key: cord-0010174-foymxwoe
authors: nan
title: 2016 ASPHO ABSTRACTS
date: 2016-04-14
journal: Pediatr Blood Cancer
DOI: 10.1002/pbc.25998
sha: 44ac87e7fbae5580d1b1764b44a42e13526ea16a
doc_id: 10174
cord_uid: foymxwoe

nan

ASPHO ABSTRACTS S19 Background: Children undergoing hematopoietic stem cell transplant (HSCT) are at increased risk of having potentially fatal viral infections including adenovirus which is a major cause of morbidity and mortality in this population. Cidofovir is a nucleotide phosphate analogue that competitively inhibits the incorporation of deoxycytidine triphosphate into DNA by viral DNA polymerase thereby disrupting further chain elongation. It has demonstrated in-vitro activity against a number of DNA viruses including adenovirus, herpesvirus, poxvirus, papillomavirus and polyomavirus when given intravenously (IV) . Recent case repots have described the safe and successful administration by inhalation for the treatment of respiratory viral infections. Objectives: To report the case of a pediatric hematopoietic stem cell transplant recipient treated with inhaled cidofovir for adenovirus pneumonitis. Design/Method: Case report and literature review Results: A 5 year old Hispanic female with past medical history of Fanconi anemia who developed multi-organ failure requiring dialysis and respiratory support for adenovirus pneumonitis 90 days after umbilical cord stem cell transplant. Tracheal aspirate at the time of intubation was positive for adenovirus by PCR. Despite maximal doses of IV cidofovir (adjusted for renal failure) her viral load continued to trend up and she was clinically deteriorating. After obtaining parental consent, she was treated with inhaled cidofovir 40mg diluted in 20mls of normal saline administered daily via ET tube for a total of 12 doses based on a previously published case report. She progressively improved clinically, eventually requiring minimal ventilator support and the adenovirus viral load in tracheal aspirate dropped progressively from 112,000 to 800 DNA copies/mL. No immediate complication was observed. Conclusion: Though adenovirus pneumonitis is a major cause of morbidity and mortality among pediatric HSCT recipients, its treatment can be challenging. Inhaled cidofovir offers an alternative to IV cidofovir for patients with renal failure in whom IV cidofovir might be contraindicated due to nephrotoxicity. Further well designed studies are needed to assess the safety and efficacy inhaled cidofovir.

Background: Invasive fungal infections (IFI) are life-threatening complications in neutropenic children being treated for acute myeloid leukemia (AML). While early diagnosis is crucial, non-specific clinical signs such as isolated prolonged fever often make correct identification of IFI a challenge. (1→3)-ß-D-glucan (BDG) is a major cell wall component of invasive fungi and is detectable in the serum to facilitate diagnosis of IFI. While BDG positivity has been validated for diagnosis of IFI in adult populations, correlation between BDG and IFI remains unproven in pediatric cancer. Objectives: To assess the correlation between detectable serum BDG (via Fungitell C assay) and IFI in at-risk pediatric populations with AML. Design/Method: This is a retrospective cohort study of pediatric subjects with AML <21 years at diagnosis treated at Miller Children's & Women's Hospital Long Beach with at least one reported BDG assay. Antifungal prophylaxis, quantity of detectable BDG, and any associated IFI evaluation (cultures, radiographic imaging, Aspergillus galactomannan antigen, pathology) were collected and independently reviewed for this study. "Positive" IFI was defined as probable/proven according to the 2008 consensus EORTC/MSG guidelines (excluding BDG). Multiple receiver operating characteristic (ROC) curves were generated with varying BDG thresholds ranging from 60 to 500 pg/ml. Using the best fit curve, we analyzed specificity, sensitivity, and true positive likelihood ratio (LR+) across thresholds to determine the optimal boundary limit of serum BDG associated with an IFI in this pediatric oncology population. Results: A total of 228 reported BDG assays and IFI evaluations were reviewed from 53 chemotherapy cycles administered to 18 eligible subjects. Routine antifungal prophylaxis was administered to all subjects (fluconazole or echinocandin);"positive" IFI was diagnosed in 6/18 subjects (33%). Inspection of the best fit ROC curve (AUC 0.856) identified a BDG threshold of ࣙ80 pg/ml as associated with the highest "correct classification" (89%, LR+ 9.2) and balance of specificity (92.2%) and sensitivity (73.0%). Increasing the threshold to 120 pg/ml decreased correct classification (86.4%), and markedly affected sensitivity (51.4%) with only a minor improvement in specificity (93.2%). Conclusion: Detection of BDG at a threshold of ࣙ80 pg/ml is sufficiently specific to aid in the diagnosis of IFI in pediatric populations with AML.

NEONATAL ABSTINENCE SYNDROME AND LEUKOPENIA

Background: Chronic administration of opioids has been associated with lymphocyte abnormalities and can affect immune system function. Little is known about the effect of maternal drug use on the neonatal immune system and lymphocyte counts. We hypothesized that maternal drug use during pregnancy can lead to neonatal lymphopenia. Recognizing this possible increased risk of infection in this population can allow for appropriate counseling and precautions. Objectives: Identify if newborns exposed to intrauterine drugs experienced hematologic abnormalities, specifically lymphopenia. Design/Method: Retrospective chart review of neonates born between 2003 and 2014 with a documented drug withdrawal syndrome was conducted. Medical records obtained by an electronic search for infants with the following ICD-9 codes: 779.4 (drug reactions and intoxications specific to newborns), 779.5 (drug withdrawal syndrome in newborn), and 305.5 (nondependent abuse of opioids); gestational age of the infant at birth, birth weight, type of maternal drug used, duration of hospitalization, treatment for neonatal abstinence syndrome (NAS), infant's absolute lymphocyte count, documented co-morbidities, and duration of drug exposure were recorded. Results: 81 neonates had a documented diagnosis of NAS during the time period reviewed. 31 had complete blood counts drawn (mean time of 6 hours of life) available for review. Manual differentials were utilized when available. By using an ALC cut-off of 3400/uL (<10th percentile), 14/31 neonates (45%) with the diagnosis of drug withdrawal syndrome were lymphopenic. Lymphopenic infants were noted to have longer NAS treatment duration (12.7 days vs. 8.9 days) as well as longer length of hospitalization (29 days vs. 16 days). 36% of lymphopenic infants were preterm (<37 weeks gestation.) 86% of infants were exposed to opioids; exposure was confirmed by a positive maternal drug screen or positive neonatal meconium drug screen. Conclusion: 45% of infants with the diagnosis of drug withdrawal syndrome were lymphopenic and these infants required longer duration of treatment for NAS. We are investigating the possible relationship between severity of NAS and neonatal lymphopenia. Further analysis is needed to determine if this correlation is noted in a larger study population, if the effect is transient, and how the child's clinical status during the neonatal period and throughout childhood may be affected.

Background: Studies have shown that patients suffering from ITP have polarized Th1 or Th2 response and cytokine deregulation. The Th1/Th2 balance was well known to regulate the immune system under normal conditions and to be impaired in autoimmune diseases like ITP. In order to study the mechanism of T lymphocyte abnormalities in children ITP, we should ensure the homogeneity of the objects. Due to children ITP often have abrupt and severe onset of thrombocytopenia, we prescribe intravenous immunoglobulin (IVIG) at the first day of hospitalization to prevent hemorrhage, as well as methypredisolone (MP), which is often be used when exclusion of malignancy. For this reason, T lymphocyte function evaluation involved detection of cytokines secreted by Th1, Th2 and Th17 etc. might be interrupted by treatment we mentioned above. Objectives: Our study was designed to explore the influence of intravenous immunoglobulin (IVIG) and methylprednisolone (MP) on cytokines secreted by T lymphocyte in children ITP. Design/Method: We enrolled 62 patients with first diagnosed ITP and ultimate duration was less than 3 months without recurrence (38 boys and 24 girls, age range 2-178 months, median 33 months). We enrolled children ITP at the onset of their disease from our department between December 2011 and March 2013. We followed them until 12months of their whole duration, choosing the patients whose ultimate duration less than 3 months and no recurrence. Cytokines measurement by cytometric bead array included IL-2, IL-4, IL-6, IL-10, TNF, IFN and IL-17. We divided patients into 3 groups according to the treatment they received before testing cytokines level, then we compared T cell cytokines' level among these groups. Results: We enrolled 62 patients with first diagnosed ITP and ultimate duration was less than 3 months without recurrence (38 boys and 24 girls, age range 2-178 months, median 33 months). We found IL-2 level is decreased in both group treated with MP for 1 day (N = 29, P = 0.042) and group in which patients treated with IVIG for 1 day (N = 18, P = 0.048) compared with group without any treatment (N = 15). While the other cytokines' level have no difference among groups. Conclusion: As for children ITP, although pathways of MP and IVIG in treating thrombocytopenia were different, they both could decrease IL-2 in children ITP ultimately. As a representative cytokine of TH1 cell, IL-2 has been demonstrated to be important in lymphocyte activation and mobilization. So we considered that MP and IVIG can reduce the T cell activation and production of auto-antibodies by decrease IL-2.

was achieved and continued at a steady dose. Maximum dose was 7 mcg/kg in both patients. Duration of therapy was 9 weeks in patient 1 and 13 weeks in patient 2. Due to a religious objection to blood products, patient 3 received three weekly 2-3 mcg/kg doses over a month period to maintain platelet count > 100×10ˆ9/L while receiving salvage therapy for relapsed parameningeal rhabdomyosarcoma. All patients maintained platelet counts above goal following discontinuation of romiplostim. No adverse effects from romiplostim injections were observed. Conclusion: Romiplostim successfully treated TRT without any adverse effects in this case series. While possible risk of leukemic clone proliferation may limit use of romiplostim for TRT in children with hematologic malignancies, romiplostim could be a very beneficial treatment for TRT in children with solid tumors. It may limit treatment delays and dose reductions, ultimately leading to improved overall survival. Prospective studies on this use of romiplostim are warranted.

progressive clinical symptoms with worsening quality of life (QOL). Unfortunately, treatment options are limited and often ineffective. Surgery is generally reserved for localized disease while conventional medical treatments like steroids and chemotherapeutic agents produce substantial side effects with variable results. Current evidence demonstrates an important regulatory function of the PI3-kinase/Akt/ mTOR pathway in vasculogenesis and supports mTOR inhibition with sirolimus as a therapeutic target. Objectives: To evaluate the safety and efficacy of sirolimus in the treatment of patients with GLA and GSD. Design/Method: This study analyzed combined data from a multicenter systematic retrospective review of medical records of patients treated with sirolimus between January 2007 and June 2014 and from the prospective Phase 2 clinical trial assessing the efficacy and safety of sirolimus in the treatment of complicated vascular anomalies (NCT00975819). Disease improvement was determined by radiologic imaging, QOL measurements and clinical status assessments. Sirolimus dosing regimens, toxicities and side effect causality were evaluated. Results: Of the evaluable patients, nineteen had GLA or GSD (13 GLA, 6 GSD). As expected, no patients had complete resolution of clinical symptoms and radiologic disease with sirolimus. Overall partial disease response was 84% (92% GLA, 67% GSD) with 79% of patients with improved QOL, 63% with improved clinical status and 39% with improved radiological response. Improvement occurred in 83% of patients with pleural effusions and 50% with pericardial effusions; no patients with pre-existing pleural or pericardial effusions worsened on therapy. Disease progression occurred in 1 GSD patient due to reported decreased QOL. Five patients experienced grade 3 or 4 drug toxicities without requiring dose reductions. Most common side effects were bone marrow suppression, mucositis/stomatitis and hypertriglyceridemia. Conclusion: Sirolimus is a safe and well-tolerated treatment that appears to reduce symptoms and/or stabilize disease in patients with GLA and GSD. Given the significant morbidity and mortality in patients with complicated lymphatic malformations, future treatment studies need to address these specific phenotypes.

Background: Genetic alterations causing overexpression of the cytokine receptor, CRLF2, are associated with a form of high-risk Ph-like acute lymphoblastic leukemia (CRLF2 B-ALL). Activation of the CRLF2 receptor by the cytokine, TSLP, results in activation of the JAK/STAT and PI3/AKT/MTOR pathways, both of which have been associated with chemoresistance and upregulation of Bcl2 family pro-survival genes. Objectives: To determine the effect of TSLP-CRLF2 mediated signals on expression of Bcl2 family proteins and the efficacy of targeting Bcl2 family pro-survival proteins in CRLF2 B-ALL. Design/Method: Flow cytometry and Western blot were used to evaluate Bcl2 family protein expression in CRLF B-ALL cells cultured with and without TSLP. Flow cytometry was used to for Annexin V/7-AAD and Caspase 3/7 assays of apoptosis following treatment of CRLF2 B-ALL cells with in the presence and absence of TSLP. Results: TSLP increased expression of the Bcl2 family pro-survival protein, Mcl-1, in CRLF2 B-ALL cell lines with activating JAK mutations (MUTZ5 and CALL4). Treatment with Mcl-1 inhibitor (Mim-1) reduced cell counts by >90% and this reduction was maintained in the presence of TSLP. Reductions in cell number were due to a dose-dependent increase in caspase-mediated apoptosis reaching >95% cell death after 3 days in concentrations of Mim-1 over 15 uM, even when TSLP was present. We saw increased expression of Bcl-xL and Bcl2 when doses of Mcl-1 inhibitor were 30 uM or higher, but very little change at lower doses, suggesting that observed increases are more likely to be selective survival of cells expressing high levels of these alternative Bcl2 family pro-survival molecules rather than compensatory upregulated expression. Conclusion: These data suggest that TSLP can contribute to chemoresistance via upregulation of the Bcl2 family protein, Mcl-1, even in cases of CRLF2 B-ALL with activating JAK mutations. These results provide evidence that therapy to target Mcl-1 could be an effective treatment for Ph-like ALL where CRLF2 is overexpressed.

Survey to ASPHO SIG VA Members; Web-based Questionnaire was distributed, New York City, Columbia University Medical Center, United States Background: Vascular Anomalies (VA), including patients with vascular malformations (VM), is an emerging field in pediatrics with growing recognition of coagulation-related complications specific to this population. To date, no specific guidelines exist. Objectives: To describe clinical practices related to pediatric VM patients with coagulation disturbances in North America, in order to facilitate future development of standards of practice and the identification of research gaps. Design/Method: The ASPHO SIG-VA conducted an Institutional Review Board approved online survey of SIG-VA members that included general practice questions and clinical vignettes describing coagulation-related issues. Items for the survey were derived from the expert experience, literature review, and suggestions from the survey committee.

Results: To date, 19/38 (50%) members responded [all 5 highest ranked centers (US), 2 largest (Canada)], and ß80% have practiced for ࣙ 6 years. Around 85% of the respondents work in a multidisciplinary clinic, seeing between 5-800 simple VM/yr and between 3-1,500 combined VM/yr. All have used anticoagulants [ie. low molecular weight heparin (LMWH)] or aspirin (ASA) for coagulopathies before [last 12 months: >10 pts (30%), 1-3 pts (ß25%), none (0%)].Three basic scenarios were included: a) periprocedural management in a combined VM with hypofibrogenemia and D-dimer elevation, ß63% would prescribe anticoagulants vs. 32% not, (5% were indecisive); enoxaparin was the agent of choice (92%, dose: 0.5-1.0 mg/kd/dose, x1 or x2/day, up to 2 wks pre-/post-procedure); b) simple VM with isolated D-dimer elevation and no symptoms, 20% would prescribe anticoagulants vs. 75% not, (5% were indecisive); enoxaparin was the agent of choice (60%, similar regimen); and c) simple VM with isolated D-dimer elevation and local pain, ß58% would prescribe anticoagulants vs. 16% not, (26% were indecisive); the agents of choice were ASA/NSAIDs (81%, and compression garments). Most common reasons to avoid LMWH were paucity of literature, perceived increased bleeding risk and needle phobia. Conclusion: Despite the prevalence of VM in children our survey highlights the expected practice variability in the management of coagulopathies. Lack of evidence was recognized as the main obstacle for the use of anticoagulants. Further characterization of coagulation complications, as well as risk stratification for both bleeding/thrombosis can pave the way towards future guidelines. Background: Ikaros, a protein encoded by the IKZF1 gene, acts as a tumor suppressor in acute lymphoblastic leukemia (ALL) by regulating expression of its target genes. Using chromatin immunoprecipitation coupled with next-generation sequencing (ChIP-Seq), we showed that Ikaros binds to the promoter of the CDC42 gene in human ALL. The CDC42 gene encodes a small GTPase that acts as an oncogene in solid tumors, but it has not been associated with leukemia. We hypothesize that Ikaros regulates CDC42 expression and that CDC42 is involved in ALL pathogenesis. Objectives: 1) To determine the role of Ikaros in regulating CDC42 expression in ALL.

2) To define the significance of CDC42 expression in ALL and 3) To test the therapeutic efficacy of targeted inhibition of CDC42 in ALL. Design/Method: Ikaros overexpression and knock-out was by transduction with retroviral vector containing Ikaros and Ikaros shRNA, respectively. Luciferase reporter assay was used to evaluate Ikaros effects on the CDC42 promoter. Gene expression was assessed using quantitative real-time PCR (qRT-PCR) and Western blot. DNA binding was measured by quantitative chromatin immunoprecipitation (qChIP). Cell proliferation was assayed by WST and synergistic cytotoxic effects of compounds was analyzed using Calcusyn. Results: Gain-of-function and loss-of-function experiments showed that Ikaros represses CDC42 transcription. CDC42 is overexpressed in B-ALL and T-ALL as compared to normal bone marrow. CDC42 overexpression correlates with high white blood cell count in ALL. Treatment of ALL with a specific CDC42 inhibitor (ML141) produced a cytotoxic effect. In leukemia, Ikaros binding to the CDC42 promoter and its ability to repress CDC42 is impaired due to phosphorylation by pro-oncogenic Casein Kinase II (CK2). Inhibition of CK2 with a clinically-tested inhibitor, CX-4945, restored Ikaros binding to the CDC42 promoter and transcriptional repression of CDC42. The use of CX-4945 in combination with the CDC42 inhibitor, ML141, produced a synergistic cytotoxic effect in both B-ALL and T-ALL. Conclusion: Our results demonstrate that CDC42 is overexpressed in ALL and is a potential therapeutic target in leukemia. Expression of CDC42 in ALL is regulated by Ikaros and CK2. Targeting CK2 in combination with CDC42 inhibitors is a potential novel treatment for ALL.

ASPHO ABSTRACTS POSTER #539

Background: Lymphatic malformations (LMs) are challenging to manage, particularly those involving the cervicofacial region and airway. Primary therapy is sclerotherapy and/or resection, while the role of sirolimus is evolving for the treatment of cervicofacial LMs. Objectives: To review our experience with sirolimus medical therapy for cervicofacial lymphatic malformation for efficacy and safety/tolerability. Design/Method: An IRB-approved retrospective review of 19 patients treated with sirolimus for cervicofacial LMs from November 2012 to October 2015.

Results: Five patients have completed therapy (duration 5, 9, 17, 25, and 26 months) and 14 remain on sirolimus (range 4-35 months). Age at initiation ranged from 2 months to 34 years. Nine patients had microcystic LM and ten had mixed macrocystic-microcystic LMs. All patients have serial photographs and 10 patients have serial imaging to gauge response. All patients demonstrated some reduction in LM bulk, ranging from dramatic to visually modest. Younger patients with mixed macrocystic-microcystic disease with less prior therapy demonstrated more significant responses. 94.7% (18) patients reported subjective improvement on sirolimus including decreased LM bulk, softening tissue, decreased bleeding/leaking related to mucosal vesicles, and decreased rates of cellulitis. All patients (n = 13) with mucosal vesicles present at initiation of sirolimus resolved or improved. Median time to initial response was 1 month (range 5 days to 4 months). Of six patients with tracheostomies, one was decannulated after maxillofacial surgery and two are tolerating capping while on sirolimus. Six patients developed cellulitis within the LM during treatment; none progressed to sepsis or had more episodes of cellulitis on sirolimus. No opportunistic infections occurred. Two patients have undergone surgical debulking following sirolimus treatment to decrease residual remaining tissue with wound healing issues.

The use of sirolimus in the management of cervicofacial LMs appears to be efficacious, especially in younger patients and for mucosal disease, with limited adverse events. Long-term follow-up, durability of response, and coordination of sirolimus around procedural therapies need further evaluation.

Aditya Sharma, Sunpreet Tandon, Christine Mella, Jamie Burke, Steven Kuerbitz

Background: We have shown previously that the neuronatin gene (NNAT) undergoes aberrant DNA hypermethylation associated with transcriptional silencing in a majority of childhood acute leukemia cases. The clinical significance of loss of NNAT expression in childhood leukemia, however, is unknown. Objectives: The goal of our study was to correlate clinical characteristics and outcomes with NNAT expression in precursor B -acute lymphoblastic leukemia (ALL). Design/Method: Sixty seven consecutive cases of non-infant precursor B-ALL presenting between 2005 and 2011 were analyzed retrospectively utilizing bone marrow samples obtained at diagnosis and data from the medical record. For each sample, site-specific NNAT methylation was quantitated by combined restriction/bisulfite analysis (COBRA) and NNAT mRNA expression was qualitatively determined by end point RT-PCR. Clinical characteristics including age at presentation, white blood cell count (WBC) at presentation, immunophenotype, induction response, and survival were compared between NNAT hypermethylator and normal methylator groups and between NNAT expressor and nonexpressor groups. Results: NNAT methylation and expression status was determined for 28 cases. Hypermethylation (defined as site-specific methylation > 60%) was identified in 16/28 ALL samples. NNAT silencing (loss of expression) was identified in 15/28 samples). We found cases exhibiting loss of NNAT expression were more likely than expressors to be associated with a WBC > 50,000/mm3 at diagnosis (p = 0.037). Also the EFS for the high-risk group approached statistically significant difference between the expressor and non-expressor groups. Conclusion: Loss of NNAT expression was associated with an elevated WBC count (>50,000/mm3) at presentation. While EFS and OS did not differ significantly between expressor and non-expressor groups in the overall analysis, when we restricted the analysis to patients exhibiting high-risk characteristics of elevated WBC or age > 10 years, the EFS advantage of expressors over non-expressors approached statistical significance. Given the relative stability of the tails of these EFS curves, analysis of additional patients may yield a statistically significance difference. While NNAT has been shown to regulate endoplasmic reticulum calcium homeostasis in some cell types, the biological basis for clinical features associated with loss of NNAT expression in childhood PB-ALL remains to be determined.

Background: Hepatic hemangiomas are the most common benign liver tumor of infancy. The typical presentation usually involves a palpable abdominal mass with or without signs of anemia and heart failure. Despite their relatively common occurrence, confusing nomenclature is still affecting the medical literature. Classification schemas based on growth pattern, immunostaining and clinical behavior have emerged in an attempt to better standardize management. Objectives: We present a case of an infant with atypical clinical course of a hepatic hemangioma and contrast it with other patients that presented with a similar diagnosis.

Our aims are to contribute to the growing data surrounding these common vascular lesions in hopes of standardizing diagnostic criteria and outcomes, as well as better guide therapeutic options. Design/Method: A retrospective chart review was performed on a 2 month-old baby boy at Texas Children's Hospital and compared to previous cases and published reports of this diagnosis. Results: The patient was a boy born at 32-weeks' gestation who presented with respiratory failure secondary to acute abdominal distension at 2 months of age. Ultrasound prior to delivery had shown a 6.9cm left hepatic lobe mass, and MRI confirmed a 7cm x5.2 cm left hepatic lobe hemangioma. On presentation, repeat ultrasound showed the hepatic mass to be stable in size without significant shunting or compression of hepatic vessels, with a large amount of ascites present. Alpha-fetoprotein (AFP) levels were within range for age . Further workup failed to reveal a primary etiology for his ascites. Due to his critical status, decision was made to excise the mass. Pathology revealed a GLUT-1 negative vascular lesion consistent with a hepatic congenital hemangioma. Post-operatively the baby recovered well the ascites did not re-accumulate. Conclusion: There is a wide range of clinical presentations for focal hepatic hemangiomas, from asymptomatic to critically ill. These lesions require close follow up from birth to identify development of complications and initiate prompt treatment.

Background: The t(10;11) CALM-AF10 translocation occurs in patients with T-ALL and AML and is associated with a poor prognosis. CALM-AF10 leukemias are characterized by upregulation of HOXA gene expression, which is a known driver of leukemogenesis. Interaction of the CALM-AF10 oncoprotein with the nuclear export factor CRM1/XPO1 is essential for upregulation of HOXA expression. We have previously demonstrated that CRM1 interacts directly with Hoxa chromatin, suggesting that CRM1 recruits CALM-AF10 to its target genes. However, other mediators may also be involved. In particular, NUP98 is a component of the nuclear pore complex that interacts with CRM1 during nucleocytoplasmic transport of macromolecules. Translocations fusing NUP98 with multiple different partners have been described in high-risk leukemias. NUP98 fusion oncoproteins can bind to and activate the transcription of HOXA genes. Objectives: To determine whether NUP98 cooperates with CRM1 and CALM-AF10 to transactivate HOXA genes. Design/Method: We previously created retroviral CALM-and CRM1-AF10 fusion vectors and demonstrated their ability to activate the transcription of a Hoxa7-luciferase reporter. We designed an inducible shRNA retroviral vector targeting Nup98. We performed transient co-transfections of the Hoxa7-luciferase reporter with Nup98 shRNA vectors, together with CALM-AF10, CRM1-AF10 or an empty vector in HEK293 cells. We also stably expressed the inducible NUP98 shRNA vector in NIH3T3 cells. Results: Luciferase assays showed that knockdown of NUP98 increased the baseline level of Hoxa7 transcription but had limited effect on the transcriptional activity of CALM-AF10 and CRM1-AF10. Inducible knockdown of Nup98 also caused an increase of endogenous Hoxa levels in NIH3T3 cells. Conclusion: Surprisingly, silencing of NUP98 increases Hoxa7 transcriptional activation and endogenous Hoxa transcripts. Since NUP98 is important for nuclear export, impeding NUP98 function likely results in nuclear retention of critical proteins and may indirectly deregulate Hoxa transcription. Experiments are underway to determine the role of NUP98 on Hoxa levels in cells expressing CALM-AF10 and CRM1-AF10. Of note, a recent report demonstrated Crm1-dependent direct binding of Nup98-Hoxa9 to Hox genes (Oka et al., Elife 2016) . This further highlights the important interactions among CRM1, NUP98, and Hox loci as a molecular basis for leukemogenic Hox gene dysregulation.

POSTER #543

Children's Hospital of Michigan, Detroit, Michigan, United States Background: Infantile hemangiomas (IH) typically are benign vascular neoplasms that spontaneously involute over time. They are most commonly found on the head, neck and trunk, but can also involve internal organs such as the liver, lung and central nervous system. Oftentimes these lesions can be treated conservatively. Medical management, when needed, consists of laser treatments, surgical excisions and medications including propranolol and steroids. Objectives: To describe a pediatric patient with diffuse hepatic and cutaneous IH and failure to thrive with progressive pulmonary hypertension (PH) due to pulmonary hemangiomas treated with sirolimus. Design/Method: The patient is a three year old African American female who presented shortly after birth with diffuse cutaneous hemangiomas, hepatomegaly, splenomegaly and anemia. Abdominal MRI/MRA noted replacement of the entire liver parenchyma by numerous nodular lesions consistent with IH, as well as signs of early heart failure. Skin biopsy confirmed IH. She was started on propranolol and prednisolone for her hemangiomas, as well as medical management of her heart failure. Hepatic and cutaneous hemangiomas improved over time. At 23 months of age, however, she developed severe idiopathic PH diagnosed by right cardiac catheterization with systemic pulmonary artery (PA) pressures at rest responsive to oxygen and nitric oxide. Computed tomography scan of her thorax noted multiple enhancing pulmonary nodules scattered throughout both lungs, suspicious for pulmonary arteriovenous malformations.

The patient was started on sildenafil. Given the severity of her PH likely from pulmonary hemangiomas and persistence of her liver and cutaneous hemangiomas despite previous therapy, she was subsequently started on sirolimus. Repeat cardiac catheterization two months after initiation of sirolimus noted improvement in her PH, as well as in her liver hemangiomas. Unfortunately the patient developed significant hypoglycemia resulting in her demise. Conclusion: Pulmonary hemangiomas are rare in the pediatric population. Sirolimus acts by inhibiting the mTOR pathway and thus decreases vascular endothelial proliferation. Steroids and propranolol are first line medical management of IH; however, sirolimus may be an effective treatment option for hemangiomas refractory to conventional therapeutic options.

University of Rochester, Strong Memorial Hospital, Rochester, New York, United States Background: While the cure rate for acute lymphoblastic leukemia (ALL) is >90%, relapse occurs in about a quarter of cases, particularly with high risk disease. T cell immunomodulation may be a valuable adjunct to standard therapy. However, studies to date have only demonstrated direct effects of immunomodulation on tumor cell survival. Our work explores methods of manipulating the microenvironment to treat ALL. Poly I:C is a dsRNA analog that has demonstrated a direct effect on tumor growth via IFN pathways, and giving it anti-leukemic effects. However, this siRNA has not been studied on primary stroma in the ALL population, thus no complete understanding of its genetic microenvironmental effect has been offered. Objectives: To determine whether Poly I:C is an siRNA that (1) upregulates IFIT1 gene expression as a measure of activation of interferon pathways and (2) indirectly induces acute lymphoblastic leukemia cell tumor cell death by way of altering primary stromal gene expression. Design/Method: (1) Reverse transfection of 3 different stromal cell lines, RNA extraction, cDNA synthesis, followed by quantitative PCR to determine poly I:C siRNA mediated upregulation of IFIT1 gene expression. (2) Transfection of three primary stromal cell lines with poly I:C, followed by cell washing, and subsequent ALL cell plating. ALL cell survival will then be measured by flow cytometry. Results: (1) Poly I:C induced IFIT1 gene expression in stromal cells. (2) ALL cells underwent apoptosis in the presence of Poly I:C treated stromal cells. Conclusion: Poly I:C dramatically reduces the capacity of nonmalignant stromal cells to support the viability of primary ALL cells. This finding suggests that drug targeting of marrow stromal cells may provide new approaches to control ALL. Current studies in the lab are exploring the key changes in gene expression pathways induced by Poly I:C in nonmalignant stromal cells that lead to ALL cell death.

Background: Bone marrow (BM) niche cells, specifically the Leptin-receptor-expressing perivascular stromal cells (LepR+), CXCL12-abundant reticular cells (CAR), and endothelial cells, play an essential role in the maintenance and self-renewal functions of hematopoietic stem cells (HSCs) . A number of secretory-related molecules like stem cell factor (SCF), CXCL12 and Angiopoietin mediate this maintenance function. In addition, functional autophagy within HSCs is known to play a critical role for maintaining HSC homeostasis, as the loss of ATG7 in HSCs leads to loss of normal HSC functions and severe myeloproliferation. However, it remains unclear as to how hematopoiesis will be affected if autophagy is selectively blocked in bone marrow niche cells.

Objectives: To investigate the effect of autophagy deficiency within bone marrow niche cells on hematopoiesis. Design/Method: A knockout mouse model was generated allowing for a selective ablation of an autophagy-essential protein, ATG5, in LepR+ perivascular stromal cells.

The deletion of Atg5 is indeed restricted to LepR+ cells, and this loss of ATG5 is sufficient to block autophagic function, was evident by accumulation of p62 protein.

The white blood cell count (WBC) is significantly reduced in 16-week old male ATG5 KO mice compare to wild type (wt) control mice (p<0.05). Further, the myeloid population (CD11b+Ly6G+) in both bone marrow and peripheral blood is significantly decreased in ATG5 KO mice (p value < 0.05, ATG KO vs. wt control). WBC count continued to decline in 24 week old ATG5 KO male mice. Both LSK (Lin-Sca-1+c-Kit+) and long term HSC (LT-HSCs, CD150+CD48-LSK) populations are decreased in both 16-week and 24-week old male mice; however, this trend did not reach statistical significance. . Although the absolute cell count of lymphocytes, including B and T cells (CD19+ and CD3+, respectively) in peripheral blood, is significantly dropped in ATG5 KO mice compared to wt controls, there is no significant change of mature B and T cells in bone marrow. Conclusion: Preliminary results suggest deletion of a key autophagy regulator in LepR+ bone marrow niche cells will cause leukopenia. The underlying mechanism is currently under investigation and it will help us to better understand the role of autophagy in hematopoiesis within the BM microenvironment.

Cathy Lee-Miller, Lori Gardner, Jennifer Rabe, Susan Zelasko, Courtney Jones, Christopher Porter

Background: Immunologic evasion is one of the hallmarks of cancer, but the mechanisms by which leukemia evades the immune system are incompletely understood. Our lab has found that calcineurin in BCR-ABL+ leukemia cells acts as a potent mediator of immune evasion during leukemogenesis. When the essential subunit of calcineurin is knocked down, immune competent hosts are able to suppress leukemia outgrowth but immunodeficient hosts succumb to disease. We hypothesize that BCR-ABL activates calcineurin and NFAT (Nuclear Factor of Activated T cells). Objectives: To determine BCR-ABL's role in the activity of calcineurin, as measured by NFAT activity. Design/Method: Baf3 cells were transduced with either empty vector MiG or p190 (BCR-ABL+). Cells were kept in culture and exposed to varying doses of PMA and ionomycin in order to stimulate them. Calcineurin activity was measured via analysis of NFAT, a known downstream effector of calcineurin. Experiments to measure NFAT expression include western blot to assess protein and phosphorylation, real time PCR to assess NFAT dependent transcripts and an NFAT reporter assay to assess transcriptional activity. Results: NFAT activity is increased in BCR-ABL+ cells as compared to control MiG cells, as is evidenced by increased total protein as well as activated protein. Increasing doses of PMA and ionomycin also lead to higher levels of NFAT in both MiG and BCR-ABL+ cells, but is more pronounced in the BCR-ABL+ population. Conclusion: There is more total NFAT and activated NFAT protein present in BCR-ABL+ leukemia cells vs control, suggesting that BCR-ABL activates calcineurin.

Studies are ongoing to determine if higher levels of protein lead to an increase in NFAT transcriptional activity and mRNA in BCR-ABL+ leukemia cells as compared to MiG. This increased activity may play a role in the ability of BCR-ABL+ leukemia cells to evade the immune system.

ASPHO ABSTRACTS POSTER #547

Background: Von Willebrand disease (VWD) is a common inherited bleeding disorder characterized by incomplete penetrance and variable expressivity. We phenotypically and genetically characterized a 2,000-member Amish pedigree with autosomal dominant VWD type 2M. Sequence analysis of VWF revealed heterozygosity for a missense mutation at position c.4120 (C>T) in 134 individuals. Even with an identical genetic mutation in VWF, these individuals show great variability in bleeding tendencies as measured by a quantifiable score provided by bleeding assessment tools (BAT). Objectives: To identify biologic and genetic variants outside of VWF that influence bleeding in VWD. Design/Method: Whole exome sequencing was performed in 16 members of the family (age and sex matched) that carry the R1374C mutation (7 with the least severe bleeding and 9 with the most severe bleeding). ANNOVAR, a software tool used to functionally annotate genetic variants, was utilized to analyze each variant and predict the effect on protein expression. Concurrently, we analyzed plasma from 12 of the above individuals using SomaLogic proteomics technology to quantify >1,100 proteins that are potentially associated with processes that are involved in bleeding. Ingenuity Pathway Analysis (IPA) was used to interpret results. Results: IPA analysis revealed differential protein expression within several pathways, of which the most significant include cellular movement (p-value 5.46 E-03), immune cell trafficking (p-value 8.44 E-03), and hematologic system development and function (p-value 9.61E-03). Within these pathways, proteins involved in cell adhesion (i.e. MMP2, VCAM1 and FN1), coagulation (i.e. PLG), and inflammation (i.e. IL1A, IL17A, and CD86) were differentially expressed between high and low bleeders. Analysis of whole exome sequencing revealed 93 genetic variants that were enriched in one group compared to the other. Interestingly, several of these variants correlated to pathways identified in the proteomic data, including KNG1, SELPLG, FGB, STAB2, C4BPA, and GP6. Conclusion: Preliminary analyses show a high prevalence of genes involved in inflammation, cell adhesion and the hematologic system that may be associated with bleeding variability within this Amish family. Further work will focus on replicating these variants in the rest of the members of the family, both affected and unaffected, as well as in hundreds of available unrelated cases with VWD. Background: Inhibition of MERTK with the small molecule inhibitor MRX-2843 decreases tumor burden and prolongs survival in acute leukemia cell line and patient-derived xenograft models. However, while treatment with MRX-2843 reduces leukemia in peripheral blood and spleen, it is less effective in clearing the bone marrow of leukemic blasts. Gas6, a MERTK, Axl, and Tyro3 ligand, is a poor prognostic factor in AML, mediates increased resistance to cytotoxic chemotherapy in leukemia cells, and is present in the bone marrow stroma. Objectives: To determine if bone marrow stromal cell Gas6 induces resistance to MRX-2843. Design/Method: Acute leukemia cell lines were cultured in the presence of Gas6-producing fibroblast-like cell lines or bone marrow derived stromal cells (BMDSCs) from wild type or Gas6 knockout mice. Axl-Fc was added to co-cultures to bind and deplete Gas6. Induction of apoptosis and cell death was determined by flow cytometry after treatment with MRX-2843 or vehicle. Expression of MERTK and related kinases AXL and TYRO-3 was determined by immunoblot. Results: Co-culture with Gas6-expressing cell lines significantly reduced leukemia cell death in response to treatment with 300 nM MRX-2843 compared to leukemia cells alone (18.25% versus 93.09%, p<0.001). The protective effect was dose-dependent and reduced by titration of Gas6 with 1 uμg/mL Axl-FC (7.4% versus 16.5%, p = 0.022). Similarly, BMDSCs from wild-type mice protected leukemia cells from MRX-2843 induced cell death more effectively than BMDSCs from Gas6 knockout mice (4.28% versus 72.39%). Immunoblot analysis demonstrated increased expression of TYRO-3 in leukemia cells in response to co-culture.

