ACOR Leukemia Links Home About This Site Contact
 
Search
 Site Contents:

• Types of Leukemia
• Living with Leukemia
• Transplants
• Blood & Pathology
• Survivor Stories
• Medical & Cancer Links
• Internet Support Email Lists
• Leukemia Links Site Map
In Loving Memory of Barbara GrannyBarb Lackritz
A report on the 2004 Tandem BMT Meetings in Orlando, Florida

By Arthur Flatau (flataua@acm.org)

Table of Contents

Introduction

The combined annual meetings of the American Society for Blood and Marrow Transplantation (ASBMT) and the International Bone Marrow Transplant Registry/Autologous Blood and Marrow Transplant Registry (IBMTR/ABMTR), -- aka the Tandem BMT meeting -- were held February 13 - February 17, 2004 in Orlando.

There are some reports on other parts of this meeting that are available on the web:

The National Marrow Donor Program (NMDP), Research and Publications committee met during this meeting so I was able to attend some of the other sessions. Below is a summary of the talks and presentations that I attended. Since I am not a medical doctor or researcher in the field, it is possible; in fact quite likely that I have misunderstood or misinterpreted some of what was said. In addition, this is based on my notes at the time and I may not have been able to read them or remember correctly what was said. This time most of the sessions that I attended were largely on clinical aspects of transplants. I did not see much talk of mice, which is good because I generally stop understanding at that point and often tend to fall asleep.  There are some sessions or talks below where I have not reported much or anything. This usually meant that I did not understand enough of the important points of the talk to say anything useful. Please send me an e-mail (flataua@acm.org) if you have questions, comments, notice a typo or just think that this was useful to you. As in any field that is undergoing a lot of changes the terminology that was used was sometimes inconsistent. I will try to use consistent terminology and acronyms throughout this report. I will use NST to refer to non-myeloablative stem cell transplants. At the meeting, the term reduced intensity conditioning (RIC) transplants was used to refer to transplants where the preparative regimen was not as intense as the usual regimen, but was still sufficiently intense enough that it would not be given with out a transplant. A true non-myeloablative regimen could be given without a transplant.   The preparative regimen in a RIC transplant still has significant  anti-cancer effects, but can be tolerated by older and less stable/sicker patients.

I use HSCT to stand for Hematopoetic Stem Cell Transplant as a generic name to refer to some kind of stem cell transplant, where the source of stem cells might be bone marrow, peripheral blood, or cord blood. I will use URD for unrelated donor to mean a transplant with a Matched Unrelated Donor (MUD) or a mismatched Unrelated Donor (which also would be abbreviated MUD, I guess). Of course, GVHD stands for Graft versus Host Disease. KIR which stands for Killer cell Immunoglobulin-like Receptor is a factor that appears to be important in predicting the likelihood of developing GVHD when transplanted with stem cells from a particular donor. KIR also shows some promise in preventing relapse, presumably from a graft versus leukemia (GVL) effect. Some other acronyms that are used:

BuBusulfan
CyCytoxan also called Cyclophosphamide
PBSCTPeripheral Blood Stem Cell Transplant
TBITotal Body Irradiation
DLIDonor Leukocyte Infusion
CR1First Complete Remission
CR2Second Complete Remission
TRMTransplant Related Mortality
DFSDisease Free Survival
EFSEvent Free Survival
OSOverall Survival

Friday, February 13, 2004

IBMTR/ABMTR Late Effects Working Committee Meeting

7:00 AM - 8:30 AM
Co-Chairs: Gerard Socie, MD, PhD, Hopital Saint-Louis;
John R. Wingard, MD, University of Florida;

I got to this session a bit late, as I had to register first.

Michelle Bishop from the University of Florida reported on a study of long-term survivors of BMT as well as their spouses. The survivors were a median of 7 years post transplant.  Not surprisingly, patients had more fatigue and sexual problems compared to controls. However, it was surprising that this was true of spouses as well.

Several groups (from ASBMT, Europeans) are trying to put together some kind of consensus document on how to follow-up long-term survivors of BMT.  This includes, what kind of vaccinations to give and not to give, what kind of routine tests to run, what problems to be on the look out for.  The document would be intended for hematologists/oncologists (not transplanters) and primary care physicians to guide them in follow-up care.

Hematopoietic Stem Cell Proliferation and Expansion

TANDEM PLENARY 01, 8:30 AM - 10:00 AM
Chair: Stephen G. Emerson, MD, PhD, University of Pennsylvania;

Genes that Control Stem Cell Proliferation and Differentiation - Stephen G. Emerson, MD, PhD, University of Pennsylvania;

BMI is a Critical Regulator of Stem Cell Self-Renewal - Guy Sauvageau, MD, PhD, Institut de Recherches;

Osteoblasts Regulate the Stem Cell Niche: Definition and Manipulation to Alter Transplant Outcomes - David T. Scadden, MD, Massachusetts General Hospital.

This session was on how to expand stem cells in vitro and what factors regulate stem cell growth. Stem cells grow well in the marrow but not in other parts of the body.  It appears that the ionic calcium in the bone helps to regulate stem cell growth.

Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

TANDEM SESSION, 10:30 AM - 12:00 PM
Chair: Karl Blume, MD, FACP, Stanford University;

Gene Expression Profiling in Acute Lymphoblastic Leukemia -- Bernard Fine, MD, PhD, Stanford University;

Bernard Fine described what a DNA micro array is. It is a about the size of a microscope slide and contains up to 40,000 different pieces of DNA. Using RNA marked with fluorescent dye, it is possible to see which spots on the microbars light up to determine which genes are present.

If you test genes that are different in different subtypes of leukemia (compared to non-leukemic cells) there is a high probability that you will find differences related just by chance. If you set a probability of 0.001 (which is very significant) that a gene that is present in leukemia cells and not in non-leukemic cells, you will find 25 genes that are different by chance in an array of 25,000 genes. This makes determining what is significant more difficult.

Yeoh et. al. [1] tested about 210 genes and can distinguish between subtypes of ALL with this technique with about 95% accuracy.

Kohlman, et. al. [2] used the same technique and was able to correctly identify 94% of patient's subtypes.

Gene expression profiling can also be used to characterize patient response to treatment.  It can distinguish between high-risk minimal residual disease (MRD) in pediatric ALL versus standard risk MRD. 

