Background: In vivo T-cell depletion with Alemtuzumab reduces the incidence of acute and chronic graft-versus-host disease (GvHD) and graft failure, yet it results in an increase of opportunistic infections and delayed immune recovery. In addition, Alemtuzumab has considerable anti-lymphoma activity in T-cell neoplasms. We report on a pilot study analysing the safety and feasibility of Alemtuzumab as pre-conditioning prior to reduced intensity conditioning allogeneic stem cell transplantation (RIC-alloSCT) in patients diagnosed with T-cell non-Hodgkin lymphoma. Methods: Six consecutive patients diagnosed with a T-cell lymphoid malignancy underwent RIC-alloSCT from a HLA-identical sibling (n=5) or a matched unrelated donor (n=1). Diagnosis were Angioimmunoblastic T-cell lymphoma (n=3), hepato-splenic gamma-delta T-cell lymphoma (n=1), T/NK cavum lymphoma (n=2) and Sèzary Syndrome (n=1). All received unmanipulated peripheral blood stem cells; At transplantation 2 patients were in CR, and 4 in PR. Median number of prior regimens was 2 (range 2-5). Conditioning regimen included Fludarabine (5 x 30mg/m2) and Melphalan (2 x 70mg/m2) in all cases. GvHD prophylaxis comprised Cyclosporine A and Methotrexate. The pre-conditioning protocol consisted on 6 escalating doses of intravenous Alemtuzumab starting on day -28 (3 mg on day -28, 10 mg on day -26 followed by four doses of 30 mg on days -24 to -17) given 3 times a week (MWF) on an out-patient basis. Results: Five patients received all six doses of Alemtuzumab as planned whereas one patient received only four doses for logistic reasons related to donor availability. Acetaminophen, Hydrocortisone and Dexchlorpheniramine were administered as pre-medication in all cases with no severe infusional reaction observed. There were no delays in proceeding to SCT conditioning and patients develop no infectious complications during the Alemtuzumab - alloSCT interval. All patients engrafted with a median time to neutrophil engraftment of 23 days (range 14-27). Acute skin GvHD (grade I and III) was observed in 2 patients (33.3%), both obtaining a CR with topical and systemic corticosteroids respectively. Two patients developed mild ocular chronic GvHD (one after subsequent infusions of donor lymphocytes - DLI) but none has suffered from extensive chronic GvHD. No opportunistic infection was observed apart from CMV reactivation that developed in 3 out of 4 seropositive patients (no CMV disease was observed). All patients experienced delayed immune reconstitution (CD4 >200/ul) at a median of 321 days (range 229-518). All 4 patients in PR prior to alloSCT achieved a complete remission. Only one patient (diagnosed with Sèzary Syndrome) experienced a relapsed and responded to DLI. With a median follow-up of 42 months, all patients remain alive and in CR. Conclusions: Our preliminary results suggest that administration of Alemtuzumab prior to reduced intensity conditioning is feasible and safe. In addition to providing T-cell depletion, Alemtuzumab may improve the response rate in T-cell lymphoid malignancies without increasing the risk of infectious complications. These results require further validation in larger phase II studies. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Background:Acute myeloid leukemia (AML) is a hematologic neoplasm characterized by the proliferation of bone marrow myeloblasts. Most of patients achieve remission after intensive chemotherapy, although they still relapse. The immune system play an important role in the pathogenesis of AML, where myeloblasts are be able to switch the immunological synapsis disabling the generation of an anti‐tumor response. In this sense, the presence of a greater number of Th17 lymphocytes has been described in AML.Aims:To elucidate whether the myeloblats modulate the Th17 population and more specifically the two Th17 subpopulations: CCR4+ and CCR4‐.Methods:From February 2015 to March 2018, 20 AML diagnosed patients at the CHN and 20 controls were included. Blood samples were collected at diagnosis from AML patients and in controls. We identified by flow cytometry the populations of T helper cells (Th1, Th2, Th17 CCR4‐CCR6+, Th17 CCR4+CCR6+) with the following monoclonal antibodies: CD3 Horizon‐V450, CCR3 FITC, IFNγRβ PE, CCR4 PE‐Cy7, CD4 PerCP, CCR6 APC, CD45 APC‐H7, CCR5 FITC, CXCR3 APC in a FACSCanto II. Serum level of cytokines were also analysed by CBA Human