The MERTK ligand Gas6 is produced by fibroblast-like cell lines and BMDSCs and mediates protection of leukemia cells from cell death induced by MERTK inhibition with MRX-2843. Gas6 depletion using genetic (GAS6 knock-out mice) and biologic (Axl-Fc) strategies decreased resistance of leukemia cells to MRX-2843 in the presence of stroma. These data are consistent with a mechanism by which increased expression and activation of Tyro3 and/or Axl promotes cell survival and resistance to selective MERTK inhibition. Further, combined treatment with MRX-2843 and a bone marrow mobilizing agent may be an effective therapeutic strategy.

Novo Nordisk, Inc., Plainsboro, New Jersey, United States Background: Noonan Syndrome (NS) is a genetic condition (1 in 1,000-2,500 individuals) that involves characteristic facial features, short stature, congenital heart defects, skeletal anomalies, developmental delays, and bleeding problems. Hematologists may be called upon to evaluate children with NS for bleeding abnormalities, particularly since many of the patients may undergo multiple surgeries beginning in early childhood.

Objectives: The aim of this systematic review was to identify specific laboratory findings and bleeding disorders in NS to inform the appropriate scope of diagnostic workup. Design/Method: Publications reviewed were from 1965-2014 including trials, case reports/series, and reviews identified via Medline, EMBASE, and Scopus. NS patients included in the analysis were from studies where a presumed bleeding disorder or bleeding phenotype were described. All available patient data were abstracted including demographics, bleeding symptoms, lab abnormalities, bleeding score and specific disorders reported.

Results: From 45 studies identified, 31 had relevant data from 428 NS patients. Nearly half (49%) were male; 43% had reported bleeding, 26% no reported bleeding, and 31% had no data on bleeding. Most (90%) had some reported bleeding laboratory test abnormalities, but only 45% had a specific diagnosis reported. Abnormal laboratories included prolonged PT (6.8%), aPTT (17%), PT/aPTT (5%) and platelet-related (10%). While 153 (79%) had single factor deficiencies, vWD or platelet disorders, 41 (21%) had multiple deficiencies. Overall, factor XI deficiency was most common (81) followed by platelet abnormalities (46), factor XII (34), and factor VIII (28). Factors XI+XII (11) and XI+VIII (7) were the most common combined disorders. Conclusion: These results support the importance of identifying bleeding disorders in patients with NS early in childhood, and particularly pre-operatively. The wide span of disorders and frequent presence of multiple disorders, from factor deficiencies to platelet function disorders and vWD, suggests screening needs to go beyond PT/aPTT and platelet count and should include assessment of platelet function. These results highlight the importance of early consultation with a pediatric hematologist specializing in coagulation disorders, and the need to rigorously document the extent of the work-up to accurately describe the types of disorders ruled-out.

Background: The receptor for hyaluronic acid mediated motility (RHAMM, CD168) has been identified as one of the leukemia associated antigens. There have been studies in which RHAMM alone or in association with CD44 and other proteins promote invasion and inhibition of apoptosis. Paediatric acute lymphoblastic leukemia (ALL) has good prognosis whereas acute myeloid leukemia (AML) does not. There is a lacunae in the study of RHAMM expression and its prognostic significance in pediatric acute leukemias. Objectives: To study the expression of RHAMM in paediatric acute leukemias and its prognostic significance. Design/Method: Paraffin blocks of 73 bone marrow trephine biopsies of paediatric acute leukemias were processed for immunohistochemistry by standardized automated technique. The primary antibody used was ABCAM USA. The relative proportion (percentage) of positively stained tumor cells was quantified by three observers. Blast percentage was done in the bone marrow aspirate taken at day 8 of induction to assess the immediate response. The percentage of RHAMM positive cells and the response to induction therapy were correlated. The clinical follow up of the cases with Kaplan-Meier plot and the initial RHAMM expression were also correlated. Results: AML: ALL ratio was 1:5 and the male: female ratio was 2:1. The mean age was 9.2 years (ALL) and 8.8 years (AML). The expression of RHAMM in AML was more than the expression in ALL. The blast percentage after induction therapy, relapse and the prognosis when correlated showed statistically significant negative correlation in both types of leukemia. The presence of more than 10% RHAMM positive cells in the initial biopsy correlated with residual disease, relapse and bad outcome. Conclusion: Significant negative prognostic effect of RHAMM expression is evident in acute pediatric leukemias. The expression was more in AML than ALL. Hence this marker maybe included in the diagnostic panel so that the parents of the patients can be counselled and the treatment can be intensified for a better prognosis. Evolution of an inhibitor for this marker as a promising targeted therapy for these patients warrants further research.

Kai Jacobson, Clifford Takemoto, Brandyn Lau, Ruchika Goel, Ricardo Velazquez, Raminder Chadha

Background: Hospital-associated VTE (HA-VTE) is associated with increased morbidity. There is a paucity of prospectively validated risk stratification tools for venous thromboembolism (VTE) in hospitalized children.

Objectives: To evaluate the performance an electronic VTE risk assessment in pediatric patients Design/Method: In August 2013, a VTE screening tool was incorporated into the computerized admission order sets for patients < 21 years hospitalized at the Johns Hopkins Children's Center. NICU patients were excluded. Assessment of mobility, VTE risk factors and bleeding risk was required for patients >14 years, and in all ages with prior VTE history or provider concern for VTE. Patients were stratified into 3 risk groups based on a score that incorporated age, immobility and risk factors. Pharmacologic prophylaxis was recommended for patients at high VTE risk, mechanical prophylaxis for moderate VTE risk or high VTE risk with bleeding risk, and no prophylaxis for low VTE risk. HA-VTE was defined as 1) VTE diagnosed ࣙ48 hours after hospital admission or 2) VTE diagnosed within 90 days of hospital discharge. Patients with HA-VTE were identified by ICD9 coding and chart review. Results: During 16 months from August 2013 to January 2015, a total of 13,067 patients underwent electronic VTE risk assessment. Provider compliance with completion of screen within 24 hours of admission was 97%. We identified 38 HA-VTE cases for a rate per 10,000 admissions of 29 (95%CI 21-40), similar to a rate of 25 (95%CI 21-29) observed from 2006 to 2013, prior to implementation of the screening tool. The rate of HA-VTE per 10,000 admissions increased with VTE risk: low risk rate was 17 (95%CI 11-26); moderate risk 78 ; high risk 350 (95%CI 188-592). Bleeding was assessed during a 4 month period; the relative risk for patients receiving pharmacologic prophylaxis was 9.9 (95%CI 3.8-25.3) for all bleeding and 6.8 (95%CI: 2.2-20.6) for major bleeding. Conclusion: An electronic VTE risk assessment tool identified patients at increased risk of HA-VTE. However, VTE rates have not significantly decreased with implementation of the screen, and increased bleeding was associated with pharmacologic prophylaxis. Additional studies are needed to improve risk assessment and prevention strategies. trial, including 34% of younger patients and 24% of older patients, which was statistically significant (P = 0.002). The differences between these rates and those from prior years in both age groups (38% and 27%, respectively) were not statistically significant (P = 0.15, 0.53). In our current data, the most common reason for the low enrollment rates was once again the lack of an open therapeutic trial. There were no statistical differences between the groups when other factors were analyzed. Conclusion: Despite initiatives at CHP and on the national level to enroll more AYA patients on clinical trials, our most recent data shows no improvement. The cause is multifactorial, but the primary reason we have found in our institution is the lack of an open clinical trial. This is a potentially remediable factor that needs to be prioritized nationally by the pediatric and medical oncology community. Objectives: To understand the role of cellular phosphorylation status and the influence of mutation (S34F) in the U2AF1 splicing factor on CSF3R splicing, specifically related to Class I vs Class IV. Design/Method: To study the effect of splicing factor mutations on CSF3R splicing, we constructed a minigene consisting of 5' exon of the CAT gene with an ATG site and a partial intron fused to intron region of CSF3R upstream of Exon 17. The retained intron is present in the exon 17 of CSF3R. We transduced 293FT cells with the minigene ± wild-type U2AF1 or U2AF1 S34F mutant. Cells were treated with sodium orthovanadate (Na3VO4) or phorbol myristic acetate (PMA). Na3VO4 inhibits tyrosine phosphatases, whereas PMA promotes activation of the protein kinase C pathway. qPCR was used to determine the expression of Class I and Class IV expression. Results: U2AF1, SRSF2 and SAM68 sites were identified in the nucleotide sequence of the spliced intron. We found that inhibition of tyrosine phosphatase activity by Na3VO4 resulted in increased intron excision, but PMA did not. The data suggest that tyrosine phosphorylation is important for intron excision. Exogenous expression of U2AF1 S34F showed a decrease in intron excision, suggesting that the mutation inhibits Class IV transcript formation. Background: Prophylactic factor replacement therapy is increasingly utilized to prevent bleeding complications in severe hemophilia. Increased prophylaxis utilization may lead to decreased admissions for bleeding complications and may alter inhibitor epidemiology. Publication of the "Joint Outcomes Study" (JOS) a phase 3 randomized controlled trial of primary prophylaxis in 2007, demonstrated that prophylaxis significantly improves joint outcomes in children with moderate to severe hemophilia A. The high-impact nature of the JOS offers an opportunity to study the epidemiological consequences of increasing prophylaxis use. Objectives: To determine differences in admissions for bleeding episodes and inhibitor bypassing therapies (a surrogate marker for inhibitors) as well as length of stay (LOS) and intensive care (ICU) utilization between timeframes before and after publication of the JOS. (14) were not included to avoid bias related to randomized prophylaxis during the active study period. Data from the remaining hospitals (43) were evaluated. Discharge diagnoses, defined by ICD-9-CM (international classification of diseases, 9th revision, clinical modification), along with medication charges were utilized to define bleeding episodes and bypassing therapies.

Results: There was no significant trend in bleeding episodes (bleeding diagnosis and use of factor replacement) or bypassing therapies. The overall LOS was shortened from 5.1 days to 4.5 days (P = 0.0009) and ICU stays decreased from 7% to 3.5% of admissions (P = 0.002) in the post-JOS era. Conclusion: This study demonstrates a decrease in overall hospital LOS and ICU utilization in the post-JOS era. There was no increase in bypass therapy utilization, suggesting that the incidence of inhibitor formation remained stable. These findings cannot be directly attributed to changes in practice resulting from publication of the JOS, since hemophilia severity and utilization of prophylaxis cannot be directly determined from PHIS. However, they suggest that increasing utilization of primary prophylaxis may decrease inpatient utilization without altering inhibitor epidemiology. Objectives: Here we describe the use of CRIPSR (clustered regularly interspaced short palindromic repeats)/Cas9 technology to create mutants in the epigenetic regulator chd1 (chromodomain helicase DNA-binding protein 1) in zebrafish. Chd1 is known to interact with the spliceosome. Our studies will determine the in vivo importance of this interplay in hematopoiesis. Design/Method: To create double-strand breaks in the chd1 gene in zebrafish, in vitro transcribed guide RNA specific for chd1 and Cas9 protein were microinjected into fertilized zebrafish embryos. These injected F0 founder fish were then mated to generate F1 carriers. The F1 progeny were screened for the presence of a mutated chd1 by performing polymerase chain reaction (PCR) to amplify the target region followed by a T7 endonuclease assay for detection of indels. Exact mutations were identified by cloning and Sanger sequencing followed by bioinformatics analysis. Results: From 13 screened F1 fish, 10 were found to carry mutations in chd1. Of those with mutations, 7 had mutations that are predicted to disrupt protein function through introduction of premature stop codons. Trans-heterozygous chd1 mutant F1 fish were incrossed and no defects in overall morphology or survival were noted, in line with our previous observations using morpholino-antisense oligonucleotide knockdown of chd1. Homozygous mutants for chd1 are now growing and will be characterized for hematopoietic defects and interactions with spliceosomal factors. Conclusion: Use of Crispr/Cas9 technology in zebrafish is an effective way of creating gene-specific mutations in MDS/AML factors to determine their in vivo contribution to disease. Understanding the pathophysiology and interaction between spliceosomal mutation and epigenetic factors will help identify prognostic factors and potentially guide treatment in MDS and AML. , with mild and rest were with severe disease. Family history was positive in 51% and in all the patients who presented before 6 months of age had severe hemophilia. APTT was prolonged in all the patients with the mean value of >1 minute. Severity of disease and family history has significant relation at p<0.005, while relation between severity of disease and the age at diagnosis is significant but compromised at p = 0.05, i.e. critical line. Post circumcision bleed (45.5%) was observed prominently as primary symptom followed by bruises and epistaxis, respectively. Life threatening bleed was reported in 9% and about 66% developed hemarthrosis. Only 2 patients had APTT done before circumcision. Most of the patients were on demand factor replacement therapy (74.6%) and only 5.4% of them were on primary prophylaxis. Conclusion: On the basis of early presentation and family history we can predict the severity of the disease. Performing PT/APTT before circumcision in all children is cost effective screening investigation as early diagnosis, adequate and timely prophylaxis can prevent early and late complications.

Background: The continued emergence of cellular therapies to treat precursor-B cell ALL has evolved to include patient-derived T cells that have genetically modified to express chimeric antigen receptors (CAR) which bind to CD19 on lymphoid leukemic blasts. There are reports of using CD19 expressing cell lines in chromium release or FACS assays, however the use of patient derived blasts in such experiments has been elusive.

Objectives: To identify a rapid assay to assess cytotoxicity for development of future CAR-T cells Design/Method: Cytotoxicity assays were set up with populations of effector and target cells. Effector cell populations were T cells collected from 2 pediatric pre-B ALL patients and 2 healthy donors. CAR-T cells were manufactured using T cells from the same 2 healthy donors transduced with a retroviral vector containing CD19-CAR. Target cell populations: 1) CD19+ cell line (Nalm6), 2) bone marrow from 2 patients with pre-B ALL, and 3) T cells from 2 healthy donors. Effector and target cells were co-cultured for 4 hours at increasing effector to target (E:T) ratios (0:1 to 20:1). Co-cultures were stained to identify dead cells and analyzed by FACS. The percentage of living target cells (LC) in each assay was averaged and the percent difference (d = LC0-LC20/LC20) in killing was calculated using these averages.

Results: Nalm6 cells when co-cultured with the 4 untransduced effector populations had 80 percent difference in killing (LC0 75%, LC20 15%). 2 populations of CAR-T cells had an 89 percent difference in killing of Nalm6 cells (LC0 83%, LC20 9%). Target cells from a healthy donor showed no difference in percent killing when cultured with untransduced effector cell populations and CAR-T cells (d = 6%). Leukemic blasts from bone marrow had a 21 percent difference in killing when cultured with untransduced effector cells from E:T of 0:1 to 20:1 (LC0 82%, LC20 65%) compared with 30 percent difference in killing with CAR-T cells (LC0 87%, LC20 60%). Conclusion: There is amplified killing of a patient's leukemic blasts by CAR-T cells compared with untransduced cells. We have plans to continue to use this novel assay to specifically measure the cytotoxicity of iPS derived CAR-T cells against CD19 blasts collected from pediatric patients. complete the decision regret scale (a 5-item tool scored from 0 "least regret" to 100 "most regret"); and complete the Decision Making component of the pediatric family satisfaction with intensive care unit (pFS-ICU) scale (a 10-item tool scored on a scale from 0 "least satisfied" to 100 "most satisfied"). Results: We received admission and discharge questionnaires from 20 parents of 16 patients. Patients ranged in age from 1 to 17 (mean 8.9) years. Of the patients enrolled, 44% of patients (n = 7) had hematologic cancers and 56% (n = 9) had solid tumors.

Parents identified that important decisions made for their child involved: medications; use of radiation; use of medical devices; surgical procedures; and general care plans. 65% (n = 13) of parents reported receiving help communicating with doctors about decisions. Parents identified bedsides nurses (n = 8); residents (n = 2); fellows (n = 3); social workers (n = 3); chaplains (n = 2); and doctors or subspecialties (n = 2) as helpful in their decision making process. The average decision regret score was 9.4 (range 0-50), and the average pFS-ICU DM score was 81.5 (range 51 -100 (1) lived illness experiences during the first 1-6 months, (2) the acceptability of engaging in a novel in-depth conversation with the primary pediatric oncologist, the "Day 100 Talk," (D100) during this period, and (3) preferred topics and goals for D100. Design/Method: We conducted semi-structured interviews with children aged ࣙ13 years and parents of all-aged children with non-relapsed cancer undergoing treatment for 4 weeks to <7 months. Sampling, interviews, and constant comparative qualitative analysis were informed by grounded theory. Results: Five of 10 (50%) adolescents and 6/11 (55%) parents participated in interviews.

Five participants or children of participants had solid tumors, 3 had brain tumors, and 3 had hematologic malignancies. Mean treatment duration was 10 (+/-4) weeks. Emergent themes reflected a combination of relative normalcy during early treatment ("you have off weeks"; "they still fight") and a "new normal," composed of cancer care, new relationships, and altered daily lives. Participants speak of emerging "out of the woods" and getting their "sea legs" during this early treatment period, and so are able to engage with their care differently than at diagnosis. Frequently, one parent takes charge of the ill child's care while the other maintains work and home life. This role division leads to different information needs for members of the same family. Overall, parents endorsed D100 (5/6, 83%) more than adolescents (3/5, 60%), though all adolescents endorsed the desire to discuss the future. Participants suggest D100 could serve to 1) reflect on progress; 2) consolidate illness understanding and create shared understanding between family members with different roles; 3) ensure the current treatment path is still "right," and 4) manage transitions, such as from hospital-based to home-based care. Results: Deficiencies of fibrinogen, FV, FVII, FX and FXIII were diagnosed in 19 pediatric patients (9 males and 10 females), accounting for 10.8 % (19/176) of all children with inherited coagulation factor deficiencies. Hypofibrinogenemia and FV deficiency were the commonest disorders diagnosed in 8 and 5 patients respectively. The age ranged from 3 days to 6 years and consanguineous marriages were found in 16/19 cases (84.2%). The clinical spectrum varied from mild mucocutaneous bleeding to serious sight-threatening intraocular hemorrhage in a neonate with afibrinogenemia. As an initial presentation, intracranial hemorrhage occurred in 6/19 cases (31.6%). Two patients; one with FV deficiency and another with FXIII deficiency suffered from global developmental delay due to severe intracranial hemorrhage in early infancy. As regards management, 4 patients with severe FV deficiency and one with severe FXIII are on fresh frozen plasma (FFP) prophylaxis. Other patients receive on-demand therapy.

In conclusion, children with RBDs constitute almost one tenth of cases of hereditary coagulation factor deficiencies in our centre. They have some unique features in terms of severity, clinical profile and the need for prophylaxis early in life. We recommend establishing a national/regional registry of RBDs in collaboration with other centres. This will serve to identify the epidemiology, clinical presentations, genotype-phenotype correlation and therapeutic options of such rare, yet significant disorders in this part of the world. We also retrospectively reviewed data from pediatric oncology patients who had undergone PET scans at our institution to identify features most likely associated with BAT uptake. Design/Method: Propranolol 20 mg (0.1-0.4 mg/kg) was given one hour prior to FDG injection. Vital signs, blood glucose measurements, and symptom assessment were performed before and after scanning. Images were reviewed by a blinded radiologist. Charts were retrospectively reviewed from 76 additional patients to assess whether gender, age, body mass index (BMI), or season of year predicted FDG uptake in BAT.

Results: Nine patients received propranolol (median age 18 years, range 14-24). No clinically significant changes were observed in blood pressure, heart rate, or serum glucose following propranolol administration. No patient had observed or subjectively reported adverse events. Four patients with previous uptake in BAT had none following propranolol. In the retrospective review of 85 total patients (median age 15 years, range 7-29), BAT uptake was identified in 57% of patients. On multivariate analysis, lower BMI was the only factor associated with BAT uptake (p = 0.0087). Conclusion: Propranolol was convenient and safe in fasting pediatric oncology patients undergoing PET scans, and effectively eliminated BAT uptake in 4 patients who had this finding on previous scans. Lower BMI was the most important factor in predicting BAT uptake. Future studies could target patients with low BMI, and compare the efficacy of propranolol with other drugs like fentanyl which have been used to reduce BAT uptake. After correction for multiple testing, DARC SNP rs3027012 was associated with low absolute phagocyte count (APC<500 and <1000 cells/μL, p = 0.009 and p = 0.0005, respectively) and hospitalization due to neutropenia (p = 0.004). We also observed an association among rs862996 (upstream DARC variant), chemotherapy cessation due to neutropenia (p = 0.004) and APC< 500 cells/μL (p = 0.008). SNPs in the ORMDL3-GSDMA-CSF3 locus were associated with hospitalization due to infection (rs3859192, p = 0.004), and hospitalization due to infection and neutropenia (rs17609240, p = 0.003, rs25645, p = 0.003 and rs2227319, p = 0.005).

This study identifies for the first time that loci modulating WBC and neutrophil count may play a role in the onset of chemotherapy complications and may thus serve as markers for adjustment or follow-up of the treatment of childhood ALL. Biomarkers and lab values were analyzed by unpaired t-test by comparing pre and post treatment to determine differences between biomarker concentration and treatment. Results: Trefoil factor 3 (TFF-3) was expressed at higher concentrations post cisplatin treatment when compared to pretreatment (p = 0.0049). No significance was found in the other biomarkers. Additionally, serum phosphorus levels were decreased post cisplatin treatment (p = 0.0268). Conclusion: TFF-3 is a member of the trefoil factor peptide family and is secreted by epitheliod cells of the urinary tract and the proximal and distal collecting ducts. In this study, children receiving cisplatin had significant changes in TFF-3 concentrations post cisplatin treatment. Serum creatinine did not change post cisplatin treatment. This suggests TTF-3 may be a sensitive biomarker of acute kidney injury secondary to cisplatin. Background: Tobacco use increases the risk of lung and many other tobacco related cancers, with higher risk conferred by longer duration and more intensive tobacco use. Further, tobacco use is associated with other adverse health outcomes, such as cardiovascular disease, stroke, chronic obstructive pulmonary disease, and decreased physical fitness, all of which may result in shortened life span. More than 90% of smokers initiate tobacco use prior to the age of 18 years and more than 42.1 million adults currently smoke in the U.S. The rate of cigarette smoking remains higher than the national average in Tennessee. Starting in 2013 and using Tobacco Master Settlement funding, the Tennessee Department of Health initiated a goal to further integrate tobacco cessation interventions into community primary care clinics. However, several barriers arose to successful promotion and integration of community tobacco cessation. Objectives: The objective of this study was to identify common barriers to integrating successful community practice-based tobacco prevention and cessation interventions and develop an action plan to facilitate successful program establishment. Design/Method: Semi-structured, key informant interviews were conducted with seven Tennessee county department of health directors to assess facilitators and barriers to implementation of evidence-based tobacco cessation interventions within community primary care practices. Facilitators or barriers were organized into themes that included intra-personal factors, institutional factors, and community factors as defined by the socio-ecologic model.

The barriers elucidated included time constraints, documentation challenges, organizational culture, resource availability and allocation, leadership approval, and lack of partnerships. The barriers identified in this study highlighted the need for an organized action plan to facilitate integration of a tobacco cessation intervention. The action plan developed includes: 1) an effective program champion; 2) utilization of local data; 3) adequate staff resources; 4) community education; and 5) strategic planning with key stakeholders. Conclusion: Leveraging strategies to offset common barriers to the integration of tobacco cessation interventions are essential to establish practical, evidence-based tobacco cessation and prevention programs into clinical practices. Background: Despite major advancements in pediatric leukemia therapy, toxicities are still a concern and morbidity from chemotherapy regimens has been detrimental. Advances in genomic research as well as precision medicine have helped identify specific mutations that may be susceptible to targeted therapy in patients with leukemia.

Overall, the use of targeted drug therapy is rising in the pediatric oncology field. Objectives: To complement genomic analysis of leukemia patients, our laboratory is developing a drug sensitivity and resistance screening assay that would provide clinically relevant drug response data of the patient's leukemia cells. Design/Method: As part of our lab's development of this assay, we first prepare pre-dosed library plates of clinically active drugs. Cells are added to these plates and treated for 72 hours at which time cell viability is determined. Preliminary work in our laboratory used a library of 56 anti-cancer and targeted agents, which were tested on 16 AML cell lines and 8 ALL cell lines. Biological replicates were performed for each cell line and drug response data in the form of IC50s and Area Under the Curve (AUC) were calculated. Hierarchical clustering was performed to determine similar responses between cell lines and drugs.

Our results identified several cell lines that showed hypersensitivity to specific drugs. Among them, the AML cell line KG-1a showed sensitivity to three FGFR inhibitors including Ponatinib, which was previously reported. Validation of the screening results was done using a 10-concentration drug dose response assay. Conclusion: Further testing will include expansion of our drug library and application to ex vivo patient samples. The results from these studies can lead to the establishment of a drug sensitivity and resistance assay that could provide specifically engineered therapies for each patient. This form of precision therapy would lead to diminished toxicities from systemic therapies as well as allow for increased cure rates. Background: Acute myeloid leukemia (AML) comprises 5% of pediatric cancers and reports 5-year event free survival (EFS) of approximately 50% and overall survival (OS) of 60-70% following intensive multi-agent chemotherapy (1) . Anthracyclines are the cornerstone in treatment of AML; however, they are associated with both acute and late cardiac toxicities. Nearly 1 in 10 pediatric patients receiving anthracyclines may develop congestive heart failure (CHF) with higher incidences when cumulative doses exceed 300 mg/m2 (3). Importantly, current AML treatment in children commonly includes anthracyclines doses that are in excess of those known to cause CHF. Objectives: Children's Hospital of Wisconsin (CHW) previously adopted a standardized clinical practice of administering dexrazoxane prior to any non-liposomal anthracycline beginning in 2011. We are reporting the differences in cardiac and treatment outcomes in children and young adults with AML treated with and without dexrazoxane at CHW from 2008 to 2013. Design/Method: A retrospective chart review of children ages 0 to 21 years who received chemotherapy for AML at CHW between January 1, 2008 and December 31, 2013 was performed. Data collected from the electronic medical record included such variables as: anthracycline administration, echocardiogram measurements and relapse status. Statistical analyses were conducted using SAS statistical software version 9.2 with two sided p value of ࣘ 0.05 considered statistically significant. Data was expressed as frequency count and percentage for categorical variables.

Results: A total of 44 patients, median age 8.3, were included with 28 (64%) who received dexrazoxane and 16 (36%) who did not. There was no statistical difference in the EFS or OS. There was a significantly higher ejection fraction, lower shortening fraction, and higher left ventricular systolic volume in patients who received dexrazoxane.

In summary, utilization of dexrazoxane prior to anthracycline chemotherapy in pediatric patients with AML demonstrated no significant difference in either EFS or OS relative to our institutional historical controls and appears to improve cardiac function. While promising, further studies in this patient population are needed to confirm these findings. While it was successful in identification of one medication error before it reached the patient, 19% of prescriptions were not verified. Since prescription bottles are usually obtained after a visit, verification of the actual bottles will require new workflows, such as additional clinic visits or uploading a picture via the patient portal. Involving the nurse in the review of oral chemotherapy not only identified a prescription error, but also highlighted issues within other aspects of patients' care, including a need for patient/family education and inconsistent documentation of the treatment plan. The inclusion of nursing in the review and management of oral chemotherapy has the potential to improve safety and outcomes for these patients. Background: Evidence-based guidelines do not exist for re-vaccination of childhood cancer survivors following chemotherapy. Objectives: To prospectively determine the response rate following re-vaccination with age-appropriate immunizations in this cohort of patients. Design/Method: We conducted a phase II, single center study of patients in remission following chemotherapy, excluding those who received an autologous or allogeneic HSCT. Immune recovery was defined by absolute CD3+4+ >200 cells/μL, T cell proliferative response to PHA> lower limit normal, and IgG>500mg/dl without supplementation of IVIG. Response to vaccine was defined as seroconversion to a positive titer. Results: Seventy-five patients, 1.1 -19.6 years (median, 9.2 years), 35 males, were enrolled at a median of 4.8 months (range, 3-20.5 months) post-chemotherapy. Patients had ALL (SR = 7, HR = 17); AML (n = 6); Hodgkin Lymphoma (n = 16); Non-Hodgkin Lymphoma (n = 4); CNS tumor (n = 17); retinoblastoma (n = 3); germ cell tumor (n = 3); embryonal rhabdomyosarcoma (n = 1); and Wilms tumor (n = 1). Thirty-six patients completed all planned vaccines and follow-up serologic testing, 19 completed at least 75%, 22 completed less than 75%; reasons for incomplete participation included relapse, poor compliance or death. Time to start vaccination ranged from 3 to 21 months (median, 3 months). At base-line, protective titers were absent for 10-25% patients for polio, tetanus, diphtheria, 30-60% MMR, varicella, hepatitis B, haemophilus influenzae B, >90% for meningococcal (A, C, W and Y), pneumococcal and pertussis. Seropositivity for tetanus, diphtheria, polio, haemophilus influenzae B, hepatitis B, and pneumococcal was >98% at the completion of the trial. The rate of seropositivity for the remaining pathogens were pertussis, 52%; meningococcal A, 94%, C, 58%, Y 61%, W 44%; measles, 69%; mumps, 73%; rubella, 82%; and varicella 72%. Primary disease type was not predictive of response. Conclusion: This study confirms poor residual immunity to many vaccine preventable diseases in childhood survivors of cancer. Re-vaccination with age-appropriate vaccines and schedule may provide protective levels for many pathogens. However, some patients continue to be at risk for pertussis, meningococcal (C,W and Y), MMR and varicella.

Stephen Nelson, Jennifer Lee, Michelle Allard, Bruce Bostrom

Background: The Children's Oncology Group (COG) has played a major role in improving survival in children with cancer. For most diagnoses, patients treated at pediatric oncology centers have much better outcomes, and children treated on standardized protocols do better than those who are not. The Project Every Child Protocol (APEC14B1) was recently launched by COG. This is a registry, eligibility screening, biology and outcome study that requires enrollment in order to participate in any COG treatment study. This requirement may lead to even fewer children of color being able to benefit from COG treatment protocols. Objectives: The goal of this study was to quantify the number of refusals to enroll in the COG registry ACCRN07 by race and ethnicity. Design/Method: We reviewed the database of oncology patients at Children's Hospitals and Clinics of Minnesota to find patients offered participation in COG study ACCRN07 between April 2008 and December 2015. Data was collected on race and ethnicity as well as refusal to enroll. Racial differences were evaluated using the Fisher exact probability test. Results: A total of 921 patients were offered enrollment on ACCRN07. Information on race/ethnicity was available for 869 children. Of these, 64 families refused enrollment (7.4%). Only 33 of 716 white patients refused enrollment (4.6%). Refusal rates were much higher for patients of color (20.3%, p<0.0001). Asian patients had the highest refusal rate (31.6%, p< 0.0001) followed by our black patients (21.2%, p = 0.0002). Bi-racial, Native American and Hispanic refusal rates were also higher, but only the refusal rate of our bi-racial patients reached statistical significance (p = 0.009).

Conclusion: The refusal rates to enroll in ACCRN07 were significantly higher for patients of color. This fact alone would not be of great concern if this did not immediately impact access to care and outcomes. The requirement to enroll on APEC14B1 will likely lead to even fewer children of color benefiting from COG treatment protocols. We would encourage COG to revisit the requirement for enrollment on Project Every Child Protocol (APEC14B1) as this will likely exacerbate the already inferior outcomes for our patients of color. were randomly assigned to receive their first HDMTX infusion as an outpatient or inpatient, with their second infusion in the alternative setting. A pediatric home health company provided HDMTX infusion oversight, supportive needs and skilled nursing care. Data included billed charges, out of pocket expenses, MTX levels and time to clearance, change in creatinine, antiemetic usage and emetic episodes with each patient serving as their own control in a matched-pairs analysis of each comparison. Outpatient subjects tracked emesis, urine pH and antiemetic usage on a standardized form. Results: Six outpatient and inpatient infusions were successfully completed. Comparing the outpatient to the inpatient HDMTX infusion in each patient, there was a significant reduction between out of pocket patient expenses (median (range) for a single infusion: $19(8-300) vs $231(40-600), p = 0.01)) and billable care charges ($2,550 (1, 197 ) vs $28,075(10,921-44,533), p = 0.004). Safety measures were similar between outpatient and inpatient infusions, including time to MTX clearance (48hr(48-72) vs 66hr(48-110), p = 0.18), change in serum creatinine from the start of HDMTX infusion to clearance (0.08mg/dl (0.0-0.12) vs 0.03mg/dl(-0.01-0.13), p = 0.48) and number of emetic episodes (0(0-1) vs 0(0-3), p = 0.46). Whereas the number of emetic episodes were similar there was a significant decrease in the number of doses of antiemetics in the outpatient setting (5(4-9) vs 18(4-29), p = 0.02).

In this feasibility study, outpatient HDMTX administration was safe and cost effective in pediatric patients with B-lineage ALL and more tolerable as evidenced by a significant decrease in antiemetic use. The objective was to describe CIPN and balance deficits longitudinally in children during and just following treatment for non-CNS cancers. The impact of diagnosis and chemotherapy type on CIPN were also investigated. Design/Method: Children (N = 66, mean age 11.4±3.5 years, 47% male) being treated for non-CNS cancer were assessed for Pediatric Modified Total Neuropathy Score (ped-mTNS) and balance (Bruininks-Oseretsky Test (BOT-2)) 3 to 6 months into treatment (based on diagnosis) and 3 and 6 month after completion of chemotherapy. Treatment was categorized by neurotoxic drug used (vincristine (V), V + Intrathecal Methotrexate (V+M), or V + Etoposide (V+E)). Results: Ped-mTNS scores decreased over time for the entire group (9.4 ± 4.5 initial, 6.0 ± 4.5 3 mo, 4.2 ± 3.6 6 mo, F = 38.14, p<0.001, effect size = 0.6). After adjusting for age and sex, when compared to those with ALL (N = 26), children with other solid tumors (OST) (n = 15), but not lymphoma (N = 25), had higher ped-mTNS scores during treatment (7.7 ± 3.1 ALL, 8.7 ± 4.6 Lymphoma, 11.8 ± 4.2 OST, F = 3.96, p = 0.02). 6-months post-treatment, both those with lymphoma and OST had higher peds-mTNS scores than those with ALL (2.3 ± 3.1 ALL, 5.7 ± 3.1 Lymphoma, 5.2 ± 3.1 OST, F = 8.38, p < 0.001). Children treated with V+E (n = 20), compared to V (n = 15) or V+M (n = 29), had the highest ped-mTNS scores during treatment (9.3 ± 1.0 V, 7.5 ± 0.7 V+M, 11.5 ± 0.9 V+E) and at 3 and 6 month follow-up. Over the same time period, balance scores improved (7.4 ± 3.3 initial, 9.1 ± 3.3 3 month, 10.3 ± 3.9 6 month, F = 11.75, p<0.001, effect size = 0.32) but never to population norms of 15.0 ± 5.0. Neither diagnosis nor treatment were associated with balance recovery at 6 months. Conclusion: While many children who experience CIPN from cancer treatment recover by 6 months post-treatment, those who are treated with vincristine + etoposide may have longer-term nerve dysfunction. All groups improved in balance over time, yet none achieve balance control comparable to population norms.