Mosquera-Caro et. al. [3] at ASH, 2003 identified a new gene, that they named OPAL1 for Outcome Predictor in Acute Leukemia 1. They tested 254 pediatric ALL patients, 87% of the patients with high expression of this gene had a long term remission, while only 32% of patients with a low level of expression of OPAL1 obtained a long term remission. There were also more induction failures in the patients with a low level of OPAL1.

In the future it may be possible to tailor treatments based on gene expression and develop new drugs and new targets for new drugs.

A Comparison of Two Myeloablative Regimens for Allogeneic Hematopoietic Cell Transplantation for Patients with Acute Lymphoblastic Leukemia - David I. Marks, MD, Bristol BMT Unit;

Compared two preparative regimens in treating patients with ALL.  The first used VP-16 (etopside) and Total Body Irradiation (TBI), this was developed and is used at City of Hope and Stanford.  The comparison was to the standard regimen of Cytoxan and TBI.

The Graft versus Leukemia (GVL) effect does not appear to be as strong in ALL compared to CML or Non-Hodgkin's Lymphoma (NHL). GVHD does protect ALL patients from relapse but Donor Leukocyte Infusions (DLI) does not work very well. This may be because DLI only works when there is a low level of disease.

The study compared 427 patients with ALL from the IBMTR with 75 from City of Hope and Stanford. All patients had matched sibling donors and were in first (CR1) or second (CR2) complete remission.  They received either bone marrow or peripheral blood stem cells (PBSC).

There was no evidence of a center effect, i.e. that survival was better at different centers (most of the VP-16 patients were from City of Hope or Stanford).  There was slightly lower (but not statistically significant) transplant related mortality (TRM) with the VP-16 regimen. However contrary to previous studies the relapse rate was similar in both arms.

When doing the analysis, the dose of TBI was important. Looking at four different groups:

Cytoxan/TBI > 13 gray (81 patients)
Cytoxan/TBI < 13 gray (217 patients)
VP-16/TBI < 13 gray (53 patients)
VP-16/TBI > 13 gray (151 patients)

There was no significant different in TRM, although there was a trend towards higher TRM with higher doses of radiation. Patients who received PBSC had higher TRM than bone marrow recipients.

Patients who received more then 13 gray of TBI had a 40% reduced rate of relapse.  Leukemia Free Survival (LFS) with standard Cy/TBI< 13 had inferior survival to other groups.  LFS was better with bone marrow compared to PBSC.  Overall Survival (OS) was best with the higher doses of radiation.

In Summary, conditioning is important. The standard conditioning of Cy/TBI<13 had the poorest outcome.  This study did not show that VP-16 was superior to Cytoxan, a randomized study is necessary to compare them.

Treatment Options for Adult Patients with Acute Lymphoblastic Leukemia - Frederick R. Applebaum, MD, Fred Hutchinson Cancer Center.

There are many different treatments for adult ALL. The response to steroids (prednisone, usually sometimes dexamethasone) in induction for ALL can predict the outcome, however it does not improve the survival of patients.

Many chemo agents have been used, Cyclophosphamide, Anthracyclines, Asparaginase is used frequently although there is little randomized data on its use.  The use of growth factors (G-CSF, Neupogen) reduces the period of neutropenia and there is a trend towards improved survival. Various studies have show induction remission rates of between 82 and 91%.

Chemotherapy for consolidation therapy has 28-38% long term (3-9 year) Event Free Survival (EFS) using various different regimens. Risk factors for relapse include cytogenetics, high white blood count at diagnosis and the subtype of ALL.

Allogeneic BMT has about a 50% Leukemia Free Survival (LFS) using HLA matched sibling donors.  A French study [LALA 1987] of allogeneic BMT in patients less then 40 years of age showed a 10 year survival of 46% with 31% survival for patients treated with chemo. High-risk patients had 44% survival with all-BMT versus 11% with chemo alone.  For standard risk patients there was no difference.  There was no difference between patients who received auto transplants versus chemo (in both high risk and standard risks groups).

A British (MRC)/ECOG study of Philadelphia chromosome (PH-) negative ALL patients younger then 50 with matched sibling donors, allogeneic BMT had 54% Overall Survival (OS) at 5 years versus  chemo or autologous BMT with 43% OS at 5 years. Standard risk patients had 67% OS with allo-BMT versus 53% with chemo; in high-risk patients OS was 48% with a transplant versus 34% with chemo. However this does not compare chemo and then a transplant after a relapse. In young adults (16-21 years old), pediatric (CCG) protocols have a 6 year EFS of 65% with chemo alone.  However a CALGB study with similar drugs had only a 38% EFS at 6 years.

Why do older adults (over 50) do worse? Is it a poorer response to drugs? or perhaps the stem cells need to be replaced.

Gleevec may be useful in Philadelphia Chromosome positive ALL.[4]

For relapsed ALL, the only potentially curative therapy is allogeneic transplant.

New Drugs, include Rituxan and Campath. 5060 (?? I am not sure what that is) is promising for T-cell ALL but not B-cell.

It seems to be important to identify patients who can benefit from additional chemotherapy and transplantation when there is minimal residual disease (MRD).

NMDP Research & Publications Committee Meeting

12:00 PM - 1:30 PM

Roberta King of NMDP reported on the corrective action plan (CAP) to obtain informed consent from patients who received transplants through NMDP since May, 2003.  85% of the patients have responded, the remaining 15% are being contacted directly.  Data collection is resuming subject to individual institutions giving approval (from their Institutional Review Board).

The second major item discussed was that the NDMP and the International Bone Marrow Transplant Registry (IBMTR) will combine their research arms. The hope is that this should remove a barrier to research

Medical Decision-Making: What Do We Need To Know To Make Tough Choices?

TANDEM SESSION, 2:00 PM -  3:30 PM
Co-Chairs: Stephanie Lee, MD, Dana-Farber Cancer Institute;
Corey Cutler, MD, SRCPC, Dana-Farber Cancer Institute.

This session presented an approach to make tough medical decisions. As an illustration it used the choice in a newly diagnosed CML patient of using Gleevec or of having a transplant. There were 3 fictitious patients used as examples, a 30 year old with low risk (according to Sokal score) CML, a 40 year old with intermediate risk and a 50 year old with high risk disease, all with matched sibling donors.  The most interesting thing about this session was that in a room full of transplant physicians, virtually all would have recommended using Gleevec first and reserved a transplant for those patients who progress.