Th1/Th2/Th17 Cytokine Kit (BD) for IL‐2, IL‐4, IL‐6, IL‐10, TNFα, IFNγ, and IL‐17A. We also study the polimorfism of IL‐17A (rs2275913) and IL‐17F (rs763780) by allele discrimination by real‐time PCR. The SPSS software was used to perform Student́s test or Mann‐Whitney test for unpaired samples between patients and controls, and simple linear regression was used to study the association between levels of cytokines and Th subpopulations in AML patients. P < 0,05 was considered to be statistically significant.Results:Patients and controls characteristics were showed in table 1. Th1 and Th2 cells levels did not differ between AML patients and controls. The mean of Th17 CCR4‐CCR6+ cells was significantly higher in AML patients (192 ± 178/μl) than those in controls (67 ± 38/μl), and the difference was statistically significant (p = 0,027). However, Th17 CCR4+CCR6+ cells levels did not differ between groups. We did not find significant differences in the levels of IL‐2, IL‐4, TNFα and IFNγ citokines. Th17 related cytokines were significantly higher in AML patients than in controls and statistically significant. The mean of cytokines (pg/ml) in AML and in controls was 32,79 ± 86,64 vs 0 (p < 0,01), 3,03 ± 2,65 vs 0,24 ± 0,52 (p < 0,001), 14,37 ± 14,12 vs 2,38 ± 4,17 (p = 0,012), for IL‐6, IL‐10 and IL‐17A respectively. No association was find by simple linear regression between the levels of IL‐6, IL‐10 and IL‐17A, and the Th17 subpopulations. There are also no significant differences between the polymorphisms studied of IL‐17 in patients and controls.imageSummary/Conclusion:Th17 subpopulations could play a role in the pathophysiology of AML. The most relevant subpopulation described is the Th17 CCR4+CCR6+. Protumoral and antitumor properties have been described for this subpopulation and associated cytokines (IL‐6, IL‐10 and IL‐17A). However, our results show an increase in the levels of the Th17 CCR4‐CCR6+ subpopulation and in IL‐6, IL‐10 and IL‐17A in untreated AML patients. The lack of association between Th17 subpopulations and cytokines implies that AML generates a protumoral microenvironment, where Th17 subpopulation and associated cytokines are regardless regulated by the tumor. Specifically, the downregulation of CCR4 antigen expression prevents the cells from migrating and having an antitumor effect and the upregulation of IL‐6, IL‐10 and IL‐17A secretion very likely from Th17 CCR4+CCR6+ could contribute to the progression of the disease.

Introduction: Homozygous mutations in the HFE gene are among the causes of iron overload worldwide. Several reports suggest an increased risk of breast cancer (BC) in these patients, although there are controversial evidences on this subject. There is some discussion on the tolerance to some BC adjuvant therapies in these patients regarding aspects like the potential cardiotoxicities. Information on adjuvant hormone therapy in this setting is very limited. Case report: A 65-year- -old woman was treated with segmental resection in the left breast and selective biopsy of the sentinel node in April 2019. Pathology showed an infiltrating ductal carcinoma of 1.2 cm, grade 1, with two negative sentinel nodes. Estrogen receptor was 100%, progesterone receptor was 20%, Her2/neu was 1+, and Ki-67 was 15%. A previous diagnosis of hemochromatosis was done in October 2018 with a high transferrin saturation and a genetic analysis disclosing a homozygous C282Y mutation in the HFE gene. Regular phlebotomies every 3 months were scheduled for the treatment of the iron overload. Several points were considered for the selection of the adjuvant hormone therapy. Articular damage is a common complication of hemochromatosis. In fact, a hip prosthesis was implanted in 2018 for our patient with severe coxarthrosis. There was some risk of further articular impairment with aromatase inhibitors (AI). Furthermore, AI may have an androgenic effect, with some effect on the red cell mass. On the contrary, tamoxifen may increase the risk of porphyria crises in patients with hemochromatosis. We selected letrozole as adjuvant therapy, with good articular tolerance and fair hematological control after nearly 3 years of follow-up. Conclusion: Although homozygous HFE mutations may increase the risk of some adverse events related to BC adjuvant hormone therapy, the tolerance to letrozole in our patients has been very good, without raising further concerns.

