and diminished apoptosis. Acute leukaemias harbouring Mixed Lineage Leukaemia (MLL) translocations are particularly aggressive, associated with upregulation of HOX and TALE genes, and have poor prognosis. Rearrangements of the MLL gene on chromosome 11 position q23 account for 5–10% of acute leukaemias of myeloid, lymphoid or mixed lineage and most commonly occur in infants and adult therapy-related cases with previous topoisomerase II inhibitors treatment. Current therapy options are limited and development of new therapeutic strategies is warranted. Salinomycin, a potassium ionophore most commonly used as a coccidiostat in poultry, has been shown to have selective toxicity towards breast cancer stem cells. Here we show that salinomycin, reduces cell viability and increases caspase 3/7 activation in human AML cell lines and preferentially inhibits colony formation in primary murine HOXA9-MEIS1 (A9M) leukaemic cells compared to normal bone marrow. As HOXA9 and MEIS1 are established targets of MLLfusion proteins the effects of salinomycin on a panel of human MLL cell lines and primary MLL-fusion leukaemias were also investigated. Preliminary data indicate that MOLM13 and MV4;11 cells are particularly sensitive to salinomycin treatment alone or in combination with the autophagy inhibitor chloroquine. Combined treatments resulted in further reduction in cell viability, a greater increase in caspase 3/7 activation and a marked reduction in colony formation. Together the data support the use of salinomycin alone or in combination with other drugs as potential therapy in poor prognosis acute leukaemias.

175 Abstract Withdrawn


ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Myeloid Malignancy – Clinical

Poster Session Myeloid Malignancy – Clinical 177 Efficacy of 5-azacitidine in obtaining complete remission (CR) in patients with AML obtaining partial remission (PR) with conventional induction chemotherapy: retrospective study of 7 patients treated at East Kent Hospitals between January 2009 and December 2013 CA Roughley, I Dharmasena, J Lindsay, V Ratnayake, K Saied, C Pocock Department of Clinical Haematology, East Kent Hospitals, Canterbury, UK It is well known that elderly patients with AML who fail to obtain CR with one cycle of conventional chemotherapy fare poorly with further conventional chemotherapy. We looked at a cohort of 7 patients who had been treated with induction chemotherapy to PR (5–19% blasts) at East Kent Hospitals and were consolidated with 5-Azacitidine rather than further conventional chemotherapy. Seven patients had received induction AML chemotherapy to PR and were commenced on the 5 + 2+2 75 mg/m2 5-Azacitidine regime and all received at least 2 cycles of this as consolidation. One patient stopped after 2 cycles due to cytopenias but had stable disease and remains off all treatment at present. A second heavily pre-treated patient who had relapsed post allograft and received FLAG-Ida to PR, had Revlimid and Azacitidine for 2 cycles but then progressed and died. Of the 5 patients who received more than 2 cycles, 1 patient progressed after 9 cycles (having attaining CR by cycle 3); another relapsed after 13 cycles. A third patient obtained a CR which was durable for 4 years (50 cycles of 5-Azacitidine). Two further patients are maintaining remissions after 13 cycles, so far, of 5-Azacitidine. As of end of December 2013, 5 of this cohort are alive, with 2 patients still on 5-Azacitidine. The mean duration of remission to date is 19.6 cycles, with median of 13 cycles. 5-Azacitidine consolidation is effective in delaying progression in AML patients treated to PR following chemotherapy induction and indeed can convert PR to CR (5/7 patients) which can be durable. Using this approach, survival appears superior than that obtained with further conventional chemotherapy in this setting.

178 A 5-azacitidine 105 mg/m2 5 day regime appears as effective at maintaining response as 75 mg/m2 7 day regime: a retrospective study of 16 patients with MDS/AML treated at East Kent Hospitals between January 2009 and December 2013 CA Roughley, I Dharmasena, J Lindsay, V Ratnayake, K Saied, C Pocock Department of Clinical Haematology, East Kent Hospitals, Canterbury, UK This is a retrospective study of patients with MDS, CMML and AML treated with 5-Azacitidine, who had responded by Cycle 6 on a ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

75 mg/m2 5 + 2+2 regime (NHS) or standard 7 days regime (Private sector). They were then converted to Azacitidine 105 mg/m2 5 days protocol (capped at 200 mg). The total dose delivered is equivalent. The aim was to see if duration of response was affected by the conversion. Sixteen patients had responded by cycle 6 and were converted to the 5 day regime. The mean overall response duration was 23 cycles, median 13 cycles (range 8–58). Four patients had responses of more than 45 cycles: 3 had CMML; 1 had AML induction therapy to PR and Azacytidine consolidation to remission (relapsed after 50 cycles including 34 of 5 days regime). One pt with CMML had been converted to 5 day regime, then developed anaemia after 17 cycles of 5 days, but counts normalised after reverting to 7 days regime (now received further 7 cycles). Another patient with CMML received 34cycles at 75 mg/m2 7 days and then had further 17 cycles of 105 mg/m2 5 days regime and maintained response. He subsequently developed gastrointestinal symptoms and was switched to 75 mg/m2 5 days regime and has so far maintained response after further 7 cycles. The 5 day regime (105 mg/m2) appears to have equal efficacy to 7 days regime in maintaining response after cycle 6. Benefits include greater convenience for the patient and chemotherapy units whilst maintaining efficacy at reduced cost (10 vials per cycle compared to 14).