In low risk CML patients, 90% obtain a complete remission (hematological, I believe) with Gleevec after 30 months. In high-risk patients, 70% obtain a remission. About 5% (per year??) will move to an accelerated or blastic phase.

There are two big questions.  What will happen to CML patients on Gleevec over the long term? Will about 5% a year progress as has happened over the first 4 years or so of use of Gleevec? or will the rate of progression level off or accelerate?

The other big question is how will patients do who go to transplant after extended use of Gleevec? Patients on busulfan did worse. Patients on Interferon did about the same (different studies had different results). Will patients on Gleevec do worse when they proceed to transplant?  It is not possible to rule out that they might do better, because Gleevec has reduced the tumor burden.

TANDEM ORAL ABSTRACTS: Session 1 -- Allogeneic

4:00 PM - 5:30 PM
Moderator: Alexandra H. Filipovich.

This session was 5 talks/abstracts. The abstracts are online with links below.

Sirolimus and tacrolimus without methotrexate as graft-vs.-host disease prophylaxis after matched, related peripheral blood stem cell transplantation: Low transplant related morbidity and excellent GVHD control, C. Cutler, et. al

Using Tacrolimus and Siroliumus instead of methotrexate. 37 patients, 20 with unfavorable risk. The hope was to reduce mucositis without methotrexate and found that 47% of patients did not require TPN and overall survival was 72%.  Siroliumus and Tacrolimus is safe and possibly more effective then standard GVHD prophylaxis.

Allogeneic stem cell transplantation (SCT) for patients (pts) with thalassemia major: An inferior outcome when antithymocyte globlins (ATG) is added to the conditioning regimen, A. Al-Jefri, et.al.

This report from Saudi Arabia compared 24 patients (Group A) with Thalassemia Major treated from January, 1998 through March, 2001 who had a sibling transplant with Busulfan and Cytoxan conditioning plus ATG (antithymocyte globlins).  These were compared with 19 patients (Group B) who were transplanted without ATG from June 2001 through March 2003.  4 patients in Group A had severe acute GVHD versus only 1 in Group B. Overall Survival was 86% at 5 years versus 100% at 2 years without ATG.  There was secondary graft failure in 5 patients in group A.

Marrow versus peripheral blood for geno-identical allogeneic stem cell transplantation in acute myelocytic leukaemia: Influence of the dose and the source of stem cells; better outcome with rich marrow. On behalf of the acute leukaemia working party (ALWP) of the European cooperative group for blood and marrow transplantation (EBMT), N.C. Gorin, et. al.

A larger dose of bone marrow cells resulted in lower Transplant Related Mortality (TRM) and better Leukemia Free Survival (LFS)  than  PBSC or bone marrow with lower doses.  A higher does of bone marrow induces lower TRM and lower relapse [5, 6].

The use of peripheral blood leads to faster engraftment and faster platelet recovery.  A higher dose of bone marrow seems a little better than  a lower dose. Leukemia Free Survival was 72% with high dose bone marrow, 54% with low does and 61% with peripheral blood.

Long-term follow up after non-myeloablative allogeneic stem cell transplantation for renal cell carcinoma: The University of Chicago experience, A.S. Artz, et. al.

Four patients out of 18 who underwent non-myeloablative hematopoietic allogeneic stem cell transplant (NST) at University of Chicago for Renal Cell carcinoma had a partial response. All 4 were alive 900 - 1405 days after transplant. 6 patients died before day 100. Patients with lower performance status and anemia at the time of diagnosis had poorer responses and a higher chance of early death.

Allogeneic transplantation for mantle cell lymphoma, A. Bence-Bruckler

Mantle cell lymphoma (MCL) has a median survival of less then 3 years.  37 patients with MCL were given allogeneic transplants. They had had a median of 2 prior treatments. There were 12 deaths by day 100, 2 from lymphoma.  39% of the patients died from transplant related complications. The 3-year Event Free Survival (EFS) was 39% and Overall Survival (OS) was 45%.  The EBMT has over 40% survival at 3 years with 160 patients.

NMDP Research & Publications Open Meeting

5:30 PM - 7:00 PM

There were a bunch of proposals to the RAP committee as new research had been delayed because of the consent problem.  Four researchers gave talks about their proposals.

There were several proposals to look at differences in outcome in different ethnic groups.  Scott Baker (University of Minnesota) gave a presentation. His hypothesis was that Overall Survival (OS) and Disease Free Survival would be similar in Caucasians and other ethnic groups.  A study from the IBMTR for the years 1995-1999 showed that Hispanics had poorer OS at 1 year and 3 years. A study from 1999-2000 again found that Hispanics had a higher TRM and graft failure.

Donna Wall (San Antonio) wants to compare cord blood transplants with Matched Unrelated Donor (MUD) transplants.  Since cord blood is immediately available this means that there may be more patients with rapidly progressive disease compared to MUD.

Saturday, February 14, 2004

CMV in Stem Cell Transplantation: New Insights and Options

Symposium 03 - Breakfast Symposium,
6:30 AM - 8:15 AM
Chair: Michael Boeckh

This session was an overview on current strategies in reducing CMV infections and treating them.  Although CMV is much less of a problem now than  it was before the introduction of Ganciclovir it still causes some deaths.

Toward Eliminating the Impact of CMV on Mortality in Stem Cell Transplantation: Accomplishments and Remaining Challenges - Michael Boeckh;

The direct effects of CMV (CMV pneumonia, gastrointestinal disease) have largely been eliminated. However several studies have shown that CMV+ patients and CMV- negative patients with CMV+ donors have somewhat poorer survival compared to CMV- patients with CMV- donors.

Preemptive Therapy with IV Ganciclovir Versus Valganciclovir: PK and Preliminary Safety and Efficacy Data - Hermann Einsele;

Valganciclovir (VGCV) is an oral version of ganciclovir. It appears to be absorbed well in HSCT patients despite problems with absorption of oral drugs in HSCT patients (because of the effects of the high-dose chemo and radiation as well as GVHD). It may be useful in preventing CMV in HSCT patients.

Prevention of Transfusion-Transmitted CMV: Current and Future Strategies - W. Garrett Nichols.

Most HSCT patients who are CMV- receive CMV- blood products, to prevent transmission of CMV.  However it is expensive to maintain a supply of CMV- blood and some communities have a high incidence of CMV and therefore CMV- blood is not always available.  One strategy is to use filters to reduce CMV. One study at Fred Hutchinson showed that this was equivalent to using CMV- donors [7].