The incidence and outcome of neurological complications of patients undergoing allogeneic stem cell transplantation (alloSCT) remains to be established. We have retrospectively studied all transplants (n = 88) performed over a five year period (2009-2014) in our transplant center with the aim of characterizing all types of neurological events. For the purpose of this study, neurological complications were divided between early (within the first 100 days of alloSCT) and late (from 3 months to 3 years after alloSCT) complications. The overall incidence of neurological complications was 21% (19 episodes in 19 patients). Median age at alloSCT for patients developing neurological complications was 39 years (range 26-65) with 73% of patients (n=13) being male. Diagnosis included acute leukemia (n=9), plasma cell dyscrasia (n=4) and a variety of other hematologic malignancies (Mantle cell lymphoma, chronic lymphocytic leukemia, chronic myelomonocytic leukemia, aplastic anemia, myelofibrosis, myelodysplastic syndrome, one each). At time of alloSCT, 11 patients (58%) were in CR, 3 (15%) in PR, 2 (11%) untreated, 2 (11%) with progressive disease and one patient with refractory leukemia. No patient had developed CNS involvement by their disease prior to alloSCT and 3 patients (15%) had a previous history of CNS events (stroke, subarachnoid hemorrhage and intraparenchymal hemorrhage). Conditioning was myeloablative in 8 patients (42%) and reduced intensity in 11 (58%). Over 95% of transplants were performed using peripheral blood stem cells from HLA-identical siblings (n=10, 53%) or matched unrelated donors (n=9, 47%). GvHD prophylaxis included Cyclosporine and Methotrexate in all cases plus in vivo T-cell depletion with Alemtuzumab (n=8) or ATG (n=1) in all unrelated donor transplants. The median interval between alloSCT and development of a neurological complication was 92 days (range 0-970). A total of 11 (57%) cases were classified as early compared with 8 (43%) neurological events that occurred beyond 3 months of alloSCT. All but one case of peripheral neuropathy were CNS complications. We further classified the neurological complications as: 1) Infectious (n=5; HHV-6 limbic encephalitis, VZV meningo-encephalitis, rhino-cerebral mucormycosis, toxoplasma chorioretinitis and Staph. Aureus invasive rhinosinusitis); 2) Encephalopathic (n=4; one Voriconazole associated; three other metabolic causes); 3) Vascular (n=2; pontine ischemia, intracranial hemorrhage); 4) Epileptic (n=2) and 5) Other (n=6, including one case each of reversible posterior leucoencephalopathy, Cyclosporine associated papilledema, optic neuritis, idiopathic leucoencephalopathy, immune transverse myelitis and drug-related polyneuropathy). Five patients (26%) died as a direct consequence of their neurological complication. Two more patients died of additional causes resulting in an associated mortality of 37% (8% overall mortality for all transplants). The Kaplan-Mayer estimated overall survival at three years for patients that develop neurological complications was 62% (similar to the overall transplant population) with a median follow up of 37 months. In summary, the incidence of neurological complications in our series was significant (21%), with a heterogeneous pathogenesis and associated with a high mortality (37% amongst patients that developed any neurological event). These data support the need for efforts directed towards the prevention of neurological complications in patients undergoing alloSCT.TableNeurogical ComplicationDescriptionTimingStatus InfectiousHHV-6 lymbic encephalitisEarlyDead*VZV meningo-encephalitisEarlyDead *Rhino-cerebral mucormycosisLateAliveToxoplasma chorioretinitisLateAliveStaph. Aureus invasive rhinosinusitisLateAlive EncephalopathicVoriconazole-relatedEarlyAliveMetabolicEarlyDeadMetabolicLateAliveMetabolicLateAlive VascularPontine ischemiaEarlyDead *Intracranial hemorrhageEarlyDead * EpilepticTonico-Clonic seizureEarlyAliveTonico-Clonic seizureEarlyAlive OtherReversible posterior leucoencephalopathyEarlyDead*Cyclosporine-associated papilledemaLateAliveOptic neuritisLateAliveIdiopathic leucoencephalopathyLateDeadImmune transverse myelitisLateAliveDrug-related polyneuropathyLateAlive * Patients that died as a direct consequence of the neurological complication Disclosures No relevant conflicts of interest to declare.