179 Posaconazole prophylaxis during intensive chemotherapy for acute myeloid leukaemia (AML) – a prospective audit of 102 treatment episodes in 57 patients CA Roughley1, F Muhlschlegel2, P Elton3, K Lang1, J Lindsay1, K Saied1, V Ratnayake1, C Pococok1 1 Department of Clinical Haematology, East Kent Hospitals, Canterbury, UK; 2Department of Microbiology, East Kent Hospitals, Canterbury, UK; 3Department of Radiology, East Kent Hospitals, Canterbury, UK Posaconazole is a broad spectrum triazole, active against aspergillus, and has been shown to be more effective than fluconazole or itraconazole at preventing Invasive pulmonary aspergillosis (IPA) in patients receiving treatment for AML or high risk myelodysplastic syndrome (HR-MDS). This study assessed the efficacy of posaconazole prophylaxis in preventing IPA in patients receiving intensive chemotherapy for AML and HR-MDS. Posaconazole 200 mg tds was started when neutrophils were 0.5 9 109/l and falling; and stopped when neutrophils 0.3 9 109/l and rising. Data collected included length of stay (LoS), duration of neutropenia, duration of any antifungals, and results of high resolution CT (HRCT) scans. Galactomannans were not monitored nor bronchoscopy performed. Change in antifungal therapy was determined by radiological changes alone: caspofungin commenced if scan high risk of IPA. This abstract looks at outcomes of 102 treatment episodes (57 patients) with prophylactic posaconazole. Mean age 57.3 years (range 20–82, median 61). Mean LoS 21.9d (median 24, range 0–53): in 7 episodes patients were not admitted. Mean posaconazole duration 22d (median 21, range 0–54). One patient did not become neutropenic. Fifty-five HRCT scans were performed showing new radiological evidence of


Poster Session: Myeloid Malignancy – Clinical IPA in 13 patients: 12 during induction, 1 during consolidation. One patient died of haemoptysis due to IPA (Hormographiella aspergillata) in remission post induction therapy. There was a radiological breakthrough rate of 21% during induction, but some ‘radiological IPAs’ may not actually be IPA. With rapid access to HRCT, galactomannan testing, bronchoscopy and empirical escalation of antifungal therapy are not required. There was one death from IPA in remission. No patient to date in complete cytogenetic and morphological remission at the start of consolidation chemotherapy went on to develop radiological evidence of IPA. De-escalation of prophylaxis should be considered in this group.

180 Pregnancy management and outcomes in myeloproliferative neoplasms ES Polushkina1, RG Shmakov1, MA Vinogradova2, MA Sokolova3, ND Khoroshko3 1 Department of Obstetrics, Federal Research Centre for Obstetrics and Gynecology, Moscow, Russia; 2Department of Haematology, Federal Research Centre for Obstetrics and Gynecology, Moscow, Russia; 3Department of Haematology, Federal Research Centre for Haematology, Moscow, Russia The development of new therapeutic strategies provides good results in survival rate and life prognosis for patients with chronic myeloproliferative neoplasms (MPN). But high incidence of pregnancy losses necessitated the creation of protocol for pregnancy management in women with MPN. The treatment during pregnancy included Interferon-a, acetylsalicylic acid, low molecular weight heparin and folic acid. Besides examination of blood cell count and hemostasis system, the additional tests for the timely detection of hypercoagulable status were performed. We analyzed 110 pregnancies in 90 women with essential thrombocythaemia, polycythemia vera and primary myelofibrosis. The prospective group (group 1) included 67 women, who were treated according to our algorithm. Retrospectively we analyzed 43 pregnancies in 23 women (group 2), who did not receive any special treatment of MPN during pregnancy. Full-term delivery occurred in 83.6% (56) and 16.3% (7) pregnancies in two groups (OR–26.18; 95% C.I.:8441; 85.448). Medical abortion was made in 3% women of group 1 and 6.9% women of group 2. In the group of women, who were treated according to our algorithm, 6% developed spontaneous abortions. In group 2 without special treatment spontaneous miscarriages occurred in 62.8%. Preterm labor were in 7.4% and 14% of pregnancies respectively. Pregnancy was uncomplicated in 34.4% and 15.4% in two groups. The most often pregnancy complications were threatening miscarriage-41%/76.9% and anemia–36%/30.8%. No hemorrhagic complications were registered. Although all pregnancies in group 1 were carefully observed and treated, 14.8% of them were complicated by placental insufficiency (30.8% pregnancies-in group 2). Thus pregnancy losses in women suffering from MPN occur in 62.8% without special treatment and complications of pregnancy – in 84.6% cases. The development of algorithm for pregnancy management resulted in considerable decrease in miscarriages to 6% (p < 0.001) and reduction of pregnancy complications to 65.6% (p = 0.3).


181 The use of azacitidine in myelodysplasia at Basildon Hospital A Zaidi, S Dasgupta, L Galuszka, D Garvey, J Howard, S Mane, J Shankari, P Jasani Basildon University Hospital, UK Introduction: Several clinical trials have shown the benefit for the use of azacitidine in patients with Myelodysplastic syndromes (MDS) versus supportive management alone and or low dose chemotherapy. These include overall survival and independence from red blood cell transfusions. NICE issued guidelines for the use of azacitidine for the treatment of MDS, Chronic Myelomonocytic Leukaeimia (CMML) and Acute Myeloid Leukaemia (AML) in March 2011. We sought to determine whether NICE guidelines on Azacitidine are being followed appropriately and if necessary, improve service at our hospital. Overall survival was also recorded to determine if trial data is reflected in our patient group. Methods: Notes from all patients at Basildon hospital with a diagnosis of MDS, CMML and AML between March 2011 (guideline introduced) and March 2013 were evaluated retrospectively. Data was collected using a standard proforma to record diagnosis, International prognostic scoring system score (IPSS), chosen management and outcome. 106 patients were evaluated. Results: Mean age was 74.5 years. 78% of patients had IPSS 2 was 12 months. For those treated with Azacitidine survival was 16, 12 months with cytarabine and 8 months with supportive care alone. Discussion: Overall azacitidine is used in accordance with NICE guidelines at Basildon hospital. For patients with IPSS > 2 those receiving treatment had longer survival compared with patients receiving supportive treatment alone. Whilst supportive care should be the mainstay of treatment in all patients with MDS, our data demonstrates benefit for chemotherapy treatment, particularly with azacitidine, in patients with high risk disease.