Nathan Hall, Terrie Flatt, Alan Gamis, Gerald Woods, Shannon Carpenter, Gary Doolittle

Background: The use of telemedicine in the pediatric hematology oncology population is greatly underutilized despite technologic advances that have made telemedicine visits as effective as in-person visits. Telemedicine is a resource that has the ability to lower the health care costs and bridge a geographic disparity that many patients and families face with a child that requires subspecialty care. However, the willingness to utilize telemedicine comes from both physicians and families. Objectives: Evaluate the cost and satisfaction of patients and families that could use telemedicine to deliver quality care to patients with hematology or oncology diagnoses that live in underserved areas. Design/Method: This is a cross-sectional study. Two subject groups aged 0-21 years old, with a Hematologic or Oncologic diagnosis that live >70 miles from Children's Mercy Hospital in Kansas City Missouri were evaluated in this study. The experimental group consisted of subjects who follow up at outreach clinics and have telemedicine capabilities. The control group are subjects who do not have outreach clinic options and must travel to Kansas City. A total of 32 patients per group were evaluated. The experimental group answered a cost analysis and a telemedicine satisfaction questionnaire following their telemedicine visit. Whereas the control group answered the same cost analysis and a utilization of telemedicine survey. Results: Study results are preliminary, and anticipated closure is February 2016. At this point in the study, the experimental group is noted: to have saved hundreds of dollars in out-of-pocket expenses, families have been able to miss less school and work, a majority thought the telemedicine visit was as good as an in-person visit, and a majority would be willing to utilize telemedicine with subsequent visits in comparison to the control group. Additionally, a majority of the control group would be willing to utilize telemedicine and they believe it would allow their family to save money, and miss less school and work. Conclusion: To our knowledge, this is the first cost-analysis and satisfaction survey evaluating the use of telemedicine in the pediatric hematology oncology population. Preliminary results favor future research investment in telemedicine to care for a subspecialized patient population in underserved communities. 

Ammonia is an expected product of Erwinia metabolism and symptomatic hyperammonemia has been previously reported as a rare occurrence, yet our findings indicate an increased incidence. Additionally, our data demonstrate a correlation between ammonia and asparaginase activity levels following Erwinia dosing. Furthermore, nearly all asparaginase activity levels were therapeutic despite dose reduction in some cases. Thus, this series provides sufficient evidence for further investigation to determine which patients require interventions to prevent symptomatic hyperammonemia, which patients may have ammonia levels used as an asparaginase activity surrogate and which patients may achieve equivalent efficacy with abridged dosing. Background: Expanded access, also known as compassionate use, programs provide an opportunity for select patients to access investigational drugs, biologics or medical devices outside a clinical trial. A successful expanded access application requires the treating physician to obtain agreement from the pharmaceutical company developing the investigational agent, authorization by the Food and Drug Administration (FDA), and authorization by the hospital's Institutional Review Board. These poorly understood and difficult to execute steps, especially in pediatric cancer cases, present barriers to obtaining access to investigational drugs via expanded access programs. Objectives: To create an intervention to help pediatric providers make more informed decisions regarding expanded access based on analysis of available resources and assessment of pediatric oncologists' experiences and challenges with expanded access applications. Design/Method: Analysis of current regulatory framework and review of literature focusing on the pediatric oncology expanded access process and physician experiences. A survey was developed to assess pediatric oncologists' experience and knowledge about the expanded access application process.

The FDA is in the process of simplifying the approval application form for expanded access and there is currently a bill under consideration by the U.S. Congress to reform expanded access programs. However, there remains a lack of data on physicians' experiences and barriers affecting use of expanded access programs. In addition, there is a paucity of support for physicians to guide them through the process. Finally, there are no data on the numbers and outcomes of expanded access applications by pediatric oncology patients. We will distribute a 30-question survey to pediatric oncologists to identify their experiences and challenges, and uncover gaps in knowledge about expanded access approval. Data will be presented at the ASPHO annual meeting. Conclusion: There are limited resources to guide pediatric oncologists who seek expanded access to investigational agents. Educational resources for providers and patients to help them navigate the process are needed. 

Background: Mucositis is a significant cause of morbidity and treatment delay in pediatric patients receiving chemotherapy. Evidence suggests a role for cryotherapy in adult patients for mucositis prevention, but it has not been fully studied as a preventative treatment in children.

To study the feasibility of cryotherapy in pediatric cancer patients. Design/Method: Participants were patients on active chemotherapy, from 5-21 years old. Samples of ice chips, ice water, and three ice pop flavors in the form of ice pellets or full ice pops were offered. Participant preferences were determined by survey, with standard taste test protocols. Participants then used their preferred preparation for up to sixty minutes. At 30 and 60 minutes, FACES scale was used to measure oral pain. At the completion of participation, parents (or patients 18 years and older) completed a survey regarding challenges during cryotherapy and estimated total time of cryotherapy use. Results: Twenty-four patients were invited to participate; nine consented. Common reasons for non-participation included feeling ill on day of invitation, and reluctance to spend additional time in clinic. Participating patients were 78% (n = 7) male and 22% (n = 2) female. Ages ranged from 5-20 years, with a mean of 12.1y. Fifty-five percent (n = 5) of participants preferred flavored ice preparations. Patients utilized cryotherapy for a range of 4 to 60 minutes, with a median time of 30 minutes, with a trend toward longer use in older patients. Mean pain score (out of 10) was 0.9 at 30 minutes and 2 at 60 minutes. Common challenges included patient distraction and discomfort due to temperature.

Among pediatric cancer patients, cryotherapy appears to be well-tolerated for short periods of time, and shows the greatest feasibility in older children and adolescents. It will likely show the most benefit in mitigating mucositis caused by agents with relatively short half-lives and predictable peaks in concentration. Additionally, children and their caregivers may be more amenable to cryotherapy if it were being attempted for a possible therapeutic purpose, rather than a feasibility study. Data collection is ongoing in order to elucidate more specific subgroups for which it is most feasible. (Chen, Journal of Oncology Pharmacy Practice, 2015).

Background: Over the past several decades there have been significant advancements in the management of pediatric malignancies and a resultant increase in survival rates and average life expectancy. As such, there is a heightened awareness of previously under-appreciated long-term treatment-related outcomes, or late effects. The endocrine system, and particularly the growth hormone axis, is particularly vulnerable to the deleterious effects of current treatment modalities. The presence or absence of growth hormone deficiency and the attainment of final adult height have become the principal measures of interest in current medical literature focusing on height-related late effects. It has been well documented that cranial or craniospinal irradiation has a negative impact on height and that concurrent chemotherapy may intensify the growth deterring effects of radiation. However, the effect of chemotherapy alone on the growth hormone axis and final adult height in the absence of confounding variables such as radiation exposure and/or the presence of a CNS tumor is less well understood. Objectives: To investigate the effect of chemotherapy on the growth velocity of pediatric cancer survivors at various stages off therapy. Design/Method: This study is a retrospective chart review of 71 patients from the oncology long-term follow-up clinic registry at Nationwide Children's Hospital from 1/1/2008 -4/1/2013 who received chemotherapy without radiation and who did not have a primary brain tumor diagnosis. Results: Over the first 5 years off therapy, the percentages of patients with growth velocities at or below the third percentile for their specific age and gender were 14.08%, 18.31%, 26.76%, 22.54%, and 24.56%, respectively. The association of specific cancer types and chemotherapeutic agents on delayed growth velocity will be discussed. Conclusion: Chemotherapy alone can lead to delayed growth velocity in pediatric cancer survivors. Pediatric oncologists and general practitioners should have a low threshold for further work-up including bone age radiographs, growth hormone levels, and placement of an Endocrinology referral when growth delay is noted in this patient population.

Background: The phenotype associated with PTEN hamartoma syndrome (PHTS) in pediatric patients is variable, and may include only macrocephaly and one other feature of PHTS. Mucocutaneous findings are pathognomonic for PHTS, including oral papillomatosis on the gingiva, though it may not appear until adolescence or early adulthood. Often, dentists are the first to refer patients for evaluation based on oral papillomatosis, and case reports show adults are being referred by dentists for PTEN evaluation. Individuals with PTEN gene mutations are at risk for several health problems, including vascular anomalies and malignancies of the breast, thyroid, and endometrium, and should be followed by appropriate specialists for recommended surveillance protocols. Early identification of at-risk individuals is of the utmost importance to prevent or treat these symptoms. Objectives: Determine gingival hyperplasia and gingivitis phenotype in cohort of five pediatric patients with PHTS, followed in the Vascular Anomalies Clinic at Texas Children's Cancer Center. Design/Method: Five pediatric patients with confirmed PTEN molecular diagnoses followed in the Vascular Anomalies Clinic at Texas Children's Cancer Center were noted to have a gingival hyperplasia phenotype. The patients were either referred to the Dental Division at Texas Children's Hospital for evaluation, or records from their primary dentist were requested and reviewed. Results: Five of five pediatric patients in the cohort of patients with confirmed PTEN molecular diagnosis have gingival hyperplasia, with dental records confirming moderate to severe gingivitis in three patients. Two dental record reviews are pending. Conclusion: Gingival hyperplasia and gingivitis may be an early indicator of the oral findings associated with PHTS. Pediatric clinical providers, including dentists, seeing patients with macrocephaly, gingival hyperplasia, and gingivitis should consider referral for PHTS evaluation. These may also be indicators to aid in identifying at-risk relatives that may be too young to have yet developed papillomatosis. Pediatric patients with confirmed PHTS should be referred to and followed by dentists for gingival hyperplasia and gingivitis surveillance and treatment.

Background: Many survivors of childhood acute lymphoblastic leukemia (ALL) exhibit deficits in neurocognitive function following treatment. Despite generally uniform treatment protocols, individual neurocognitive outcomes are not predictable. One potential genetic risk factor for neurocognitive late effects is the apolipoprotein (APOE) e4 allele. This allele has been most strongly associated with increased risk for dementia and also has been implicated as a risk factor for cognitive deficits following various neurological stressors. Central nervous system (CNS)-directed chemotherapy, as utilized in childhood ALL treatment, may be considered a similar insult to the brain. Objectives: To evaluate the association between APOE genotype and neuropsychological functioning following treatment for childhood ALL. Design/Method: Participants were survivors of childhood ALL, treated with chemotherapy only, currently 8 to 18 years of age. During a routine clinic visit, blood was obtained for APOE genotyping, and participants completed a brief neuropsychological assessment battery to evaluate attention, processing speed, memory, and executive function. Analysis of covariance (ANCOVA) and multiple analysis of covariance (MANCOVA) were used to detect significant differences in neurocognitive performance variables between groups defined by APOE status while controlling for age, gender, education, and socioeconomic status. Results: Fifty-seven patients were enrolled (57.8% male; 51.9% Caucasian; mean age 12.82 years). The average age at time of ALL diagnosis was 5 years, with an average time to completion of treatment of 5 years. Fifteen participants (26.3%) were found to carry the APOE e4 allele. Preliminary results indicate that pediatric ALL survivors who carry the APOE e4 allele have no significant difference in attention, processing speed, memory, or executive function when compared to non-carriers of the e4 allele (all p > 0.05).

In previous studies, the effect of APOE genotype on neurocognitive outcome in children has been mixed (1). Our pilot sample found no significant difference in neurocognitive functioning between carriers and non-carriers of the APOE e4 allele. A larger sample size is needed to evaluate for subtle neurocognitive differences between the two groups; thus, enrollment is ongoing. Longitudinal follow-up is required to investigate whether e4 carrier status influences neurocognitive outcome for survivors of pediatric ALL in adulthood. 1. Blackman, Dev Med Child Neurol, 2005 .

Background: The BABY HUG clinical trial of hydroxyurea in infants and young children with sickle cell disease (SCD) established the safety and clinical benefit of hydroxyurea therapy in this age group. The study did not establish, however, if escalation to maximum tolerated dose (MTD) could be safely and effectively accomplished in this age group. Objectives: We sought to determine the safety and effectiveness of dose-escalation hydroxyurea therapy in children with SCD under age two years. Design/Method: We conducted a retrospective chart review of children with HbSS or HbS β0 Thalassemia under the age of two years started on hydroxyurea therapy between 2013 and 2016 at the Texas Children's Hematology Center. We determined the laboratory response to dose-escalation therapy as well as any clinical or laboratory adverse events associated with hydroxyurea therapy. Results: We identified 29 patients ranging from 5 to 21 months in age (mean of 12.9 ± 4.2 and median of 13 months) initiated on hydroxyurea therapy in the study period. MTD was reached in 19 of 29 patients during the study period, with the remainder having had their dose escalated but not having reached MTD. The mean and median MTD were 22.7 ± 6.3 mg/kg and 20.5 mg/kg respectively. MTD dose correlated strongly with baseline absolute reticulocyte count (ARC) and absolute neutrophil count (ANC), but less so with baseline creatinine or body mass index. All patients had significant increases in hemoglobin concentration and %HbF and declines in ARC and ANC, with the magnitude of increases in [Hb] and %HbF being greater than those seen in the BABY HUG cohort on hydroxyurea. There were no clinically significant adverse events attributable exclusively to hydroxyurea over 413 patient-months of therapy.

There were six episodes of neutropenia, nine of reticulocytopenia, and four of thrombocytopenia, all associated with intercurrent illnesses and all self-limited. Conclusion: Hydroxyurea therapy with dose escalation to MTD appears to be safe in infants and young children in a standard clinical setting and results in more significant increases in hemoglobin concentration and %HbF than were seen with fixed dosing in the BABY HUG study. 

Background: Cardiopulmonary and renal complications are major causes of morbidity and mortality in sickle cell anemia (SCA). Recently, we have observed that SCA is characterized by a unique cardiomyopathy, with features of both restrictive physiology (diastolic dysfunction, disproportionate left atrial (LA) enlargement and normal systolic function) and an anemia-related hyperdynamic state with ventricular enlargement. Restrictive physiology could lead to secondary elevation in tricuspid regurgitant jet velocity (TRV) and exercise intolerance, independent of pulmonary artery hypertension. Albuminuria is an early manifestation of sickle nephropathy. Albuminuria has been correlated with echocardiography-estimated pulmonary hypertension using TRV as a surrogate measure. Whether the sickle cardiomyopathy correlates with nephropathy is unknown. Objectives: Assess the relationship between sickle cardiomyopathy and albuminuria in SCA. Design/Method: Echocardiograms were performed in individuals with SCA (SS and Sβ0-thalassemia) participating in a clinical trial of losartan for sickle nephropathy. We analyzed baseline (pre-losartan) results and correlated the cardiac phenotype with urine S40 ASPHO ABSTRACTS albumin-to-creatinine ratio (UACR), 6-minute walk distance (6MWD) and hematological markers. Albuminuria was defined as UACR ࣙ 30 mg/g. Results: Thirty-six SCA patients were included (mean age 24.1y; 53% female). Fifteen had normal UACR (mean±SEM 9.2±1.5 mg/g) while 21 patients had albuminuria (UACR 373±87 mg/g 2±0.3 g/dL, P = 0.04); however, there was no difference in TRV, LV mass, LV diameter or reticulocyte count between groups. 6MWD correlated significantly with the diastolic measures E/A and septal e'/a' (P = 0.013 and P = 0.015, respectively). Patients with albuminuria had significantly shorter 6MWD (1182±78 vs 1472±86 ft, P = 0.018).

The restrictive physiology of sickle cardiomyopathy, irrespective of elevated TRV, is associated with albuminuria, a marker of sickle nephropathy. Common mechanisms may underlie both complications. Albuminuria should be studied as a predictor of cardiomyopathy in SCA.

Background: Vitamin D is a significant topic of interest in patients with Acute Lymphoblastic Leukemia (ALL), particularly in long-term survivors who have been shown to have decreased bone density. However, there has been a lack of investigation into vitamin D levels at diagnosis and during treatment for leukemia. Objectives: The primary aim of this single institution prospective pilot study was to evaluate vitamin D levels at time of diagnosis in patients with ALL and their closest in age sibling. The secondary aim was to determine the efficacy of vitamin D supplementation in increasing serum levels of vitamin D in patients with ALL.

were obtained from patients with ALL and matched sibling controls at diagnosis. In addition blood was drawn from patients at 3 month intervals for a total of 4 blood draws. Patients with levels less than 30 were given vitamin D supplementation as per the Institute of Medicine recommendations.

The study included 16 patients with newly diagnosed ALL, and 16 siblings controls, average ages 9.5 and 10.6, respectively. There was no significant difference in the vitamin D level of patients and siblings at diagnosis (p = 0.215). At diagnosis, 37.5% of patients had sufficient, 43.8% had insufficient and 18.8% had deficient serum vitamin D levels. There was a decrease in vitamin D levels between diagnosis and the second blood draw (p = 0.001). There continued to be differences between the diagnosis and vitamin D levels (p = 0.026) during maintenance, with the latter being higher. In the patients getting supplementation, the second vitamin D serum levels were lower in 70% of patients compared with 88% of patients without supplementation.

Conclusion: This exploratory pilot study suggests that treatment for ALL is associated with a significant decrease in vitamin D levels even in the face of supplementation. Diagnosis of leukemia in of itself does not appear to have an effect on vitamin D levels. Given these findings it will be important to perform a larger multi-institutional study to further evaluate levels of vitamin D during treatment, effects of increased supplementation on serum levels and long-term bone health. transfusions, acute chest (ACS) and vaso-occlusive (VOC) episodes, and laboratory data from the most recent encounter. Results: We reviewed 453 patient charts containing both inpatient and outpatient encounters. Electrophoresis data were available for 72% of patients and among these the genotype distribution was 87% Hgb SS and 13% Hgb SC. Median age at diagnosis was 7.7y (1.25y-18y). The most common presenting symptoms were fever (57.6%), anemia (49.7%), and pain (48%). We counted 907 total hospital admissions in the cohort, with a mean of 2 (0-25) per patient. Sixty-three percent of children required at least one transfusion in their lifetime with a mean of 1.9 (0-19) per patient. Mean number of episodes of VOC and ACS were 1.1 (0-13) and 0.5 (0-10), respectively. Hepatomegaly and splenomegaly were each documented in 5% of the patients. Mean hemoglobin concentration was 8.0g/dL (1.9-14.1). Mean WBC count was 15.9×109/L (1.4-83.6). Mean platelet count was 395×109/L (0.5-1264).

The clinical features of Haitian children with sickle cell disease are similar to those in African countries. Most patients present with a morbid encounter. This study provides valuable data describing the presentation and clinical characteristics of children with SCD in Haiti which may be useful when considering initiation of newborn screening and comprehensive care models is this setting.

Background: Many adult survivors (AS) of pediatric acute lymphoblastic leukemia (ALL) suffer from unexplained neurocognitive (NC) deficits. 23Na magnetic resonance (MR) imaging measures brain volume (BV) and tissue sodium concentration (TSC). Elevated TSC reflects decreased cell volume fraction (CVF), a measure of brain cell density. The biological mechanism for why some AS have NC changes has never been studied.

Objectives: BV, regional TSC and NC performance were measured to investigate if NC performance was related to changes in neuroimaging. ALL and its treatment with intrathecal and systemic chemotherapy ± radiation were hypothesized to lower NC performance by decreasing BV and possibly CVF. Design/Method: Adult patients with a diagnosis of ALL during childhood and off all anti-cancer therapy at least two years were recruited and signed informed consent for both imaging and NC testing. Quantitative 23Na MR imaging at 9.4T provided TSC maps from which regional TSC and BV values were measured. Mean BV values and linear correlations between regional TSC values and BV values were performed for the AS group. Validated NC assessments were performed on the AS group. Relationships between NC scores, regional TSC and BV were examined by Pearson correlation. Results: Ten AS (60% female, mean age 25.4 years) were enrolled. BV was decreased (P<0.015) from age-matched controls and significant inverse linear correlations existed between BV and regional TSC for frontal (p<0.011) & parietal (p<0.004) lobes, basal ganglia (p<0.001) and thalami (p<0.001) but not for temporal (p>0.05) or occipital (p>0.05) lobes (OL) in AS. NC performance was not related to BV. There was a suggestion of increasing NC performance with increasing OL TSC, most prominent in processing speed (p<0.020). Conclusion: Results of this exploratory study showed ALL and its treatment during childhood results in smaller cerebral volume and this decrease is correlated with regional increases in TSC, reflecting decreases in CVF in fronto-parietal and deep gray matter regions. Preliminary results also suggest a possible relationship between OL TSC and processing speed but the etiology of this relationship is unclear. Both small sample size and lack of consistent regional correlation likely reflects the wide variations in NC performance found. Future larger studies are warranted. 

pathophysiology and mechanism explaining the poor prognosis and propensity to sudden death has been elusive. Objectives: To define the progression of cardiac pathology in SCA and determine the pathophysiology that underlies the diverse reported cardiopulmonary phenotypes including sudden death. Design/Method: Mouse models of SCA and iron-deficient anemia mice underwent a longitudinal comprehensive cardiac analysis, combining state-of-the-art cardiac imaging (cardiac MRI and echocardiography), electrocardiography, histopathology and molecular analysis to determine the basis of cardiac dysfunction. Results: SCA mice showed anemia-induced hyperdynamic physiology, with gradual additional development of restrictive physiology. There was a progressive increase in the left atrial diameter and diastolic dysfunction despite normal systolic function. This restrictive physiology was noticeably absent in chronic iron-deficiency anemia mice. In SCA mice, this was associated with increased extracellular volume by cardiac-MRI and resulted from microscopic myocardial fibrosis. Mitochondrial ultrastructural changes were consistent with severe hypoxia/ischemia/oxidative stress, and significantly shortened sarcomere diastolic lengths were noted. Transcriptionally, genes involving angiogenesis, extracellular-matrix, circadian-rhythm, lipid metabolism and oxidative stress/hypoxia were upregulated and ion-channel transport and fatty-acid metabolism genes were downregulated. A functional interaction network analysis suggested lowered expression of genes essential for normal cardiac conduction. Indeed, prolonged QTc, with remarkably increased prolongations occurring pre-mortem, arrhythmias and ischemic changes were observed prior to sudden death. Conclusion: Collectively, SCA mice developed a distinct sickle cardiomyopathy with restrictive physiology from cumulative cardiomyocyte hypoxia/ischemia-induced fibrosis, resulting in an arrhythmogenic myocardium. Sudden cardiac death is common in restrictive cardiomyopathies and prolonged QT syndromes. This comprehensive longitudinal analysis and our finding of this cardiomyopathy in this preclinical SCA mouse model may be the unifying cardiac pathophysiology of the previously reported diverse cardiac phenotypes, which also explains the sudden death seen in this disease. Furthermore, it will also open new avenues for early diagnostics and targeted therapies for human SCA-related cardiac disease.

Background: Neuropathic pain is a known complication of cancer therapy and worsens quality of life. Poor understanding of patient and treatment-related risk factors for neuropathic pain limits development of targeted screening and prevention strategies to decrease morbidity of therapy. Objectives: In pediatric oncology patients: 1) Determine prevalence of neuropathic pain and 2) Investigate risk factors for neuropathic pain. Design/Method: We conducted a retrospective cohort study of newly diagnosed or relapsed pediatric oncology patients between 11/2/2012 and 5/7/2015. Neuropathic pain was defined a priori as documentation of one or more of the following in the medical record: 1) "neuropathic pain"; 2) "pain" in a nerve distribution; 3) "pain" + qualitative neuropathic pain descriptor (i.e., numb, burning); 4) "pain" + initiation of neuropathic pain medication. Demographic variables were compared using Mann-Whitney test for continuous variables and Chi-square test for categorical variables. Multivariable logistic regression (forward stepwise selection method and α = 0.10) was performed to find the best set of predictive factors for the diagnosis of neuropathic pain. Results: Charts were reviewed for 162 patients. Median (IQR) age at cancer diagnosis was 7.5 (3.2, 13.8) years and 45% were female. Diagnoses included 55% leukemia/lymphoma, 32% solid tumors and 13% central nervous system tumors. Twenty-eight percent (95% CI 21-35%) of patients met our definition of neuropathic pain. Age was not significantly different between those with and without neuropathic pain (p = 0.110), but was significantly lower in those treated with vincristine (median age 5.8 vs. 12.7 years, p = 0.004). Older age (OR 1.10, 95% CI 1.03-1.17) and vincristine therapy (OR 8.65, 95% CI 2.88-26.02) were associated with increased odds of neuropathic pain diagnosis and radiation therapy (OR 0.11, 95% CI 0.03-0.40) was associated with decreased odds of neuropathic pain diagnosis. Gender, ethnicity, intrathecal chemotherapy and surgery had no significant impact on neuropathic pain diagnosis. Conclusion: Neuropathic pain is diagnosed in over a quarter of children with cancer. Older age and vincristine therapy are associated with increased risk for diagnosis of neuropathic pain. Improved prevention, diagnostic and treatment modification strategies are needed to reduce the burden of neuropathic pain from cancer treatment.

Background: Under-5 mortality for children with sickle cell disease (SCD) in low and middle-income countries (LMIC) is high, with the majority of deaths likely related to infectious complications. In the United States, dramatic decreases in childhood mortality for SCD over the past 40 years have been aided by interventions to reduce mortality associated with infections. In LMIC, these interventions (i.e. penicillin prophylaxis, rapid investigation and treatment of febrile illness, and vaccination) may not be consistently available.

Objectives: To determine provider practices in LMIC regarding prevention of infectious complications in patients with SCD. Design/Method: A survey of English and French-speaking providers at SCD programs in LMIC. The survey was available online and offline, distributed via email distribution lists, at applicable meetings, and by referral. Results: Providers from 13 LMIC returned 27 interpretable surveys, including 23 from malaria-endemic areas. Newborn screening is associated with 34% (n = 10/27) of programs. Pneumococcal conjugate vaccine is available at 66% (n = 14/25) of programs. Penicillin prophylaxis is prescribed to some or all patients by 65% (n = 17/26) of respondents. Malaria prophylaxis is prescribed by 83% (n = 19/23) in malarial-endemic areas. Forty-eight percent of programs (n = 14/27) have written fever management protocols. To patients with SCD presenting with fever, 21% (n = 5/24) of respondents 'always' give antibiotics, although 54% (n = 13/24) give antibiotics 'almost always'. First line antibiotics are given orally by 27% (n = 7/26); 77% (n = 20/26) would consider oral antibiotics in some circumstances. The preferred first line antibiotic is ceftriaxone for 9/19 giving IV/IM antibiotics and amoxicillin-clavulanate for 4/7 giving oral antibiotics. At programs in malaria-endemic areas, 79% (n = 18/23) 'always' or 'almost always' give antimalarials to febrile patients. Forty-six percent (n = 12/26) of respondents report that a majority of febrile patients receive antibiotics prior to presentation. In malaria-endemic areas, 74% (n = 17/23) report that a majority receive antimalarials prior to presentation. Conclusion: There is considerable practice variation around management of infection prophylaxis and fever in patients with SCD in LMIC. In a majority of responding programs, oral antibiotics are acceptable for use in some febrile patients with SCD. Results of this survey will inform a consensus-based protocol for fever management in SCD in LMIC.

Background: Intracranial hypertension (IH) is characterized by elevated cerebrospinal fluid (CSF) pressure, defined as an opening pressure greater than 25 mmHg, in the context of normal CSF composition and normal neuroimaging studies. IH is an uncommon condition particularly in childhood, presenting in 0.9 per 100,000 children annually (1) . Untreated IH can cause significant debilitation, particularly chronic headaches, and lead to papilledema and visual failure. Objectives: The aim of this study was to determine the incidence of IH in pediatric patients in maintenance therapy for acute lymphoblastic leukemia (ALL). Design/Method: This study was conducted at Wolfson Children's Hospital in Jacksonville, Florida, United States. Opening pressure was measured during routinely scheduled lumbar puncture under general anesthesia for intrathecal chemotherapy administration during maintenance therapy for ALL. IH was defined as opening pressure greater than 25 mmHg. In patients with IH, measurements were repeated up to 2 additional times during routine lumbar punctures. Results: Twenty seven patients between the ages of 4 and 15 were enrolled. Opening pressure was measured 43 times. Intracranial hypertension was found 25 times in 18 patients. The overall incidence of IH was 63%. All participants with the exception of one were asymptomatic at the time of diagnosis of IH. The patient with symptomatic IH was treated successfully with acetazolamide. The incidence of IH was not statistically significant based on gender, age groups, and leukemia risk type. Additionally, the number of prior lumbar punctures/intrathecal chemotherapy administration was not associated with development of IH.

Our results indicate that there is a significantly higher incidence of IH in patients undergoing maintenance therapy for ALL. This suggests that ALL treatment may be associated with the development of IH. Given this high incidence, IH should be strongly considered in any child being treated for ALL who has persistent headaches or visual disturbances. Further studies are needed to determine when IH develops in ALL patients. Treating physicians should consider measuring opening pressures routinely with all intrathecal chemotherapy administration to identify patients with IH before they become symptomatic which may prevent significant symptoms and irreversible damage such as optic atrophy leading to blindness. (1) 

Background: Chemotherapy induced acral erythema (CIAE) is an uncommon side effect of high-dose cytotoxic chemotherapy in children. Prior case reports of CIAE in pediatrics have been limited, and the predisposing factors to CIAE remain unknown. Objectives: To identify characteristics and genetic risk factors of CIAE in children. Design/Method: Adverse events databases for 9 front-line treatment protocols were reviewed to identify cases of CIAE following either high-dose methotrexate or cytarabine, which were confirmed by chart review. Controls comprised up to 449 patients treated on front-line protocols who received either high-dose methotrexate or cytarabine. Germline DNA was genotyped and a two stage genome-wide association study (GWAS) treating CIAE as a categorical outcome measure was performed. In stage 1, we performed a GWAS of the non-acute lymphoblastic leukemia (ALL) cases compared to controls; in stage 2, we included all diagnoses, and adjusted for ancestry and chemotherapy. Results: 21 patients experienced a total of 38 episodes of CIAE with symptoms lasting a mean of 5.8 days. Hands and feet were both involved in 71% of initial episodes. CIAE occurred following the administration of cytarabine [22 events in 13 patients (mature B-cell lymphoma in 7 patients, acute myeloid leukemia in 6 patients)] and methotrexate [14 events in 9 patients (ALL in 2 patients; osteosarcoma in 4 patients; and mature B-cell lymphoma in 3 patients, all 3 of whom also had CIAE following cytarabine)]. Administration of both agents together occurred prior to 2 events in 2 patients (both with mature B-cell lymphomas). Parenteral opioids were required for symptom control in 28.6% of patients. No genetic variants reached the genome-wide association threshold of P<5×10-8. The top identified variant was intronic in MSRA (rs17708090, P = 1.09×10-5, OR 7.7), with a risk allele frequency of 27.5% in cases and 9.4% in controls. Additionally, the intronic variant rs13214952 in MTHFD1L was also associated with an increased risk of CIAE (P = 4.25×10-5, OR 5.7), with 90% of patients developing CIAE following methotrexate carrying the risk allele.

Conclusion: CIAE is a rare toxicity in children receiving high-dose methotrexate or cytarabine. Genetic variants in folate metabolism and oxidative stress response genes may predispose to the development of CIAE.

Rida Abid, Bruce Bernstein, Jennifer Eng, Deepti Raybagkar, Nataly Apollonsky

Background: Patients with Sickle cell anemia (SCA) have an 11% risk of overt stroke and up to 30% risk of silent infarction during their lifetime. Routine screening with Transcranial Doppler ultrasound (TCD) allows for selecting patients with the highest risk and providing chronic transfusions to decrease their risk of stroke by 90 %. Abnormal velocities on TCD are associated not only with an increased risk for stroke, but also with poor cognitive performance and irreversible changes on magnetic resonance imaging (MRI) in a subset of patients. Even in the absence of MRI abnormalities patients with SCA can experience neurocognitive problems and decline in performance over time. Early laboratory predictors of TCD velocities would allow identification of patients at risk during the first years of life to introduce appropriate treatment modalities and educational support. Objectives: To study the linear correlations of early biomarkers with TCD velocities at different age intervals. Design/Method: We performed a retrospective chart review of patients with SCA and Sbeta0thalassemia followed at Marian Anderson Center at St. Christopher's Hospital for Children in Philadelphia. We identified 132 consecutive patients who meet inclusion criteria. Pearson correlations were calculated to explore linear associations of steady state biomarkers of anemia, hemolysis and inflammation with patients' maximum left middle cerebral artery (MCA) velocities at different age intervals (2 to 6 years, 6 to 11 years, and older than 11 years). Results: In the 2 to 6 year age group, there was a positive linear correlation of TCD velocities of the left MCA with lactate dehydrogenase (n = 51, r = 0.341, p = 0.014), reticulocyte count (n = 92, r = 0.314, p = 0.002) and bilirubin (n = 71, p = 0.037 p = 0.037), white blood cell count (n = 94, r = 0.249, p = 0.015) and a negative linear correlation with hemoglobin (n = 94, r = 0.317, p = 0.002). In the 6-11 year age group the only significant correlation was lactate dehydrogenase (n = 29, r = 0.452, p = 0.014) and no correlation of laboratory biomarkers in the older than 11 age group. Conclusion: Decreased hemoglobin, increased white blood cell count, increased bilirubin and increased lactate dehydrogenase from the first few years of life correlate with increased MCA velocities in the 2 to 6 year age group and may help to identify high risk patients.

Background: Antimetabolite dose intensity and compliance during maintenance therapy for ALL are associated with improved event free survival. The focus on racial disparities in ALL has been on poor compliance with 6-mercaptopurine (6MP) as indicated by high ANC as a surrogate marker. Less in known about the influence of benign ethnic neutropenia (BEN) on prescribed 6MP/methotrexate (MTX) dosing. Objectives: We evaluated whether prescribed doses of 6MP and/or MTX varies by patient race during maintenance therapy for ALL. Design/Method: A single institution retrospective study of prescribed 6MP and MTX dose during monthly visits for the first 6 cycles of maintenance therapy was done in children treated for ALL on Children's Oncology Group studies for B-and T-ALL. The initial and average ANC, weighted average dose of 6MP and MTX prescribed per visit, and the number of visits where prescribed doses were less than 90% of goal were abstracted. Descriptive statistics were dichotomized by race in univariate analysis. Results: Among 99 patients eligible, 17% were black and 83% were non-black. There were no differences in key demographic, risk characteristics or TPMT status by race.

The median ANC at study entry was 1.43 thou/uL and did not differ by race (1.36 vs 1.58, p = 0.67), but the average ANC over the course of therapy was greater in non-blacks (2.00 vs 1.63, p = 0.07). The median weighted dose of 6MP and MTX prescribed over all courses was 63 mg/m2/dose and 16.6 mg/m2, respectively (p = 0.40; p = 0.43) and did not differ by race. Interestingly, the number of visits with prescribed MTX doses less than 90% of expected was 51% in blacks and 45% in non-blacks (p = 0.04). No difference was present with respect to 6MP. Conclusion: Despite the 15% incidence of BEN in black children, the ANC of patients at entry of maintenance did not differ by race in our population. The lack of significant differences in prescribed 6MP/MTX may be a reflection of the small number of black patients in our study. Black children did have significantly more visits with less than 90% of expected MTX prescribed prompting the need for further analysis of factors influencing prescribed antimetabolite dose intensity.

Elizabeth Perry, Patricia Carter, Heather Becker, Alexandra Garcia, Michael Mackert, Karen Johnson, George Buchanan

Background: Health literacy is defined as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions". There is a paucity of literature regarding health literacy in adolescents and specifically no published data describing the state of health literacy in adolescents with sickle cell disease (SCD).