However a later study showed an increase risk of CMV infection [8].

Immunogenetics of Hematopoietic Cell Transplantation

TANDEM PLENARY 02, 8:30 AM -  10:00 AM
Chair: Effie Petersdorf, MD, Fred Hutchinson Cancer Center;

Genetics of the MHC - Mary Carrington, PhD, NCI Frederick Cancer Research Center;

Caucasians with HLA type of B-35 progress from HIV+ to AIDS more rapidly  than  other patients. Patients with 2 copies of B-35 (homozygous) progress much more quickly. Patients who are heterozygous (only 1 copy of B-35) do not progress as rapidly.  A single amino acid difference in a gene can have a dramatic effect in disease resistance.

There may be differences in KIR haplotypes in different populations because of difference in disease frequency encountered in different populations.  This may play a significant role in resistance and susceptibility to various diseases (infections, cancer, auto-immune diseases).

HLA Matching in Unrelated HCT - Effie Petersdorf, MD, Fred Hutchinson Cancer Center;

The goal is to increase safety and efficacy as well as availability with unrelated donors.  GVHD is increased and survival is decreased. The risk is increased for a single allele mismatch at HLA-A, B, C, DRB1 and DQB1. Multiple mismatches increase the risk. Most patients do not have a matched donor, but everyone has a mismatched donor. Can the mismatches that can be tolerated be identified?

Clinical Significance of the Matching of HLA Alleles, NK Cell Receptors and Minor HAs in Hematopoietic Stem Cell Transplantation from Unrelated Donors - Yasuo Morishima, MD, PhD, Aichi Cancer Center Research Institute.

Recent Advances in Treatment of Adult and Pediatric AML

TANDEM SESSION 3, 10:30 AM -  12:00 PM
Chair: Gary Gilliland, MD, PhD, Harvard Medical School;

Genetic Basis of AML: Therapeutic Implications - Gary Gilliland, MD, PhD, Harvard Medical School;

The FLT3-ITD mutation is present in 46% of APL patients.  In mouse models, mice bred to have the PML-RAR abnormality (which is present in APL), 20% develop APL. Inducing FLT3-ITD makes almost all the mice develop APL in a shorter time. APL with FLT3-ITD seems to have a poorer prognosis then without. Can FLT3 inhibition be combined with ATRA (the standard treatment for APL) to treat patients?

Current Therapeutic Strategies in Adult AML - Martin Tallman, MD, Northwestern University;

In  2003, there were 12,000 cases of AML in the U.S.. The median age of patients is 70 years. Induction therapy produces remission in 50-80% of cases.  Even in patients with unfavorable risk factors, more then 50% achieve a complete remission.  Survival in patients under 55 has increased from 11% in the 1970s to 37% in the 1990s. In patients older then 55 there has been little improvement. In older patients, there tend to be worse cytogenetics, prior Myelodysplastic Syndrome (MDS) as well as comorbidities.

A diagnosis of AML now requires 20% blasts as opposed to 30% used in earlier definitions. Except when the t(8,21), inv(16) or t(15:17) chromosomal abnormalities are present when there is no limit.

There has been a new definition of a response, molecular remission.

Induction Therapy: Anthracycline dose escalation (daunorubicin), using 90 mg/m2 (CALGB) produces 90% complete remission.  Mylotarg (Gemtuzamab Ozogamicin) has been combined with standard dose daunorubicin and Ara-C with an 83% complete remission. In England, a trial using Mylotarg with DAT or FLAG resulted in an 85% rate of complete remission.  New trials are looking at using Mylotarg at various stages of treatment. Daunorubicin at 45-60 mg/m2 plus Ara-C remains the standard induction therapy.

For consolidation therapy, in younger patients 2-4 rounds of High Dose Ara-C are standard.  The optimal dose and number of doses are unknown. Maintenance therapy (except in APL) is not standard.

Core Binding Factor (CBF) group (including inv(16) with High Dose Ara-C have a complete remission rate of 85-100% with a disease free survival of 60-70%. The role of auto transplants or NSCT are not known and a fully ablative transplant is not recommended in first remission.

For APL, induction with ATRA and an anthracycline, plus consolidation with an antracycline seems like the best therapy.  Maintenance with ATRA possibly with low dose chemo.  If there is a relapse, Arsenic works well, possibly with an auto transplant.

Advances in Treatment of Pediatric AML - Robert J. Arceci, MD, PhD, Johns Hopkins University School of Medicine.

Overall Survival for AML has increased from 3% in 1960 to 21% in 1990.  With dose intensification overall survival is now about 50%.  AML with monosomy 7 is very difficult to treat successfully with anything.

Can specific biologic features predict outcome and direct therapy?

FLT3-ITD is rare in babies but more common in patients over 55.

Minimal Residual Disease (MRD) in APL, the presence of PML-RAR means relapse.  Flow cytometry to detect occult leukemia can predict relapse in some patients.

IBMTR/ABMTR Acute Leukemia Working Committee Meeting

12:15 PM -  1:45 PM* * (WC06) Co-Chairs: Armand Keating, MD, Princess Margaret Hospital;
Daniel J. Weisdorf, MD, University of Minnesota;

There were a number of discussions on ongoing and proposed research using the IBMTR/ABMTR database. One study proposed by Martin Tallman of Northwestern University would look at APL patients who had relapsed and had received an allogeneic transplant, an autologous transplant or arsenic trioxide alone (this data would be from the Pharmaceutical company database).  One major problem of such a study is that the IBMTR/ABMTR data does not record whether the patient becomes molecularly negative for the PML-RAR molecule after a transplant.

Session 3 - Allogeneic

TANDEM ORAL ABSTRACTS, 2:00 - 3:30 PM
Moderator: Julie Vose.

Effect of Very High CD34 Cell Dose on the Outcome of Allogeneic HLA Identical Related Transplants, Vikram Mathews, et. al., Washington University, St. Louis, Missouri

High doses of CD34 cells in sibling PBSCT resulted in lower relapse but higher severe GVHD and deaths from GVHD.  Overall Survival was similar in both groups.  Chronic extensive GVHD was high in both groups, but experienced at a similar rate.

Even coagulase negative staphylococcus infections following reduced intensity transplantation are associated with increased transplant complications and poorer overall survival, G. W. Chan, et. al., Tufts-New England Medical Center, Boston, MA.