182 Stop imatinib in East Kent: a 2014 update for the BSH CE Graham, R Trikha, C Pocock Department of Haematology, East Kent Hospitals, Canterbury, UK Imatinib mesylate (IM) is widely accepted as first line treatment for chronic myeloid leukemia (CML) and life-long treatment remains the standard of care worldwide. Interim analysis from the French multicentre prospective STIM trial that followed patients for a minimum of 24 months after IM was stopped, has suggested that durable complete molecular remission (CMR) is maintained in ~40% of patients. Additionally it showed that, in patients destined to, relapse ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Myeloid Malignancy – Clinical always occurs within 18 months and usually within 6 months. We have previously reported our experience of stopping IM in 5 patients with CML in CMR (BSH 2012, P153). Here we present further follow up results of 3 of the original cohort and one additional patient who has stopped IM due to potential interaction with ant-tuberculous therapy. Other reasons for discontinuation included nausea, anorexia, myalgia, hair loss and patient choice. Age at CML diagnosis ranged from 45–75 years. These four patients had been on IM for between six and nine years. Following discontinuation, they were closely monitored for molecular relapse by standard qPCR techniques. At the last follow-up the cohort of four has been off IM for 49, 48, 46 and 24 months and remains in CMR. Of the original cohort one patient died of non-CML related causes and one patient restarted within 6 weeks due to molecular relapse (CMR was reestablished). Imatinib costs around £25K per annum, per patient. Our cohort of four patients has to date saved roughly £400K for the local health economy. Our findings are consistent with a growing body of work suggesting that IM can be safely stopped in some CML patients and a sizeable minority will remain in durable CMR. Further work, the ‘Destiny’ trial in the UK, hopes to identify which patients can safely discontinue treatment and includes initial dose de-escalation.

183 Use of radioactive phosphorus (p 32) in the management of polycythaemia rubra vera (PRV) and primary thrombocythaemia (ET) in East Kent Hospitals (EKUFHT) UK (01/01/2008– 31/12/2012) SE Alhassan1, G Shabo2, I Dharmasena1, C Pocock1, G Evans1, J Lindsay1, K Saeid1, R Senthiraman1 1 Department of Haematology, East Kent Hospitals (EKUHFT), UK; 2Nuclear Medicine Department, East Kent Hospitals (EKUHFT), UK As per the British Committee for Standardisation of Haematology (BCSH) guidelines for ET and PRV (2010 and 2005), P32 therapy is effective in controlling blood counts with few acute side effects. The dose is 150–300 MBq (can be repeated after 3 months). Use of P32 is recommended as second line therapy in those older than 70 years who fail to respond to or are intolerant of the first line therapy (hydroxycarbamide). P32, the radioactive isotope of Phosphorous, had long been successfully used in treatment of myeloproliferative disease, namely PRV and ET. It is a pure beta emitting radionuclide with a physical halflife of 14.3 days, given intravenously or orally in aqueous solution. It is actively incorporated into the nucleic acids of rapidly proliferating cells, thus suppressing hyperproliferative cell lines rather than eradicating them. Early side-effects of transient leucopoenia and thrombocytopenia are observed. The late potential for leukaemogenicity is a risk but its incidence is comparable to that associated with the alternative chemotherapeutic agents. (EANM procedure guideline for 32P phosphate treatment of myeloproliferative diseases; Eur J Nucl Med Mol Imaging (2007)34:1324–27). Between 01/01/2008–31/12/2012 there were 43 episodes of usage of P32 in EKHUFT (23 (53.5%) for PRV/20 (46.5%) for ET). 25 (58.1%) episodes were CR, 8 (18.6%) were PR and 10 (23.3%) were NR. This led to 18 episodes of discharge from the haematology outpatient clinics (41.9% of the total episodes). P32 is an effective modality of treatment for those over 75 years of age with PRV/ET, which reduces/abolishes outpatient clinic attendance; thus contributing to improved quality of life.

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

184 The CSF3R T618I mutation as a disease-specific marker of atypical chronic myeloid leukaemia post-allogeneic stem cell transplantation SE Langabeer1, SL McCarron1, K Haslam1, MT O’Donovan2, E Conneally2 1 Cancer Molecular Diagnostics, St James’ Hospital, Dublin, Ireland; 2Department of Haematology, St James’ Hospital, Dublin, Ireland Atypical chronic myeloid leukaemia (aCML) and chronic neutrophilic leukaemia (CNL) are rare diseases classified according to myeloid cell differential, dysplastic features and exclusion criteria, notably absence of the BCR-ABL1 rearrangement. The outcome for aCML/ CNL patients is generally poor due to disease transformation with allogeneic stem cell transplantation (ASCT) potentially the only curative option. No specific molecular abnormalities have been described in aCML/CNL until recent reports of CSF3R and SETBP1 mutations. CSF3R mutations can be membrane proximal point mutations that result in activation of JAK signalling pathways or nonsense/frame shift mutations that result in premature truncation of the receptor cytoplasmic tail with activation of SRC family kinase signalling pathways. Retrospective sequencing of SETBP1 and CSF3R mutational hotspots was performed in eight patients with aCML, CNL and aMPN. No SETBP1 mutations were detected. A CSF3R T618I mutation was detected in two aCML patients both of whom underwent ASCT. The CSF3R T618I was present in patient #1 three months pre-ASCT (reduced-intensity, CSF3R wild type sibling donor). By day 72, chimerism was only 20% with the T618I mutation still evident. Full donor chimerism was not achieved with relapse nine months postASCT. The patient had increasing myeloblasts and continued evidence of the CSF3R T618I despite donor lymphocyte infusions and further chemotherapy. Patient #2 presented with the CSF3R T618I mutation, commenced treatment with hydroxyurea and 6 weeks prior to ASCT (myeloablative, CSF3R wild type sibling donor) the CSF3R T618I clone remained evident but at a reduced level. The T618I mutation was not detected by day 46 post-ASCT. Allele–specific monitoring of disease-associated mutations is of value in predicting response to ASCT. Both persistence and eradication of the CSF3R T618I correlating with the clinical course indicates that serial monitoring of CSF3R mutations in aCML patients undergoing ASCT is a useful adjunct in the assessment of transplant efficacy.