Objectives: The purpose of this study was to evaluate health literacy in a cohort of 75 adolescents with SCD. Design/Method: This cross-sectional, descriptive correlational study included assessment of demographic measures and evaluation of data resulting from completion of the REALM-Teen and Newest Vital Sign (NVS) instruments by 75 Black, non-Hispanic adolescents with SCD followed at Children's Medical Center (CMC) in Dallas, Texas. Convenience sampling was utilized. Inclusion criteria were a diagnosis of one of the four primary genotypes of SCD and age 10-19 years. UT Austin and UT Southwestern Institutional Review Boards approved the study. Results: Thirty-seven males and 38 females were recruited for the study. Their mean age was 14.7 years (SD = 2.2; range 8.1). Their grade level ranged from 4 to 12 (mean 8.7; SD = 2.2). The following SCD genotypes were represented: SS (81.3%); SC (14.7%); Sβ+ (2.7%) and Sβ0 (1.3%). Scores on the REALM-Teen ranged from 12 to 66 (mean 53.7; SD = 12.8). Scores on the NVS ranged from 0 to 6 (mean 2.37; SD = 1.33). These health literacy scores were lower using both the REALM-Teen and the NVS instruments when compared to scores in healthy adolescent and adult controls. However, the mean REALM-Teen score of this sample was slightly higher than Black controls from the validation study. Current grade level and health literacy scores showed a moderately high positive correlation (r = .52, p < .01). Health literacy scores were also significantly positively correlated with age (r = .49, p < .01) and income (r = .37, p < .01). Conclusion: Health literacy in adolescents with SCD appears to be suboptimal. Future research should include identifying facilitators and barriers to health literacy levels in a larger cohort of adolescents with SCD. Ratzan, S. C., & Parker, R. M., National Library of Medicine Current Bibliographies in Medicine: Health Literacy, 2000.

Background: ALL is most common malignancy in Children. All treatment protocols include multiple bone marrow examination to check treatment response including minimal residual disease (MRD). In our country we are following these protocols even in absence of MRD facility. Objectives: Acute lymphoblastic leukemia (ALL) is most common hematological malignancy among pediatric population. Different protocols like UKALL and COG are used for management and all protocols suggest bone marrow biopsy at day 8 or 15 and then at day 29 during induction phase. 

Vivien Sheehan, Anthony Wood, Sachin Allahabadi, Sara Curtis, Allexa Hammond, Ling-Chen Chien, Jaden Schupp, Matthew Rees, Peter Yeh, Kate Travis, John Shumway

Background: An estimated 93-98% of sickle cell disease (SCD) patients now reach adulthood in high resource countries. Studies show that this growing cohort of young adult SCD patients aged 18-26 years old experiences a marked rise in medical complications and early mortality, coinciding with decreased use of life-prolonging therapies and increased use of emergency care. Objectives: We surveyed SCD patients who previously transitioned to adult care to determine: 1) If they currently had an adult SCD provider, 2) If they continued their pre-transition therapies, and 3) Their perception of the transition process. Design/Method: 441 SCD patients transitioned from pediatric care at Texas Children's Hematology Center (TCHC) between 01/1999 and 01/2014. We contacted these patients at their last known address and phone number to request completion of a 23 question survey assessing patient demographics, post-transition medical outcomes, and personal experiences. Results: 48 surveys were completed. 17 patients (35.4%) lack a provider, with top reasons being lack of insurance/funding (44%) and "can't find a physician" (38%). Patients without an adult physician within 6 months of transition were less likely to have a physician currently (p<0.017). 83.3% of patients on hydroxyurea as pediatric patients (15/18) continued hydroxyurea therapy after transition. Subjects reported difficulties with finding knowledgeable adult providers, medical insurance, and inadequate transition preparation. Examples of qualitative results include comments such as the following: "The adult doctors are not aware of the disease …They have to call the pediatricians." While another said, "[It was] hard finding a physician in the two years after TCHC [because of insurance loss] … my health worsened because I wasn't getting the medication that I needed." When asked, 94% of patients wanted a dedicated SCD transition clinic. 12 patients were identified as deceased from all causes. Conclusion: This survey shows that the first 6 months after transition is a critical period in identifying a sickle cell healthcare provider, supporting the need for a dedicated transition clinic to facilitate transition for SCD patients. It also quantitatively and qualitatively demonstrates that lack of sickle cell focused healthcare providers for adults is a barrier to successful transition.

Background: Adolescents and young adults (AYAO) may experience greater toxicity than younger patients, treated for HR-ALL, with greater vulnerability to steroids and asparaginase which are commonly included in the induction phase of therapy. The relative role of age when ethnicity and body mass index (BMI) are taken into account has not been addressed. Objectives: We sought to determine the impact of age on the number and/or maximum grade of chemotherapy-related toxicities during induction while controlling for BMI, ethnicity, and gender. Design/Method: Consecutive non-Down Syndrome patients with HR ALL aged >1 and < 22 years at diagnosis, treated on or as per the Children's Oncology Group protocols AALL0232/AALL1131, over the past 10 years, were identified through the pediatric oncology registry at Children's Health. A retrospective chart review was conducted and all toxicities graded using the CTCAEv4 system. Patient characteristics were summarized by quartile of age at diagnosis. Unadjusted trends between toxicity outcomes and age were tested using the Jonckheere-Terpstra nonparametric method. Trends between toxicity outcomes and age adjusted for BMI, ethnicity, and gender were tested using Poisson regression models. Results: The 158 patients experienced 69 distinct toxicities. Common toxicities included febrile neutropenia (FN), sepsis, hypertension, and hyperglycemia. There were 4 deaths during induction (ages > 13 at diagnosis). We omitted FN in analyses since patients did not have an infection. Unadjusted trends between age at diagnosis and both maximum grade of toxicity and number of grade 3-5 toxicities are significant with p = 0.011 and 0.009, respectively. However, multiple regression analysis indicates that when the relationships between age at diagnosis and toxicity are adjusted for BMI, ethnicity, and gender, the relationships are no longer significant. Conclusion: Age was not a significant risk factor for a higher number or greater severity of chemotherapy-related toxicity when adjusted for BMI, ethnicity, and gender. This ASPHO ABSTRACTS S45 research will allow for better supportive care measures and counseling of patients and their parents with respect to the risks associated with ALL therapy.

Background: Utilizing an electronic medical record (EMR) offers a unique opportunity to study large cohorts of patients over time. However, the ability to identify and follow these cohorts relies on the use of a valid computable phenotype consisting of a defined set of data elements in the form of a computable query to an EMR data warehouse. Although such computable phenotypes have previously identified patient populations with various conditions, a computable phenotype has not yet been developed to identify patients with sickle cell disease (SCD). Objectives: To develop a computable phenotype identifying our patient population with SCD using an algorithm approach and to validate and refine the computable phenotype as a means of improving its accuracy. Design/Method: This retrospective study utilized our computable phenotype to search our EMR data warehouse. Eligible patients included those ages 0-18 years, diagnosed with a qualifying SCD ICD-9 code, and being followed by the SCD clinic at the Children's Hospital of Wisconsin. The computable phenotype was developed as a series of queries to the data warehouse aimed at identifying our patient population with SCD. These queries included patients with a qualifying diagnosis of SCD who also had two outpatient visits at least 30 days apart or one hospitalization in the EMR. Validation studies using medical record numbers from the clinical program database were run against the results of the queries. Results: The computable phenotype identified 352 patients. Of these patients, 350 were confirmed to meet the inclusion criteria. Two patients identified by the computable phenotype were incorrectly identified as having SCD. The computable phenotype failed to identify 2 patients meeting inclusion criteria. Overall, the computable phenotype accurately identified 350 of 354 (98.9%) patients known to fit the inclusion criteria. Conclusion: The advent of EMRs provides a unique opportunity to track and follow known cohorts of patients with a given disease and is a rich resource for future clinical trials. The computable phenotype developed in this study allows for rapid and accurate identification of pediatric patients with SCD and provides a distinct advantage over administrative claims methods.

Suleimman Al-Sweedan, Rafat Jafri, Khawar Siddiqui, Ali Alahmari, Ibrahim Ghemlas, Amal Alseraihy

Background: Hyperleukocytosis is defined as a peripheral leukocyte count of ࣙ 100×109/L. This problem is seen in 5-20% of newly diagnosed cases causing hyperviscosity, culminating in early morbidity and mortality in these patients. Our results show that hyperleukocytosis in ALL is associated with T-cell ALL, less frequent favorable cytogenetics, slow early responder, CNS3, and poor outcome with more frequent deaths and relapses which is comparable with published data.

April Naegeli, Lori Heath, Chunmei Zhou, Neehar Gupta, Carlton Dampier

Background: The modified Faces Pain Scale Revised (Modified FPS-R) is a patient-reported outcome measure with established content validity, that is used to assess pain intensity in children and adolescents, 7 to <18 years of age, with sickle cell disease (SCD). A daily evaluation of pain can provide important insight on the clinical consequences of SCD that is not obtained from occasional inpatient or outpatient healthcare visits. Objectives: To evaluate the psychometric properties (validity, reliability and responsiveness) of the Modified FPS-R in pediatric patients with SCD. Design/Method: This evaluation was conducted in the context of a randomized, multinational clinical study in pediatric patients with SCD, 7 to <18 years of age. Symptom intensity was reported in a daily diary during the 2 week screening period/prior to randomization starting at Visit 0 through Month 9. The Modified FPS-R asks patients to consider their pain related to SCD, and report their worst pain over the course of a day. Mean monthly scores were calculated based on the number below the chosen face selected by the patient ("0" = "no pain", "10" = "worst pain possible"). Intra-class correlation coefficient (ICC) was used for test-retest reliability between Month 1 and Month 2. Pearson correlation between monthly mean intensity of sickle-cell-related pain and analgesic use and narcotic use was conducted to assess convergent validity. Responsiveness was assessed with correlations of calculated changes from baseline corresponding to changes in analgesic use and change in activity score from Month 1 to Month 9. Results: ICC was 0.77 (n = 42) indicating agreement among stable patients; moderate associations were shown between the Modified FPS-R and analgesic use (r = 0.39) and narcotic use (r = 0.44); and moderate-to-large associations were observed between the Modified FPS-R and change in analgesic use 0.39 (p<0.001) and activity scores 0.92 (p<0.001).

Results of the quantitative analyses support use of the Modified FPS-R in children and adolescents aged 7 to <18 years with SCD. The instrument has sufficient reliability, validity, and responsiveness to measure pain in clinical studies and will provide valuable insight when measured on a daily basis. This study was sponsored by Daiichi Sankyo, Ltd and Eli Lilly and Company.

Suleimman Al-Sweedan, Khawar Siddiqui, Jafri Syed, Amal Alseraihy, Ibrahim Ghemlas, Ali Alahmari

Background: ALL treatment is often marred by a relapse in about 10-20% patients, which is the main cause of treatment failure in most cases, more so in high risk patients. Background: Perturbations in the arginine pathway with hemolysis associated nitric oxide (NO) depletion plays a central role in the pathogenesis of vaso-occlusion in sickle cell disease (SCD). Multiple studies have shown that citrulline is an effective NO booster, even during conditions of inflammation and acute arginase-induced arginine deficiency, characteristic of SCD. Objectives: To assess the safety and pharmacokinetic profile of intravenous (IV) L-citrulline in steady-state SCD (ClinicalTrials #NCT02314689). Design/Method: Each cohort of participants received an IV bolus of 20mg/kg of L-citrulline over five minutes with dose increments of 10 mg/kg until a target citrulline level of 80 to 100 μmol/L, a level known to elevate NO based on previous studies. Plasma samples were collected at certain time points for pharmacokinetic studies. Adverse events were followed according to the NCI Common Terminology Criteria for Adverse Events (CTCAE).

In the first cohort of four participants, the intravenous bolus infusion of 20mg/kg of L-citrulline yielded a mean peak level of 259 μmol/L and trough level in the range of 20-40μmol/L 4 hours after the infusion. The average rate of citrulline appearance, Rapp, was 11.1umol/hr/kg (+/-2.8 SD) and the average constant for citrulline removal, Krem was 1.06 (+/-0.19 SD). The mean clearance was 0.52L/hr/kg with a volume of distribution of 0.50L/kg. All subjects had a significant rise in their arginine level within one hour of receiving the bolus IV citrulline (mean increment of 182%). One subject transiently dropped the diastolic blood pressure by >20% within 30 minutes of study drug with no intervention needed. There were no other reported side effects. Further analysis using a simulated dosing scheme shows that a 20 mg/kg bolus dose of IV citrulline followed by a continuous infusion of 7 mg/kg/hour is needed to maintain the target citrulline concentration. Conclusion: Bolus intravenous L-citrulline is safe and well tolerated in patients with SCD but has a rapid clearance. Further studies are needed to evaluate the pharmacokinetic and safety profile of continuous dose IV citrulline in SCD, including its effect on NO production as a potential novel therapeutic option for sickle cell pain crisis. Background: Asthma is a common comorbid condition in patients with sickle cell disease. It has been well reported that patients with sickle cell and asthma have increased risk of morbidity and mortality, especially in regards to acute chest syndrome. Limited research, however, has been done to establish the role of asthma in vaso-occlusive crisis.

The study was designed to clinically assess the hypothesis that patients with sickle cell disease and asthma have increased severity and frequency of vaso-occlusive crisis secondary to increased impairment in oxygen exchange and associated sickling. Design/Method: Following development of a comprehensive institutional database, 68 of 223 patients were identified with sickle cell disease and comorbid asthma ages 6 to 12 years of age. An additional 43 patients were identified as phenotypic and age-matched controls. Rates of emergency department visits and hospitalizations, frequency of vaso-occlusive crises, association with respiratory symptoms, and use of asthma controller medications were retrospectively analyzed over a 5 year period. Data collection and interpretation were accompanied by review of existing literature. Results: Over the study period, patients with sickle cell and asthma had an increased frequency of acute chest presentations and other respiratory symptoms, as previously established. Of note, a similar increase was seen in pain presentations (4.14 compared to 1.5 hospital encounters per patient). While results did not definitively show causation between respiratory symptoms and onset of vaso-occlusive crises, the data suggest a direct correlation. Additionally, a statistically significant association between use of asthma controller medications and patients presenting with pain was identified (p<0.05). Conclusion: Asthma management may have a role in the treatment of sickle cell vaso-occlusive crisis as evidenced by more frequent pain presentations in patients with asthma, as well as, a correlation in those patients on controller therapy. Further study of the use of asthma management is in progress with the intent to improve pain management and decrease hospital encounters and hospital length of stay. Initially 50% with less than 10,000 leukocytes in the peripheral blood; 2% were between 50,001 and 100,000; 4% commais of 100,001 cells. The most common subtypes were AML AML M3 and M5, each representing 28%. According to cytogenetic analysis, 49% AML with recurrent abnormalities, and of these 56% were promyelocytic AML, Background: Cerebrovascular disease is a severe complication of sickle cell disease (SCD) affecting 25-30% of patients1. The most common cerebrovascular events in SCD patients are ischemic, however there is an increase in hemorrhages in the 3rd decade of life attributed to Moyamoya disease2. Ruptured intracranial aneurysms (IAs) are thought to be responsible for 2% of intracranial hemorrhages in SCD. The incidence and prevalence of IAs remain unknown in SCD. Objectives: To assess the prevalence of IAs in a cohort of SCD patients who had not suffered stroke or been identified with an abnormal transcranial doppler (TCD). Design/Method: Retrospective review of the SCD database to identify patients meeting the objective who underwent brain magnetic resonance imaging (MRI) and angiography (MRA) screening for headache or other non-stroke indication. Time period included patients scanned from 2010-2015. Demographic information collected included age (at scan), gender, genotypes, IAs, the indication for imaging, and management. All included patients didn't report history of stroke or abnormal TCD. Results: Forty-three patients average age 18.20 years (SD = 7.43) were included. Five of forty-three patients (11.6%) imaged by MRI/MRA were found to have incidental unruptured IAs. Four patients (80%) had HbSS and one patient had HbSbeta+. All patients were asymptomatic. Multiple aneurysms were seen in 3/5 patients (75%). IAs were located at both the anterior and posterior cerebral circulation territory. 4/5 (80%) patients were managed conservatively with follow up scans. 1 patient was taken to the OR for aneurysm coiling and resection of an arterio-venous malformation. Conclusion: The 11.6% prevalence of unruptured IAs in this cohort is much higher than the 3.2% reported prevalence of IAs in the general population3. SCD patients with IAs are likely at increased risk for hemorrhagic stroke or subarachnoid hemorrhage as they age. None of the patients included in this cohort had a history of abnormal TCD. Larger prospective studies are needed to accurately identify the prevalence, outcomes and optimal management of unruptured IAs in SCD. Additionally, maintaining a high index of suspicion for IAs in SCD patients with neurologic symptoms is necessary. This study is limited due to a small sample size of selected population.

The Children's Hospital of Eastern Ontario, Division of Hematology Oncology, Ottawa, Ontario, Canada

Background: Complementary and alternative medicine (CAM) includes therapies, practices and remedies that are not part of conventional medicine. The use of CAM is increasing among the Canadian pediatric population, but the incidence within pediatric oncology is not known. Objectives: To determine the incidence of CAM use within a Canadian pediatric oncology population. Design/Method: A questionnaire was developed and completed by parents/guardians of pediatric oncology patients (aged 0 to 18 years old) at the Children's Hospital of Eastern Ontario from January 2015 to July 2015. The questionnaire on CAM included reasons for use or non-use, types practiced, frequency of use, unwanted side effects, satisfaction of therapy, amount spent and supervision. Demographic characteristics, including ethnicity, marital status, level of education and profession were also collected. Results: Of the 62 respondents, 61% of parents reported using CAM during their child's cancer treatment. Of those not using CAM therapies, the most common reason to not use CAM was that CAM "may interfere with the medicinal therapies my child is on" and that CAM "is not scientifically based" (n = 25%). Of those that used CAM therapies, the most commonly used modality was prayers/faith (n = 35%). Females (μ = 61.0%) and males (μ = 61.9%) were equally likely to use CAM. Ethnicity played a role in CAM use, as 100% of those that identified as European or Aboriginal used CAM, whereas approximately half of those that identified as Canadian (μ = 57.4%), French (μ = 50.0%), Asian (μ = 60.0%) and African (μ = 50.0%) used CAM. Parents who identified as married were least likely to use CAM (μ = 59.8%) and those that were widowed were most likely to use CAM (μ = 100.0%). Parents who completed a university degree were least likely to use CAM (μ = 53.25%) and those who attained a college degree were most likely to use CAM (μ = 70.0%). Only 57% of patients discussed their CAM use with a physician. Conclusion: There is significant variation in HU prescribing practices, even within a regional consortium. Protocoled guidelines and more study into pediatric use of hydroxyurea is needed to optimize prescribing practices and its impact in sickle cell disease.

Background: Abnormal uterine bleeding (AUB) is a frequent gynecologic complaint in adolescents. Despite this, research on management strategies for AUB is limited and there is often variation in acute care. Objectives: Our objective was to improve pediatric residents' knowledge and confidence in the management of AUB in the emergent setting by implementing a local consensus algorithm and an electronic health record (EHR) order set with concomitant education. Design/Method: We used a multidisciplinary approach involving the departments of emergency medicine, adolescent medicine, and hematology/oncology to create and implement an algorithm for the emergent management of AUB, along with an accompanying EHR order set to facilitate testing and treatment. Education on AUB management, the algorithm and EHR order set were provided to pediatric residents via didactics in-person and electronic mail. Resident knowledge (2 scenarios, 7 questions) and confidence in AUB management was assessed pre and post-intervention (algorithm/EHR order set implementation and didactics) with electronic surveys. χ2 statistics were used to compare groups.

The pre-and post-intervention surveys were completed by 48 and 30 residents, respectively. Knowledge in AUB management improved post-intervention (p <0.01).Residents reported lacking confidence in AUB management less often post-intervention (36% versus 13%; p = 0.03).

Conclusion: Implementation of an algorithm and EHR order set may be an effective method to improve residents' knowledge in the management of AUB in the emergent setting. In the future, we hope to assess the association between our implementation and clinical outcomes. Transfusion rates (p = 0.10), oxygen requirement (p = 0.09), and readmission rates (p = 0.41) did not differ between groups. Conclusion: More controls had bilateral infiltrates in this study, suggesting more severe ACS, yet initiation of ICS in cases did not significantly decrease morbidity despite having less severe disease. More cases were diagnosed with asthma which may be why they were treated with ICS on admission despite less severe ACS. Overall, initiation of ICS did not decrease ACS morbidity as measured by the need for transfusion, oxygen supplementation, or PICU intervention. While systemic steroids increase the risk of readmission for VOC, cases were not more likely to be readmitted after the use of ICS. Despite a plausible pathogenic mechanism to reduce airway hyperreactivity, our study did not demonstrate a significant benefit of ICS in the treatment of ACS.

Background: Bereaved parents experience significant psychosocial and health sequelae, suggesting that this population may benefit from ongoing extension of support and resources throughout the grief journey. The interaction of healthcare providers (HCPs) and hospital staff with patients and families at the end of a child's life and after death profoundly affects the parental grief experience, offering a unique opportunity for the medical community to positively impact the bereavement experience. Objectives: To explore the role of the health care team and the institution in the grief journeys of parents who lost a child to cancer. Design/Method: Eleven bereaved parents participated in 2 focus groups. Responses to each of the 3 main prompts were coded and analyzed independently using semantic content analysis techniques. Results: Four main concepts were identified within the parental narratives, including the importance of strong and ongoing relationships between HCPs and bereaved families, the importance of high quality communication between HCPs and families, the effect of negative experiences between HCPs and families on parental grief, and the importance of the institution's role in the grief journeys of bereaved parents. Conclusion: Bereaved parents consistently identify the critical role played by HCPs and medical institutions throughout the grief journey. Key components of bereavement support identified by parents should serve to guide the actions of HCPs as well as provide a template for the development of a comprehensive bereavement program within an institution.

Background: Sickle cell disease (SCD) is associated with airway hyper-reactivity (AHR), and with augmented inflammation and leukotriene production, known mediators of AHR. Zileuton is a specific inhibitor of 5-lipoxygenase, a key enzyme in the leukotriene synthetic pathway, and is licensed for asthma. However, its safety/pharmacokinetics is not investigated in patients with SCD, where liver and renal functions are often compromised. We hypothesized that zileuton will be safe in patients with SCD, with pharmacokinetics similar to asthma Objectives: The primary objective was to determine safety, tolerability and pharmacokinetics of twice daily administration of ZL (Zyflo CR) in patients with SCD. Design/Method: We employed a 3×3 dose escalation/de-escalation design of twice daily zileuton for 6 weeks. Nine patients 7-30 years of age with SCD at steady state, who were not on hydroxyurea or chronic transfusions, were enrolled. Pharmacokinetics was performed after the first dose, using a Bayesian model. Total zileuton exposure was defined by the area under the concentration-time curve between zero and 24h (AUC0-24h) normalized by dose Results: Zileuton was well tolerated at doses of 2400mg/day and 3000mg/day. No significant changes in any clinical or laboratory safety parameters occurred. Adverse events were limited to grade-1/2, the most common being pain and hypertension. Pharmacokinetic parameters of zileuton were [mean, (CV %)]: plasma clearance (CL/F) 0.53 L/h/kg (36.4%); volume of distribution (V/F) 1.12 L/Kg (32%); absorption rate constant (Ka) 0.12 1/h (82.2%); elimination phase half-life (t1/2) 1.52 h (24.4%); AUC0-24h (per 1200 mg) 52.61 μg·h/ml (45.7%). The population CL/F estimate of 0.51 L/h/kg in the NONMEM analysis was consistent with MWPharm results (0.53 L/h/kg). Variability was smaller when CL/F and V/F were normalized to body mass, suggesting that differences in body weight helped to explain some variability. The coefficient of determination (R2) between body weight and CL/F was 0.44 (P < 0.1), and the R2 between body weight and V/F was 0.40 (P < 0.1). Conclusion: This phase-1 trial demonstrates that zileuton was safe, well tolerated by patients with SCD although there was significant inter-individual pharmacokinetic variability; and warrants a future phase 2/3 trial to study its efficacy in reducing AHR and associated pulmonary morbidity in SCD.

Background: Parents report that end of life decisions are the most difficult treatment related decisions that they face during their child cancer experience. Research into the parent's perspective of the quality of end of life care of their cancer children are scarce, particularly in developing countries like India. Objectives: This study aimed to identify the symptoms (medical/social/emotional) that most concerned parents during the last days of their child's life and to identify the strategies parents found to be helpful during this period. Design/Method: Parents who lost their child to cancer, treated in our institution were interviewed with a validated prepared questionnaire. Results: 50 % of them were able to understand the concept of palliation vs curative option while 20 % could not understand at all. 80% of them were able to come in terms with palliative mode of treatment while 20 % could not. Only 40 % of them opted for alternative medicine and 70 % of them accepted that it worsened the symptoms. 60 % of them wanted their child to be at the hospital during the period of death and 40 % opted home to be the place of death. When questioned about what made them to opt for aggressive therapy towards the end of life, 60% reported that they hoped for a miracle, while 30 % wanted to do everything possible to reduce the suffering. Retrospectively, 70% of them felt that what they did was right as they wanted to help the child in all possible ways. Towards death, dullness (30%), irritability (30%) and withdrawn from surroundings (10%) were the most common symptoms encountered. 30 % of the children had fear to be alone. 50% of the children had the fear of death. Pain, fatigue, loss of appetite, were the main distressful symptoms that these child suffered from parent's perspective. Conclusion: In developing countries, with scarce financial resources and the increasing magnitude of competing problems, little resources are left for hospice and palliative care services. However, the human factor should not be underestimated, and as end of life of care is far more than medical treatments and pain killers. Greater attention should be paid to symptom control and overall well-being of the child on end of life care.

Background: Sickle cell disease (SCD) is a chronic disorder with lifelong effects. Complications include: pain crises, chronic fatigue, organ damage, infections, acute chest syndrome and stroke. Research shows that health related quality of life suffers along with daily activities. Stem cell transplant is an option for eligible patients. Cure by transplant can markedly improve quality of life, but how patients perceive this benefit is not clear. Objectives: The goal of this study was to explore self-reports of the effects of SCD on work or school along with common themes regarding participants' perspectives on life without SCD. The hypotheses were that patients (1) perceive greater disability of SCD as they age, and (2) recognize that transplant could relieve them of that disability. Design/Method: Mixed methods surveys were administered in person to patients seen at the UI Health Comprehensive Sickle Cell Center hospital, pediatric clinic, or adolescent transition clinic. Participant ages ranged from 10 to 40+. Exclusion criteria were: respiratory or contact isolation or extreme pain. Qualitative responses were examined using thematic analysis. Results: Themes identified by all ages about the effect of SCD on work and school included "Disability," "School absence," and "Motivation to disprove odds." Thematic analysis identified that patients would live their lives differently if cured: "More energy to improve myself," "New educational goals", "Career aspirations." The potential that stem cell transplant would relieve their disability was recognized by nearly all subjects. Older age correlated significantly (P< 0.02) with responses that as relieving their disability, and almost universally the patients would pursue more in their career or education if cured. Conclusion: Advances in transplantation for SCD can achieve cure for adults and often reduces disability from pain. Heightened perception of benefits by adults supports the important role of adult SCD transplant programs. This survey is the first to examine perception of disability among the factors that patients consider in their decision about stem cell transplant for sickle cell. Further, few studies include both adolescent and adult sickle cell patients in a single survey, and this opens the door on age-related differences in perception of stem cell transplantation. Background: Families and caregivers of pediatric oncology patients can get overwhelmed when coping with the multitude of tasks required to maintain health, much less improve health. Although Children's Hospitals are loving and caring environments, there is no place like home. Objectives: Our goal in 2015 was to transform care delivery of a largely inpatient focused solid tumor chemotherapy team into one that could provide outpatient forward observation. This involved: a) facilitating outpatient chemotherapy, b) anticipating and preventing side effects, c) improving nutrition, d) providing resources to enable families and caregivers to take more active roles, and d) encouraging a "forward observer" mind set. Design/Method: Tools used to facilitate and foster forward observation and more active participation in improving health included: 1-improved EMR notes using the Snipping Tool to embed calendars, images, and photos into EMR notes for better team communication, 2-web resources (lotsahelpinghands.org; chemocare.org or ASPHO chemo; disease oriented groups such as ACOR for osteosarcoma or Ewing sarcoma), 3provision of calendars for families, pharmacy, and infusion nurses, 4-one-page summaries of care (including contact information, previous treatments) which provide the relevant clinical details to facilitate meaningful discussions during clinic visits and improved anticipation of plans and tasks, 5-flash drives containing articles+ nutrition info, images, calendars+ roadmaps, and summaries for caregivers, 6-advance directives information, 7-after-visit-summaries, and 8-creating things to look forward to (make-a-wish, college scholarships).

We provide most chemotherapy regimens safely in the outpatient clinic including VAC, VDC, IE, HDMTX with fewer readmissions. Forward observation as a mindset for improving health of patients with metastatic medullary thyroid carcinoma, clear cell sarcoma, neuroectodermal tumor, rhabdomyosarcoma, Ewing's sarcoma, osteosarcoma, and desmoplastic round cell tumor resulted providing successful outpatient care. Snipping Tool use in EPIC has made our notes more informative "at-a-glance". Many of our children and AYA seem to have improved performance status, excellent QOL, and superlative coping skills that positively affect family dynamics and outcomes. Conclusion: Instead of "expecting the worst", we have adopted a forward observer mind set to actively create an environment to "hope and prepare for the best"-and now routinely exceed expectations. Clinical severity index correlated with the SOman percent in the carriers with a cut-off value of 14% and with decreased production of α-chains due to deletional or non-deletional mutations; however, there were no such correlations in the compound heterozygotes who presented in early infancy with severe transfusion-dependence. Other genetic modifiers seem to have no effect. Activation of a deoxygenation-induced Cl-independent K+flux, i.e. Psickle-like permeability, a lack of Gardos channel activity and minimal activity of potassium chloride co-transporter was found in SOman carriers.

HbSOman is a severe form of SCD; carriers can be severely symptomatic and compound heterozygotes present as thalassemia major with early transfusion dependence. Alpha thalassemia mutation is the main genetic modifier in carriers. SOman cells have increased sickling and hemolytic characteristics.

Background: The Pediatric Symptom Checklist (PSC-P) is a well validated questionnaire completed by a caregiver in about 5 minutes to screen children and adolescents for psychosocial difficulties. The Pediatric Symptoms Checklist-Youth (PSC-Y) is a less extensively studied parallel version of the PSC designed for self-report by youth ages 11 years and up. Neither the PSC-P nor the PSC-Y has been studied in adolescents with chronic hematological disorders.

Objectives: This study examined using the PSC-P or PSC-Y to screen adolescents with sickle cell disease or chronic idiopathic thrombocytopenic purpura (ITP) for psychosocial problems that may require more evaluation and/or intervention. Design/Method: Subjects were patients who routinely visited a comprehensive sickle cell or pediatric hematology clinic (ITP). Any parent/caregiver-patient dyad (age eligibility 11-19) was invited to participate. Consenting caregivers completed the PSC-P and CBCL (Achenbach Child Behavior Checklist), and corresponding adolescents completed the PSC-Y and YSR (Achenbach Youth Self Report). Total number of evaluable pairs was 19 (10 female; 8 Hemoglobin (Hb) SC disease, 5 Hb SS disease, 1 Hb S/β thalassemia, and 5 chronic ITP). The agreement between parallel forms was analyzed descriptively. Correlation coefficients were calculated for each pair of instruments (the PSC-P and CBLC and the PSC-Y and YSR.)

Results: Patients age ranged from 11 to 19 years with a mean of 15.2 (± 2.2). We regarded CBCL and YSR as the reference instruments. Of the four patients who exceeded the CBCL threshold score indicating psychosocial risk (T-score >65), 100% also exceeded the PSC-P threshold (>28 points). PSC-P percent agreement with the CBCL was 84.2% (n = 16). PSC-Y agreement with the YSR was 68.4% (n = 13). Each instrument detected risk when it was not detected in the parallel instrument. Conclusion: Our results suggest that the PSC-Y may have limitations to screen sickle cell disease or chronic ITP patients for psychosocial problems, though this conclusion is very tentative due to the very small sample size. In contrast, the PSC-P may be a reasonable alternative to the CBCL that should be explored further. We report the possibility of chronic splenic sequestration as a cause of poor Hb S control in 3 patients with SCD on CTT for stroke prevention and suggest consideration of splenectomy to optimize transfusion parameters in select high-risk children.

Design/Method: Patients were ages 7-9 years with Hb SS disease managed with chronic, partial-exchange PRBC transfusions every 3-4 weeks following a standardized institutional protocol with poor Hb S control. Indications for CTT were prior stroke (2) and abnormal TCD (1). Surveillance magnetic resonance angiography showed progressive CNS vasculopathy. Spleens measured 9.5-13.5 cms. There was no evidence of alloimmunization. After careful consideration, these patients underwent laparoscopic splenectomy. Mean hematologic parameters were compared by paired t-tests 6 months pre and post splenectomy. Results: Prior to splenectomy, mean pre-transfusion Hb was 7.4 gm/dL, reticulocyte count 20.7%, and Hb S 56%. Post splenectomy Hb was 9.5 gm/dL, reticulocyte count 3%, and Hb S 17%. Following splenectomy, there was a mean reduction in Hb S of 39.77% (95% CI 34.3-45.3, p<0.001). With a mean follow-up of 19 months, there were no perioperative or infectious complications. One patient appeared to have reduced iron burden with a mean reduction in baseline serum ferritin of 1,500 ng/mL, perhaps in part because his transfusions were spaced out due to improved Hb S control. Conclusion: This data suggest splenic sequestration may cause shortened red cell survival resulting in suboptimal Hb S control and increased risk of incident or recurrent stroke. Splenectomy may be a reasonable therapeutic option for select high-risk patients. Additional research is warranted into the causes of variable Hb S control in patients with SCD on CTT so that therapeutic options can be refined to reduce the risk of overt stroke. Background: Timely antibiotic administration in febrile neutropenic patients has been associated with improved outcomes. Analysis of our inpatient BMT unit revealed only 50% of patients with new onset fever received antibiotics within 60 minutes. The aim of this project was to increase the percentage of febrile BMT inpatients receiving antibiotics within 60 minutes, from 50% to 75% by October of 2015 using the Model for Improvement. Objectives: 1. Recognize the importance of timely antibiotic administration in immunocompromised patients2. Identify potential barriers to timely antibiotic administration3. Demonstrate the importance of establishing a standardized process for provider notification, antibiotic order entry and administration Design/Method: Through Pareto analysis and Failure mode effects analysis (FMEA), we identified variables and underlying causes associated with delays. Pareto analysis revealed: orders placed by the providers, delays in pharmacy processing, delays in order placement, and delays in notification of new onset fever were associated with 80% of failures. FMEA revealed insufficient awareness of pharmacy, nursing, and providers of new onset fever; no standardized ordering process; and lack of provider and nursing accountability as likely causes of timely antibiotic delivery failures. From these findings, we created key drivers and through small tests of change developed a standardized process consisting of: 1) bedside nurse notifying ordering provider, charge nurse, and safety coach of a febrile patient, 2) a standardized order set specifically used for inpatients with their first fever, 3) pharmacy notification of a newly febrile patient via a STAT sticker printing off when antibiotics were entered via the order set. We monitored compliance with the process via a software monitoring system called VigiLanz. Results: After implementing an antibiotic order set and developing a process in which the bedside nurse notified both the charge nurse and safety coach of a febrile patient, we saw an increase in the percentage of patients receiving antibiotics within sixty minutes of documented fever from a median of 55% to 80%. Our median time for antibiotic administration decreased from about 60 minutes to 45 minutes. Conclusion: Implementation of a standardized process for provider notification and order entry has resulted in improved times to antibiotic administration in our patients. A month later, she received two cycles of Rituximab 375 mg/m2 with good response. In January 2015, the platelet count went back to 12×109/L and she received a third course of Rituximab with no sustainable response. It was then decided to introduce Romiplostin in February at a starting dose of 2 mcg/kg and was increased to a maximal dose of 5 mcg/kg. Within a month, she had normalized her platelet count (from 9 to 444×109/L). Romiplostin was then titrated as per standard recommendation to maintain platelet count between 50 and 200×109/L. Although platelet count remained stable, ofatumumab was further given one month later to avoid relapse of the other immune manifestation of SLE. Given sustained normal platelet count, romiplostin was gradually weaned and ceased in September 2015. The medication was well tolerated and the patient did not experienced any side-effects nor any pain crisis. Conclusion: To our knowledge, this is the first report of utilization of Romiplostin in a patient with SCD. The medication was efficacious and well tolerated. In particular, no increase in pain crisis was noted. In contrast to GCSF, romiplostin might safely be used in SCD. Objectives: Identification of effective strategies is necessary to optimize uptake of the HPV vaccine. This study is a systematic review of the literature for national and international interventions that have successfully increased HPV vaccine uptake. Design/Method: We conducted searches using a standardized protocol in 3 electronic databases: PubMed, Scopus and Embase. We identified interventions designed to increase HPV vaccine uptake among adolescents 11-26 years old. All study designs were acceptable. Only manuscripts that included post intervention vaccination rates were included. Two authors independently reviewed each article for data extraction and quality assessment. Three reviewers independently classified interventions according to predefined criteria.