Infections lead to higher Transplant Related Mortality and lower Overall Survival.
Comparison of outcomes after transplantation of unrelated donor umbilical cord blood versus matched sibling bone marrow for pediatric patients with leukemia and myelodysplastic syndromes, Susana Rodriguez-Marino, et. al. Children’s Memorial Hospital, Chicago, IL.
Compared transplant for children with leukemia, those who did not have a matched sibling donor had unrelated cord blood transplants, the others had matched siblings.  The conditioning was similar although the cord blood patients received ATG as well. Generally the groups were about the same risk, although the cord blood group had more higher risk patients -- cord blood transplants are considered more risky. Engraftment (white counts and platelets) was slower with cord blood but the Transplant Related Mortality was similar. Severe GVHD was higher in the cord blood group. Overall Survival was similar.

Allogeneic HSCT with reduced intensity conditioning regimens in high risk patients with myelofibrosis Damiano. Rondelli, et. al., University of Illinois at Chicago, Chicago, Il.

21 patients with myelofibrosis were treated with transplants.  The median age was 54.  2/3 of the patients had previously been treated, the other 1/3 were not treated. 18 had matched sibling donors, the other 3 received MUD transplants. All engrafted, 4 DLI were given (2 for relapse and 2 for partial remission with no GVHD).  The overall survival was 85%.  No patients are transfusion dependent and there was no severe marrow fibrosis
Effect of comorbidities on allogeneic hematopoietic stem cell transplant outcomes in AML/MDS patients in first complete remission Munir Shahjahan, University of Texas MD Anderson Cancer Center, Houston, TX
Determine the effects of pre-transplant comorbidities on outcome. Determine if a single score can predict outcome.  Used Charlsom Comobidity Index (CCI).  CCI was a stronger predictor of survival in younger patients (less then 40 years old).
Stem cell transplantation for fanconi anemia: 20 years of progressive decrease in the dose of cyclophosphamide without irradiation, Ricardo Pasquini, Federal University of Parana, Curitiba, PR, Brazil
Over 20 years, 97 Fanconi Anemia patients were treated with related donor transplants and 29 with unrelated donors (15 cord blood and 14 others).  Poor survival in first patients, decreasing Bu to 60mg/kg lead to better survival with less toxicity. In this latter group, there was not transplant related mortality and low GVHD.

Session 6 -- Late Effects, Quality of Life, Pediatric Disorders and Supportive Care

TANDEM ORAL ABSTRACTS, 4:00 --5:30 PM
Moderator: Alexandra H. Filipovich

Reduced-intensity conditioning (RIC) regimens result in low prevalence of premature ovarian failure (POF) in women who underwent hematopoietic stem-cell transplantation (HST), Yee Chung Cheng, et. al., The University of Texas M. D. Anderson Cancer Center, Houston, TX

Females aged 16-40 years at transplant without breast cancer or ovarian cancer. Ovarian failure is defined the same as Bines[9].

Of the 3945 patients who underwent transplants at M.D. Anderson from 1987 through September 2001, 488 were females aged 16-40 who did not have breast or ovarian cancer. 413 received high dose conditioning (HDC) and 75 received RIC. Both groups had similar characteristics, age, disease status and previous treatment. 79% of the high dose group reported ovarian failure, while only 37.5% reported ovarian failure in the RIC group. There were 4 patients in the HDC group who reported successful pregnancies and 2 in the RIC group. M.D. Anderson is currently running a trial of a drug that they hope will help prevent ovarian failure in younger female SCT patients.

A decade of myeloablative hla-matched sibling marrow transplantation for children with severe sickle cell disease: Outcomes and lessons learned from the Atlanta experience, Ann.E. Haight, et. al., Emory University School of Medicine, Atlanta, GA

There have been over 200 transplants worldwide for severe sickle cell disease.  There are over 1000 sickle cell patients in the Atlanta area. 16 patients (12 male) were transplanted in Atlanta between 1993 and 2003.  Special treatment was given for blood pressure and transfusions to prevent sickle cell specific complications. Overall, event free and disease free survival was 100% at a median of 3 years post-transplants. Good outcomes were seen, even if transplants were delayed until sickle cell complications occurred.

Bone marrow transplantation (BMT) for children and adolescents with severe acquired aplastic anemia (SAA): A single center experience in 171 patients (pts) comparing two different preparatory regimens, Carmen M.S. Bonfim, et. al., Federal University of Parana, Curitiba, PR, Brazil

171 patients with severe aplastic anemia (SAA) were transplanted between 1986 and 2003.  Patients were treated with 3 different regimens. Cytoxan and ATG were used for patients with a large number of transfusions (more then 15) to prevent graft rejection. However ATG is not reliably available in at least some developing countries so Busulfan has been used since 2003. Patients with more then 15 transfusions got Cytoxan and Busulfan, those who had 15 or fewer transfusions, received Cytoxan alone. Overall survival (OS) was 70%, with those with less then 15 transfusions having an OS of 87%, while OS was 50% in heavily transfused patients who received only Cytoxan, but 70% in those patients who received Cytoxan and Busulfan.  There was a low rate of graft failure in less heavily transfused, and those that do have graft failure can be rescued. If transplants were done earlier (i.e. patients received fewer transfusions) early complications could probably be reduced.

Prevention of cytomegalovirus (CMV) reactivation by standard dose valacyclovir (VACV) after allogeneic bone marrow transplantation, Takehiko Mori, Division of Hematology, Keio Univ. School of Medicine, Tokyo, Japan

High dose VACV has been shown to be effective at preventing CMV re-activation [10].  12 patients who were CMV+ received VACV, 33% had CMV re-activation. 24 out of 35 patients who had transplants without CMV prophylaxis had CMV re-activation. There was no outright CMV disease in the VACV group, but 4 cases in the control group, although the difference was not statistically significant. No serious adverse events were associated with VACV.  A randomized trial is to start soon.

Oral valganciclovir is safe and effective as preemptive therapy for CMV infection in allogeneic hematopoietic stem cell transplantation, Ernesto Ayala, et. al., Moffitt Cancer Center & Research Institute, Tampa, FL

A Phase III trial showed that valganciclovir (VGV) is effective for CMV retinitis in AIDS patients [11].

If patients tested positive for CMV they were treated with VGV at 900 mg/day for 2 weeks.  93% of patients treated with VGV returned to having no evidence of CMV.