185 32P in the treatment of myeloproliferative disorders S Lawless1,2, MF McMullin1,2,3, R Cuthbert1,2, R Houston2,4 1 Department of Haematology, Belfast City Hospital, UK; 2 Queen’s University Belfast, UK; 3Centre for Cancer Research and Cell Biology, UK; 4Department of Clinical Oncology, Belfast City Hospital, UK Introduction: 32P has been available for the treatment of myeloproliferative disorders for over seventy years. Its use has decreased due to introduction of newer agents and concerns regarding its leukaemogenic potential. Polycythaemia rubra vera (PRV) and essential thrombocythaemia (ET) remain the only myeloproliferative conditions in which 32P remains indicated in. The aim of the review was to examine the use of 32P in these conditions, particularly examining its effectiveness and complications.


Poster Session: Myeloid Malignancy – Clinical Materials and methods: A retrospective review of all patients who had received 32P at our unit was performed. Nineteen patients were identified over a 24 years period. Eight men and eleven women were included. Fifteen subjects suffered from ET and four from PRV. The time to successful response, duration of response, number of times 32P was given and complications were reviewed. Results: 32P was successful in inducing remission in 90% of patients. This remission was sustained following one dose without the need for further therapy in 37% cases. The longest duration of response in this group to date is 156 weeks. 47% required repeated doses. 26% required recommencement of alternative therapies. Length of follow up varied from 7 months to 24 years. No cases of thrombosis, myelofibrosis or acute leukaemia were observed. Discussion: We conclude that 32P is a well tolerated and efficacious treatment option in the elderly. It has the benefit of reducing the monitoring and adjustments needed when on cytoreductive agents which require good compliance. Our results have been compared with previous work in this area, with extensive discussion and comparison.

186 Single centre experience of low dose cytarabine (LDAraC) treatment outcomes in myeloproliferative neoplasms (MPN), high risk myelodysplasia (MDS) and acute myeloid leukaemia (AML) ME Young, AD Arasaretnam, D McLornan, H De Lavallade, T Pagliuca, J Marsh, A kulasekararaj, R Ireland, V Potter, K Raj, GJ Mufti Department of Haematology, King’s College Hospital, London, UK We reviewed the outcomes of treatment in 57 patients (32 male, 25 female with average age 60 years: range 29–82 years) between 2007 and 2013 including MPN (n = 7), high risk MDS (n = 12), de novo AML (n = 10) and relapsed/refractory AML (n = 21) receiving LDAraC. Patients received 0–7 lines of therapy prior to receiving LDAraC including 12 with previous allograft. Ten patients had no prior treatment whilst 38 had previous induction chemotherapy: 19 having achieved complete remission (CR), 13 partial remission (PR) and six had primary refractory disease. 39 received subcutaneous cytarabine (10–20 mg/m2 BD 7–14 days), 18 infusional cytarabine (20 mg/m2 for 7–14 days) with a median of 2 cycles received (1–21). Four received concomitant donor lymphocyte infusions, three oral fludarabine and two hydroxycarbamide. Favourable response rates (CR, PR and stable disease) of 57% and 64% were seen in de novo AML and high risk MDS respectively compared to 25% in relapsed/refractory AML. Median overall survival (OS) rates were 332 days (37–1657) in de novo AML versus 106 days (8–1183) in relapsed/refractory AML, compared with progression free survival of 172 days (0–1982) versus 0 (0–1183) respectively. Those receiving subcutaneous LDAraC had a median OS of 246 days (23–1982) versus 121 (8–1190) in the infusional group – which comprised 52% refractory/relapsed AMLs, 57% MPNs and 25% high risk MDS patients. 12 patients were post allograft at time of LDAraC initiation. Four received concomitant DLI therapy with a median OS 1139 days (452–1562) compared to 146 (42–651) in those receiving LDAraC alone.


The use of LDAraC is not a standard treatment but this review would suggest it may be beneficial in elderly de novo AML and high risk MDS. Outcomes in the relapsed/refractory setting appears poor, however it may have a role when combined with DLI in post allograft patients. Our analysis demonstrates that there is a role for LDAraC in a carefully selected patient group.

187 Combination therapy with ruxolitinib plus 5- azacytidine or continuous infusional low dose cytarabine (LDAC) is feasible in patients with blast-phase myeloproliferative neoplasms (MPN) AN Mwirigi1,2, S Galli1, C Keohane1, N Shepherd1, Y Francis1, G Ong2, D Radia1, K Raj1,2, C Harrison1, D McLornan1,2 1 Guy’s and St Thomas’ NHS Foundation Trust, London, UK; 2 King’s College Hospital NHS Foundation Trust, London, UK Management of leukaemic transformation of ‘MPN or ‘MPN/MDS overlap’ syndromes poses significant challenges. Estimated survival of blast phase (BP) is less than 6 months. Many patients are unsuitable for intensive therapy/ transplantation. Novel therapeutic approaches are required. Single agent Ruxolitinib displayed only modest antileukaemic activity in refractory/relapsed acute leukaemias. We present three cases of BP-MPN treated with combination Ruxolitinib and 5-azacytidine or low dose cytarabine (LDAC). Case 1: 69 year old with progressive JAK2V617F negative MF and, worsening portal hypertension. 18 months after Ruxolitinib therapy progressed to BP. LDAC was ineffective. Switched to 5-azacytidine with Ruxolitinib. After 20 weeks has stable disease (SD) with marked objective improvements in the portal hypertension, constitutional symptoms and reduced transfusion requirements. Case 2: 71y old with JAK2 V617F positive ‘MPN/MDS’, rapid progression to accelerated phase (16% blasts). Failed to respond to single agent 5-azacytidine or decitabine and developed BP. Ruxolitinib introduced, with marked improvement in symptoms, spleen size and transfusion requirements with SD for 4 months. LDAC then introduced as a single agent but failed. Ruxolitinib was re-introduced with infusional LDAC (3 weeks 20 mg/m2/day). After 10 weeks, has good leukaemic cytoreduction, complete resolution of splenomegaly and symptoms and has stable transfusion requirements. Case 3: 65 year old with PV. Ruxolitinib responder but progressed to post-PV MF 12 months later and then frank AML (37% blasts; complex karyotype). Standard dose 5-azacytidine was introduced and he continues on dual therapy. After 27 weeks, he remains asymptomatic, transfusion independent and has SD. These cases demonstrate the feasibility and tolerability of Ruxolitinib in combination with either LDAC or 5’aza in BP-MPN. Conclusions are limited due to cohort size but these patients demonstrated good responses as regards attenuation of symptoms, splenomegaly and disease stability with minimal haematological toxicity. No adverse events occurred. A future UK trial is planned.

