Nine plasma cell myeloma patients spontaneously developed histologically proven autologous graft-versus-host disease (GVHD) limited predominantly to the gastrointestinal tract within 1 month of initial autologous hematopoietic cell transplantation (AHCT) using high-dose melphalan conditioning. All recipients responded promptly to systemic and nonabsorbable oral corticosteroid therapy. All patients previously received systemic therapy with thalidomide, lenalidomide, or bortezomib before AHCT. Using enzymatic amplification staining-enhanced flow cytometry, we evaluated expression of selected transcription regulators, pathway molecules, and surface receptors on samples of the infused hematopoietic cell grafts. We demonstrated significantly enhanced expression of GATA-2, CD130, and CXCR4 on CD34(+) hematopoietic progenitor cells of affected patients compared with 42 unaffected AHCT controls. These 3 overexpressed markers have not been previously implicated in autologous GVHD. Although we did not specifically evaluate T cells, we postulate that exposure over time to the various immunomodulating therapies used for induction treatment affected not only the CD34(+) cells but also T cells or relevant T cell subpopulations capable of mediating GVHD. After infusion, the affected hematopoietic progenitor cells then encounter a host that has been further altered by the high-dose melphalan preparative regimen; such a situation leads to the syndrome. These surface markers could be used to develop a model to predict development of this syndrome. Autologous GVHD potentially is a serious complication of AHCT and should be considered in plasma cell myeloma patients with otherwise unexplained gastrointestinal symptoms in the immediate post-AHCT period. Prompt recognition of this condition and protracted treatment with nonabsorbable or systemic corticosteroids or the combination may lead to resolution.

Plasma cell myeloma, characterized by clonally aberrant plasma cells that produce abnormal monoclonal Igs, is the most common indication for autologous hematopoietic progenitor cell transplantation (AHPCT) in North America. We observed appearance of new monoclonal gammopathies different from the original protein in the post-AHPCT setting and termed this condition 'secondary MGUS' (monoclonal gammopathy of undetermined significance). Hence, we performed a retrospective, single institution review of serum protein electrophoresis/immunofixation electrophoresis data in 92 AHPCT recipients from the period 2000 --2009. In all, 22 of 92 patients (24%) undergoing AHPCT met criteria for secondary MGUS. Contrary to previous studies, often referred to as 'abnormal protein banding,' we did not observe this condition as a favorable prognostic indicator in affected patients when compared with the control group (P ¼ 0.686). However, we did note that a subgroup of the study cohort who developed secondary MGUS after a prolonged latency (410 months) had an improved median OS compared with the remainder of the study cohort (75 months vs 41 months, P ¼ 0.005). As there have been significant advancements in understanding the pathobiology and clinical significance of MGUS, we believe that secondary MGUS merits dedication of resources for investigation to determine its true clinical relevance, prognostic value and pathophysiology.

The combination of sunitinb (37.5 mg orally daily) + paclitaxel (90 mg/m intravenously on days 1, 8, 15 every 4 weeks) was examined in patients with advanced esophageal or gastroesophageal junction cancer, and progression-free survival (PFS) was compared to that of historical controls. The end points included response rate, overall survival, and toxicities. Twenty-eight patients were enrolled at six centers. Median age was 59.5 years. The 24-week PFS rate was 25% (90% confidence interval [CI], 12-42%). Three (11%) of 23 evaluable patients had a response (1 complete response and 2 partial response) (90% CI, 3-25%). Median overall survival was 228 days (90% CI, 140-283 days). Grade 3/4 toxicities included leukopenia/neutropenia (25%), anemia (18%), fatigue (11%), and hemorrhage (11%). There were four grade 5 toxicities including upper gastrointestinal hemorrhage (n = 2), gastrointestinal/esophageal fistula (n = 1), and unexplained death (n = 1). In our study, we found that sunitinib + paclitaxel in patients with advanced esophageal or gastroesophageal junction cancer had a 24-week PFS no better than the PFS of historical controls. The combination also had a high rate of serious toxicities and will not be pursued.

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1296 New monoclonal gammopathies (secondary MGUS) sometimes appear after autologous hematopoietic progenitor cell transplantation (AHPCT) for multiple myeloma (MM). While the pathophysiology and prognostic significance of this phenomenon is incompletely defined, previously published series hypothesize that this phenomenon is due to recapitulation of early B-cell ontogeny, and suggest that it confers a more favorable prognosis.[1-3] We retrospectively reviewed immunoelectrophoretic data on MM patients who underwent AHPCT at University Hospitals Case Medical Center from January 2000 - May 2009, searching for development of secondary MGUS after AHPCT. Secondary MGUS was defined as the occurrence of a monoclonal gammopathy of a different isotype (i.e. change in either the heavy chain, light chain, or both) than the patient's previously identified MM-associated monoclonal gammopathy at any time point after AHPCT. We identified 89 MM patients who underwent AHPCT during that period. All patients received pre-transplant conditioning with melphalan 200 mg/m2 +/− TBI. Eighteen patients (20%) subsequently developed one or more secondary MGUS. There was no significant difference in age, gender, and stage of disease between patients who developed a secondary MGUS and those who did not (p=0.88). No patients who developed secondary MGUS had light-chain only disease at diagnosis. Nine patients developed a single new isotype, nine patients developed two or more new isotypes. The maximum number of new isotypes of monoclonal gammopathy in a single patient was six. Time to development of a secondary MGUS (latency) was highly variable, from 1.9 to 63.9 months, with a median of 10.5 months. One-third (33.3%) of patients who developed secondary MGUS developed their new isotype or isotypes more than a year after AHPCT. Amongst patients with secondary MGUS, the number of secondary isotypes was predictive of overall survival (OS). The hazard of death was 2.04 times higher with one increase of isotype (p = 0.016). There was a statistically significant association between latency to developing secondary MGUS and OS; for patients with latency ≤10 months, the median OS was 38 months, compared to 74 months for those with latency > 10 months (p = 0.023). Secondary MGUS is a phenomenon observed in a substantial subset of patients undergoing AHPCT for MM. Our study demonstrates that this phenomenon cannot be entirely attributed to immune reconstitution, as previously postulated, as one-third of patients developed secondary MGUS a year or more after AHPCT. While selection bias may explain why patients who have longer latency to secondary MGUS have significantly better overall survival, further study is needed to clarify predictors of developing secondary MGUS and the pathophysiology underlying this phenomenon. Figure 1 Overall survival by latency (cases with secondary MGUS only) Figure 1. Overall survival by latency (cases with secondary MGUS only) 1. Maisnar, V., et al., Isotype class switching after transplantation in multiple myeloma. Neoplasma, 2007. 54(3): p.225-8. 2. Zent, C.S., et al., Oligoclonal protein bands and Ig isotype switching in multiple myeloma treated with high-dose therapy and hematopoietic cell transplantation. Blood, 1998. 91(9): p.3518-23. 3. Mitus, A.J., et al., Monoclonal and oligoclonal gammopathy after bone marrow transplantation. Blood, 1989. 74(8): p. 2764-8. Disclosures: No relevant conflicts of interest to declare.