Palifermin reduces severe oral mucositis (OM), improves patient quality of life, and reduces health resource use in patients with hematologic malignancies receiving high-dose chemotherapy (HDCT) and total body irradiation (TBI) with autologous peripheral blood stem cell (PBSC) support: Results from a phase III trial, William Bensinger, et. al., Fred Hutchinson Cancer Research Center, Seattle, WA

Oral mucositis is one of the most debilitating side effects of autologous HSCT.

212 patients randomized to receive either Palifermin or a placebo, for 3 consecutive days before TBI and 3 days after transplant.  62% of patients in the placebo group had Grade 4 OM versus only 20% in the group treated with Palifermin. There was no difference in serious adverse events. There were more mild side effects in the Palifermin group, including the tongue feeling "thick".  There was a significant reduction in the use of pain medications (opiates) in the Palifermin group.

Sunday, February 15, 2004

Revitalization of Pentostatin: A New Approach to the Management of GVHD and to Allogeneic Transplants

Satellite Symposium 07 - Breakfast Symposium, 6:30 AM - 8:15 AM
Chair: Julie Vose.

GVHD Prophylaxis With Tacrolimus, Mini-methotrexate and Pentostatin: A Phase I/II Study - Marcos JG de Lima, The University of Texas M. D. Anderson Cancer Center, Houston, TX;

Deaths due to GVHD are much higher in transplants using MUDs compared to MRDs. Pentostatin reduces leukocyte activity in various lines and does not produce marked myelosuppression.

61 patients who were fairly high-risk received transplants, most also received ATG.  Pentostatin was given at 5 levels, no pentostatin, 0.5 mg/m2, 1 mg/m2, 1.5 mg/m2 and 2 mg/m2. Severe (grades III and IV) GVHD was 8% in the 1.5 mg/kg group and 10% in the 2 mg/kg group, versus 29% in the no pentostatin group. Infections seem to be similar in the control and other groups.  Deaths from acute GVHD were 19% in the no pentostatin arm, 27% in the 0.5 mg/kg group versus 8% and 10% in the 1.5 and 2 mg/kg groups. Conclusion, pentostatin reduces acute GVHD without appearing to effect engraftment.

Nonmyeloablative Hematopoietic Cell Transplantation for Patients With Hematologic Malignancies - Brenda M Sandmaier, Fred Hutchinson Cancer Research Center, Seattle, WA;

457 patients, approximately half in Seattle and half at other institutions, received NSCT. Donors were MRD in 303 patients, with a median age of 54 and MUDs in 148 patients with a median age of 51.  MRD transplant patients were followed for a median of 25 months, MUDs for a median of 17 months.

Acute GVHD appears to occur later than in conventional transplants, 40-50% of patient had chronic GVHD.

51% of the MRD patients had a complete remission, and 41% of the MUD patients achieved a complete remission. 5% of the MRD patients died from transplant related complications at 100 days, 11% of MUD patients died at 100 days. GVHD accounted for most of the transplant related mortality.

The overall survival was 51% at 2 years and progression-free survival was 37% at 2 years.

DLI was used when there was disease progression or chimerism was low.  Patients with less then 50% chimerism or a drop of 20% received DLIs. 

Reduced-Intensity Conditioning for Allogeneic Transplantation - Francine M. Foss, Tufts-New England Medical Center, Boston, MA;

The protocol at Tufts uses photopheresis at days --7 and --6 to modulate the activity of dendritic cells. In addition, pentostatin and 600 cGy of TBI are used.  106 patients have been treated, most were high-risk. Transplant Related Mortality was 15% with MRD and 25% with MUDs. 7% had severe acute GVHD in the MRD group, while it was 23% in the MUD group.  Extensive chronic GVHD was seen in less then 30% of patients. The median survival at 1 year was 50%.

The Role of BMT for CML in the Gleevec Era

TANDEM PLENARY 03, 8:30 AM -  10:00 AM
Chair: Richard E. Champlin, MD, MD Anderson Cancer Center;

Imatinib and the Current Standard of Care for CML - Jorge Cortes, MD, MD Anderson Cancer Center;

Patients given Interferon Alpha had a median survival of 6-7 years, patients with good risk survived 9 years. Cytogenetic response predicted survival.  78% of patients who had a good cytogenetic response on Interferon survived 10 years or more.  30% of patients with a cytogenetic response had a molecular response (the BCR-ABL protein not detectable).

90% of patients who received Imatinib (Gleevec) at M.D. Anderson were still alive at 4 years and all of those patients had failed Interferon treatment.  Even with no cytogenetic response, survival is better compared to other therapy. If there is no cytogenetic response to Imatinib by 12 months or a complete response by 15 months, other therapy should be considered.  8% of patients at M.D. Anderson developed other chromosomal abnormalities by 30 months.

New strategies for patients who do not achieve molecular remission.  90% of patients treated with 800 mg of Imatinib (versus the standard dose of 400 mg) had a cytogenetic response. 30% versus 20% achieved a molecular remission.

Some patients become resistant to Imatinib. One strategy is to add another drug, candidates include PEG-Intron, Ara-C and Pegasys. Vaccines appear to be promising in producing complete remissions.

Ablative Allogeneic Transplantation for CML - Jerald Radich, MD, Fred Hutchinson Cancer Research Center;

Outcome for transplants with MRD for CML. Patients transplanted with BU/Cy had better Overall Survival at 10 years when the BU was targeted to make sure the blood levels were optimal.  In that case there is no age effect.

With MUD, in patients aged up to 50 years there were similar results.  Patients over 50 do significantly worse.

For both MUD and MRD, there is little difference in outcome for transplants done less then 1 year from diagnosis versus those done 1-2 years after diagnosis.  After 2 years Overall Survival falls significantly.

In good risk patients, there is little difference between MUD and MRD.

Detection and significance of minimal residual disease.  Options for relapse, include second transplant, DLI, Interferon -- which has a good response with 1 year of treatment and Gleevec, 100% of patients who relapse in the chronic phase achieve a hematological response, 30% achieve a molecular response.

Branford found point mutations with Gleevec resistance.  Patients who achieved a molecular response have few point mutations. [12].

Non-myeloablative Allogeneic Transplantation, Immunotherapy, and Multimodality Treatment for CML - Richard E. Champlin, MD, MD Anderson Cancer Center.