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Nursing

188 A case of platelet refractoriness in acute myeloid leukaemia: management in a low resource setting KI Korubo1, HC Okoye1, G Ekeh2 1 Department of Haematology & Blood Transfusion, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria; 2Department of Paediatrics, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria We present a 14 year old male referred with fever, bone pains, anaemia, hepatomegaly and paraplegia. Investigations revealed haemoglobin- 7.3 g/dl, WBC- 8 9 109/l, platelet- 05 9 109/l, WBC differential showed 73% blasts and absolute neutrophil count of 0.32 9 109/l. Bone marrow aspirate confirmed a diagnosis of AML –M1 with CNS involvement. He was optimized for chemotherapy with fresh whole blood (FWB), four units of apheresis platelet transfusions and G-CSF. However, he developed platelet refractoriness (PR) with lack of post transfusion platelet increment 24 hours after each platelet transfusion. By the 21st day of admission, platelet count was 02 9 109/l. Decision to commence chemotherapy at 75% of the calculated dose (despite severe thrombocytopenia) was taken, while withholding intrathecal chemotherapy in the meantime. Cytosine Arabinoside (days 1–10), Vincristine (days 1 and 8), Cyclophosphamide (days 1 and 8) and prednisolone were given. Chemotherapy was given with daily alternating transfusions of FWB or platelets. Subsequently, platelet count started to rise by day 12 of first cy cle. Serial platelet counts at days 12, 16 and 21 were 15, 27 and 207 9 109/l respectively. He also received intrathecal chemotherapy. Presently, he has received 4 cycles of chemotherapy with platelet counts ranging from 109–397 9 109/l during the last 3 cycles. He had no episode of spontaneous bleeding from presentation to date. His clinical condition and laboratory parameters have remarkably improved. PR is a feared complication that may arise in haematological malignancies. In developing countries routine leukodepletion of components is rare, the risk of developing platelet refractoriness is high. This is worsened by inability to determine leukocyte HLA or platelet HPA antibodies and transfusion HLA/ HPA matched platelets. Cost intravenous immunoglobulin or other therapy is also an issue. This case shows management of AML with subsequent correction of thrombocytopenia in a low resource setting.

189 A district general hospital experience of azacitidine usage LJ Vanhinsbergh, M Al Obaidi, A Babb Department of Haematology, West Middlesex University Hospital, UK Azacitidine is a hypomethylating agent known to be effective in prolonging survival of patients with Acute Myeloid Leukaemia (AML) or Myelodysplastic Syndrome (MDS). We present a case series of patients, which reflect a typical district general hospital experience of azaciditine usage. 19 patients (3 female, 16 male) with mean age of 76 years (range 60–84) were retrospectively analysed to assess treatment response and tolerance. 9 of these patients had a diagnosis of AML (bone marrow blasts >20%) at treatment initiation. The mean number of cycles of azacitidine was 8 (range 1–59). Bone marrow trephine blast count at treatment initiation ranged from 2 to 61% with some inconcordance in aspirate count. 3 of 9 ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

patients re-staged achieved a haematological response, with 2 achieving complete remission (CR) by International Working Group criteria. Inpatient days per azacitidine cycle averaged 3.2 overall (5.4 in AML, 1.9 in MDS). As expected, patients achieving haematological response had a demonstrable improvement in red cell and platelet transfusion dependency. 8 out of 12 patients re-assessed after completion of 3 cycles had a haematological improvement in neutrophil count. When subdivided, median survival of AML patients was 8 months, despite none achieving CR. Median survival of MDS patients was 13 months. Although our patient numbers are low these results support the use of azacitidine in this patient population.

190 Rare examples of Philadelphia positive CML with concomitant BCR-ABL1 translocation and JAK2 V617F mutation S Akiki1, S Rose1, J Bryon1, S Jeffries1, J Murray2, M Raghavan2, M Griffiths1 1 West Midlands Regional Genetics Laboratory, Birmingham Women’s NHS Foundation Trust, UK; 2Centre for Clinical Haematology, University Hospitals Birmingham, UK Myeloproliferative Neoplasms (MPNs) are characterised by hyperplasia of the three major myeloid lineages. There is considerable overlap between these phenotypically distinct entities and transitional forms can occur with varying potential to transform to AML. The revised WHO 2008 classification of MPNS relies on genetic features to distinguish between Philadelphia positive CML and Philadelphia negative neoplasms, the majority of which have a JAK2V617F mutation. The two mutations are considered to mutually exclusive and reports of coexistence are rare. We describe six BCR-ABL1 positive CML patients who appear to have a concurrent, independent myeloid neoplasia. Two patients with CML were found to have a history of MPN and a JAK2 V617F mutation. One patient had ‘mixed MPN’ with both a BCR-ABL1 fusion and a JAK2 V617F mutation. A further patient showed emergence of a Philadelphia negative JAK2 V617F positive clone post Imatinib treatment. A fifth patient was diagnosed with ET 9 years prior to CML; retrospective analysis did not detect JAK2 V617F mutation. Analysis of a sixth MDS patient referred for disease progression revealed the presence a t(9;22)(q34;q11) clone. Five of the six patients achieved a complete cytogenetic response to treatment for CML but only 2 achieved a major molecular response (MMR), of which only one was sustained. The dynamics of the two events suggest two independent clones although patients with a concurrent myeloid neoplasia may represent a sub-group of CML derived from common precursor clones. Our results suggest CML patients with a concurrent neoplasia may not respond optimally to treatment and the outlook for these patients could be worse, if this is due to precursor mutations rather than truly independent clones. We recommend further genetic analysis should be considered for CML patients where marrow morphology indicated a prior MPN or MPN/PMF phenotype post-treatment or to investigate poor imatinib tolerance.