Results: Manuscripts were classified according to the Community Guide and results were reported according to the RE-AIM framework. 51 manuscripts met eligibility criteria: 2 informational interventions, 18 behavioral interventions and 31 environmental interventions. Factors associated with HPV vaccine uptake were increased vaccine availability, decreased financial barriers and interventions targeting providers and patients. Conclusion: Population based vaccination strategies that increased vaccine availability reached the greatest number of adolescents and were most successful in achieving high rates of vaccination. Interventions that targeted providers and patients were also successful.

Background: Acute chest syndrome (ACS) is the most common cause of death in children with sickle cell disease (SCD).Hematologists need to be aware of assessment of ACS severity to guide therapy and measures to prevent ACS. An ACS severity assessment tool has been utilized in research but not validated in the real-world setting. Existing guidelines including from NHLBI do not provide a uniform grading for ACS severity. In contrast, evidence for role of incentive spirometry in preventing and decreasing severity of ACS is strong and incentive spirometry recommendations are included in guidelines. Objectives: To assess the current knowledge of resident physicians and nurses regarding two aspects of ACS: Severity assessment and Incentive spirometry. Design/Method: Our tertiary care hospital admits over 20 patients with SCD per month on the pediatric floor. Pediatric residents and nurses learn about ACS management and prevention through 2 didactic sessions on SCD/year and bedside teaching. An anonymous survey was administered to 40 pediatric residents/20 pediatric nurses who routinely engage in care of ACS patients. This was followed by a house-staff education session on ACS. Results: SEVERITY SCORING: 15% residents/5% nurses had been educated on the use of ACS severity assessment in past. An overwhelming 92% felt that a scoring system would be useful for assessing their patient's condition and guiding management, however only 5% residents /3% nurses had used a severity scoring for ACS in the past. A clinical vignette on ACS was answered incorrectly by 60% of the residents and nurses. INCENTIVE SPIROMETRY: 91% responded they were aware that incentive spirometry can decrease the severity of and improve outcomes of ACS. 90% of residents/95% nurses thought that the patients are compliant less than 50% of the time with incentive spirometry which is almost always ordered.

The knowledge of residents and nurses regarding severity assessment of ACS is limited and greater efforts are needed to educate them to include this assessment in their management decisions. The importance of incentive spirometry is recognized by house-staff, however, patient compliance is below desirable. Reinforcement is needed to improve ACS outcomes. Our pilot study identifies room for quality improvement at several steps in the care process for SCD. Data were extracted using a standardized data collection form.

The full text of 53 of the 590 (9.0%) references identified was reviewed based on the title/abstract. Thirty-three articles (62.3%) are included in this analysis; 20 articles were excluded based on pre-determined exclusion criteria. Fetal hemoglobin (HbF) and alpha globin gene number were the most commonly studied severity predictors (7 studies each) with hemoglobin (6), white blood cell count (5) and absolute reticulocyte count (4) rounding out the top 5 studied predictors in this systematic review. Nearly three quarters (5/7) of the HbF studies reported beneficial effects with increasing HbF levels; however, increased HbF levels were not associated with lower rates of hospitalization or stroke risk in two articles. Increasing ARC was positively associated with increasing risk of cerebro-vascular complications in all 3 of the reports in which it was studied, while alpha thalassemia trait was protective against stroke and abnormal TCD, but not rate of painful crisis.

The ability to predict SCA complications was mixed for all studied variables, including HbF. More reliable predictors of disease complications are urgently needed to guide therapeutic decisions in pediatric patients with SCA.

Nupur Mittal, Paul Kent

Background: Survivors of pediatric cancer are at risk of long-term consequences of therapy one of which is loss of pre-existing protective antibody predisposing them to illnesses such as Measles. Measles in recipients of immunosuppressive chemotherapy can have mortality rates up to 50%. Up to 35% of children < 7 Years lose humoral immunity to measles as a result of chemotherapy induced alterations in immune system. Despite proven strategies of the WHO for improving measles vaccine coverage, the disease still continues to circulate leading to outbreaks in developed countries. In 2015, the US experienced a major measles outbreak related to an amusement park in California. 189 cases (40% < 18 years) were reported across 24 states including our state. Measles is highly contagious from 48 hours prior to the first symptoms. Our pediatric oncology practice shares office and floor space with other pediatric practices, placing our patients at risk for measles infection. Objectives: Measles protective humoral immune status was checked in our patients because of the new risk of Measles in the period of the outbreak from January-June 2015. At the time, it was not our standard practice to check measles titer prior to initiation of chemotherapy. Design/Method: Patients <21 years receiving chemotherapy between January 2015-June 2015 in our department were included in the prospective review. We defined immunity according to our lab standards. Results: A total of 21 (13 female) patients were included. Three patients (15%) had non protective measles antibody levels. 2 of the patients were < 3 years at diagnosis and had leukemia, one was an adolescent with sarcoma. All three came weekly to the clinic and were admitted to floor for chemotherapy during this period and thus shared the common clinic and floor space. None of the patients developed measles. All are in remission.

Measles outbreaks in the US pose a grave threat to recipients of chemotherapy. This danger is increased in the nosocomial setting with shared clinical space. Universal vaccination, stringent isolation in pediatric clinical areas and standard practice of checking measles immunity in all patients prior to chemotherapy initiation may prevent this devastating disease in this sensitive population. Results: Our cohort included 70 patients with SCD (39 males and 31 females), with an age ranging between 4 and 18 years. According to their transfusion need prior to surgery, the patients were categorized into 3 groups; namely: no transfusion (group I), simple transfusion (group II) and exchange transfusion (group III). The 3 groups included 23, 33 and 14 patients respectively. There was no significant difference between the 3 studied groups as regards main post-operative complications of SCD. Vasoocclusive crisis occurred in a comparable number of cases in all three groups (2, 1 and 1 respectively). Acute chest syndrome developed in 1 patient in both non-transfusion group and exchange transfusion group, and 2 patients in simple transfusion group. The pre-transfusion average hemoglobin value was significantly lower in simple transfusion group in comparison to the other 2 groups. Of note, patients with simple transfusion required almost half blood volume compared to those with exchange transfusion (9.1+/-3.3 ml/kg vs. 17.7+/-6.7 ml/kg), with statistically highly significant difference between both groups (p = 0.000).

We conclude that it is safe to do adenotonsillectomy without simple or exchange transfusion pre-operatively in patients with SCD, maintaining a hemoglobin level above 8 g/dl. Transfusion does not improve surgical or SCD-related outcome. (1). Management of priapism is controversial and not evidence-based. Red cell exchange transfusion has been used to manage sickle related complications but several case reports have described acute neurological events following exchange transfusion for priapism (2, 3) ,which limits enthusiasm for routine adoption of this therapy. Presently there are little data characterizing exchange transfusions utility and safety in treating priapism. Objectives: To determine and compare the incidence of adverse events seen in patients with SCD receiving red cell exchange transfusion for refractory priapism and secondary stroke prophylaxis. Design/Method: The University of North Carolina's blood bank database was used to identify patients with SCD who were enrolled on chronic exchange transfusion program for refractory priapism from years 2004-2015. An age-matched cohort of seven patients enrolled in exchange protocol for secondary stroke prophylaxis was identified. The first exchange procedure for both groups will be used for comparison. Adverse events such as vital sign instability and acute neurologic events were collected. Data collected will be analyzed to determine if there is a difference in adverse events in the priapism group compared to those receiving exchange transfusions for secondary stroke prophylaxis.

We identified seven patients with SCD who were enrolled on a red cell exchange protocol for refractory priapism. We evaluated 6 episodes of exchange transfusions per patient. The mean age was 24; six patients have HbSS and one patient has HbSC. Two episodes of hypotension were recorded in one patient on two separate procedures. This resolved after decreasing the inlet pump flow rate to the patient. No adverse neurologic events were recorded. One patient experienced lip tingling that resolved with calcium carbonate tablets. The comparison data for the patients being transfused for secondary stroke prevention is being collected. Conclusion: Although exchange transfusion is infrequently used for treating refractory priapism in patients with SCD, the incidence of adverse events appears to be minimal. Analysis is ongoing to compare the safety of red cell exchange transfusion for priapism to stroke. Future controlled trials using blood exchange transfusion for refractory priapism are needed.

and may result from preceding restrictive cardiomyopathy. Few studies have investigated right and left ventricular global longitudinal strain (RVGLS and LVGLS) among children with SCD or non-sickling hemolytic anemias; none has investigated the role of disease-modifying therapies (hydroxyurea, chronic transfusions) and elevated tricuspid regurgitant velocity (TRV) on strain in SCD. Objectives: 1) compare RVGLS and LVGLS in pediatric SCD with other pediatric non-sickling hemolytic anemias, 2) investigate the association of age, disease-modifying therapies, TRV, and global longitudinal strain in SCD. Design/Method: Prospective measurement of RVGLS and LVGLS by speckle-tracking and TRV by 2D M-mode echocardiography in children with Hb-SS and HbSβ0thalassemia (n = 151) and non-sickling hemolytic anemias (hereditary spherocytosis, Hb-E, pyruvate kinase deficiency; n = 16) ages 5-19 performed with central reading by one single cardiologist. TRV was categorized as normal (<2.5 m/s) or elevated (ࣙ 2.5 m/s). Results: In univariate analysis, increased (worsening) RVGLS and LVGLS were associated with age and any disease-modifying therapy in children with SCD (p = 0.00011 and 0.029). When controlling for age in a multivariate model, however, treatment was no longer associated with strain. For each 1 year increase in age, there is an increase in RVGLS of 0.26 (p = 0.0016). Elevated TRV was associated with increased LVGLS in SCD (rho = -0.17, p = 0.048). In non-sickling hemolytic anemias, age was associated with increased LVGLS (rho = 0.63, p = 0.096). LVGLS but not RVGLS was significantly decreased in SCD compared with non-sickling hemolytic anemias (-22.6 vs. -21.4, p = 0.049). More patients with SCD had elevated TRV compared with non-sickling hemolytic anemias (26.4 % vs. 0%, p = 0.029). Conclusion: Global longitudinal cardiac strain declines with age in children with hemolytic anemias and may represent an early marker of pathologic cardiac change. Elevated TRV was more common in SCD than in non-sickling hemolytic anemias and may modulate LVGLS. Global longitudinal strain should be further studied in longitudinal prospective cohorts of patients with hemolytic anemias for its value as a marker of early cardiac damage.

Background: Neuroblastoma is the most common extracranial malignancy of childhood. The Myc family of proteins regulates cell growth and proliferation and has been implicated in the etiology of many cancers, and MYCN amplified neuroblastoma is associated with a poor prognosis. Investigating specific tumor pathways will further our understanding of neuroblastoma pathogenesis and lead to future therapeutic options. Mxi1 is a member of the MAD family that inhibits N-Myc activity. Mxi0 is an alternatively spliced variant of Mxi1 with a different first exon (Exon 0) whose function has not been determined. Objectives: Test the hypothesis that Mxi1 and Mxi0 differentially impact N-Myc-dependent neuroblastoma cell proliferation. Design/Method: We expressed Mxi1 and Mxi0 in SHEP neuroblastoma cells, and SHEP cells stably transfected to express high levels of MYCN (SHEP/MYCN). We also utilized native neuroblastoma cell lines with inducible expression of Mxi1 and Mxi0. Cell proliferation and survival were quantified using BrdU and MTT assays, respectively. The impact of Mxi1 and Mxi0 on N-Myc expression was measured by RT-PCR and immunoblot analysis. Results: Overexpression of Mxi1 inhibits neuroblastoma cell viability. Conversely, overexpression of Mxi0 in neuroblastoma cell lines leads to increased viability, suggesting that Mxi0 has a counter-regulatory role to that of Mxi1. Further examination reveals that these changes in viability are partially due to changes in cell proliferation, with Mxi1 decreasing proliferation and Mxi0 augmenting it. Additionally, we observed that N-Myc levels decrease in response to Mxi1 expression, and increase when Mxi0 is expressed. Compared with Mxi1, expression of Mxi0 results in enhanced chemoresistance of neuroblastoma cells to doxorubicin or etoposide. Conclusion: Overexpression of Mxi1 in neuroblastoma cell lines leads to inhibition of N-Myc-mediated cell proliferation, while Mxi0 appears to promote cell growth. Mxi1 expression enhances chemosensitivity of neuroblastoma cells, while Mxi0 has the opposite effect. These effects may partially be due to alterations in N-Myc expression. A better understanding of the interactions among Mxi1, Mxi0 and N-Myc and how the relative expression levels of these proteins affect neuroblastoma physiology may aid in developing more effective targeted therapies to improve outcomes in pediatric neuroblastoma patients.

Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States

Background: There are currently no standard national guidelines regarding the optimal time of screening for iron deficiency anemia (IDA) in infants and children. The United States Preventive Services Task Force, CDC and American Academy of Pediatrics all recommend screening different age groups and populations based on IDA risk and the potential for subsequent poor outcomes. Objectives: The aim of this study was to compare the cost-effectiveness of screening for IDA at varying ages within both a high risk group and the general population. Design/Method: We used a Markov decision analysis model to estimate the cost-effectiveness of screening for IDA in 9, 12 or 18 month-olds within high-risk groups or the entire population. Identical hypothetical cohorts were evaluated over 27 months, tracking anemia severity over time and the possibility of neurodevelopmental outcomes with undiagnosed severe anemia. Clinical outcomes, utilities and costs were all obtained via literature review. We varied parameter estimates in one-way sensitivity analyses. Results: In the base case, screening high-risk 9 month olds gained 0.0054 quality-adjusted life years (QALYs) and cost $4.49 more than no screening, or $838/QALY gained. Screening all 9 month olds cost $5593/QALY gained, and screening all 12 month olds cost $15,403/QALY gained. Other strategies were eliminated due to dominance. Using an accepted standard of $50,000 dollars/QALY gained as being cost effective, screening all 12 month olds is the most cost effective strategy. Varying the most uncertain variables in our model over plausible ranges, specifically probability of neurodevelopmental outcomes, probability of anemia in high-risk populations, and the probability of being high-risk, the preferred strategy remained screening all 12 month olds. In a probabilistic sensitivity analysis, varying all parameters simultaneously over plausible distributions resulted in screening all 12 month olds being favored in 99.98% at a $100,000/QALY threshold. Conclusion: Screening all children at 12 months of age for IDA is an economically reasonable strategy. In light of this, reexamination of the various currently suggested guidelines may be warranted.

Background: Neuroblastoma remains the most common solid extracranial solid tumor in children. Approximately 600 new diagnoses are made each year. Despite advances in therapy, including a multimodal approach, high risk neuroblastoma remains very difficult to treat. Current long term survival rates for high risk neuroblastoma are approximately forty percent. Biologically targeted novel therapeutics are potential treatments for neuroblastoma that could improve cure rates. Aberrant growth factor receptor (GFR) expression and receptor kinase signaling are associated with the pathogenesis of many malignancies. These kinases therefore serve as targets for a number of novel therapies. Fibroblast growth factors (FGFs) activate their cognate receptors (FGFR1-4) to stimulate cell proliferation and migration, and FGFR inhibition is effective in a variety of preclinical cancer models. Objectives: To test the novel pan-FGFR inhibitor ponatinib for efficacy in preclinical models of neuroblastoma. Design/Method: We treated a panel of established neuroblastoma tumor cell lines with increasing concentrations of Ponatinib and viability was determined using MTT assays. Additionally, neuroblastoma cell migration into a wound before and after treatment with ponatinib was monitored at 24 hour time intervals. Cells were treated with Ponatinib and western blots using antibodies for downstream targets of FGFR4 were performed.

Results: All neuroblastoma cell lines tested were sensitive to Ponatinib with IC50 values in the nanomolar to micromolar range. Migration of neuroblastoma cells was inhibited by treatment with Ponatinib. Phospho-MEK and phospho-ERK were significantly decreased after treatment with Ponatinib. Conclusion: Treatment of neuroblastoma tumor cells with Ponatinib causes cell death and reduces cell migration. Inhibition of FGFR family members represents a novel therapeutic strategy for neuroblastoma, and further preclinical studies of Ponatinib and additional FGFR inhibitors are warranted.

Background: The inherited stomatocytoses are a group of hemolytic anemia disorders characterized by altered red blood cell (RBC) membrane permeability to monovalent cations. Cryohydrocytosis is one subtype where the cation leak is mild at 37°C but significantly increases when temperatures approaches 0°C. Single amino acid substitutions in the transport domain of band 3 caused by mutations in SLC4A1 have been demonstrated as causative of this phenotype. Objectives: We describe a novel SLC4A1 mutation associated with monovalent cation leak, particularly marked at 4°C, in a patient with congenital hemolytic anemia. Design/Method: Next-generation sequence analysis of 32 genes associated with hemolytic anemias was performed in a 2-year old female who had presented with neonatal hemolytic anemia and jaundice with a family history positive for hemolysis. Further RBC phenotypic analysis included ektacytometry, red cell cytogram, and measurement of intracellular K+ and Na+ content at 4°C compared to control samples.

The patient's hemoglobin was normal at 13.1 g/dL with an elevated reticulocyte count (10.36%) indicating persistent hemolysis. The elevated mean corpuscular hemoglobin concentration (39.1 g/dL) and the red cell cytogram showing the majority of cells in the hyper chromic zone is consistent with increased cell density. Ektacytometry of the patient's RBCs produced a curve indicating impressive cellular dehydration with low Omin (the hypotonic osmolality where 50% of the cells hemolyze in an osmotic fragility assay) of 73 mOsm/kg (normal: 149.6 ± 8.1); a low El (Elongation Index) max of 0.52 (normal: 0.59 ± 0.01) indicating decreased deformability; and low Ohyp of 298 mOsm/kg (normal: 460.9 ± 13.6) indicating increased intracellular viscosity. The RBC intracellular K+ cation content was reduced to 155 ± 3.7 mmol/kg Hb (controls: 270 ± 3.1 and 268 ± 3). Next-generation sequence analysis of the patient's sample revealed a novel heterozygous variant in SLC4A1 gene (c.2173A>G) causing a single amino acid substitution in the transport domain of band 3 (p.S725G).

We report a novel genetic defect in SLC4A1 associated with significant RBC cation leak at cold temperatures in a patient with congenital hemolytic anemia. The substitution p.Ser725Gly is possibly a novel cryohydrocytosis mutation converting band 3 from an anion exchanger into an unregulated cation channel.

The Results: This French Canadian male was incidentally found to be polycythemic at the age of 2 yrs. old (Hb 17.5g/L, Hct 0.52 with no other abnormalities). He had no evidence of oxygen desaturation, and a normal calculated p50. Bone marrow revealed no morphologic and cytogenetic abnormalities. Epo level was undetectable, and In vitro testing revealed increased erythroid sensitivy with very rare Epo-independent erythroid growth. Search for JAK2 V617G and exon 12 somatic mutations were negative. A germline, heterozygous G6002A EPOR mutation was detected. Although this mutation had been previously reported among 16 other EpoR-mutations causing the dominantly inherited primary familial congenital polycythemia (PFCP), this mutation was found in no other family members. Given the development of moderate to severe headaches, phlebotomies were eventually initiated at the age of four to maintain a hematocrit <0.45. Over 14 yrs. of follow-up, he developed mild arterial hypertension, and hyperuricemia, but never had thrombotic complications under aspirin prophylaxis. Anti-hypertensive therapy was switched to enalapril at the age of 16 yrs. old. At the age of 17, in spite of well-controlled hematocrit level, anti-migraine agent zolimitriptan, a serotonin 5-HT receptor agonist was initiated due to worsening headaches. Phlebotomies were ceased for up to 24 weeks given stable hematocrit since the introduction of this medication. Bone marrow remained normal without evidence of marrow fibrosis. Conclusion: Although usually benign, inherited EpoR mutation may cause vascular complications such as hypertension. Given that serotonin has a known role in erythropoiesis, we propose that zolmitriptan alone, or in combination with angiotensin antagonist may be beneficial. Its effect should be evaluated in further studies. 

Background: 131-MIBG has been used in the treatment of relapsed/refractory NB for the past 30years,with response rates of around 20-40%.It is now used in regimens, often in conjunction with chemotherapy or myeloablative therapy.Data from LMICs is lacking.We describe here our experiences with 131-MIBG therapy in the treatment of NB Results: There was data on 31children who received a total of 46courses of MIBG therapy (median 1; range1-6courses). Median age was 6years, and male: female ratio 20:11. Intent was palliative in 21patients (total 28courses); most were high risk NB and had received multiple courses of treatment, including Autologous Stem Cell Transplant in 3/21. Response rate was 45 %(12/28), with 4 patients alive at last follow up. Median time to progression was 7months. Ten patients received a total of 19courses of MIBG therapy as part of frontline therapy (inoperable mass-4patients, refractory disease-2patients, residual post-operative mass-4patients). Response rate was 40%, with 5/10 alive at last followup. The most common toxicity was grade3/4cytopenia, documented in 30%patients, and often delaying further courses. Conclusion: With the limitations of a retrospective study, it is feasible both in relapsed/refractoryas well as frontline NB in LMICs, with acceptable toxicities. MIBG therapy offers a reasonable salvage strategy in LMIC settings, where other aggressive salvage therapies are often not possible. We hope that incorporation of MIBG therapy in the frontline treatment regimen at our centre in the near future will help improve outcomes in High Risk NB. ) will be compared with the general population. A competing-risks approach will be used to estimate cause-specific hazard functions and cumulative incidence curves for DBA, as done previously.

The DBAR reported the first quantitative assessment of incidence of neoplasia in 608 DBA patients (median age, 18 years) with analysis through August 2010. Seventeen patients who had not received a BMT had 1 or more cancers and 4 patients had MDS. The significantly elevated O/E (observed to expected) ratios were 36, 33, 28, and 287 respectively, for colon carcinoma (N = 3), osteosarcoma (N = 2), acute myeloid leukemia (AML; N = 2) and MDS (N = 4). As of December 2015 (N = 708), with a median patient age of 22 years, 16 additional patients who had not received a BMT had 1 or more cancers and 4 additional patients developed MDS. There is a total of 32 cancers reported in 28 patients, including 10 patients with gastrointestinal carcinoma, 4 with sarcoma, and 3 with AML; there are 8 patients with MDS. A statistical analysis will be available at the time of presentation. Not included in our analysis are 3 patients who developed colorectal cancer in two and OS in one, respectively, following hematopoietic stem cell transplantation. Conclusion: Our extended analyses including additional follow-up and more patients will inform our assessment of cancer types and risks that are unique to DBA.

Background: Hyponatremia (serum Na <135mEq/L) is the most frequent electrolyte abnormality in children. Previous research has reported that hyponatremia affects between 3.4-49% of hospitalized pediatric patients, but no studies have been done to evaluate the incidence of hyponatremia in pediatric oncology patients. In oncology the etiology of hyponatremia depends of many factors, illness, type of cancer, type of chemotherapy, type of hydration during chemotherapy. Objectives: To determine the incidence of hyponatremia in pediatric oncology patients by comparing those admitted for chemotherapy to those admitted for acute illness Design/Method: Retrospective cohort study involving chart review of all pediatric oncology admissions to the Children's Hospital of Illinois over an 18 month period. Results: During the study period, 74 eligible patients were admitted to receive chemotherapy and 63 due to acute illness. There was no significant difference between the two groups with regards to sex (p = 0.1385), and age (p = 0.9896). Most patients received fluids with 0.45% or 0.9% normal saline. A serum Na of < 135 was found in 15/74 (20%) patients admitted for chemotherapy and 27/63 (42%) of those admitted for acute illness (p = 0.0043). Even when accounting for differences in fluid type, hyponatremia was 3.1 times more likely to occur in patients admitted for acute illness in contrast to those admitted for scheduled chemotherapy (OR = 3.1 [1.4, 6 .7], p = 0.0044). In 45% patients had hyponatremia was present at the time of admission and 31% in the first 24 hours. None of the patients had symptomatic hyponatremia. There was no difference in the hospital length of stay (p = .00579) between the two groups Conclusion: Among the oncology patients those who present with acute illness are more likely to have or develop hyponatremia during their admission. Hyponatremia was subclinical and did not prolong the length of stay. We plan to compare the incidence of hyponatremia in patients receiving different regimens of chemotherapy and in patients with leukemia versus solid tumors. Design/Method: Case report and gene sequencing after family's informed consent.

A 5-year-old Caucasian male was referred to our clinic for evaluation of a transfusion-dependent, non-immune hemolytic anemia with suboptimal reticulocytosis and skeletal deformities involving his fingers and toes. The child had presented soon after birth with severe neonatal jaundice and hepatosplenomegaly. In the blood smear red cells showed marked anisopoikilocytosis with dacryocytes, red cell fragments and macrocytes. In the bone marrow aspirate, erythroid cells showed prominent dyserythropoiesis, including megaloblastoid maturation, binucleation, nuclear contour irregularities and chromatin bridges; occasional multinucleated erythroids were present. Next-Generation sequence analysis of 29 genes associated with hemolytic and dyserythropoietic anemias was performed on DNA isolated from peripheral blood. The patient was found to be compound heterozygous for two mutations in CDAN1 confirming the suspected diagnosis of CDA I. The first mutation, c.3051_3052delTG, is a previously unreported deletion that results in a frameshift. The second mutation, c.3071C>T (p.P1024L), is a missense variant that affects a highly conserved amino acid residue. Through the use of mutation prediction software, the amino acid substitution P1024L is predicted to be "deleterious" and "probably damaging". This variant is known as rs145041909 and was found in ExAC database, with very low MAF of 0.0001. Patient is currently managed with regular blood transfusions and iron chelation which has been effective, as monitored by MRI for liver iron, while the family is considering the option to try interferon-alpha therapy. Conclusion: CDA should be considered in the differential diagnosis of non-immune hemolytic anemia with suboptimal reticulocytosis. Next-Generation sequencing can provide a definitive diagnosis, may unveil new disease-causing mutations and may allow the consideration of other therapies like interferon-alfa that has been found to increase hemoglobin levels and decrease iron overload in patients with CDA I.

Stephen Kirchner, James Bartram, Daniel Wechsler, Michael Armstrong

Background: The Myc family regulates cell growth and has been implicated in the etiology of many cancers, including neuroblastoma. Mxi1, a member of the MAD family, inhibits N-Myc activity. Mxi0 is an alternatively spliced variant of Mxi1 with a different first exon (Exon 0) whose function has not been determined. These proteins appear to have differential functions in neuroblastoma pathogenesis: Mxi1 inhibits neuroblastoma cell proliferation, while Mxi0 promotes it. While Mxi1 and Mxi0 are mostly homologous, including their Sin3 repressive domains, they possess distinct N-terminal exons, suggesting a critical role of Exon 0 in the differential function of Mxi0.

Objectives: Determine the role of subcellular localization as a potential mechanism for the differential function of Mxi0. Design/Method: We created GFP-tagged constructs of Mxi1, Mxi0, and Exon 0 to assess cellular localization of these proteins. Proteins were expressed in 293T cells, and subcellular localization of Mxi1, Mxi0, and Exon 0 was detected by immunofluorescence. To assess whether these proteins undergo nuclear/cytoplasmic translocation, cells were treated with Leptomycin B (LMB) to block nuclear export. Results: Examination of Mxi1 and Mxi0 subcellular location reveals that Mxi1 resides in the nucleus, while Mxi0 is found primarily in the cytoplasm. Exon 0 also displays cytoplasmic localization, indicating that the presence of Exon 0 contributes to differential localization. Treatment with LMB resulted in accumulation of Mxi0 in the nucleus, suggesting that Mxi0 cycles in and out of the nucleus in response to appropriate signals. This effect appears to be mediated by Exon 0, as it also accumulates in the nucleus after nuclear export inhibition.

Conclusion: Mxi0 and Mxi1 exhibit distinct subcellular localization patterns, with Mxi1 residing in the nucleus and Mxi0 found predominantly in the cytoplasm. Exon 0 directs the cytoplasmic localization of Mxi0. Finally, nuclear export inhibition leads to nuclear accumulation of Mxi0, suggesting that the Mxi0 protein translocates in response to appropriate signals. A better understanding of how Mxi0 impacts neuroblastoma physiology and how Exon 0 imparts the differential function of Mxi0 may aid in developing more effective targeted therapies to improve outcomes in children with neuroblastoma.

Background: SWI/SNF subunit mutations have been identified in many cancer types and these mutations lead to specific vulnerabilities, which may be targeted with novel therapies. In a recent phase I clinical trial of an EZH2 inhibitor in adults with advanced cancers, tumor responses were seen in patients with loss of the SMARCB1 subunit as detected by negative INI1 immunohistochemistry (IHC) and in a patient with negative SMARCA4 IHC. Data suggest loss of ARID1A function also results in susceptibility to EZH2 inhibition 

Background: Clostridium difficile infection has gained relevance in last decades, particularly among pediatric cancer patients. Metronidazole has been patterned as primary choice for treatment whereas Vancomycin, even in long courses, has been elected as 2nd line for relapsing infections. In case of multiple recurrences or refractory infection the drug choices are scarse and with no proven efficacy in pediatric patients.

Fecal microbiota transplantation has evolved as a safe and successful tool for patients failing antimicrobial therapy but minimal pediatric data are available to warrant its use in childhood, namely to those under immunosuppressive treatment. Objectives: 1st end point was erradication of recurrent C difficile infection. 2nd end point was demonstration of procedure safety. Design/Method: A 4 years old boy with high risk neuroblastoma developed abdominal pain and diarrhea caused by C difficile while in chemotherapy. Metronidazole used in first place induced symptoms relief but other bouts ocurred with the same features, despite administration of oral vancomycin and vancomycin taper. Fecal microbiota transplantation was then considered. The father was selected for donnation after health overview including screening for STD, viral infections and parasitic infestation. After taking 4 days of Vancomycin 10mg/kg QID, the boy was admmited and a duodenal probe was placed. Stools from the donnor were colected and 30g of the stuff were homogenized in 50ml of saline, then filtered twice before the infusion of 25ml of the final solution. After flushed with 15ml of saline the probe was removed.

In the 14th day after the procedure a stool test was negative for both toxins and DNA of the agent. No side effects were reported neither during the transplantation nor through the days after. Conclusion: Fecal microbiota transplantation has been expected to overcome unresponsive C difficile infections. Fidaxomicin could be an option but has no aproval in our settings. Although promising also for children, fecal transplantation needs to be more extensively studied.

Abhishek Objectives: The aim of our study was to molecularly characterize MEGNT, provide insight into the biology of this tumor and identify potential targets for treatment. Design/Method: Whole exome sequencing (WES) and transcriptome sequencing (RNA-seq) were performed on pre-treatment tumor samples from three patients with MEGNT, as well as two additional post-radiation samples from one of these patients. Blood was available for germline WES in one case. Clinical information was obtained retrospectively by chart review. Results: All three patients underwent subtotal (Patients 1 and 2) or gross total (Patient 3) resection followed by involved field radiation therapy. Patients 1 and 3 had disease recurrence less than a year after treatment. Patient 2 has stable disease six months off therapy. Targeted clinical testing revealed Patient 1 to have both a KIAA1549-BRAF fusion and a BRAF V600E mutation; WES identified an additional TSC1 frameshift mutation. RNA-seq analysis of patient 2 revealed an in-frame NTRK2-BEND5 fusion that is rarely found in pediatric high grade glioma. Patient 3 was found to have a BRAF V600E mutation by WES and RNA-seq revealed an in-frame SOS1-MAP4K3 fusion that has been previously reported in a case of thyroid cancer, but not CNS tumors. A post-XRT sample from this patient revealed TSC1 and TP53 mutations that were not seen in the primary tumor. Conclusion: Potentially targetable somatic alterations targeting the MAPK pathway were identified in all three cases of MEGNT, with TSC1 mutations indicating activation of mTOR signalling also found in two tumors. Molecular studies of larger series of MEGNTs are needed to confirm the primary role of these pathways in this rare tumor. Clinical trials evaluating the efficacy of agents (BRAF, MEK, NTRK, and mTOR inhibitors) targeting the genetic lesions identified in these patients are indicated.

Background: Vorinostat, a histone deacetylase (HDAC) inhibitor, has been of interest in adult and pediatric cancers. However, there is some concern that the effects of the HDAC inhibitors are compensated by autophagy. Hydroxychloroquine, an autophagy inhibitor, treatment leads to the accumulation of autophagosomes, and accelerates tumor cell death. We hypothesize that by combining a HDAC inhibitor with hydroxychloroquine, there will be an improved anti-tumor response compared to HDAC inhibitor alone in pediatric cancer cell lines. Objectives: To determine if there is an improved efficacy of vorinostat when combined with hydroxychloroquine in pediatric solid tumor cell lines. Design/Method: Different pediatric cancer cell lines were treated with varying concentrations of vorinostat or hydroxychloroquine, and cell viability was measured. Dose-response curves were plotted to determine IC50 (inhibitory concentration 50%). Western blot analysis was performed to measure expression of proliferation and autophagy markers.

Results: The IC50 of vorinostat and hydroxychloroquine was in the range of 0.5-1.25μM and 25-50μM, respectively. The combination treatment resulted in a dramatic decrease in cell viability, with these two drugs cooperating in a dose-dependent manner. Hydroxychloroquine treatment resulted in profound conversion of LC3-I to LC3-II, indicative of autophagy blockade, and this effect was greater in cells treated with both vorniostat and hydroxychloroquine alone. Finally, exposure to the combination of vorinostat and hydroxycholroquine resulted in decreased levels of phospho-ERK compared to single-agent treatment, signifying reduced cell proliferation. Taken together, our data demonstrate that when autophagy was inhibited by hydroxychloroquine in the presence of vorinostat, autophagosomes accumulated and cell viability/proliferation reduced. Conclusion: Our results show a clear and improved response when vorinostat is combined with hydroxychloroquine compared to vorinostat alone. We also observed an increase in autophagy inhibition as well as a decrease in cell proliferation in combination studies. Furthermore the IC50 concentration of vorinostat, about 200ng/ml, necessary for effect is well within the achievable clinical range of 150-500ng/ml. This combination of drugs has yet to be explored in pediatrics but has the potential to enhance the effect of an established chemotherapy agent with a well-known and easily accessible non-cancer drug.

Background: Drugs that radiosensitize tumor cells while sparing normal tissues could have a significant impact on the efficacy of cancer radiotherapy. CLR1404 is a novel alkyl phosphocholine analog and belongs to the family of synthetic anti-tumor alkyl phospholipid compounds, some of which have demonstrated radiosensitizing capabilities. CLR1404 shows tumor-selective uptake in a wide variety of malignant tissues, and therefore we hypothesized that CLR1404 could be used as a tumor-targeted radiosensitizer to augment radiation response in a variety of solid tumors. Objectives: To examine the capabilities of CLR1404 as tumor-targeted radiosensitizer to augment radiation response in a variety of solid tumors. Design/Method: We examined the radiosensitizing effect of CLR1404 on several pediatric and adult solid tumor-derived human cell lines in vitro and in vivo. The selective uptake of CLR1404 in cancer cells versus normal cells was evaluated by flow cytometry, using a CLR1404-Bodipy fluorescent derivative. The in vitro radiosensitization of cancer cells was evaluated by clonogenic survival assay using CLR1404 at different concentrations with or without external beam radiation (XRT). Tumor growth rate after radiosensitization with CLR1404 followed by XRT was examined in vivo in xenograft-bearing athymic nude mice. Results: CLR1404 demonstrated significantly higher uptake and retention in all cancer lines tested (neuroblastoma: CHLA20, NB-1691, SK-N-AS; rhabdomyosarcoma: RD, Rh-30, Rh-41; Ewing sarcoma: TC-71, TC-106; and prostate carcinoma: PC3) when compared to uptake in normal human fibroblasts (p<0.05). CLR1404 significantly reduced clonogenic survival in a dose dependent manner when combined with XRT (CHLA20, Rh-30 and PC3; p<0.01). Treatment of human tumor xenografts with fractionated external beam radiation combined with CLR1404 revealed a significant increase in tumor growth delay compared with CLR1404 or radiation treatment alone (Rh-30, TC-71, PC3; p<0.01). There was no observable toxicity during or after the treatment.