CML patients who receive a BMT have a small risk of relapse even more then 15 years post transplant.

The controversy is: Can one delay the use of a BMT until early signs of treatment failure?  Will the delay in going to transplant change the outcome?

Non-myeloablative SCT.  A truly non-myeloablative regimen did not work well at M.D. Anderson. A reduced intensity (RIC) regimen, which was more intense but still non-myeloablative had better results. Slavin showed more then 80% survival for CML patients treated with the modified  reduced intensity regimen [13].

Strategy:  Use a RIC allogeneic-SCT.  Give Gleevec at 3 months if there is no molecular remission. Then use a DLI later on if necessary. So far 11 patients have been treated and there has been no transplant related mortality.

Gleevec is the preferred initial treatment for most patients with newly diagnosed CML.  Patients less  than 30 may receive a transplant.

Clinical Resource Challenges: 2004

TANDEM SESSION, 10:30 AM -  12:00 PM
Chair: C. Fred LeMaistre, MD, Texas Transplant Institute;

Management of the "Cured" Patient - John R. Wingard, MD, University of Florida;

The majority of patients (long-term survivors have good performance status post-BMT [14].  Late deaths (after 1 year) are mostly due to relapse (more then 45%) and GVHD (more then 30%).

BMT survivors are poorer than their spouses or normal controls.  They experience more fatigue.  Seven years post-transplant 30% have depression, while 12-27% of spouses have depression, compared to normal controls where 4-8% have depression. Being "cured" not the same as perfect health [15].

Healthy behaviors include infection prevention, vaccination, osteoporosis (regular exercise, calcium supplement). An endocrine assessment is useful particularly in children. Cancer prevention should include avoidance of tobacco, moderate alcohol consumption and sunscreen. Normal cancer screenings should be done. Guidelines for screening and prevention are being developed by the Late Effects committee, along with the EBMT and ASBMT.

Another study of long-term survivors found that most did not smoke, wore seat belts, but did not exercise as much as recommended. This was similar to the general population. Women and those with more education were more like to do better at following guidelines.

Stem Cell Transplant Center Characteristics and Posttransplant Mortality - Fausto R. Loberiza, Jr., MD, IBMTR/ABMTR;

This study is about what characteristics of transplant programs lead to better outcomes and how we might be able to improve outcomes at different centers by better practices.

Center Effects are defined as differences in outcomes that cannot be explained solely by identifiable patient characteristics or treatments.  187 centers were studied, 88 of them performed allogenic transplants on adult leukemia patients and 142 centers preformed autologous transplants on adults (obviously some did both).

The Clinical Severity Score looks at patient characteristics and produces a score for each patient. The median for each center was computed and then centers were divided into low and high-risk centers.

Some characteristics of the centers studied:

  • The median number of transplants performed annually was 70, ranging from 11 to 400
  • The median number of allogeneic transplants was 28 (range 11-200)
  • Median center experience (how long have transplants been done there) was 11 years (range 1-30+)
  • Nurse-patient ratio was 1:3
  • Most do not use Laminar Air Flow (LAF) rooms, but do use HEPA filters
Mortality:
  • When a doctor (as opposed to a nurse or nurse practioner) was their first contact, patients (when they were out of the hospital) had better outcomes
  • Centers that were part of medical schools, where students saw patients, had worse outcomes, but if fellows saw patients outcomes were better
  • Low risk patients at favorable centers had 90% 100 day survival
  • Low risk patients at unfavorable centers had 80% 100 day survival
  • High risk patients at favorable centers had 70% 100 day survival
  • High risk patients at unfavorable centers had 55% 100 day survival
  • High risk patients at favorable centers had almost the same survival at 100 days as low risk patients at unfavorable centers

In the future they would like to do prospective studies to see if it is possible to modify center characteristics to improve outcomes.

What is Quality in a Transplant Program? - C. Fred LeMaistre, MD, Texas Transplant Institute.

Why is quality important -- patients, referring physicians and payers need to know what is a quality program.

For patients, important factors are recommendations of referring physicians, center reputation, in payer network and support system/logistics.

For payers, important characteristics are Survival, Volume, Physician training, Accreditation (FACT or AABB ), papers and research. Also good communications with doctors is important and being a "full service center".  Obviously payers are also interested in contract rates.

Important issues for referring doctors are communications with the transplants physicians and other team members, both pre and post transplant, and having a plan of care. Being a "full service center" is important here as well.

FACT accredited programs appear to have better survival, although this is not statistically significant.

Past, Present and Future of Hematopoietic Transplantation

E. Donnall Thomas Lecture, 2:00 PM -  3:00 PM
Richard E. Champlin, MD, MD Anderson Cancer Center

In 1978, a BMT was in many ways different than today. Methotrexate and steroids were the primary treatments to prevent GVHD.  Viral infections were a major cause of morbidity and mortality, and about 1/3 of patients died from CMV. Very high doses of chemotherapy and radiation were used. BMT were limited to patients under 45 with matched sibling donors and advanced diseases.

Now GVHD is prevented by cyclosporine, T-cell depletion as well as a number of other options. Supportive care has made great advances, including anti-viral drugs, improved antibiotics, the use of PBSC and growth factors.  Regimens have been optimized somewhat, non-myeloablative transplants are used, as well as DLIs. Alternative donors, include unrelated donors, cord blood, and haploidentical related donors. It is routine to treat older patients who are in poorer health and also BMTs are used earlier in the disease process.

There have been decreases in TRM over time. There has only been a small if any improvement in reducing relapse.  Improvement in unrelated transplants  outcomes is due about equally from improved supportive care and better typing.

Using fludarbine and busulfan instead of busulfan and cytoxan results in significantly lower TRM and equivalent DFS, except possibly in refractory disease.

Non-myeloablative regimens reduce direct toxicity. It also appears to reduce GVHD. The theory is that GVHD is mediated by the release of cytokines because of tissue damage. A less toxic regimen should produce less tissue damage.  Reduced Intensity Conditioning (RIC) still requires a transplant, but has less toxicity than  standard regimens.

Does the preparative regimen matter? It does matter for AML/MDS.

NST for indolent lymphoma using Rituxan plus fludarabine for conditioning.  For follicular lymphoma, NST produces 94% DFS with 5-10% TRM. For mantle cell lymphoma, DFS is about 90%. For CLL, DFS at 3 years is 90% (although only 10 patients have been treated). 