Poster Session: Nursing

191 CALR mutations are rare in childhood myeloproliferative neoplasms SE Langabeer1, K Haslam1, C McMahon2 1 Cancer Molecular Diagnostics, St James’ Hospital, Dublin, Ireland; 2Department of Haematology, Our Lady’s Children’s Hospital, Dublin, Ireland The incidence of the myeloproliferative neoplasms (MPN) in children is estimated to be 40–90-fold lower than that observed in adults with the frequency of the JAK2 V617F and other MPN-associated mutations lower than in adult MPN implicating alternative pathogenetic mechanism(s). These data suggest a distinct molecular diagnostic algorithm should be considered in conjunction with the idiosyncratic morphological and clinical features of childhood MPN. Mutations of CALR have recently been reported in a significant proportion of adult MPN and appear to be mutually exclusive of the JAK2 V617F and MPL mutations. CALR insertion or deletion mutations occur within exon nine and are either insertions or deletions that generate a + 1 basepair frame shift resulting in a protein with a novel C-terminal. The incidence of CALR exon 9 mutations was retrospectively sought in either blood or bone marrow from a small, single centre cohort (median age nine years) comprising of JAK2 V617F-negative essential thrombocythaemia (n = 4), JAK2 V617F-positive MPN (n = 3), JAK2 V617F-negative polycythaemia (n = 2) and reactive thrombocytosis (n = 8). Fluorescent PCR fragment analysis was used to detect known CALR exon 9 mutations. Two adult type mutations (resulting in 52 and 19 bp deletions) were used as positive controls. No CALR mutations were detected in the six JAK2 V617F-negative MPN patients nor in those JAK2 V617F-positive and reactive thrombocytosispatients. Whether CALR mutations will have a role in the diagnosis and classification of childhood MPN requires further verification. Nevertheless, this brief study serves to highlight another potential biological difference between childhood and adult MPN.


192 Droplet digital polymerase chain reaction (PCR) assessment of deep molecular response in chronic myeloid leukaemia (CML) S Akiki1, J Bryon1, M Jyothish1, C Campbell1, S Rose1, K Wall1, C Craddock2, M Raghavan2, M Griffiths2 1 West Midlands Regional Genetics Laboratory, Birmingham Women’s NHS Foundation Trust, UK; 2Centre for Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust, UK Using tyrosine kinase inhibitors up to 40% of patients with CML with complete molecular responses of more than 2 years can stop therapy in the long term without relapsing from their disease (Mahon et al 2010). The criterion for stopping therapy is is not yet defined and patients with fluctuating low level disease may have an increased risk of molecular relapse (Rousselot et al 2013). However, real time quantitative PCR (RT-qPCR), the gold standard for assessing molecular response, is susceptible to these fluctuations at the limits of its sensitivity. It is important to closely monitor patients who do come off treatment with maximum sensitivity to allow therapeutic intervention should a BCR-ABL1 clone reemerge. We aimed to improve the sensitivity using a single molecule counting techniques, droplet digitalPCR (ddPCR). It offers a highly sensitive and robust method of quantification capable of detecting very subtle differences in mutation level. The method segregates target template DNA molecules into numerous individual compartments, the amplification and detection of low-level templates is not affected by the predominant counterpart, increasing the accuracy and sensitivity of detection of low level clones. Patients who achieved a major molecular response were retrospectively monitored for BCR-ABL1 transcripts using ddPCR. Three broad categories were identified. Persistent negative patients had undetectable BCR-ABL1 transcripts for over 2 years. Intermittent positive patients had transcripts alternating between undetectable and detectable low level BCR-ABL1 transcripts. Patients with molecular relapse had detectable BCR-ABL1 transcripts and lost MMR. Monitoring absolute changes in minimal residual disease levels using ddPCR at the limits of detection of current RT-qPCR assays can be used as a precise measure of deep response and has the potential to accurately discriminate between those patients achieving a sustainable response who can be considered for treatment cessation studies from those in whom detectable BCR-ABL1 transcripts are likely to reemerge.

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Paediatrics

Poster Session Nursing 193 Development of a patient/relative self-administration programme to administer subcutaneous cytarabine H Walker, W Anderson Department of Haematology, South Tees Hospital NHS Foundation Trust, UK Low dose Cytarabine is currently the gold standard for non-intensive treatment of Acute Myeloid Leukaemia in the elderly. It is given by sub-cutaneous (sc) injection twice daily for 10 days every 4–6 weeks for 4 courses or more, in total 80 contacts. Patients have a shortened life expectancy so many prefer to spend time at home, not attending numerous hospital appointments. Despite their poor prognosis patients are well enough to be treated at home with access to support as required. Within South Tees NHS Foundation Trust, patients and relatives requested to self/relative administer cytarabine and the Haematology team developed a protocol providing a practice framework to ensure safe delivery of chemotherapy, whilst ensuring a quality service that enabled patients to have effective treatment and choice of treatment delivery irrespective of geographical location. It identified inclusion and exclusion criteria, a training package for patients or relatives with an assessment, including risk assessment and manual dexterity. Approval for the initiative was obtained from the Trust clinical standards group. Underpinning the protocol was how patients/ carers access 24 hour specialist advice to manage disease/treatment related problems and education/training was delivered by trained Haematology Chemotherapy nurses. Uptake of patients/relatives to commence training was good. An audit of clinical and patient experience focussing on efficacy, side effects and satisfaction was completed to evaluate the impact. The main challenges were ensuring the training package was user friendly and gaining trust approval. Evaluation demonstrated 100% patient/relative satisfaction and safety, with demonstrable improved patient experience, flexibility and quality of life. Delivery of home sc chemotherapy ensured we reflected current strategic drivers, compliance with the NHS Outcomes Framework, freed capacity in the day unit and provided high job satisfaction for the nursing team. This has led to expansion of the service to other deliveries of sc treatment.