We conclude that tumor targeted CLR1404 has the capacity to augment the therapeutic response to external beam radiation in a variety of solid tumors. Given the importance of radiotherapy in pediatric cancer treatment strategies, our data warrant further pre-clinical testing with the goal to translate our findings into future clinical trials.

Background: Retinoblastoma is the most common ocular tumor in pediatrics. Standard of care currently includes local control (laser therapy), surgical approach (enucleation), radiation and chemotherapy as potential treatment options. Despite advances in chemotherapy administration, allowing pediatric oncologist to use intra-arterial and intravitreal chemotherapy in an attempt to avoid systemic chemotherapy side effects, recurrent cases continue to be challenging to treat while trying to preserve sight through avoiding enucleation. The use of plaque brachytherapy is not yet a well-established option in recurrent retinoblastoma. Objectives: Discuss the role of brachytherapy in relapsed retinoblastoma patients. Design/Method: Case report Results: A 15 month old male diagnosed with bilateral retinoblastoma group C disease in his right eye and group D in his left eye after presenting to his pediatrician with mild strabismus. He had an extensive treatment history due to continued disease recurrence. He has been followed closely with exams under anesthesia (EUAs) and local control with different laser therapies. He received five cycles of systemic chemotherapy (vincristine, carboplatin, and etoposide), followed by intra-arterial chemotherapy (including: melphalan, carboplatin, topotecan and etoposide combinations) and then intravitreal chemotherapy (melphalan), and including left eye enucleation due continued disease recurrence. Despite all these measures a central macular tumor remained measuring 9cm x 12cm with a 4cm depth and choroidal invasion without seeding on the right eye. It was then decided to attempt plaque brachytherapy as salvage treatment. The plaque used was an EP2340N (Eye Physics 2340 Notched). It was a gold ophthalmic plaque with Iodine-125 seeds, 22mm in diameter containing 32 sources with varying activity from 0.53 millicuries to 3.17 millicuries delivering 45 Gy to depth of 7mm for treatment time of 48 hours. He tolerated brachytherapy well, with no significant immediate side effects and a continued excellent response with no evidence of active tumor 27 weeks after initial plaque placement. Conclusion: An excellent disease response can be seen with plaque brachytherapy, as seen in our case. The use of plaque brachytherapy should be considered a viable treatment option for retinoblastoma relapse cases. Further research is needed to determine how to maximize incorporation of brachytherapy within standard of care practices for retinoblastoma.

Background: Patients with small, well-differentiated appendiceal carcinoid tumors are at a very low risk for recurrence. Current NCCN guidelines recommend monitoring "as clinically indicated." There is practice variation between providers and institutions regarding extent and duration of follow-up. Objectives: Characterize follow-up of patients with appendiceal carcinoid tumors. Design/Method: A retrospective chart review was performed at our institution of patients with a pathology diagnosis of appendiceal carcinoid from 2000-2015. Variables analyzed included demographics, tumor location, size, extent of invasion, surgical intervention, postoperative staging, surveillance, and tumor recurrence. Costs of follow-up, including financial, time, and family anxiety were noted. Results: Thirty patients were incidentally diagnosed with carcinoid tumor of the appendix after undergoing appendectomy as clinically indicated. Average age was 13.5±2.8 years (range 8-18). Mean tumor size was 5.4±4mm (range microscopic -15mm) with most occurring at appendiceal tip (n = 18, 60%). No node infiltration was found, though three patients had perineural and one patient had lymphovascular invasion. Six tumors (20%) had appendiceal perforation and five tumors had transmural invasion into mesoappendix. Nineteen (63%) patients were referred to oncology postoperatively for staging and surveillance examinations including ultrasonography (n = 11, 65%), MRI (n = 7, 41%) and CT (n = 6, 35%) scans. The majority (79%, n = 15) underwent serial 5-HIAA testing. Mean oncologic follow-up was 36±34 months with 58% (n = 11) continuing surveillance. Two patients have ongoing follow-up 10 years after diagnosis, including referral to cancer survivor clinic. All surveillance testing was normal and no patients required further interventions. At least two patients traveled >4 hours for clinic visits and one patient commented on stressors related to the cancer diagnosis. Medical cost of follow-up including clinic visits, laboratory monitoring, and imaging ranged from $8,500 to $44,400 per patient. No patient without oncologic follow-up re-presented to surgery or oncology clinics. Conclusion: Appendectomy is an adequate treatment for pediatric appendiceal carcinoid <16mm despite presence of histologic risk factors. Length and intensity of post-operative follow-up varied within our institution from no follow-up to prolonged surveillance. Based on our findings, we recommend minimal or no oncologic follow-up as prolonged surveillance did not lead to identification of recurrences, but rather heightened family inconvenience, anxiety, and cost of medical care.

Background: Alveolar rhabdomyosarcomas (ARMSs) are aggressive pediatric malignancies originating from primitive mesenchymal tissue and associated with skeletal muscle lineage. Sarcomagenesis is driven by the signature PAX3-FOXO1 fusion gene. Using a genetically defined model of ARMS based on early expression of PAX3-FOXO1 in human skeletal muscle precursors, our laboratory identified PAX3-FOXO1-mediated transcriptional changes that silence the Hippo pathway, a recently described tumor suppressor network widely dysregulated in human cancer. TAZ (transcriptional co-activator with PDZ-binding motif), a transcriptional co-activator ordinarily kept in check by upstream Hippo kinases, has been implicated in adult epithelial cancers. TAZ is a known regulator of wild-type PAX3, and although it conveys a mesenchymal phenotype, its role in sarcomas has not been reported. Objectives: Investigate the oncogenic role of TAZ in ARMS tumorigenesis.

Design/Method: After confirming TAZ upregulation in our ARMS model, we determined using the NIH Oncogenomics database that TAZ is upregulated in human RMS tissue samples. We then examined basal TAZ expression in human ARMS cell lines cultured as monolayers and spheres, and used loss-of-function with two independent, lentivirally-delivered, TAZ shRNAs to interrogate the role of TAZ in supporting transformation in vitro. Last, we used a dox-inducible TAZ shRNA system in murine xenografts to interrogate the role of TAZ in supporting tumorigenesis in vivo. Results: TAZ is expressed in human ARMS cell lines, and enriched in ARMS rhabdospheres, suggesting an increase in stemness. TAZ-directed shRNAs suppressed TAZ at both the mRNA and protein level, and caused a profound growth arrest. In vivo mouse xenograft studies rendered a strong phenotype, with tumors from the mice treated with doxycycline exhibiting decreased tumor growth and prolonged survival (median survival 17 days in the sucrose group vs 31 days in the dox group, p = < 0.0001).

The transcriptional co-activator TAZ supports ARMS cell growth in vitro and in vivo, suggesting silencing of the Hippo tumor suppressor pathway. Future studies will investigate the mechanism through which this occurs, and will determine how TAZ alters the transcriptional output or physically interacts with PAX3-FOXO1. While PAX3-FOXO1 is currently not therapeutically tractable, we hypothesize that targeting TAZ may be an attractive approach for treating patients with ARMS.

Background: Lymphatic malformations are vascular anomalies that typically occur in the head and neck, and less frequently in the mesentery. Objectives: To describe the clinical characteristics, treatment and outcome of children with mesenteric lymphatic malformations from a single institution. Design/Method: A retrospective analysis of children diagnosed with mesenteric lymphatic malformations between 2006 and 2015 was performed.

The median age at diagnosis of 16 patients was 4 years. Approximately two-thirds of the patients were male. The most common presenting symptom was abdominal pain. Less commonly patients presented with a volvulus (N = 2) or a small bowel obstruction (N = 2). Four patients were febrile at presentation, two of which had documented bacterial infections. Diagnosis was confirmed by histopathology and when assessed, immunostaining was positive for D2-40, a marker for lymphatic endothelium. 15 patients underwent a gross total resection, 12 of which had partial bowel resection. Two patients had post-operative complications involving fever, feeding intolerance, and/or perforation. One patient underwent a biopsy alone followed by observation, has remained asymptomatic and has had stable growth of the malformation proportionate to size on imaging at 12 year follow-up. Length of follow-up for all patients ranged from 0-149 months with no recorded recurrences. Conclusion: Mesenteric lymphatic malformations in pediatrics are rare and patients commonly present with abdominal pain. Differential diagnosis includes abdominal solid tumors. Surgical resection has often been standard of care at our institution, however alternative management strategies, including medical therapy or sclerotherapy, warrant further investigation.

Background: Rhabdomyosarcoma is the most common pediatric soft-tissue sarcomaHedgehog pathway effectors GLI1 and/or GLI2 are over-expressed in the majority of embryonal RMS cells and aberrant HH pathway activation confers a poor prognosis in rhabdomyosarcoma. Sixty-three percent of SLCT and gynandroblastoma (n = 46) were intermediately or poorly differentiated. Twenty-two percent (n = 16) of SLCT had heterologous elements, including 14% sarcomatous (n = 10) and 11% (n = 8) with a retiform pattern. Nineteen percent (n = 14) of patients had thyroid nodules and 8% (n = 6) had thyroid cancer. Four percent (n = 3) of patients developed metachronous ovarian stromal tumors, and 4% (n = 3) of patients had pleuropulmonary blastoma. In addition 14% (n = 10) reported other non DICER1-related tumors, 12% (n = 9) recurred and 4% (n = 3) died of progressive disease. Forty percent (n = 23) of the 57 patients tested had germline DICER1 mutations. Of patients with SLCT, 53% (20/38) of tested patients had germline DICER1 mutations as did 3 of 4 patients with gynandroblastoma. Preliminary analyses show 5 additional SLCTs with biallelic somatic DICER1 mutations. Compared to DICER1 germline negative patients, the prevalence of thyroid nodules (39% vs. 9%, p = 0.009) and thyroid cancer (26% vs. 0%, p = 0.003) was significantly higher among germline positive patients. Germline DICER1 mutations do not appear to impact outcome of the primary tumor, but are a risk factor for other tumors. The impact of biallelic somatic mutations in DICER1 is under investigation. Conclusion: Enrollment is ongoing. More than half of individuals with SLCT and 3 of 4 patients with gynandroblastoma had germline mutations in DICER1. Biallelic somatic DICER1 mutations were also found in SLCT. These findings warrant further investigation of germline and somatic DICER1 mutations and review of screening guidelines.

Doxorubicin-based chemotherapy was used upfront in 4 (20%). 75% received upfront chemotherapy with vincristine, actinomycin and cyclophosphamide. Median time to relapse was 15 months (range 2.7-45 months). VIT was used as 1st, 2nd, 3rd or 4th line of therapy in 5, 7, 6 and 2 patients, respectively. 6% of patients had ࣙ 2 sites of relapse, 24% had solitary distant relapses, and the remainder had local relapse. Dose of vincristine was 1.5 mg/m2. Irinotecan (50 mg/m2 intravenously or 70-100 mg/m2 orally) was administered daily for 5 days. Temozolomide 100-150 mg/m2 was administered orally daily x 5 days. Local control included radiation for 45%, and surgery for 35% patients. Best response to VIT was as follows: 3 (CR), 0 (PR), 5 (SD) and 12 (PD) for an overall RR of 15%. The PFS at 3 months was 37%. At a median follow up of 8 months, 2 patients were alive without disease, 3 were alive with disease and 15 patients had died of progressive disease. Conclusion: Our retrospective study demonstrates that VIT has moderate activity in patients with relapsed rhabdomyosarcoma. Further study of this backbone in combination with newer agents is warranted.

Background: Impairments in memory, attention and executive function affect 15-50% of childhood leukemia survivors and has been associated with methotrexate exposure. Systemic cisplatin is used to treat a variety of childhood and adult cancers, yet the risk and extent of cognitive impairment due to platinum-based chemotherapy is unknown. Systemic cisplatin is CNS penetrating and is cytotoxic to neurons, neuronal stem cells and hippocampal dendrites. Survivors of non-leukemic cancers may be at risk for significant memory impairment related to cisplatin driven neurotoxicity. Objectives: Explore the effects of systemic cisplatin on hippocampal and amygdala-dependent memory functions in a juvenile rat model. Design/Method: Twenty-four male Sprague Dawley rats were obtained weaned at post-natal day 21 or 31. Cisplatin (2mg/kg/day for 5 consecutive days, intraperitoneal) was administered in infancy (post-natal day 25) and adolescence (post-natal day 35).

Matched controls received normal saline intraperitoneally. Validated hippocampus-dependent memory testing was completed during adulthood (post-natal day>65), including novel object exploration and contextual object discrimination. Object exploration was recorded in seconds and a discrimination ratio was calculated by dividing the difference in exploratory time between objects by total exploratory time.

Context and cued fear conditioning was performed to examine hippocampus and amygdala function, respectively. Percent of time spent freezing in response to context stimulus and cued stimulus was observed. Comparisons were made using unpaired t-test. Results: During novel object testing cisplatin treated adolescents showed significantly poor retrieval of a familiar object as compared to controls (p = 0.033). Both cisplatin treated infants and adolescents, however, showed poor discrimination for an out-of-context familiar object as compared to controls (infants: p = 0.08; adolescents: p = 0.017). Finally, cisplatin treated infants showed near significant diminished freezing response to conditioned context stimulus (p = 0.059). Cisplatin treated infants also showed significant diminished response to conditioned cued stimulus (p = 0.015). Conclusion: Hippocampal-dependent memory functions are impaired in rats exposed to systemic cisplatin during infancy and adolescence. The type and degree of hippocampal dysfunction differs depending on age at time of cisplatin exposure. Further, exposure during infancy affected both hippocampus and amygdala function, signifying a more global effect on memory functions at this age.

Background: The optimal treatment strategy for patients with refractory and/or metastatic osteosarcoma (OS) is yet to be defined and continues to be a persistent challenge. The high degree of genetic aberrations and tumor heterogeneity has impeded the identification and testing of effective therapeutic targets. Therefore, finding and characterizing cellular mechanisms, which contribute to OS chemoresistance is a promising strategy for designing therapies that can change the outlook for patients with this disease.

Objectives: Endoplasmic reticulum (ER) stress pathways are known to promote survival and progression of cancer cells. The objective of the current study is to examine the role of this pathway in promoting chemoresistance in OS. Design/Method: We utilized immunohistochemistry, Western blotting, qPCR and immunofluorescence and bioinformatics tools and techniques to examine the role of activating transcription factor-6 (ATF6) and its downstream effectors on OS cells and patient samples. Results: Using pathway analysis of gene expression datasets of human OS primary tumors, protein processing in the ER was found to be significantly enriched in OS tumors as compared to normal tissue. We confirmed the activation of ER stress pathways IRE-1, PERK and ATF6αin human OS cell lines and found that while all three pathways were differentially activated in the OS cell lines, only ATF6α activation significantly enhanced chemoresistance to cisplatin, irinotecan and combinatorial treatment with cisplatin and the mTOR inhibitor rapamycin. This occurred via inhibition of Bax activation, suppression of RHEB-mTOR and inhibition of NOTCH signaling. Our findings highlight a novel mechanism of chemo-resistance in OS. Retrospective analysis of primary tumors from patients with OS showed that about 60% of these tumors expressed high levels of the ER stress induced transcription factor ATF6α and its downstream pro-survival effectors such as BiP and PDI. This expression was associated with poor histological response and/ or poor survival in patients Conclusion: Our findings emphasize a previously uncharacterized role for ATF6α as the nexus of a unique and versatile signaling network that regulates pathways that is crucial for the pathogenesis and therapy resistance of OS. Hence therapeutic targeting of the ATF6α pathway holds promise as an innovative and effective treatment strategy for OS.

Background: Hepatic infantile hemangioma (HIH) is a benign vascular tumor with a natural course of proliferation, stabilization and involution. Angiosarcoma is a rare but highly fatal soft tissue sarcoma of endothelial cell origin. Reviewing the literature, from 34 cases of pediatric hepatic angiosarcoma, 20 had co-or pre-existing hepatic hemangioma. There are no accepted guidelines for long-term monitoring of hepatic hemangiomas, nor are accepted standards of care in pediatrics for treatment of angiosarcoma.

Objectives: To describe our experience with hepatic hemangiomas associated with hepatic angiosarcoma and integrate our results with published literature. Design/Method: Both patients were three-years-old, unrelated, presenting with abdominal distension, constipation and the history of small, untreated, cutaneous infantile hemangioma. Results: Case one is a girl admitted with multiple, diffuse hepatic hemangiomas that required liver transplantation. Histologic analysis of the resected liver revealed GLUT-1 positive HIH and islands of highly proliferative cellular atypia with malignant transformation. One year after the transplant, surveillance imaging detected pulmonary nodules. Two of the nodules were resected and histology revealed the same pathology. She completed six cycles of ifosfamide/doxorubicin and now remains in complete remission sixteen months after diagnosis.Case two is a boy admitted with a large hepatic mass, hypothyroidism and multiple pulmonary nodules. He underwent gross total resection and tumor pathology showed GLUT-1 positive HIH and islands of angiosarcoma. His disease progressed rapidly on sorafenib therapy. Therapy was changed to ifosfamide/doxorubicin, and after an initial partial response, his disease again progressed. He was subsequently switched to bevacizumab/gemcitabine/docetaxel, and despite good quality of life, he again experienced progressive disease. The newly formed metastatic hepatic nodules proved to be Glut-1 positive infantile hemangioma. He died fourteen months after diagnosis due to massive intratumoral hemorrhage. Conclusion: HIH may be a risk factor for developing angiosarcoma at a very young age. We recommend that hepatic Glut-1 positive hemangioma to be added to the potential cancer predisposition conditions. These patients should be monitored prospectively in vascular anomalies or cancer predisposition clinics, so that the incidence/true risk of developing angiosarcoma can be ascertained. Hopefully, early detection of atypical progression may lead to life-saving medical intervention.

Background: Despite advances in diagnostic and therapeutic approaches, metastatic Ewing sarcoma (ES) continues to have extremely poor overall survival. The mechanisms driving metastasis remain largely unknown, necessitating examinations into molecular mechanisms of pathogenesis, novel targets and investigational therapies. Integrins, such as ITGB3, are a family of cell-surface proteins participating in important cell-surface-mediated intracellular signaling pathways involved in regulating critical tumor cell properties such as differentiation, proliferation, dissemination and apoptosis. Our hypothesis is that upregulation of ITGB3 and its downstream signaling events perform important roles in metastasis of ES and may be a potential therapeutic target. Objectives: To investigate the role of ITGB3 and its downstream signaling pathways in driving establishment of metastasis in ES. Design/Method: We performed in vivo studies designed to gain insights into metastatic transcriptome and proteomic signatures for ES. Established human ES cells (TC71 and A673) were orthotopically transplanted into the tibia of mice and, after 4-6 weeks, the primary bone tumors as well as distal metastatic lesions were isolated and processed. We completed proteomic studies using reverse-phase protein array comparing protein expression profiles of primary ES tumors to the corresponding metastatic lesions in the lung and secondary bone sites. We used Western blot analysis to validate the results.

The array showed significant alterations in a few key signaling molecules, including upregulation of ITGB3 in both metastatic lung and secondary bone lesions compared to primary bone lesions, with a 2.67 fold change (p<0.0012). We validated ITGB3 upregulation by performing protein isolation from the previously resected primary and metastatic tumors and individually assessing expression of ITGB3 using Western blot analysis, confirming consistently elevated ITGB3 expression in the metastatic sites compared to the primary tumors for both ES cell line models. Conclusion: These results suggest that ITGB3 and its downstream signaling events may play a key role in the ability of ES to establish metastatic foci and may serve as a potential therapeutic target. We continue to investigate this pathway both in vitro and in vivo, using ITGB3 knockdown and overexpression approaches to assess proliferation, apoptosis and invasion/migration, as well as small molecule inhibitors to investigate this pathway as a potential therapeutic target.

Background: Anthracyclines are commonly used anti-neoplastic agents in pediatric oncology. However, their use is limited due to their potentially severe cardiac toxicity. Attempts to mitigate cardiotoxicity have included dose limitation and the use of iron chelators such as dexrazoxane. Recent preclinical data has shown that low to moderate intensity exercise attenuates long-term cardiotoxicity in animals receiving chronic doxorubicin treatment. Little is known about the effect of exercise on doxorubicin diffusion into cardiac tissues. Objectives: To determine whether exercise preconditioning prior to treatment reduces doxorubicin uptake in the hearts of tumor-bearing mice. Design/Method: 2.5×106 TC 71 Ewing's Sarcoma cells were injected subcutaneously into 14 nude mice. Tumors were allowed to grow for 10 days. Animals were then allocated to exercise (6) and no exercise groups (6). Animals in the exercise group were exercised on a treadmill for 45 min/day at a rate of 12m/min for 5 consecutive days followed by a 2 day rest period; exercise was then repeated for a second week. 24 hours after the final exercise session 12 of the 14 animals received a 10mg/kg bolus dose of doxorubicin via tail vein injection. The remaining 2 animals served as tissue controls. Organs were excised 30 minutes post injection. Organ tissue was weighed prior to homogenization. All tissue samples were then evaluated for doxorubicin uptake using acid isopropanol extraction and spectrophotometry.

The average heart size of exercise trained animals was larger (20.8g) than non-exercise trained animals (15.9g). After adjustment for cardiac tissue size, exercise preconditioned animals had significantly less doxorubicin present in cardiac tissue compared to unexercised controls, 224.6 vs 595.5 fluorescent units (p = 0.04, Fig 1) . Interestingly, this may be a cardiac specific effect; there was no change in doxorubicin levels in liver or soleus muscle between exercised and non-exercised mice (Fig 1) .

We found that exercise preconditioning decreases doxorubicin uptake by cardiac tissue. Currently, we are evaluating both cardiac vasculature and expression of MDR transporters, which may impact doxorubicin uptake, to identify the mechanism by which exercise preconditioning reduces doxorubicin in cardiac tissue.

Background: Osteosarcoma (OS) and Ewing sarcoma (EWS) are the most common pediatric bone cancers, and patients with OS and EWS have dismal five year overall survival rates of 20-30% for metastatic disease. Adequate local control is imperative for patient survival, but little has been done to elucidate mechanisms of bone sarcoma radioresistance. EWS is considered radiosensitive, and OS is relatively radioresistant. We hypothesize there are specific mechanisms that contribute to forms of radiotherapeutic resistance in bone sarcomas. Objectives: Elucidate mechanisms of radiotherapeutic resistance in OS and EWS. Design/Method: We administered radiation in vitro to three OS cell lines and three EWS cell lines to establish radiation-treated populations. The controls for each population were respective wild type cells which did not receive radiation. We characterized radiation-treated population phenotypes with proliferation, invasion/migration, and clonogenic assays, as well as cell survival after repeat radiation exposure. We also performed microarray gene expression (GEX) and reverse phase protein array (RPPA) in the radiation-treated populations.

Results: There were some significant changes in cell proliferation and clonogenicity, but these changes were not consistent in all OS and EWS populations. We noted no difference in the cell survival of any of the radiation-treated cell lines when re-exposed to radiation. However, we did see an upwards trend in the invasiveness of various radiation-treated cell lines. Our GEX and RPPA data also revealed two pathways of interest with statistically significant differences in both RNA and protein expression: KLF4 pathway and mTOR pathway. Derangements in both have been linked to multiple cancers, and the mTOR pathway has been implicated in the pathogenesis of bone sarcomas. Conclusion: Our data suggest increased invasiveness as well as demonstrate statistically significant differences in both RNA and protein expression in pathophysiologically relevant pathways in radiation-treated bone sarcoma cells. We conclude that these findings warrant further investigation in both in vitro and in vivo models to elucidate mechanisms of radiotherapeutic resistance, and we are currently developing a Ewing sarcoma mouse model using our radiation-treated cell populations. We also plan to apply relevant radiosensitizers to this model with the goal to translate significant results to improvement in outcomes for patients with bone sarcomas.

Background: Immunotherapy relies on several patient-specific parameters, including i) cell number before and after expansion, ii) targeting immune cells to tumors, iii) cell survival and function after infusion, and iv) on-and off-target adverse events. Novel approaches, such as expansion of gamma delta T cells, as opposed to alpha beta T cells, are being pursued. Gamma delta T cells are reasonable candidates for anti-neoplastic immunotherapy because they i) possess inherent anti-tumorigenicity, ii) require no priming, iii) direct tumor killing via recognition of stress-responsive ligands, and, as we show, iv) can be expanded in cGMP serum free media (SFM). Bioengineering of gamma delta T cells to express chimeric antigen receptors (CARs) can augment their anti-cancer effects. High-risk neuroblastoma is an appropriate choice for gamma delta T cell-based immunotherapy as naïve gamma delta T cells are cytotoxic to neuroblastoma cells and neuroblastoma cells express known target antigens. Objectives: Optimize expansion and transduction of anti-neuroblastoma gamma delta T cells. Design/Method: The effectiveness of gamma delta T cell expansion stimulated by IL-2 and bisphosphonates was evaluated in several SFMs. The expanded gamma delta T cells were evaluated for transduction efficiency using lentiviral vectors. Expanded naïve and modified gamma delta T cells were assessed for cytoxicity toward neuroblastoma cells. Results: Of the SFM cultures, only one showed reliable expansion to clinically relevant numbers. OpTmizer media supplemented with high-dose IL-2 led to robust expansion as well as efficient transduction across multiple donors, comparable to that observed for alpha beta T cells with similar multiplicity of infection. Naïve gamma delta T cells were cytotoxic toward a neuroblastoma cell line, which was enhanced by addition of an anti-GD2 CAR. Conclusion: An optimized method of gamma delta T cell expansion and transduction was developed that can be tested in early phase clinical trials. The absence of MHC-restriction affords the opportunity, with appropriate elimination of alpha beta T cells, for use in the allogeneic setting with limited risk of graft versus host disease, and the use of SFM provides a clinically safer and potentially more efficacious cellular immunotherapy. Gamma delta T cells display cytotoxicity toward neuroblastoma that increases with the addition of an anti-GD2 CAR.

Background: Osteosarcoma is the most common primary bone cancer in children and adolescents. Despite real improvements in patient outcomes over the past decades, a diagnosis of metastatic osteosarcoma portends an exceptionally poor prognosis: the five-year survival rate of patients with metastases is less than 25% even with neoadjuvant chemotherapy treatment. PAR1, a G-protein coupled cell surface receptor, activates an intracellular signaling cascade when acted upon by thrombin, a secreted serine protease important in the coagulation cascade. PAR1 expression has been associated with increased osteosarcoma invasion and metastasis; we sought to determine the molecular mechanism by which this increase occurs. In endothelial cells, our laboratory observed that PAR1 stimulation caused activation of the inflammatory transcription factor family NF-κB. NF-κB activation is closely associated with the tissue invasion and extravasation steps of metastasis in osteosarcoma and other cancers. We hypothesized that an intracellular signaling complex, the CARMA3 / Bcl10 / MALT1 signalosome, may play a role in this signal transduction. Objectives: To identify the mechanism by which PAR1 activates NF-κB in osteosarcoma and to determine whether this pathway is suitable for pharmacological inhibition. Design/Method: Activation of NF-κB was examined using immunoblotting of phosphorylated Inhibitor of kappa-B (IκB) and through the use of a luciferase reporter assay. NF-κB-dependent gene transcription was evaluated by real-time PCR. To study osteosarcoma invasiveness in vitro, we used a transwell chamber (Boyden chamber) assay in which cells invaded through a matrigel layer. Results: We found that treatment of U2OS human osteosarcoma cells with either thrombin or with the PAR1-specific peptide agonist TRAP6 induced robust activation of the canonical NF-κB signaling pathway. Specifically, we observed PAR1-dependent phosphorylation of IκB, transcriptional activation of an NF-κB luciferase reporter plasmid, and nuclear translocation of the RelA subunit of NF-κB. Further, we discovered that siRNA-mediated knockdown of MALT1 completely abrogated PAR1-dependent NF-κB activation in osteosarcoma cells. Additional gene expression profile array data detailing the metastatic reprogramming in PAR1-stimulated osteosarcoma cells will be presented. Conclusion: PAR1 stimulation caused NF-κB activation in a MALT1-dependent fashion in osteosarcoma cells. MALT1 proteolytic activity inhibition may be a potential therapeutic strategy to combat osteosarcoma in the future. 

Background: Central giant cell granuloma (CGCG) is a benign osteolytic neoplasm of the jaw characterized by a mass that is infiltrated with osteoclast like giant cells. It is typically slow growing and painless but can cause loosening and and displacement of teeth as well as anatomical distortion of teeth. The management of CGCG is conservative though a minority of patients may require more aggressive surgical management of the affected area. Denosumab, a RANK-L inhibitor, has been demonstrated to induce regression of giant cell tumor of bone (GCTB) though a distinct condition shares many similarities with CGCG. Objectives: To evaluate the off label use of denosumab in the management of CGCG. Design/Method: A 14-year-old male presented with an 8-year history of a large recurrent and progressive, non-tender mandibular biopsy proven CGCG. Although initially treated with numerous attempts at curettage, on subsequent progression, he also received intralesional steroids and calcitonin. With recurrence and ongoing progression, there was consideration of a more definitive surgical management consisting of partial mandibulectomy and reconstruction. To avoid a potentially morbid procedure, off label use of denosumab was initiated based on its current use in patients with GCTB. The patient received Denosumab 120mg SC every week for three weeks followed by Denosumab 120mg SC every month. Response to therapy was based on panoramic dental radiographs as well as physical exam. Results: Initial exam prior to start of denosumab showed an opaque, greyish, 2.5cm lesion of the anterior mandible that was nontender, nonmobile. Adjacent teeth were also loosened and mobile. Radiographs showed a radiolucent multiloculated anterior mandibular lesion. After four weeks of treatment with denosumab, the lesion showed regression on the lateral and medial aspects of the lesion with increased cortical stability. Radiograph showed calcification of the lesion. After 6 months of denosumab there is almost complete resolution of the lesion. There were no toxicities or adverse events from denosumab treatment. Conclusion: Although the underlying pathogenesis of CGCG is unclear, various studies implicate disregulation of odontoclasts, osteoclasts associated with resorption of deciduous teeth. As such, we hypothesize that inhibition of the RANK/RANK-L signaling pathway in this disease may be an effective therapeutic modality.

ASPHO ABSTRACTS POSTER #714

Background: Pediatric sarcomas are a diverse group of malignancies of the bone and soft tissue that accounts for approximately 15 -20% of pediatric cancer. Only a subset of sarcomas harbor known recurrent genomic alterations or oncogenic gene fusions that are pathognomonic. Tumors that lack such recurrent alterations frequently represent a diagnostic challenge. Epigenetic modifications, such as global or specific changes in DNA methylation, are increasingly being recognized as a primary mechanism of oncogenesis in pediatric cancer. Genome-wide methylation profiling is emerging as a powerful tool to identify biologically and clinically relevant subgroups.

To date, few studies with limited sample sizes have examined genome-wide DNA methylation in pediatric sarcomas. Objectives: Using the Illumina Infinium Human Methylation450 BeadChip Array (450K array) platform, we performed genome-wide DNA methylation analysis on a pilot/discovery cohort of pediatric sarcomas to identify their associated gene, promoter, and CpG island methylation signatures and explore key clinical and biological associations. Design/Method: We analyzed DNA from 61 pediatric sarcoma samples, including osteogenic sarcoma (n = 21), Ewing sarcoma (n = 15), rhabdomyosarcoma (n = 10) and synovial sarcoma (n = 15). Unsupervised hierarchical clustering analysis was performed to compare epigenetic signatures between and among disease subtypes. Results: Unsupervised hierarchical clustering analysis revealed that osteogenic sarcoma, Ewing sarcoma, and synovial sarcoma tumours have distinct DNA methylation profiles whose distribution is associated with known histological subtypes. Although the DNA methylation profiles of rhabdomyosarcomas do not cluster distinctly, they tend to be grouped with either osteogenic or synovial sarcomas. Conclusion: We were able to identify epigenetic signatures that are distinctly associated with known histologic subtypes of pediatric sarcoma. These results suggest that DNA methylation profiling has diagnostic utility in these tumours. An exploratory analysis investigating the clinical and prognostic significance of the genetic/epigenetic changes is currently ongoing.

Background: Ependymoma (EPN) is the third most common malignant pediatric brain tumor. Current standard treatment is maximally safe surgical resection followed by radiation therapy. Chemotherapies have not been proven to increase survival outcomes (5-year Event Free Survival 40-85%). Prognosis is even more dismal in those with recurrent EPN which occurs in nearly half of the patients, and there are no known curative options. Therefore, it is imperative to learn more about the biology of recurrent diseases and identify the cellular driver of EPN recurrence, as well as understanding the mechanisms of therapy resistance. We hypothesize that ependymoma recurrence is driven by a subpopulation of therapy-resistant tumors cells with enhanced tumorigenicity in SCID mice. Objectives: To study the tumorigenicity of recurrent pediatric ependymomas at the different clinical stages, whether at diagnosis, first recurrence, second recurrence, or beyond. Design/Method: Over the last 10 years, we have collected a total of 77 pediatric ependymoma patient tumor samples from across the country. Of those, we identified 9 patients with recurrent ependymomas in which we have collected tumor samples from each recurrence (n = 9 sets). The median age of these patients is 6 years old (ranges from 2 -10 years). The median time to first recurrence is 35 months (ranges from 9 -61 months). Each set has from 1 to 5 recurrences. To study the tumorigenicity of these brain tumors at the different clinical stages, we directly implanted tumor cells (1×105 cells/mouse) from all 9 patients into the matched locations in the brains of SCID mice (e.g., human cerebral tumors to mouse cerebrum, human cerebellar tumors to mouse cerebellum) and monitored for tumor formation. Results: In 3 of the 9 sets, tumor formation was confirmed in mouse brains from the latest recurrent patient tumor, while samples from the same patient from earlier stages either did not form tumors in mouse brains or are currently pending. Tumor formation in the remaining models are still pending. Conclusion: Our preliminary findings demonstrate progressive enhancement of tumorigenicity during ependymoma recurrence. This has become a very unique and extremely valuable platform to study brain tumor recurrence. Results: Seven patients were analyzed, with a mean age of 10 years, ranging between 5 and 15 years. The local recurrence rate was 0%. The consolidation time varied between 3 and 6 months, occurring on average 4.5 months after surgery. The limb function after consolidation was classified between good and excellent. They recorded three deaths, unrelated to the applied technique. Conclusion: This technique offers an alternative biological reconstruction, with the added benefits of allowing perfect bone fitting, easy adjustment to ligaments and tendons, not depend on bone bank or foreign material, provide more rapid consolidation, and have lower cost and greater graft longevity.

Background: Vemurafenib has been US FDA approved for the treatment of relapsed or refractory BRAF V600 mutation positive malignant melanoma. It has demonstrated activity in multiple non-melanoma BRAF V600 mutation cancers as well. [1] Resistance always develops with monotherapy. Pre-clinical studies demonstrate that concurrent mTOR inhibition can overcome the innate or acquired resistance to BRAF inhibition. Objectives: We hypothesized that combination of vemurafenib plus everolimus, an MTOR inhibitor will be well tolerated. Secondary objectives included the efficacy of the combination therapy for BRAFV600E positive pediatric and AYA brain tumors Design/Method: We conducted phase I study of vemurafenib and everolimus for BRAF mutated tumor that includes pediatric and AYA brain tumor. We applied standard 3+3 design with step wise dose modification. Dose for Vemurafenib was started at 480 mg/day and Everolimus was started at 2.5 mg/day. Results: Five patients with BRAFV600E brain tumor with age range from 10 to 38 were treated, two glioblastoma, one optic pathway glioma, one pleomorphic xanthoastrocytoma, one anaplastic astrocytoma. All of the patients were previously treated including BRAF inhibitor as monotherapy for three patients. 480-720 mg/day of Vemurafenib and 2.5-5 mg/day of Everolimus were given for 3-17 months. Toxicities included Grade 3 rash. Two heavily pre-treated patients showed progression of disease after 3 and 4 cycles of treatment. One discontinued the treatment due to non-compliance although radiographic partial response was seen. Two patients are active on the study with partial response and stable disease for over 6 months.

The combination therapy was well tolerated with one exception of Grade 3 rash and the patient was able to continue the treatment with dose modification. Treatment effect was observed with the combination therapy even for the patients previously treated with BRAF inhibitor monotherapy. This study emphasizes the importance of genomic profiling of pediatric and AYA brain tumors.

