Decitabine is a hypomethylating agent that irreversibly inhibits DNA methyltransferase I inducing leukemic differentiation and re-expression of epigenetically silenced putative tumor antigens. We assessed safety and efficacy of decitabine maintenance after allogeneic transplantation for acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). Decitabine maintenance may help eradicate minimal residual disease, decrease the incidence of graft-versus-host disease (GVHD) and facilitate a graft-versus-leukemia effect by enhancing the effect of T-regulatory lymphocytes. Patients with AML/MDS in complete remission (CR) after allotransplant started decitabine between day +50 and +100. We investigated 4 decitabine doses in cohorts of 4 patients: 5, 7.5, 10 and 15 mg/m2/day x 5 days every 6 weeks, for maximum 8 cycles. The Maximum Tolerated Dose (MTD) was defined as the maximum dose at which ≤25% of people experience dose limiting toxicities (DLT) during the 1st cycle of treatment. Twenty-four patients were enrolled and 22 were evaluable. All 4 dose-levels were completed and no MTD was reached. Overall, decitabine maintenance was well tolerated. Grade 3/4 hematological toxicities were experienced by 75% of patients, including all patients treated at the highest dose-level. Nine patients completed all 8 cycles and 8 of them remain in CR. Nine patients have died due to: relapse (n=4), infectious complications (n=3) and GVHD (n=2). Most occurrences of acute GVHD were mild and resolved without interruption of treatment; one patient died of acute gut GVHD. Decitabine maintenance did not clearly impact the rate of chronic GVHD. Although there was a trend of increased FOXP3 expression, results were not statistically significant. In conclusion, decitabine maintenance is associated with acceptable toxicities when given in post-allotransplant setting. Although MTD was not reached, the dose of 10 mg/m2 for 5 days every 6 weeks appeared to be the optimal dose rather than 15 mg/m2, where most hematological toxicities occurred.

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Population-based studies suggest that black patients with multiple myeloma (MM) have a higher mortality rate than white patients; however, other studies suggest this disparity is related to socioeconomic status (SES) rather than race. To provide clarity on this topic, we reviewed 562 patients diagnosed with MM at our institution. Patients with high-SES had a median OS of 62.8 months (mos) (95% CI 43.1–82.6 mos), compared to 53.7 mos (45.2–62.3 mos) and 48.6 mos (40.4–56.8 mos) for the middle and low-SES, respectively (p =0.015). After controlling for race, age, year of diagnosis, severity of comorbidities, stem cell transplant utilization, and insurance provider, patients with low-SES had a 54 percent increase in mortality rate relative to patients with high-SES. To support our findings, we performed a similar analysis of 45,505 patients with MM from the Surveillance Epidemiology and End Results-18 (SEER) database. Low-SES is independently associated with poorer OS in MM.

Previous studies suggest that diabetes impairs hematopoietic stem cell (HSC) mobilization in response to granulocyte colony-stimulating factor (G-CSF). In this study, we tested whether the CXCR4 antagonist plerixafor, differently from G-CSF, is effective in mobilizing HSCs in patients with diabetes. In a prospective study, individuals with and without diabetes (n = 10/group) were administered plerixafor to compare CD34+ HSC mobilization; plerixafor was equally able to mobilize CD34+ HSCs in the two groups, whereas in historical data, G-CSF was less effective in patients with diabetes. In a retrospective autologous transplantation study conducted on 706 patients, diabetes was associated with poorer mobilization in patients who received G-CSF with/without chemotherapy, whereas it was not in patients who received G-CSF plus plerixafor. Similarly in an allogeneic transplantation study (n = 335), diabetes was associated with poorer mobilization in patients who received G-CSF. Patients with diabetes who received G-CSF without plerixafor had a lower probability of reaching >50/μL CD34+ HSCs, independent from confounding variables. In conclusion, diabetes negatively impacted HSC mobilization after G-CSF with or without chemotherapy but had no effect on mobilization induced by G-CSF with plerixafor. This finding has major implications for the care of patients with diabetes undergoing stem cell mobilization and transplantation and for the vascular regenerative potential of bone marrow stem cells.

We conducted a phase 1 study using midostaurin (25 mg or 50 mg orally twice daily), all-trans retinoic acid (ATRA) and CLAG chemotherapy to target multiple pathways in relapsed/refractory AML. 10 patients received the combination and no dose limiting toxicities were observed. Two patients (22%) achieved complete remission and 1 patient (11%) achieved complete remission with incomplete count recovery. Pharmacokinetic data showed that the 25 mg dosing of midostaurin achieved therapeutic levels with no significant interaction between midostaurin and ATRA. With evidence of activity of ATRA in NPM1 mutated AML and midostaurin in FLT3-ITD AML this combination warrants further investigation.