194 The Acute Oncology/Haematology Service (AOHS) C Jenkins1, H Williams2, A Pugh3, H Cosh3, H Rogerson3, E Hopkins1, L Cleaveland1 1 Department of Haematology, Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, Wales; 2 Department of Oncology, Velindre Cancer Centre, Cardiff, Wales, UK; 3Cancer Services, Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, Wales, UK

cancer patients, and to revolutionise the acute care of patients in three main areas: (i) New cancer diagnosis. Identifying patiens sooner with rapid referral to haematologist/oncologist, MDT or palliative care. (ii) Complications of therapy, eg Neutropenic sepsis. (iii) Complications of malignancy, e.g. Spinal Cord Compression. Initial review into the need for the service investigated the number of patients admitted into the hospital in one month. Out of 1490 acute admissions, 123 (8.2%) had a cancer diagnosis. These included 26 new cases of cancer, 59 patients with complications of cancer and 17 patients with malignant complications. In the first three months, 281 patients have been reviewed with a cancer diagnosis. Relevant patients are identified and have earlier haematology/oncology input. Protocols for common acute cancer problems have been developed. Education of staff has reduced unnecessary investigations and reduced length of stay. The proportion of the 29 patients with neutropenic sepsis having correct investigations has improved from 16% to 86%, correct antibiotics from 66% to 100% and door-to-needle time 2.5 m/s, EPR was searched for correspondence with the National Pulmonary Hypertension service. 275 registered adult patients were identified (age 16–82 years). 143 patients had an echocardiogram report available (52%), 98% of these were within the past 5 years. 45 patients had multiple scans, 19 patients had >3 scans. The mean interval between scans was 1.8 years. There was no significant progression in size of TR jet within this time frame. 19 echocardiogram reports omitted TRV measurement. The mean TRV was 2.29 m/s. There was a weak (R = 0.22) but significant (p < 0.05) correlation between increasing TRV and increasing age. 39 patients (27%) had a TRV >2.5 m/s of which only 10 were referred to specialty services. We recommend less frequent echocardiography screening than the national guidelines but better capture of all registered patients. Risk stratification should be considered when planning for frequency of screening scans. Specific measurement of TRV and PASP should be requested and abnormal findings highlighted to the referrer. Selection for confirmatory investigations including referral to specialist services should be optimised. No set age to commence screening could be determined from the data set.

220 The use of transcranial doppler ultrasonography in adult patients with sickle cell disease: a retrospective analysis S Galli1, S Padayachee2, J Howard1 1 Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK; 2Ultrasonic Angiology Department, Guy’s & St. Thomas’ NHS Foundation Trust, London, UK Unlike in children, Transcranial Doppler Ultrasound (TCD) can’t be used to predict stroke risk in adults with Sickle Cell Disease, confounded by an age related decline and lack of an established normal range. Retrospective data was collected on imaging and non-imaging TCD and carotid duplex in 107 adult patients over 10 years and correlated with neurological outcome. Mean age was 35.4 (range 17–79) years. The patients were divided into two groups; Group I (no neurology, n = 95) and Group II (abnormal neurology, stroke preceded TCD/carotid duplex, n = 12).


Poster Session: Transfusion Medicine

TCD normal by STOP Limited scan Asymmetric velocities 25%) and low velocities Asymmetry >25% Low velocities (3 scans. The commonest reasons for ECHO outside of pulmonary hypertension screening were exertional dyspnoea, chest pain, fatigue, hypoxia or dizziness (15), new murmur (6), infective


endocarditis screen (6), pre-operative (4), renal transplant work-up (4), transient ischaemic event/ stroke/ collapse (3), peripheral oedema (2), hypertension or diabetes screen (2), finding of cardiomegaly on other imaging (2). The most common abnormal findings were a dilated left atrium (48%), trace/mild pulmonary regurgitation and trace/mild mitral regurgitation (53%). Left ventricular dilatation and hypertrophy were less common findings (10% and 11% respectively) in our cohort. 27% of patients had a TRV >2.5 m/s. The data set did not examine additional clinical and laboratory correlations. Abnormal ECHO findings including mitral regurgitation and left atrial dilatation in adult sickle patients is not uncommon though the clinical significance of these findings is less clear. We recommend further studies to explore the natural history of sickle cardiac disease and examine the benefit of interventions including transfusion therapy on outcomes.

222 Abstract Withdrawn

223 Performance assessment of DNA diagnostics for the haemoglobinopathies by UKNEQAS(H) BJ Wild, B De la Salle, A Mahon, K Hyde UKNEQAS(H), Watford, UK UKNEQAS(H) is the leading provider of EQA for Haemoglobinopathy analyses in UK laboratories. The individual Schemes target sickle solubility testing, diagnosis and monitoring of affected patients, national antenatal and newborn screening programmes, and, more recently developed, an international scheme for DNA diagnostics. A survey of the DNA pilot scheme participants (35) indicated that all wished the scheme to be continued and that 90% wanted to be performance assessed. With the agreement of the European Molecular Quality Network, UKNEQAS(H) has developed the Scheme into an established programme, which will be submitted for ISO17043 accreditation in 2014, once the performance criteria have been ratified by the National Quality Assurance Advisory Panel for Haematology. Two samples, each containing either alpha, or beta, or both globin gene mutations are distributed every fourth month. Participants undertake mutation analysis and interpret their results using brief clinical details and FBC data provided. Shadow scoring of four successive surveys from July 2012 to July 2013 was undertaken by both a UKNEQAS(H) specialist and an external expert whereby a model answer was agreed at the outset, participants’ results assessed independently and final scores jointly agreed. Outcomes from the shadow scoring have been used to develop performance criteria, with adverse scores given for errors within: failure to participate in the survey, incorrect mutation analysis or interpretation and incorrect or absent recommendations provided. Results of shadow scoring indicate that incorrect mutation analysis occurs infrequently and that most errors arise from unsatisfactory annotation, interpretation and recommendations. The development of performance criteria and the provision of culturally appropriate, educational comment for diverse participants have proved a challenge and were discussed at an international workshop in 2013, with recommendations that guidance notes and websites to use for reference are included in the report to participants.