NST has been used for Hodgkin’s disease for patients who relapse after autologous transplant. OS is about 50% in these patients. A more intensive regimen (fludarbine plus cytoxan) appears to be better then melaphalan and cytoxan.

NST seems to be better for indolent disease (like CML, CLL and LGL), rapidly progressive disease (e.g. AML) may outpace the immune response.  However they are still only effective in patients who are chemo-sensitive.  NST appears to be highly effective (better then fully ablative transplants) in LCL, CLL, mantle cell lymphoma, Hodgkin’s disease, renal cell carcinoma and breast cancer.

The Future: The transplant related mortality of bone marrow and other blood stem cell transplants exceeds that of almost any other routinely used treatment.  It impairs the quality of life of patients. The use of BMT will be displaced by development of less toxic therapies.  High dose therapy will become less important over time.  BMT will become an effective platform for antigen specific immunotherapy. BMT will be a platform for treatment of genetic diseases.

If GVHD can be prevented, BMT will markedly increase as a treatment for a broad range of hematological, immunological and metabolic diseases. It may also be used to treat degenerative diseases.

NMDP Workshop: Strategies in Unrelated Donor Selection

TANDEM SESSION, 4:00 PM -  5:30 PM
Presented by the National Marrow Donor Program
Co-Chairs: Daniel Weisdorf, MD, University of Minnesota;
Stella Davies, MD, PhD, University of Minnesota.

Panelists: Claudio Anasetti, MD, Fred Hutchinson Cancer Research Center;
Carolyn Hurley, PhD, Georgetown University Lombardi Comprehensive Cancer Center.

This looked like an interesting session on how to pick a donor when there is no matched sibling. Should you use cord blood, a mismatched donor, what kind of mismatches were acceptable, etc. Unfortunately, I had to leave for the airport just when the background information was finished.

References

  1. Yeoh EJ, et. al. Classification, subtype discovery, and prediction of outcome in pediatric acute lymphoblastic leukemia by gene expression profiling. Cancer Cell. 2002 Mar;1(2):133-43. From the Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
  2. Kohlmann A., et. al,  Pediatric acute lymphoblastic leukemia (ALL) gene expression signatures classify an independent cohort of adult ALL patients.Leukemia. 2004 Jan;18(1):63-71.  From the Laboratory for Leukemia Diagnostics, Department of Internal Medicine III, Ludwig-Maximilians-University, Munich, Germany.
  3. Mosquera-Caro, Monica, et. al., Identification, Validation, and Cloning of a Novel Gene (OPAL1) and Associated Genes Highly Predictive of Outcome in Pediatric Acute Lymphoblastic Leukemia Using Gene Expression Profiling.  ASH, 2003.  University of New Mexico Health Sciences Center.
  4. Thomas, Deborah A, et. al.  Treatment of Philadelphia chromosome-positive acute lymphocytic leukemia with hyper-CVAD and imatinib mesylate, Blood, 2003-08-2958,
  5. Sierra, J. et. al., Transplantation of Marrow Cells From Unrelated Donors for Treatment of High-Risk Acute Leukemia: The Effect of Leukemic Burden, Donor HLA-Matching, and Marrow Cell Dose, Blood, Vol. 89 No. 11 (June 1), 1997: pp. 4226-4235.
  6. Rocha, V., et. al, Relevance of Bone Marrow Cell Dose on Allogeneic Transplantation Outcomes for Patients With Acute Myeloid Leukemia in First Complete Remission: Results of a European Survey, Journal of Clinical Oncology, Vol 20, Issue 21 (November), 2002: 4324-4330.
  7. Bowden, RA, et al, A comparison of filtered leukocyte-reduced and cytomegalovirus (CMV) seronegative blood products for the prevention of transfusion-associated CMV infection after marrow transplant, Blood, Vol. 86 No. 8 (November 1), 1995: pp. 3598-3603.
  8. Nichols, W. Transfusion-transmitted cytomegalovirus infection after receipt of leukoreduced blood products, Blood, Vol. 101, No. 10 (15 May) 2003, pp. 4195-4200.
  9. Bines, J. et. al., Ovarian function in premenopausal women treated with adjuvant chemotherapy for breast cancer, Journal of Clinical Oncology, Vol 14, 1718-1729,
  10. Ljungman, P., et. al., Randomized study of valacyclovir as prophylaxis against cytomegalovirus reactivation in recipients of allogeneic bone marrow transplants, Blood, 15 April 2002, Vol. 99, No. 8, pp. 3050-3056.
  11. Martin, D. F., et. al, A Controlled Trial of Valganciclovir as Induction Therapy for Cytomegalovirus Retinitis, ., New England Journal of Medicine, April 11, 2002, Volume 346, Number 15, pages 1119-1126,
  12. Susan Branford Blood, Detection of BCR-ABL mutations in patients with CML treated with imatinib is virtually always accompanied by clinical resistance, and mutations in the ATP phosphate-binding loop (P-loop) are associated with a poor prognosis, 1 July 2003, Vol. 102, No. 1, pp. 276-283
  13. Or, R. Nonmyeloablative allogeneic stem cell transplantation for the treatment of chronic myeloid leukemia in first chronic phase Blood, 15 January 2003, Vol. 101, No. 2, pp. 441-445.
  14. Socie, Gerard., et. al, Long-Term Survival and Late Deaths after Allogeneic Bone Marrow Transplantation, New England Journal of Medicine, July 1, 1999, Vol. 341, No. 1, page 14.
  15. Bishop M. et al., The gift of life comes with a price: The impact of hematopoietic cell transplant on the long-term quality of life of survivors and their spouses, February 2004, Supplement, Volume 10, Number 1, page 7.


I would like to thank the National Marrow Donor Program (NMDP) and the Bone Marrow Transplantation Branch of the Deparment of Transplantation of the Office of Special Programs of the United States Department of Health Resources and Services Administration (HRSA) for paying for my travel and conference registration. The views expressed in this article are my own and do not necessarily reflect the views of NMDP or HRSA


Arthur Flatau
flataua@acm.org Austin, Texas





GrannyBarb and Art's Leukemia Links Site Map

HOME  ::  ABOUT THIS SITE  ::  CONTACT

Last updated: February 27, 2005

Copyright ©2004, 2005 ACOR, Inc. All worldwide rights reserved.
ACOR and ACOR.org are registered trademarks of
the Association of Online Cancer Resources, Inc.