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Transfusion Medicine

224 Life threatening hepatic complications in sickle cell disease – a case series of 5 patients IN Novitzky-Basso, A Matsou, R Vijapurapu, F Leonforte, E Fogden, S Pancham, C Wright Department of Haematology, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, UK Intrahepatic cholestasis (IHC) and hepatic sequestration (HS) are rare complications of sickle cell disease (SCD) with high mortality rate and are characterised by high bilirubin levels and potentially fatal liver decompensation or a rapidly enlarging liver with a fall in haemoglobin and rising reticulocytosis, respectively. Liver histology reveals intrasinusoindal congestion and sickling, and Kupffer cell hyperplasia with phagocytosis of sickled erythrocytes. Early exchange transfusion may resolve cholestasis, yet no factors are described that predict primary episodes.

Patient 1 Age Genotype Reticulocytes SCD complications

Other liver pathology

24 y HbSS 420 9 109/L Acute chest syndrome (ACS), Chronic Hypoxia Abdominal Surgery, cholecystec-tomy

Table 1 We describe 5 patients (age 24–38 years) with SCD complicated by recurrent (2–5) episodes of IHC (4) and hepatic sequestration (1), and examine risk factors. Four patients had multiple SCD-related and other comorbidities. Three patients were considered to have acute precipitating events (sepsis) for IHC, and another had hepatic malignancy. Other causes of cholestasis were excluded. Patients were treated with red cell exchange (RCE) acutely to achieve HbS 8%), non- responders were excluded. The sample population was subdivided: Group A (n = 27, mean age 33, HU mean duration 7 years): none of these patients showed any progression of proteinuria or eGFR. Group B (n = 9, mean age 46, no response or worsening of uPCR on HU (mean duration 10 years), commenced ACE-I/ ARB): 7/9 showed reduction in proteinuria, 9/9 stable eGFR. Group C [n = 7, mean age 41, ACE-I/ARB (mean duration 3 years) then HU commenced for non renal factors] showed no consistent effect; 2/7 uPCR was increasing prior to addition of HU; it subsequently stabilised in 1 patient and reduced in the other. 3/7 uPCR were stable, 2/7 increased. 7/7 stable eGFR. Group D (n = 1, age 59, Simultaneous HU + ACE-I, duration 12 years): stable uPCR and eGFR. From our data it seems the combination of HU with ACE-I/ARB may offer benefit in adult SCD patients who have persistent proteinuria. HU could be considered as part of treatment options in this group. The potential use of this combination treatment needs further study, ideally in a controlled trial.

ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

Poster Session: Transfusion Medicine

Poster Session Transfusion Medicine 226 Are medical students using hospital patient identification guidelines prior to venepuncture for cross-match samples? J Knight1, J Uprichard2 1 St George’s University, London, UK; 2Department of Haematology, St George’s Hospital, London, UK The Serious Hazards of blood transfusion (SHOT) report showed that between 1996 and 2004 in the UK 1,832 patients received incorrect blood component transfusions (IBCT) resulting in 20 deaths. 79% of all transfusion related adverse events are due to IBCT. Between November 2003 and July 2005 the UK National Patient Safety Agency reported 236 identification related incidents. A self-completed survey was sent to all clinical medical students at St George’s University of London. Of the 906 clinical year students 210 (23%) responded, 131 (62%) of these had taken a cross-match previously, 40 (30%) stated ‘many times’ and a total of 108 (82%) ‘more than once’. Only 54% (71) of Students admitted to having followed the protocol ‘every time’. 21% (7) of students in their first clinical year who responded to the survey had ‘never’ followed the hospital guidelines prior to venepuncture. According to one of the survey questions asked it is clear that students were not ‘fully aware’ of the identification procedure prior to answering the survey; 24% (8) first clinical year, less than 14% (6) second clinical year and 49% (28) of final-year were previously ‘fully aware’ of the hospital patient identification guidelines. All students receive teaching on transfusion safety via Problem Based Learning sessions, lectures and tutorials in first clinical year. From the survey it is not due to student apathy, as 86% said that they would now follow these guidelines in the future, with the remainder stating that they ‘possibly would’ and none stating that they wouldn’t. It is proposed that preclinical students should attend a workshop showing the importance of proper patient identification. Although these learning objectives are taught in the above mentioned sessions, it may be that they are overshadowed by the wider content of those sessions; it is expected that a dedicated session will have more of an impact.

227 Quantifying and analysing use of blood products intra- and post-operatively in relation to primary hip and knee replacement at Basingstoke and North Hampshire Hospital J Cassell, M Ghaffar, N Sargant Department of Haematology & Orthopaedics, Basingstoke and North Hampshire Hospital, UK Basingstoke Hospital (BNHH) performs 450 primary elective knee replacements (TKR) and 350 hip replacements (THR) a year. We aimed to audit transfusion practice and safety for this group of patients. Retrospective data collection, analysing the hospital blood bank system, patient notes and hospital results reporting system. Data was ª 2014 Blackwell Publishing Ltd British Journal of Haematology, 165, (Suppl. 1), 1–103

collected on pre- and post-operative haemoglobin (Hb) levels, transfusion rates, and whether key parameters were linked to increased transfusion. Length of stay and transfusion costs were also evaluated. 187 patients data was analysed, >99% had a pre and post operative Hb check and >90% had a pre-operative G&S. Transfusion rates were 14.5% for THR & 12.5% for TKR. Increased age in THR & pre-operative Hb 160 were transfused. BNHH and British Orthopaedic Association national guidelines were not followed for both documentation and clinical practice. A pre-operative Hb

Abstracts of the 54th Annual Scientific Meeting of the British Society for Haematology, 28-30 April 2014, Birmingham, UK.

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