[ Conclusion: Our population-based study examined racial/ethnic differences in survival for pediatric medulloblastoma and high-grade glioma, while adjusting for socioeconomic and neighborhood characteristics. Alarmingly, medulloblastoma patients with public health insurance fared worse than those with private insurance regardless of other status. In comparison, racial disparities were found for pediatric high-grade glioma even after adjusting for SES. Future research needs to uncover remediable reasons for these disparities.

Background: Adolescent and young adult (AYA) patients with high-risk recurrent/metastatic sarcomas have very poor prognosis, with few living 2 years. There are currently no standard treatments for these patients. Docetaxol (Taxotere, T), Bevacizumab (Avastin, A), and Gemcitabine (Gemzar, G) have activity in sarcomas. One study of 3 children using "TAG" yielded a partial response in 2 patients, and stable disease in one (JPHO 2012 34:524-7). Objectives: We report our preliminary experience with this novel combination for 22 high-risk sarcoma AYA patients. Background: Medulloblastoma (MB) is the most common malignant pediatric brain tumor. Molecular profiling recently enabled the classification of MB into four distinct subgroups, of which group 3 patients have the worst prognosis. Objectives: We aimed to discover and validate targetable lesions in MB using a high-throughput functional screen. Design/Method: We performed kinase inhibitor screening on group 3-like MB cell lines D341, D425 and CHLA-01-Med. Comparing the sensitivities of the individual cell lines to each other, >400 primary leukemia samples and >100 established human cancer cell lines we identified recurring "hits" within pathways that were specific to particular lines. We then used targeted western blotting to evaluate the biochemical correlates of these pathways. In vivo efficacy was assessed using a murine model and clinically available inhibitors. Lastly, primary patient cells were expanded in an intracranial murine model then plated on our functional screen, the results interpreted as with the cell line data. Results: Kinase screening revealed clustering of sensitivity to mTOR inhibitors, IGFR inhibitors and aurora kinase inhibitors in D341, D425 and CHLA-01-Med cells, respectively. Western blotting corroborated that these pathways were hyperactivated in the cell line of interest. Uniquely, exome sequencing of D341 revealed a novel somatic variant (A415V) with unknown functional significance in the tumor suppressor gene, TSC2. Molecular analysis of the TSC2 A415V mutation demonstrated diminished TSC1-interaction and protein destabilization in a heterologous expression system. In vivo studies showed targeted tumor suppression when using an FDA-approved mTOR inhibitor against D341 cells with minimal suppression of CHLA-01-Med cells, confirming that the screening reveals specific targetable pathways. Perhaps most importantly, we successfully obtained inhibitor data on a primary patient tumor, which is an important proof-of-concept that this tool can provide reliable information on primary samples in less than 72 hours. Conclusion: Taken together, these findings indicate that a subset of high-risk MB patients may have functionally relevant hyperactivation of targetable pathways, some of which may not have been found on traditional exome sequencing. This functional screen may offer an additional tool to inform adjunct treatment decisions in this complex and heterogeneous disease.

Background: Osteosarcoma (OS) is the most common primary malignant bone tumor in children and adolescents. Survival has remained stagnant for the past 20 years and new therapeutic combinations are desperately needed. Previous studies using IL-11Rα CAR T-cells have shown benefit for the treatment of OS. However, IL-11Rα CAR T-cell therapy alone did not completely eradicate the tumor. Up-regulation of the immune checkpoint pathway programmed death-1 (PD-1) and its ligand (PD-L1) in tumor cells have shown to limit immunotherapeutic efficacy. Anti-PD-1 blockade has shown survival and prognostic benefit in various tumors. Objectives: To investigate a combination approach using IL-11Rα CAR T-cells and an anti-PD-1 antibody to treat OS cells. Similarly, it was noted in a MYC induced lymphoma model that shRNAs directed against ATG5, an essential autophagy gene, augmented cell death following p53 activation (Amravadi et al 2007) . Based on the current literature and our preliminary data, we hypothesized that MYC driven medulloblastoma have high autophagy, which is the key mechanism of therapeutic resistance and cell survival. Objectives: Primary objective is to establish that increased MYC expression induces higher levels of autophagy in medulloblastoma cells, and that chemical inhibitors of autophagy can augment the effect of cytotoxic drugs used in treatment of medulloblastoma. Design/Method: The experimental model used to test this hypothesis were DAOY cells which are medulloblastoma cells derived from pediatric patient tumor with no known MYC amplification. Oncogenic MYC was introduced using a lentiviral construct (DAOY-MYC) and empty expression vector (DAOY-CTR) as the control in order to generate these isogenic cell lines. The primary assays utilized to assess autophagy and autophagic flux used the detection of LC3B and p62 protein levels by immunoblotting with and without lysomotrophic agents. Results: DAOY-MYC cells have consistently demonstrated higher basal autophagy compared to DAOY-CTR ¬ as demonstrated by detection of higher LC3B proteins when not treated with lysomotrophic agent. One-hour treatment with HCQ demonstrates similar flux in both the cell lines, indicating the presence of functional autophagy. Furthermore, this phenotype was lost in when MYC was inhibited using RNAi in DAOY-MYC cells. Moreover, p62 protein expression was diminished in DAOY-MYC cells. Conclusion: Introducing MYC into medulloblastoma cells increases autophagy under basal growth conditions. This phenotype where autophagy is increased has been noted in our lab in other cell lines driven by KRAS oncogene, highlighting a shared resistance mechanism by these two distinct oncogenes.

Patrick Leavey, Harish Babu Arunachalam, Bogdan Armaselu, Ovidiu Daescu, Anita Sengupta, Dinesh Rakheja, Stephen Skapek, John-Paul Bach, Samuel Glick, Kevin Cederberg

Background: Tumor necrosis (TN) remains the most significant predictor of survival for patients with non-metastatic osteosarcoma. Interpretation of TN, which provides data only after the first 10 weeks of chemotherapy, provides information too late to make clinically meaningful adjustments to therapy. We propose that modern technology such as digital whole slide image (WSI) and image pattern recognition will provide the basis for further enhancements in the interpretation of this important biomarker. Objectives: To accurately identify features of tumor necrosis by image pattern recognition (IPR) on histology whole slide images (WSI) of resected osteosarcoma. Design/Method: We have developed an investigative team of clinical scientists at University of Texas Southwestern Dallas and computer scientists at University of Texas Dallas. Archival samples for 50 patients treated at Children's Medical Center Dallas, between 1995-2015, have been identified. Each case is represented by a single tumor slide at the time of biopsy when available (used in image segmentation) and 8-50 slides / case at time of resection when necrosis is determined. Slides are scanned using an Aperio Scanscope C and stored on a portable 3.0 terabyte hard-drive in SVS format (a compressed TIFF file format). Using a tumor map, created at the time of original histological evaluation, slides are digitally knit into a single whole slide image. Image segmentation, which requires feature identification based on regional color, cellular shape and regional cellular density, is ongoing.

We have retrieved tumor maps, tumor biopsies and tumor resection specimens from archival stores on 50, 33 and 50 cases of high-grade osteosarcoma respectively. We have completed the digitization of 25 cases and have developed the computational tool to digitally knit all single slides (8-50 / case) into a single whole slide image (WSI). We have initiated the process of image segmentation and prospective re-evaluation of tumor necrosis on all test cases by two pathologists, blinded to each other's interpretation in the development of necrosis-digital analysis software.

We have begun to develop the necessary technology that will automate the interpretation of TN in osteosarcoma and will prospectively study this in comparison to routinely evaluated TN in newly diagnosed patients.

Background: Central nervous system (CNS) tumors are the most common solid tumors of childhood and adolescence, and the leading disease-related cause of death between one and nineteen years of age in the United States. In the United Kingdom (UK), recognition of delay in diagnosis led to the development of a program called 'HeadSmart', designed to enhance the awareness of signs and symptoms of brain cancer in children among both healthcare providers and the general public, with the goal of reducing the delay in diagnosis. Apart from a single report of diagnostic delays in children with low-grade gliomas, no additional reports have evaluated this delay in the United States since the late 1980s. Objectives: To establish an accurate Ohio baseline from symptom onset to definitive diagnosis in children with newly-diagnosed CNS tumors. Design/Method: The medical records were retrospectively reviewed for over 300 children with newly-diagnosed CNS tumors from January 2004 to August 2015 at Nationwide Children's Hospital. Since our electronic medical record system began in late 2006, we had usable data on only 171 patients (57%). Records were reviewed for age, gender, tumor type, presenting symptoms, number of healthcare visits prior to diagnosis, time interval (in months) from onset of symptoms to definitive diagnosis and any associated genetic syndromes. Results: Of the 171 patients with newly-diagnosed CNS tumors, 26 children had a known pre-disposition syndrome (Neurofibromatosis Types 1 and 2, and tuberous sclerosis). Among the remaining 144 children, the median time interval from symptom onset to definitive diagnosis was 42 days while the mean symptom interval was 138 days (range < 1 to 2,190 days). Additionally, the most common presenting symptoms among our institutional cohort were headache (53%), nausea and vomiting (43%), unsteady gait (29%), visual disturbances (25%) and seizures (12%).

We have documented and quantified the contemporary delay in diagnosis of childhood brain tumors in central Ohio, to serve as a "benchmark" for our future Background: Brain tumors are the second most common cause of cancer in children, and the most common solid tumor. Neuronal and mixed neuronal-glial tumors of the central nervous system (CNS) are relatively rare. In 2007, the World Health Organization (WHO) classification was revised to include four additional tumor types for a total of 13 subtypes. Although there are two published meta-analyses, both studies included mixed populations with many adult patients. To our knowledge there is no available neuronal-glial tumor case series including a large number of pediatric patients from one center. Objectives: To describe the demographic and clinical characteristics, treatment and outcomes of neuroglial tumors in pediatric patients at a tertiary care center. Design/Method: This study is a retrospective review of patients age less than 21 years diagnosed by surgical pathology with neuronal or mixed neuronal-glial tumor subtypes based on the 2007 WHO Classification at our tertiary care children's hospital between 1999-2014 . Cases that met eligibility were reviewed and data including demographic, clinical, imaging, pathology, treatment, morbidity and mortality were extracted from the hospital CNS database. A neuropathologist and neuroradiologist participated in patient selection to adjust pathologic patient classifications diagnosed prior to the 2007 WHO guidelines. Results: 51 patients met eligibility criteria with an average follow up time of three years. The predominant tumor subtypes were ganglioglioma (33.3%) and dysembryoplastic neuroepithelial tumors (23.5%). 46 patients were treated with surgery alone (90.1%), three patients received chemotherapy (5.9%) and two patients received radiation (3.9%). Nine patients had progression of their tumor after the first resection with an average time to progression of 35 months. Patients who had progression were more likely to present with seizures (77% v. 47%) and more likely to undergo subtotal resection.

Overall survival was 96%. Conclusion: Neuronal and mixed neuronal-glial tumors of the CNS are extremely rare, and understanding the differences between the neuroglial tumor subtypes remains difficult. This study contributes to the pediatric literature by describing for the first time the diagnosis, treatment and prognoses of these rare tumor types in children. Results: Nine patients were male (75%) and 3 female (25%), with a median age at diagnosis of 18.5 years (range 3-27 years of age). Median follow-up was 77 months (range 29-243 months). Eight patients had parameningeal tumors as primary site (67%); 5 patients had extraosseous tumors (42%) including 2 patients with orbital tumors, and 3 patients presented with metastatic disease (25%). Seven tumors had EWSR1 translocation (58%). Initial chemotherapy regimens included VDC/IE (58%), VAI (33%) and VAC (8%). Local control consisted of surgery (17%), radiation therapy (58%), or surgery + radiation therapy (25%). Median dose of radiation therapy received was 55Gy (range 45-60 Gy). At last follow-up, 6 patients (50%) were alive with no evidence of disease (NED), while 2 (17%) patients were alive with disease. Four patients (33%) died from disease, including all 3 patients who initially presented with metastasis. In patients with parameningeal tumors, 4 were alive NED while 2 were alive with disease. Both patients with orbital tumors were alive NED at 34 and 79 months follow-up.

In patients with Ewing sarcoma of the head and neck, as with ES of other locations, the presence of metastasis at diagnosis is the single most important factor for overall survival. The small cohort size prevented subset analysis for prognostic factors. Treatment of H&N ES patients requires multimodal specialty care, which should be performed at treatment centers well versed in treating this rare bone tumor.

Background: Choroid plexus carcinomas are aggressive WHO grade III tumors commonly found in children. Despite multimodal treatment, the 5-year overall survival is close to 40%. Objectives: Describe the case of a patient with a recurrent choroid plexus carcinoma, with no evidence of disease after undergoing treatment for abscesses in the resection cavity. Design/Method: Case Report Results: A 3-year-old girl was diagnosed with a right parietal choroid plexus carcinoma after presenting with progressively unsteady gait. Family history was notable for breast cancer in her mother. Subsequent genetic workup was positive for the TP53 mutation, and Li Fraumeni syndrome was diagnosed. She underwent a near total resection of the tumor, followed by 6 cycles of chemotherapy of etoposide, carboplatin and cyclophosphamide. Three months after completion of treatment, she was noted to have a large recurrence in the surgical cavity. After a repeat resection, she underwent radiation therapy. Her first brain MRI after radiation therapy showed an enhancing nodule; upon resection, this was found to be recurrent/residual tumor. She started on chemotherapy with temozolomide, irinotecan and bevacizumab. Ten days after initiation of chemotherapy, the patient developed subgaleal, epidural, and intraparenchymal abscesses along the surgical tract. Operative wound cultures were positive for methicillin-sensitive Staphylococcus aureus, and treatment with antibiotics was initiated. Her course was complicated by recurrent wound dehiscence and unsuccessful primary closure despite multiple attempts. Due to deteriorating quality of life in the face of tumor recurrence, her parents chose to pursue palliative care, with continuation of oral antibiotic prophylaxis. After 3 months, repeat MRI of the brain showed persistence of the right parietal lobe abscess and peripheral enhancement around the surgical cavity more suggestive for an inflammatory reaction, rather than tumor. She was restarted on IV antibiotics for palliative purposes, and repeat MRI of the brain after 3 further months of antibiotic therapy showed a resolution of the abscess and no evidence of tumor. Conclusion: This case raises interesting questions regarding the role of immunomodulation in cancer therapy, given that following the development of an inflammatory response to bacterial intracranial abscess, a tumor previously resistant to numerous resections, chemotherapeutic agents, and cranial irradiation has apparently resolved.

Background: Primary Histiocytic Sarcoma (HS) is a rare neoplasm that is more common in adults than children. It originates in liver, splenic, gastrointestinal, lymphoid, and cutaneous tissue. Central Nervous System (CNS) primary location is less common, and usually aggressive with poor prognosis. Few cases has been reported in children in the medical literature; and among these cases even fewer are primary CNS tumors. Currently the underlying etiology of HS is unknown and there is no standard therapy. Objectives: We report a case of primary CNS histocytic sarcoma in a 6 year old male in order to increase the knowledge available in medical literature regarding this rare tumor. Design/Method: A review was performed of the patient's medical record and available medical literature pertaining to pediatric HS with a focus on CNS tumors.

We reviewed the English medical literature since 1970 and identified 7 pediatric patients with CNS HS. Among these patients, there was only 2 under the age of 11. Our patient is a 6 year old male with a PMH of Autism, Speech Delay, Perinatal HIV exposure, Asthma, and Sleep Apnea. He presented with visual hallucinations and new onset seizure disorder. MRI of the brain identified a left parietal dural based mass. Surgical resection of the mass was performed and pathology showed a proliferation of histiocytes with nuclear atypia consistent with HS. The patient received proton beam radiation therapy and then started ICE (ifosfamide, carboplatin, etoposide) based therapy which is ongoing, with evaluation after the third cycle. Conclusion: Currently there is no standard therapy for HS. Treatment strategies include surgical resection, chemotherapy, and radiation. Complete surgical resection when feasible should be considered since it may provide a better prognosis. Several chemotherapy regimens have been used including ALL type therapy, high dose cytarabine, CHOP, and ICE, with reported poor outcomes. By reporting more patients and treatment regimens, we highlight the needs for collaborative efforts for international registry and clinical trial to develop a novel therapeutic approach. Results: Age at diagnosis ranged from 9 months to 6 years. Locations of the tumors included hypothalamic and chiasmatic region, ventricle, and cerebellar hemisphere. Two cases achieved gross total resection, both of which presented in the cerebellar hemisphere. Three cases had partial resection or no surgery and progressed during an observational period. No patients with gross total resection had progression of disease. Those with progression eventually received radiation therapy, all after age 5 years, with no further progression. All patients were living with no disease or stable imaging findings at the time of our review. Endocrinopathy was present in all non-cerebellar tumors, but neurological deficits were rare and typically involved visual defects. Conclusion: Gross total resection for cerebellar PMA prevented tumor recurrence in our cohort and was similar to findings for PA. Hypothalamic and chiasmatic lesion tumors were less apt to be completed resected and hence require different management. The hypothalamic and chiasmatic tumors also experience different late effects based on location and treatments. Our patients are all alive and hence have not revealed a poorer prognosis compared to PA although it will be important to observe these patients for a longer period of time to definitively establish progression-free survival and late effects in PMA patients compared to more mature PA patient series.

Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada

Background: Outcomes for children and infants diagnosed with acute myeloid leukemia (AML) have improved, however there is no literature on treatment for infant AML diagnosed in utero.

Objectives: Here we report the first case of a fetus diagnosed with AML in utero. Design/Method: With parental consent, background clinical information, history of presenting illness, results of relevant laboratory investigations, and intended course of management are reviewed. Results: Cordocentesis done on a 34-year-old woman at 30+4 weeks gestational age (GA) to investigate fetal hepatomegaly showed a hemoglobin of 70 g/L, leukocytosis (166×10ˆ9/L) and thrombocytopenia (24×10ˆ9/L). Further investigations, including morphologic examination and flow cytometry, confirmed the diagnosis of AML, monocytic type, in the fetus. Subsequent cytogenetic analysis showed mixed lineage leukemia (MLL) aneuploidy, but no MLL gene disruption. An exchange transfusion via cordocentesis was planned to extend gestation and optimize neonatal outcome, but the mother developed mirror syndrome, and at 30+6 weeks GA underwent an urgent caesarean section. A live female infant was born with edema, distended abdomen, petechiae, ecchymoses and no spontaneous respiratory effort. Labwork showed a hemoglobin of 66 g/L, white blood cell count of 218×10ˆ9/L, platelets of 111×10ˆ9/L, and abnormal coagulation profile. Resuscitation was unsuccessful and at two hours of life, parents chose to palliate their child. Autopsy demonstrated disseminated leukemia involving central nervous system, liver, bone marrow, and placenta. Conclusion: It is possible to diagnose hematologic malignancy in a fetus, but even in neonates there is little information to direct management. We intended to begin with exchange transfusion via cordocentesis to reduce leukocytosis and thereby prolong gestation. Then, once stable after delivery, to use low dose chemotherapy until the infant was term and thought to be able to tolerate full treatment. Unfortunately the mother and infant were not well enough to pursue this course. Fetal leukemia should be considered in the differential diagnosis of a fetus presenting with hepatomegaly. As similar cases are identified, clinicians should share their experience to provide future guidance in management.

Background: Indoleamine 2,3-dioxygenase (IDO) is a natural counter-regulatory mechanism that suppresses anti-tumor immunity. Although few clinical trials currently combine immunotherapy drugs with standard-of-care chemotherapy, our preclinical data suggest the IDO-inhibitor indoximod will synergize with chemotherapy and radiation. We therefore developed a first-in-children phase-1 trial to study indoximod.

In the companion adult glioblastoma study (NCT02052648), the combination of indoximod and temozolomide was well tolerated with no dose-limiting toxicities. Six-month progression-free survival (PFS) for 12 adult phase-1b patients was 25%, compared to 15% for relapse glioblastoma historically. Two patients who had previously progressed on temozolomide, one phase-1b patient and one phase-2 patient, demonstrated partial response in month 13 and 7 of therapy, respectively, with the phase-1b patient surviving 21 months to date and continuing therapy. Objectives: To present interim results for the ongoing pediatric phase-1 study (NCT02502708). Design/Method: This trial assesses the feasibility, safety, and preliminary evidence of efficacy of combining indoximod either with temozolomide or with radiation therapy followed by temozolomide to treat children age 3 to 21 with progressive malignant brain tumors (excluding DIPG). Indoximod dose levels start at 80% of the adult recommended phase-2 dose.

One 7 year old patient with recurrent metastatic ependymoma was treated with indoximod and stereotactic radiosurgery, which he tolerated without toxicity, and went on to receive indoximod combined with temozolomide. At the time of enrollment, he had previously received 6 separate surgeries, proton therapy to the posterior fossa (54Gy/30 fractions), cranio-spinal proton therapy (36Gy/20 fractions), proton therapy Background: Hepatoblastoma is the most common type of pediatric liver malignancy. Signaling abnormalities in the beta-catenin pathway are associated with 90% of these tumors. In fact beta-catenin-YAP (Yes-associated protein) co-activation was observed in 80% of hepatoblastoma patients. Overexpression of YAP and beta-catenin in mice led to hepatoblastoma development. A gene array analysis of mRNA isolated from the tumor bearing livers revealed 5 genes that showed significant upregulation in the tumors and also had binding sites in their promoters of transcription factors TCF4 (which binds beta-catenin) and TEAD (which binds YAP). One of these genes was lipocalin 2, a small molecule protein with known antibacterial properties that has been found to be expressed in a variety of adult cancers. Objectives: To determine if lipocalin 2 is expressed in human hepatoblastoma. Design/Method: We used a tissue microarray of 74 patient hepatoblastoma samples from a tertiary care Pediatric Hospital to evaluate the presence of lipocalin 2 by immunohistochemistry. The tumors were classified by histology type and the degree of lipocalin 2 staining was graded on a 0-3 scale. Staining was further stratified as either nuclear, cytoplasmic, or both. Next, cell lysates from HepG2 cell culture (a human heptoblastoma cell line) were tested for the presence of lipocalin 2 using western blot analysis. Results: Lipocalin 2, which is normally not expressed in hepatocytes, was found to be present in either the nucleus or cytoplasm of 70 (95%) of the pediatric hepatoblastoma samples. The degree of staining for lipocalin 2 varied within each sample based on tumor histology. All embryonal components were strongly positive for lipocalin 2 with staining scores of 2-3. Ninety-six percent of crowded fetal histology components had positive lipocalin 2 staining, although the staining ranged from 1-2 in intensity. There was minimal to no expression of lipocalin 2 in blastema and small cell undifferentiated components. Lipocalin 2 was also confirmed to be present in HepG2 hepatoblastoma cell cultures by western blot analysis.

We have identified increased expression of lipocalin 2 downstream of beta-catenin and YAP activation in hepatoblastoma cells and in patient tissues. Lipocalin 2 may be playing an important role in beta-catenin-Yap driven hepatoblastoma development.

Primary Children's Hospital, University of Utah, Salt Lake City, Utah, United States

Background: Cytomegalovirus (CMV) retinitis is a complication of immunosuppressed hosts that is typically seen in acquired immunodeficiency syndrome and hematopoietic stem cell transplant patients. However, CMV retinitis occurring during therapy for acute lymphoblastic leukemia (ALL) without transplant is rarely described.

Objectives: Describe the case of an adolescent with T-cell acute lymphoblastic leukemia (T-ALL) in maintenance presenting with acute vision loss due to CMV retinitis. Design/Method: Case report and review of literature.

with acute vision loss in the right eye. Ophthalmologic examination showed right-sided afferent pupillary defect, poor visual acuity, and large visual field deficits. Left eye vision was unaffected. Fundoscopic examination revealed bilateral optic disc edema with peripapillary hemorrhages, scattered retinal hemorrhages centrally, large areas of retinal whitening, and cotton wool spots. Differential diagnosis based on ophthalmologic examination included leukemic versus infectious retinopathy. MRI Brain/Orbit was negative for intracranial pathology, orbital masses, or optic nerve edema. Total white blood cell count was 1000 cells/μl with absolute neutrophil count (ANC) 400 cells/μl, and absolute lymphocyte count (ALC) 100 cells/μl. Vitreous aspiration was performed with intravitreal injection of amphotericin, vancomycin, ceftazidime, clindamycin, and ganciclovir. Vitreous fluid was positive for CMV by polymerase chain reaction (PCR). CMV DNA was also detected in serum by quantitative PCR. Vitreous cells were negative for malignancy by flow cytometry. Bone marrow and cerebrospinal fluid were also negative for malignancy. Therefore the diagnosis of CMV retinitis was made. He was treated with a three-week course of valganciclovir followed by prophylactic dosing. Visual acuity is stable with improvement in retinitis by fundoscopic exam but he remains with visual field deficits. Conclusion: CMV retinitis has rarely been reported as a complication of ALL therapy without transplant but occurrence of CMV-reactivation should be recognized, especially in patients with cell-mediated immunodeficiencies. Our patient had an ALC of 100 cells/μl at time of presentation with CMV retinitis. Ophthalmologic exam findings alone may not differentiate between leukemic infiltrate and CMV retinitis, and in these cases vitreous aspiration should be considered to confirm the diagnosis. million). All patients received pre-operative chemotherapy with platinum agents with a median of 6 cycles (range: 4-7 cycles). Extended right hepatectomy was performed in 5 patients, (1 patient had two additional wedge resections in segment 2 of the left lobe), extended left hepatectomy in 1 patient. Margins were positive in 2 patients; in 4 patients, margins were negative with the closest margin ranging between 2-5 mm. Two patients required vascular reconstruction of the IVC. At 9 months, of median follow-up (range 3 months-2.8 years) none of the patients had local recurrences, 1 patient had recurrence of pulmonary disease 2 months after surgery, in this case, AFP did not fall as expected and started to rise soon after surgery. Conclusion: Patients with advanced HB who received complex surgical resections with positive microscopic margins or close negative margins (margins ࣘ5 mm) had good outcomes. We hypothesize that planned positive microscopic margins in highly selected HB patients may spare the morbidity of OLT.

Background: There has been a dramatic increase in obesity rates among children in the United States (US). The association between obesity and cancer has been widely studied, showing that obese patients are at risk for multiple side effects and poor outcome. Nonalcoholic fatty liver disease (NAFLD) is now the most common cause of chronic liver disease in pediatric patients in the US. There is no known effective treatment of NAFLD except diet and exercise. L-carnitine has been used in prior studies to treat chemotherapy-induced liver toxicity but has not been used in pediatric oncology patients with fatty liver. We have identified a high-risk group of pediatric oncology patients at risk for developing fatty liver and its complications. Objectives: Describe a pediatric patient with relapsed T-cell acute lymphoblastic leukemia (T-ALL) and fatty liver disease treated with L-carnitine. Design/Method: Review of medical record. Results: An obese thirteen year-old boy with relapsed T-ALL was found to have persistent elevations of liver enzymes (AST and ALT peaking at 2.5x and 10x normal respectively), despite breaks in chemotherapeutic regimen. Imaging performed showed changes consistent with fatty liver. Due to the risk of sinusoidal obstructive syndrome (SOS), bone marrow transplant (BMT) was held. To maintain his remission, he was given further chemotherapy and additionally started on L-carnitine 1 gram orally twice a day in an attempt to lower his liver enzymes. After three months of treatment, both AST and ALT gradually improved to near normal levels and BMT with a haplo-identical donor was pursued. Transplant regimen was overall well tolerated, without evidence of SOS. The patient continues to be in remission and continues on L-carnitine with no side effects from L-carnitine observed. Conclusion: In this patient, L-carnitine was thought to improve the transaminitis, which enabled him to undergo BMT. Transaminitis due to fatty liver can be a significant factor leading to alterations or interruptions in chemotherapy regimens, increase transplant morbidity and thus affect overall survival and increase risk of relapse. L-carnitine supplementation along with a diet and exercise regimen may be able to improve transaminitis and reverse fatty liver. Overall, it is well-tolerated without significant toxicities. Further prospective studies are needed.

Background: Hepatocellular carcinoma (HCC), the second most common pediatric liver malignancy, has an annual incidence of 0.41 per million children in the United States. HCC associated with underlying hepatic cellular injury leading to liver cell dysplasia is described in hemochromatosis, α-1-antitrypsin deficiency, hereditary tyrosinemia, and some glycogen storage disorders. Niemann-Pick Disease type C (NPC) is an autosomal recessive liposomal storage disease characterized by dysfunctional cholesterol transport. Accumulation of sphingomyelin and cholesterol in lysosomes results in hepatosplenomegaly and hepatic dysfunction. Rare cases of HCC in NPC exist in the literature, but no clear link between the two has been established. Objectives: We present a 12-year-old male with NPC, who presented acutely with abdominal distension and hemodynamic instability. MRI revealed a large heterogeneously-enhancing solid mass in the medial segment of the left hepatic lobe with a smaller lesion in the anterior right hepatic lobe, concerning for intrahepatic metastasis. Head and chest CT scans were negative for distant metastases. Biopsy confirmed HCC, stage III disease. Alpha fetoprotein (AFP) at diagnosis was elevated to 52,775 IU/mL. Patient underwent upfront resection of the left sided mass and biopsy of right hepatic lesion.

Design/Method: Upfront resection improved the likelihood of successful treatment, but due to residual right hepatic disease the patient received 6 cycles of cisplatin and doxorubicin administered every 3 weeks (modified PLADO regimen) with twice daily sorafenib, an FDA-approved tyrosine kinase inhibitor, at 200 mg/m2/dose. Due to vomiting and diarrhea there were compliance issues and approximately 50% of planned sorafenib doses were administered. Results: Patient responded to treatment, with no evidence of disease on MRI imaging and AFP normalization to 2.9 IU/mL following surgical resection and 6 cycles of chemotherapy. Three months off therapy there was no evidence of disease recurrence on MRI imaging and monthly AFP remained normal, ranging 1 to 2 IU/mL. Conclusion: HCC is a rare and challenging entity in pediatric oncology. While not classically associated with NPC, these patients can suffer hepatic damage over time and are at risk for malignant transformation. This raises questions with regard to routine screening, either radiographically or laboratory testing to monitor AFP level.

Background: Invasive fungal infections in children with cancer disproportionately affect leukemia patients. Conidiobolus is an Entomopthoromycota found in tropical regions associated with rhinofacial infections. Although rare in pediatric oncology, it has high mortality and can spread rapidly. We report our treatment of an adolescent with acute lymphoblastic leukemia (ALL) and multidrug resistant (MDR) invasive sinopulmonary Conidiobolus infection. Objectives: Describe management strategies that support neutrophil function to treat invasive Conidiobolus infection in a patient receiving chemotherapy for ALL. Design/Method: Case report.

A 16 year-old male presented with intermittent fever, fatigue, cough, and petechiae. He was severely neutropenic with circulating blasts, and was diagnosed with ALL. He began induction chemotherapy with concomitant antifungal prophylaxis. On day 5 of induction, he developed congestion and left-sided facial pain. Nasal endoscopy revealed pale and insensate mucosa, and imaging showed diffuse, nodular ground glass opacities throughout the lungs. Nasal biopsy revealed branching hyphe with septations, suggestive of Aspergillus. Voriconazole and micafungin were started empirically. On day 4 of culture, the fungus showed zygospores with a prominent beak and sporangiola characteristic of Conidiobolus species. The organism was resistant to all antifungal agents except terbinafine (amphotericin B and anidulafungin intermediate). Treatment was changed to liposomal amphotericin B (LAmB), anidulafungin, and terbinafine. Bone marrow aspirate was negative for leukemia at day 17 of induction. Due to progressive pulmonary and sinus disease extending to the skull base, chemotherapy was temporarily halted and neutrophil support was augmented with daily GM-CSF, granulocyte infusions and hyperbaric oxygen therapy (HBOT). Granulocyte infusions were discontinued following endogenous neutrophil recovery 30 days after ALL diagnosis, while LAmB, GM-CSF and HBOT continued for several more weeks. Imaging dramatically improved, and sinus fungal cultures became negative. After 7 weeks without neutropenia, his chemotherapy was resumed while continuing aggressive neutrophil support when severely neutropenic. His leukemia remains in remission without evidence of progressive fungal disease. Conclusion: Multidisciplinary care is crucial for simultaneous treatment of both ALL and a life threatening fungal infection. The use of aggressive support of neutrophil function was effective in controlling disseminated MDR Conidiobolus infection and allowed delivery of myelosuppressive chemotherapy.

Design/Method: Two young people lost their lives to cancer the same year they turned eighteen: "The thespian": 18 year-old (yo) theatre lover burdened by both osteosarcoma and bladder sarcoma. The tumor infiltrated his spine, leaving him paraplegic and completely dependent on his family at a time when independence is paramount. While he lay in a hospital bed, his twin brother searched for the college of his dreams. At the end-of-life, Mom "fired" palliative care after a frank code status discussion slapped him in the face with his own mortality. "The guardian": 18 yo with metastatic Ewings sarcoma, who was the "ring-leader" of a gang of AYA males who carried the same diagnosis, but not the same prognosis. His mother insisted he never be told "how bad it was." Delirium plagued his final days, and despite their desperate attempts to keep the truth from him throughout his treatment course, his parents were then devastated that he couldn't participate in end-of-life decision making. Due to patient and family refusal, palliative care was not involved until two weeks prior to his death …and only under the guise of being called the "supportive care team." Results: Both of these young men died in the hospital with minimal palliative care support.

The unique developmental, social, emotional, ethical and existential struggles of the AYA population benefit from a highly specialized interdisciplinary approach. However, the above cases highlight conflict between autonomy and parental protection, and possible deviation from normative development as barriers to effective end-of-life care in the AYA population. Earlier engagement and education of AYA patients and families regarding palliative care may facilitate improved communication and awareness.1. (Weiner, Clin Oncol Adolesc Young Adult, 2015)

POSTER #750

It is an EBV-driven polyclonal B-cell proliferation occurring in mucocutaneous tissues of elderly patients (immunosenescence) and patients on immunosuppressive therapy who have a limited Tcell-repertoire. The true incidence of EBVMCU is unknown due to its self-resolving nature and limited awareness amongst clinicians.

Objectives: Generate awareness about EBVMCU amongst clinicians. Design/Method: Case report Results: A 29 year old male with intermediate risk T-cell ALL, in maintenance phase of chemotherapy (COG Protocol AALL0434), presented with left sided throat pain with an exudative left tonsillar ulcer concerning for abscess versus leukemic infiltration. Tonsillar biopsy showed a dense polymorphous infiltrate of lymphocytes, neutrophils, plasma cells, and histiocytes. Small sheets of large atypical B-lymphoblasts, consistent with Reed-Sternberg-like cells, were prominent and raised a concern for large cell lymphoma or lymphoproliferative disorder. These cellsdemonstrated the following immunophenotype: CD5-, CD10-, CD15-, CD20+, CD30+, CD45+, EBER RNA+, consistent with EBV-transformed immunoblasts. TdT immunostain was negative. EBV PCR in peripheral blood was 6200 IU/mL. Peripheral blood smear did not reveal any blasts. Peripheral blood immunophenotype showed reduction in CD4+ and absence of CD19+ cells. A whole body PET CT showed localized hypermetabolic foci in the left tonsil. Based on the clinicopathologic findings, a diagnosis of EBVMCU was made.

Since the ulcer did not regress despite stopping oral chemotherapy for a week, a dose of Rituximab (375mg/m2) was tried. The tonsillar ulcer completely resolved 2 weeks after Rituximab. Presently, 3 months following the dose of Rituximab, he remains in remission. Conclusion: Despite a striking histopathologic and immunophenotypic resemblance to B cell lymphoma and EBVLPDs, EBVMCU represents an indolent and localized variant of EBVLPD with excellent prognosis. More extensive workup including imaging, bone marrow biopsy, and serology may be needed to rule out a systemic LPD, which mandates more aggressive treatment. Appropriate diagnosis will help clinicians in making critical decisions like withholding immunosuppressive drugs necessary for immune reconstitution of T-cell repertoire to control EBV infection. Most cases resolve spontaneously or after stopping immunosuppressive therapy. Refractory or relapsing cases may require a more aggressive approach like Rituximab or radiotherapy.

Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, United States Background: Background: Williams Syndrome (WS) is a genetic syndrome associated with characteristic facies, hypercalcemia, and cardiovascular anomalies but hematologic abnormalities have rarely been described. Objectives: Objective: We present an infant with WS and bone marrow (BM) failure, found to have autosomal recessive (AR) infantile malignant osteopetrosis (OP). Design/Method: Design/Method: Case ReportA full term infant was found to have a murmur early in life. An echocardiogram showed supravalvular aortic and pulmonic stenosis, raising concerns for WS. Genetic testing confirmed this at 2 months of age, finding a characteristic 7q deletion. Soon after, she was evaluated for dehdyration and found to be anemic and thrombocytopenic. A BM biopsy demonstrated fibrosis, and she required periodic transfusions. Further work-up for BM failure syndromes, including Fanconi Anemia and Dyskeratosis Congenita, was negative, but imaging showed bony changes concerning for OP. A repeat BM biopsy showed increased osteoclasts, and genetic testing demonstrated pathogenicTCIRG1 mutations (c.304delG and c.1887+1G>A) consistent with infantile malignant OP, AR type 1. The patient then underwent hematopoietic stem cell transplant (HSCT). Results: Results: WS is a constellation of signs and symptoms caused by a deletion in chromosome 7. The American Academy of Pediatrics has established clinical guidelines for the care of patients with WS, including necessary surveillance, but hematologic issues are rarely associated with this syndrome, and not a part of these guidelines.OP can manifest at various ages depending on its mode of inheritance. The AR form, infantile malignant OP, presents early in life and is caused by mutations in TCIRG1, CLCN7, OSTM1, RANK and RANKL. It manifests as hypocalcemia, sclerotic bones, frequent fractures, and sometimes visual loss, hearing loss, and BM failure due to expansion of bone. HSCT can halt or slow disease progression by replacing defective osteoclasts. WS and OP have not been previously described together, although some WS mouse models have shown osteopetrosis-like features without the osteoclast dysfunction or deficiency seen in OP. Conclusion: Conclusion: While WS and OP have been well characterized, this is the first documented case of both diagnoses in the same patient. Further research into potential genetic associations between these two diseases may elucidate the pathophysiology of both further.

Background: Primary pleural synovial sarcoma (PPSS) is an extremely rare tumor. It was first described in 1996 as a case series of 5 patients, 3 of whom were children < 18 years. We report the first case of PPSS in association with paraspinal ganglioneuroma and serous cystadenoma of ovary with a mutation in MET oncogene of unknown significance. Occurrence of multiple different tumors in a young patient with a genetic mutation suggests a possibility of a hitherto unknown cancer predisposition syndrome. Objectives: Report a rare presentation of PPSS in association with paraspinal ganglioneuroma and serous cystadenoma of ovary. Design/Method: Case report Results: A 16-year-old, Caucasian female presented with 3 weeks of right chest pain in August 2013. Family history was significant for multiple solid tumors (laryngeal, thyroid, colon and renal). MRI chest showed a right pleural mass. Biopsy of resected mass was suggestive of monophasic synovial sarcoma with positive margin. Immunohistochemistry was positive for Vimentin, EMA and CK7. Cytogenetics revealed t(X;18)(p11.2-q11.2)(SYT-SSX). Metastatic workup revealed a left lumbar paraspinal lesion and right adnexal mass. Biopsy of the left paraspinal lesion revealed mature ganglioneuroma. Biopsy of resected adnexal mass was consistent with a diagnosis of serous cystadenoma of ovary. The genetic work up revealed constitutional heterozygous mutation in MET proto-oncogene-p.D208G(c.823A>G).The patient was staged as IRS GradeIII, StageIII, POG Grade III. She received 6 cycles of Ifosfamide + Doxorubicin (COG Protocol ARST0332) and 55.8 Gy of radiation. Currently, patient remains in remission. Conclusion: PPSS has never been reported in association with other tumors. Cell of origin for PPSS still remains an enigma. Based on recent demonstration of immunophenotypic overlap between SS and malignant peripheral nerve sheath tumors (Folpe et al) besides constitutive expression of SS associated fusion genes (SYT-SSX) in neuroepithelial tissue (Brujin et al) and a genetic mutation of unknown significance in our patient, we hypothesize that the constellation of tumors in our patients may not be merely coincidental. These tumors may be arising from a common pleuripotent mesenchymal stem cell. We will verify this hypothesis by further immunophenotypic and cytogenetic analysis of ganglioneuroma and cystadenoma.

Background: Sickle-cell disease (SCD) is one of the most common severe genetic disorders worldwide. In SCD, individuals demonstrate an increased adhesiveness of blood cells, including red blood cells, neutrophils, eosinophils and platelets; this plays a fundamental role in the vaso-occlusive process. Aplastic Anemia (AA) is characterized by peripheral blood pancytopenia and a hypocellular bone marrow. Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired hemolytic disease associated with intravascular hemolysis and thrombosis. Objectives: We present a very rare occurrence of severe aplastic anemia (SAA) with a PNH clone in a teenager with SCD and the clinical challenges that this combination presents.

Results: A 12-year old African American female with SCD was following in our comprehensive care clinic. She was initially found to have isolated thrombocytopenia which later progressed to pancytopenia. Bone marrow done was consistent with the diagnosis of SAA. She was started on cyclosporine as Immune suppressive therapy (IST) and responded transiently but eventually became transfusion dependent. 12 months later her PNH clone was increased and she declared herself with PNH. At this point she underwent transplant with unrelated donor (7/8 DRB1 molecularly matched) without any complications. Currently she is 12 months post transplant with no evidence of PNH clone, stable counts and hemoglobin electrophoresis consistent with sickle cell trait.

Conclusion: AA is a rare, life-threatening disorder, which is thought to be due to immune-mediated destruction of hematopoietic cells in the bone marrow. IST and Bone marrow transplant are the first line treatment options. About 30 % of AA children will not respond to primary IST and will require second-line therapy, 15-30% of those who respond will relapse. Clonal evolution of hematopoiesis and PNH is thought to occur in about 10-15% of AA patients, with the clonal abnormality frequently detected at diagnosis. Clonal hematopoiesis and PNH may also develop years after IST treatment. These patients require a long-term follow up by a specialized care center knowledgeable in late manifestations of disease. A 9 year old Indian male who presented with symptoms of obstructive hydrocephalus was found to have a large posterior fossa mass with a 'drop lesion' in the thoracic spine at T1 level. He had a near total resection and the pathology showed WHO grade IV medulloblastoma. He received radiation and chemotherapy with lomustine, vincristine and cisplatin. While on treatment, the patient developed an external mass over the surgical scar with associated posterior cervical lymphadenopathy. Further imaging showed a new lesion in the subcutaneous plane infiltrating the erector spinae muscles with loco-regional lymph node metastasis. There was no simultaneous recurrence in the primary tumour bed and no other metastasis. Biopsy of this lesion confirmed subcutaneous recurrence of medulloblastoma. Aggressive surgical resection combined with high dose chemotherapy and stem cell rescue was suggested as a curative option by the treating team but the family opted for a palliative approach with metronomic chemotherapy using cyclophosphamide and etoposide. He had rapid disease progression with worsening lymphadenopathy resulting in internal jugular vein compression and facial edema as well as right facial nerve palsy. Metronomic chemotherapy was withdrawn and patient ultimately succumbed to the disease five months after the recurrence was noted.

Conclusion: This report discusses the unusual subcutaneous metastasis in medulloblastoma. Subcutaneous metastasis may indicate an aggressive tumour with poor prognosis. However available literature on subcutaneous metastasis have shown that almost always the metastasis have been in the vicinity of the surgical incisions, which could imply that they were implanted during surgical procedures.

Background: Although it is traditional practice to avoid concurrent use of allopurinol with the administration of mercaptopurine in the world of oncology, recent literature describes the intentional use of allopurinol to "optimize" 6-mercaptopurine (6-MP) metabolism in the treatment of inflammatory bowel disease processes and even malignant processes such as acute lymphoblastic leukemia. Reportedly shown to safely shunt metabolism of 6-MP away from the hepatoxic/myelotoxic 6-MMP metabolite and toward the more favorable/efficacious metabolite 6-TGN metabolite, the synergistic potential of allopurinol is now being employed by some cancer centers. Despite recent evidence to support the potential efficacious nature of this drug combination, users must remain cautious for possible myelotoxic and even life-threatening effects. We report a case of how such attempts at optimization of the 6-MP metabolite profile may result in aplastic anemia.

Objectives: Describe aplastic anemia as a complication of concurrent allopurinol and mercaptopurine therapies for pediatric patients. Design/Method: Case Report Results: 10 y.o. (TPMT*1/TPMT*1(Wild Type)) male (weight-40kg, BSA-1.27m2) with history of Crohn's disease, diagnosed at age-9 presented with progressive pancytopenia, (WBC-1600/MM3, ANC-100/MM3, Hgb-7.9g/dL, PLT-33K). He was receiving combination mercaptopurine (50mg daily) and allopurinol therapy (100mg daily). Combination therapy was initiated 1-month previously due to unfavorable 6-MP metabolite profile while on mercaptopurine monotherapy (100mg daily) (6-MMP 16,157pmol/8×108RBCs (risk of toxicity when >5,700), 6-TGN 186pmol/8×108RBCs (most therapeutic when >230<400)). This metabolite profile was associated with mild pancytopenia, (WBC-2600/MM3, ANC-1100/MM3, Hgb-11.7g/dL, PLT-143K/MM3). The addition of allopurinol, even with a concurrent 50% dose reduction of mercaptopurine, resulted in significant elevations in both 6-MP metabolites, (6-MMP 26,874pmol/8×108RBCs, 6-TGN 463pmol/8×108RBCs). Bone marrow evaluation revealed a markedly hypocellular marrow (5-10%) with panhypoplasia, most consistent with drug-induced aplastic anemia, no evidence of infectious etiology, malignancy or lymphoproliferative disorder. One month off therapy, our patient had return of peripheral blood counts, (WBC-4200/MM3, ANC-2200/MM3, Hgb-12.0g.dL, PLT-212K/MM3). While pancytopenic, our patient required one PRBC transfusion for symptomatic anemia, Hgb-6.4g/dL. He required no other interventions for his other cytopenias.

Optimizing mercaptopurine metabolite profiles through concurrent allopurinol therapy is a difficult balancing act with the potential for significant myelotoxic effects including aplastic anemia. Both patients remain on drug for over 12 months and 6 months, respectively, though the second patient had a dose reduction due to adverse effects (AE). Common AEs related to Cabozantinib include palmar-plantar erythrodysesthesia, loss of appetite, weight loss, diarrhea, and nausea. In the adult patient population, these are often dose limiting, however both patients tolerated it well overall. One has had mild nausea requiring no dose adjustment; the other exhibited erythrodysesthesia that required a dose reduction with resolution of the AE. Both also manifested hypothyroidism managed with levothyroxine. Conclusion: Cabozantinib has demonstrated clinical and radiographic benefit for two pediatric patients with metastatic RCC. It presents an additional therapeutic option for this disease and further studies should examine its use more broadly in RCC and other pediatric cancers. Objectives: To address clinical and laboratory findings in a 3 year-old male with probable PI3KCD mutation whose initial presentation was early onset hemolytic anemia in association with acute febrile illness. Design/Method: Retrospective review of clinical and laboratory findings in the presented case whose clinical features have been dominated by hematological abnormalities.

The patient initially presented with Coombs negative hemolytic anemia at the age of 6 weeks. He subsequently developed pancytopenia and hepatosplenomegaly within a few months. He had frequent episodes of febrile illnesses with worsened pancytopenia that responded to oral steroids. A gradual rise of IgM and positive family history of hyper IgM syndrome (his mother) led to immune workup, although he has maintained age-appropriate immunoglobulin levels and lacked clinical evidence of deep seated sinopulmonary infections. Eventually, his mother was diagnosed with PI3KCD mutations (P110δ E1021K) which lead us to test him for the same (result pending). Although he never exhibited low IgG or IgA prior to starting supplemental IVIG, enumeration of T/B cell subsets revealed decreased numbers of regulatory T cells and isotype switched memory B cells (not absent) along with inverted ratio of naïve vs. memory T cells (1:2), persistent lymphopenia, and compensatory increase in NK cell numbers. It is unclear how maternal PI3KCD mutation affected his clinical features. The patient has been clinically stable with sirolimus and supplemental IVIG. Conclusion: PI3KCD mutation can be manifested as predominant hematological abnormalities without hypogammaglobulinemia, but enumeration of T/B cell subsets may be informative before proceeding to gene mutation analysis. High index of suspicion will be required given the fact that the disease specific treatment (i.e., sirolimus) is available. 

We report a 5-year old male with a history of kidney transplant secondary to ARPKD and known hepatic fibrosis, who was found to have biopsy proven HCC with pulmonary metastases. He is currently undergoing neoadjuvant chemotherapy with cisplatin and doxorubicin, and has had a partial response to therapy based on Response Evaluation Criteria in Solid Tumors (RECIST) criteria. Both his primary lesion and metastases have decreased in size and alpha-fetoprotein (AFP) has decreased from 263,500 to 23.9 after 5 cycles of cisplatin/doxorubicin chemotherapy. Germline patient exome sequencing results are pending and will be reported at the time of publication. Conclusion: This is the first reported case of HCC in a pediatric patient with ARPKD. While the history of concurrent hepatic fibrosis likely contributed to progression to HCC, the extremely young age of presentation is uncommon. Exome sequencing may be helpful in determining whether the patient has a novel pathogenic variant in polycystic kidney and hepatic disease 1 (PKHD1), the ARPKD gene.

A RARE CASE OF LUPUS ANTICOAGULANT HYPOPROTHROMBINEMIA WITH ASSOCIATED THROMBOCYTOPENIA Nicole Baca, Aimee Foord, Arash Mahajerin

Background: Lupus anticoagulant-hypoprothrombinemia (LAHPS) is a rare condition resulting in hypercoagulability, which is often seen in patients with underlying autoimmune disorders. Thrombocytopenia is found in 27% of patients with LAHPS and is associated with bleeding risk.

Objectives: Describe a case of a patient with lupus anticoagulant hypoprothrombinemia with associated thrombocytopenia presenting as protracted oral bleeding following dental extraction. Design/Method: Medical record and literature review.

Results: A previously healthy 10-year-old boy, presented with ecchymoses, petechiae and oral bleeding ten days following a dental extraction. Initial labs were significant for a platelet count of 8 K/uL, prothrombin time (PT) 13.5 seconds with international normalized ratio 1.3, and activated partial thromboplastin time (aPTT) of 87 seconds. The aPTT 1:1 mixing study demonstrated an inhibitor but the PT 1:1 mixing study revealed a factor deficiency, later found to be lupus anticoagulant and low Factor II activity, respectively. Other autoimmune workup revealed triple antiphospholipid antibody positivity (APA), positive antinuclear antibody (ANA) and double stranded DNA (dsDNA) antibodies as well as low complement component 3 and 4 and positive direct antiglobulin test. Given the presence of the lupus anticoagulant as well as low Factor II activity, he was diagnosed with LAHPS. Initial therapy included intravenous immunoglobulin (IVIg) (1 gm/kg) and hydroxychloroquine 200 mg oral daily. The peak platelet response after IVIg was 49K/uL. A bone marrow aspirate and biopsy revealed trilineage hematopoiesis and megakaryocytic hyperplasia, normal cytogenetics, and negative myelodysplastic syndrome panel by FISH. After the third dose of IVIg, his platelet count remains above 50k/uL and all clinical signs of bleeding have resolved. Conclusion: LAHPS is a rare phenomenon in children with predominant hematologic concern of thrombosis. A small percentage of patients can have bleeding complications typically due to thrombocytopenia. Due to these contrasting but very serious risks, patients need to be monitored closely by hematologists. Future assessments include serial monitoring of blood counts, renal function, APA, ANA, and dsDNA antibodies. Future therapies considered for LAHPS are typically chosen based on clinical symptoms and include corticosteroids and anti-CD20 monoclonal antibody therapy as well as thrombopoietin mimetics for worsening thrombocytopenia. This patient is currently stable on his single regimen of hydroxychloroquine.

Background: Undifferentiated Embryonal Sarcoma of the Liver (UESL) is a rare, aggressive pediatric liver malignancy characterized by frequent recurrences. Standard curative therapy involves a complete resection and systemic chemotherapy. Transcatheter arterial chemoembolization (TACE) is commonly utilized to treat liver tumors, particularly Hepatocellular Carcinoma (HCC). Y90 radio-embolization is an emerging therapy for liver tumors. Currently, there are no reports of either modality being used for local control of pediatric UESL. Objectives: We report the case of a 17yo female with an extensive UESL with diaphragmatic invasion. After a poor response to two cycles of neoadjuvant ifosfamide and doxorubicin, two cycles of gemcitabine and taxotere were administered. While the tumor showed a moderate volumetric response, the patient experienced gemcitabine-related neurotoxicity, the tumor remained unresectable and severe tumor-related pain persisted. Therefore, Y90 radio-embolization was performed on the largest portion of the tumor followed by TACE with doxo-eluting beads to the diaphragmatic portion of the tumor via the phrenic artery. Design/Method: This case is being reported due to the unique approach to the local control of this UESL. Y90 beads were chosen over TACE for the large inferior portion of the tumor from studies in HCC showing equivalent outcomes, but less pain with radio-embolization. TACE was chosen for the smaller superior portion in an attempt to spare healthy liver tissue that shared blood supply through the phrenic artery.

The procedures were well tolerated. Within three weeks of Y90 embolization, long acting narcotics were discontinued. At the time of the TACE procedure she had decrease in tumor size, but no measurements available. TACE was also well tolerated, requiring one overnight stay for pain control. The tumor was deemed resectable within 3 weeks following her procedure. Conclusion: Our case highlights the possible role of embolization in UESL therapy. In this case, both radio-embolization and TACE were utilized as part of a neoadjuvant regimen to facilitate surgical resection. These modalities should be considered viable options for unresectable UESL unresponsive to upfront chemotherapy.

Background: Multicentric reticulohistiocytosis (MRH) is a rare, multisystem, non-Langerhans cell histiocytic disorder. MRH is rarer in children, as the onset of disease typically occurs in the fourth decade of life. Clinical presentation includes papulonodular skin eruptions and inflammatory polyarthritis that can be debilitating. The etiology of this disorder is unknown, but an association with solid tumors or hematologic malignancies is present in 25% of reported cases. The treatment of MRH without associated malignancies includes nonsteroidal anti-inflammatory drugs, corticosteroids, and disease-modifying antirheumatic drugs. Objectives: To report a pediatric patient with multicentric reticulohistiocytosis. Design/Method: Single case report Results: A 5 year old Caucasian female presented with a 1 year history of periungal papules in her hands and feet and a few months history of bilateral knee swelling and stiffness in multiple joints. Her periungal papules were initially treated as warts, but they failed to improve, and she was subsequently referred to Dermatology. A shave biopsy of one of these lesions resulted as MRH. Due to the association of MRH with malignancy, she was referred to Oncology. On our evaluation, she had no signs or symptoms of malignancy and her screening labs were normal. A CT of her neck, chest, abdomen, and pelvis was obtained to further evaluate for malignancy and was normal. Rheumatology diagnosed her with arthritis of her neck, elbows, and knees and she received methotrexate and naproxen. Three months into therapy, she has improvement of her skin lesions and arthritis. Her future evaluation for malignancy will depend on signs, symptoms and clinical exam with no plans for routine surveillance imaging.

There are very few pediatric cases of MRH reported in the literature. Due to the rarity, there is currently no standardized approach in surveillance for malignancy. Pediatric oncologists need to be aware of the association between MRH and malignancies. Patients with MRH need to be evaluated for malignancies prior to treatment of MRH, since it involves drugs with anti-neoplastic activity.

Background: Hepatoblastoma is the most common liver tumor in children.

Hepatoblastoma affects mostly children under 3 years of age, Three-year event-free survival for patients with non-metastatic hepatoblastoma is 90%. However, for patients with refractory or metastatic disease, prognosis is dismal.Bevacizumab, Sorafenib and low-dose Cyclophosphamide use has not been reported in Hepatoblastoma. Objectives: We report on a patient with recurrent resistant metastatic Hepatoblastoma treated with this combination leading to stable disease and falling AFP with excellent quality of life. Design/Method: A 5-months-old male with right-sided abdominal mass and initial alpha-fetoprotein (AFP) of 492,894ng/ml, was proven to be pure fetal hepatoblastoma. Initial staging work-up showed no evidence of metastatic disease. However surgical resection was not possible due to compression of inferior-vena-cave. Standard adjuvant chemotherapy of cisplatin, 5-flurouracil, and vincristine (C5V) was given for four cycle followed by complete surgical resection with negative margins, surgery was followed by two more cycles of C5V. The AFP level fell gradually to a nadir of 31ng/ml at the end of treatment. 4 months off therapy, a rise in AFP and Computed tomography of the lungs revealed two pulmonary nodules proven to be Hepatoblastoma by biopsy. Over the course of the ensuing 8 months, three distinct chemotherapeutic combinations were utilized. These regimens included: (i) Ifosfamide/Carboplatin/Etoposide, (ii) Doxorubicin / Ifosfamide (iii) Irinotecan/temodar/ temsirolimus, In addition to resection of pulmonary metastases, Patient developed transthoracic mass that invaded the 6th rib causing pathologic fracture. Despite extensive exposure to multi-agent chemotherapy, AFP levels continued to rise and serial CT scans demonstrated progressive disease. Background: Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening hyperinflammatory syndrome caused by excessive but ineffective immune system activation. Pulmonary alveolar proteinosis (PAP) is the abnormal accumulation of surfactant in lung alveoli causing respiratory disease. We describe two cases of critically ill toddlers who presented with signs of immune-hyperactivation along with progressive respiratory compromise, and subsequently were diagnosed with acquired HLH and PAP.

Objectives: To increase index of suspicion of PAP in patients with HLH, support early and thorough evaluation in similar cases and describe available treatment options. Design/Method: The first patient is an ex-28 weeks, 1 year old girl with chronic lung disease and the second patient is a 13 month old boy with history of failure to thrive and recurrent pneumonias. Both of them presented with persistent fevers and respiratory failure alongwith significant lymphadenopathy and hepatosplenomegaly.

Workup for HLH showed a very elevated ferritin (>16,000), bicytopenia, hypertriglyceridemia, hypofibrinogenemia, hemophagocytosis in the bone marrow in both patients plus an elevated soluble IL-2 receptor in patient one. NK function was normal in both. They met 7/8 and 6/8 criteria for HLH respectively. Results: Genetic testing for HLH was normal in patient one, but showed a compound heterozygous mutation of SLC7A7 associated with Lysinuric protein intolerance (LPI) in patient two. Lung biopsy to evaluate progressive respiratory disease showed PAP in both cases. Both patients were treated with induction chemotherapy as per HLH-2004 protocol. PAP was treated with whole lung lavages and ECMO with resolution of symptoms in patient one, however treatment options for PAP were limited for patient two due to underlying LPI. HLH and PAP have been described independently in patients with LPI. Our second patient unifies the picture of an inborn aminoaciduria leading to macrophage dysfunction and immune dysregulation causing HLH and PAP. Whole lung lavage has limited utility in this situation and bone marrow transplant has not been described. Conclusion: Diagnosis in similar complex cases can be challenging given multi-systemic and progressive nature of the disease, broad range of differentials and time required for diagnostic evaluation. However a high index of suspicion and early thorough evaluation can be beneficial and life-saving in severe cases.

Background: Sotos Syndrome (SS) is a rare genetic condition (1 in 14,000) characterized by excessive growth, frontal bossing, downslanting of the palpebral fissures, dolichocephalic head shape, hypertelorism and prominent jaw, caused by mutation in the NSD1 gene. There is an increased risk of pediatric cancer associated with SS (3.9%), especially hematopoietic malignancies. We present a case of a 13 year old boy with SS diagnosed with classic Hodgkin's Lymphoma (HL). Objectives: Describe a case of an adolescent with HL and SS. Design/Method: We conducted a search of PubMed, Ovid, Google Scholar search using the terms "Sotos Syndrome" and "Hodgkin" and "lymphoma." There were 11 previously reported cases of hematologic malignancies in association with Sotos Syndrome, but none of HL. Of note, these studies indicated that males are affected much often than females. Our case increases the number of reports to 12.

A 13 year old young man with SS presented with a2×3 firm, fixed anterior neck mass, proven by excisional biopsy to be HL. Workup confirmed Stage Ia disease. Our search yielded 17 manuscripts. The patient was successfully treated with 3 cycles of doxorubicin, vincristine, prednisone and cyclophosphamide and has remained in remission now for 33 months. Conclusion: Sotos Syndrome is a rare genetic disease that appears to have an increased risk of leukemia and lymphoma. Our case is the 12th such case and the first HL. We hope that this will increase awareness of the possible association of SS and HL and Background: Thymic carcinomas (TC) are rare in adults and less common in children, accounting for less than 1% of childhood mediastinal tumors. In adults, the first treatment is usually surgical resection. Approximately 30% of TC are metastatic at diagnosis and are unresectable. The medial survival with current platinum-based chemotherapy regimens is approximately 2 years. There are ongoing studies of tyrosine kinase inhibitors (TKI) for advanced thymic tumors, but no reports of their use in maintenance therapy in metastatic TC in children.

Objectives: We report the use of cisplatin and docetaxel followed by sunitinib as maintenance chemotherapy in a pediatric patient with metastatic TC. Design/Method: A 13 year old male with autism, who presented with a mediastinal mass, was diagnosed with stage IV TC. The tumor was unresectable and there were multiple metastatic lung lesions. The patient was treated with cisplatin 75mg/m2 and docetaxel 75mg/m2 every 3 weeks. To prevent regrowth, we initiated maintenance therapy with sunitinib, a drug reported to stabilize disease in adults with advanced thymic malignancies. Results: After 4 cycles of chemotherapy, imaging revealed reduction of the anterior mediastinal mass (36% reduction) and decreased pulmonary metastases. Following 8 cycles of chemotherapy, repeat imaging showed further decrease in size (76% reduction) and number of pulmonary metastases. Due to the aggressive nature of the disease, he was started on sunitinib 25mg oral daily. Side effects included discoloration of skin surrounding his g-tube which was used for administration and a faint, erythematous rash on his chest. Since starting sunitinib, the patient continues to have reduction in the primary tumor size. Most recent chest CT performed 22 months after initiation of sunitinib showed an 88% reduction from the original mass and further resolution of lungs metastases. Conclusion: Thymic malignancies are rare tumors that are aggressive and difficult to treat in advanced stages. We demonstrate disease response using sunitinib, a multi-TKI, as maintenance therapy to prevent regrowth. While on sunitinib, the patient continues to have disease reduction with minimal side effects. Given the rarity of these tumors, this is a promising therapeutic approach for an advanced-stage tumor in a pediatric patient.

Background: Ataxia-Telangiectasia (A-T) is an autosomal-recessive DNA-mismatch repair disease causing predisposition to malignancies. Up to 30% of A-T patients will develop cancer, mostly of lymphoid origin. These patients pose a unique challenge due to their sensitivity to radiation and increased risk of chemotherapy complications such as hemorrhagic cystitis and severe infection. Objectives: We discuss a 12-year-old female with A-T who presented with two weeks of neck swelling. Excisional biopsy revealed mature B-cell lymphoma. Staging PET/CT scan showed localized disease. Design/Method: The patient's treatment was based on the successful treatment of elderly patients with high-grade non-Hodgkin lymphoma with 6 cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) combined with rituximab (375 mg/m2), which resulted in complete response (CR) rate of 85% which was modified therapy to limit toxicity. She received one cycle of COP (cyclophosphamide, vincristine, and prednisone) with near CR on MRI. For her first cycle of R-CHOP, cyclophosphamide dose was reduced and she remained hospitalized for count nadir and recovery due to risk of infection. She did not have a significant nadir so cyclophosphamide was escalated to full dose for subsequent cycles.

Complications included prolonged (culture-negative) febrile neutropenia, C. difficile colitis, and right intra-atrial thrombus requiring anticoagulation. Results: Following four cycles of R-CHOP, MRI showed CR. Following her fifth cycle she was admitted with fever, neutropenia, and hypotension requiring vasopressor support. Echocardiogram revealed ejection fraction of 22% following a cumulative anthracycline dose of 250 mg/m2. She was intubated, and developed worsened hypotension and desaturation, progressing to cardiac arrest. Despite cardiopulmonary resuscitation, spontaneous cardiac function did not return, and patient died. Signs of heart failure were evident on limited autopsy of chest, however underlying etiology remained unclear. Conclusion: Despite superior treatments for many non-Hodgkin lymphomas, patients with A-T continue to present obstacles due to their exquisite sensitivity to commonly employed anti-cancer therapies. R-CHOP may be an acceptable regimen for these patients, but may still be too toxic. Increased risk for cardiac toxicity has not been reported, and may be another sensitivity in A-T patients. Additional studies are warranted to further understand this special patient population, leading to adaptation of treatments or improved protection from toxicities. Background: Ulcerated primary melanoma is associated with a poor prognosis. Studies show that ulcerated melanoma treated with adjuvant pegylated interferon alfa-2b (PEG-IFN-α-2b) has improved recurrence-free survival in adults with cutaneous melanoma. Objectives: To report our experience using pegylated interferon alfa-2b in a pediatric patient with ulcerated stage IIIB Melanoma. Design/Method: Case report Results: An 8-year-old girl presented with a right lower extremity lesion with pathology revealing a malignant melanoma with spitzoid features invasive to at least Clark level IV, Breslow depth of at least 1.4 mm with a microscopic focus of ulceration, and a mitotic rate of 3/mm2. A PET scan showed increased uptake in a right inguinal lymph node with no distant metastasis. She underwent a wide local excision with full-thickness skin grafting and a sentinel lymph node biopsy. Pathology was negative for residual disease with a 1.5 cm margin. One lymph node was focally involved by metastatic melanoma (0.7 mm). A radical inguinal lymph node dissection was performed and negative for disease.Given the presence of high-risk disease with ulceration, she was started on PEG-IFN-α-2b induction therapy for 8 weeks. With limited pediatric data she was started at the maintenance adult dose of 3 mcg/kg/dose by weekly subcutaneous injection. The dose was increased by 1 mcg/kg each week to the full induction dose of 6 mcg/kg. Following induction she continued on maintenance therapy, 3 mcg/kg/week for 52 weeks. Side effects and organ toxicity were monitored monthly throughout her course. Despite premedication with acetaminophen, the patient experienced a low-grade fever with chills and myalgias following the first dose. Subsequent injections were followed with scheduled acetaminophen for 24 hours, which prevented symptoms. She reported mild fatigue for one to two days following each injection, but denied symptoms of depression, headache, and nausea or vomiting. Monthly laboratory monitoring for myelosuppression, hepatic and renal dysfunction was performed along with a TSH and triglyceride level every three months. No persistent abnormalities were seen. Conclusion: Our patient tolerated pegylated interferon alfa-2b with no significant adverse side effects or organ toxicity. This is the first reported pediatric patient with melanoma treated with this therapy. Background: Tumors with the t (7;12) and ACTB-GLI1 fusion are a recently described entity, usually arising in the soft tissue. Two prior published articles reported six cases, two of them in children, both arising in the tongue. Objectives: To report an unusual gastric tumor arising from the pyloric wall of the stomach in a 9-year old child harboring the exceptionally rare translocation t(7;12) resulting in ACTB-GLI1 gene fusion. Design/Method: Case report Results: A 9-year-old previously healthy female, presented with one episode of abdominal pain and vomiting. An epigastric mass was palpated. Computed tomography scan of the abdomen showed a localized 6cm X 7cm X 6cm solid and cystic mass arising from the distal stomach. Preoperative differential included gastrointestinal stromal tumor and inflammatory myofibroblastic tumor. The child underwent an exploratory laparotomy, which revealed a mobile mass attached to the anterior portion of pylorus. The mass was completely resected, and a Heineke-Mikulicz pyloroplasty was performed. Microscopic examination of the mass revealed a spindle cell proliferation diffusely positive for CD56 and vimentin and focally for EMA and CD10. Initially the pathology was reported as angiomatoid fibrous histiocytoma. Cytogenetic studies showed a balanced translocation involving the short arm of chromosome 7 at p22 and the long arm of chromosome 12 at q13 [46,XX,t(7;12)(p22;q13)]. The diagnosis was changed to pericytoma t(7:12). The presence of ACTB-GLI1 fusion transcripts was confirmed by RT-PCR and genomic DNA amplification. The child was in remission at 6 months follow-up. Conclusion: Our case is the first report of a gastric tumor with the translocation t(7;12)(p22;q13) and confirmed ACTB-GLI fusion gene, in a pediatric patient. The unusual location and morphology made the differential diagnosis quite difficult, making genetic and molecular analyses imperative for the correct diagnosis. No evidence of recurrence or metastasis has been documented in the prior reported cases and resection seems to be the treatment of choice. He has a history of refractory epilepsy, severe intellectual disability and was diagnosed using whole exome sequencing with a very rare potassium channelopathy due to a heterozygous mutation in the KCNT1 gene. He also has a history of recurrent volvulus with significant colonic resection, pseudo-obstructive syndrome with colonic neuropathy and TPN-dependent intestinal malabsorption. Results: Colonoscopy revealed a tubular villous adenoma with high-grade dysplasia consistent with CIN. Staging workup, including CEA and CA19-9 evaluation was negative. Reanalysis of the exomic data for 56 known cancer-related genes revealed a heterozygous c.851C>G mutation resulting in a stop codon p.Ser284X in the PMS2 gene, not present in his mother's exome sequencing. Conclusion: This case report presents a novel PMS2 mutation, uniquely observed in a patient with a known channelopathy. The emerging role of PMS2 mutation in pediatric cancer, possible mechanisms of a second hit and the therapeutic dilemma of CIN in patients with LS are important considerations illustrated by this unique case. We will also highlight the ethical dilemmas surrounding reporting of incidental findings in whole exome sequencing in the context of detection of clinical oncogenetic potential.

Background: Neuroblastic tumors have an age-linked classification that is dependent on the differentiation of the neuroblast and the presence or absence of Schwannian stromal development. They fall along a spectrum of tumor maturity, which dictates tumor aggression and course. Ganglioneuromas and intermixed ganglioneuroblastomas are the most mature subtypes that tend to present with unifocal disease and have a benign course. Objectives: We present a unique case of a 3-year-old boy with multiple tumors identified at initial presentation, with histology consistent with multiple soft tissue ganglioneuromas and an abdominal intermixed ganglioneuroblastoma. Design/Method: Our patient is a previously healthy boy who presented with a mass on the posterior aspect of his right thigh that was increasing in size over a 1-month period. An MRI of his thigh revealed 3 well-circumscribed lesions within the muscle. The biopsy of these lesions was in keeping with a ganglioneuroma. An abdominal MRI performed as part of a staging work-up revealed a mass in the right adrenal fossa. The biopsy of this mass was consistent with an intermixed ganglioneuroblastomas. N-MYC was not amplified in either lesion. The remainder of the staging work-up including urine vanillylmandelic acid (VMA) and homovanillic acid (HVA), a bone scan, bilateral bone marrow aspirates and biopsies, and a MIBG scan were unremarkable. Although metastatic disease was present upon presentation, based on the histological subtypes of his tumors, the likelihood of progressive disease was low. Therefore, he was observed without active treatment.

He remains well without disease progression almost 1-year following diagnosis. Conclusion: Reports of metastatic ganglioneuromas and intermixed ganglioneuroblastomas in the literature are limited. To our knowledge, this is the first pediatric case with concurrent adrenal ganglioneuroblastoma and multiple soft tissue ganglioneuroma metastases present at the initial diagnosis. This rare presentation of multifocal soft tissue ganglioneuromas, with an abdominal intermixed ganglioneuroblastoma, raises the possibility that these lesions were once less mature neuroblastic tumors that underwent maturation. Given the distribution of disease in our patient, it is possible that our patient once had a stage IV-S neuroblastoma, with subsequent maturation of the primary tumor and metastases. Background: Neuroblastoma is the most common extracranial solid tumor in children, and the most common cancer in infancy (1). It is a tumor which may present with a spectrum of paraneoplastic syndromes. Protein losing enteropathy (PLE) has been described in a small number of children with neuroblastoma unrelated to the gastrointestinal involvement by cancer, and has been thought to be either a rare paraneoplastic syndrome due to catecholamine effects on the gut or to lymphatic obstruction from mass effect (2) . Noonan Syndrome has been associated independently with neuroblastoma and with PLE (3). Objectives: To describe the clinical course of phenotypically normal baby with concurrent neuroblastoma and PLE whose tumor DNA was found to have a mutation in the PTPN11 gene. A biopsy was performed, due to tumor unresectability, which noted myofibroblastic proliferation with marked inflammation consistent with IMT. Next-generation sequencing revealed an alteration in the CPS1 (A347S) gene, previously reported as a poor prognostic marker in rectal cancers, and a normal ALK-1 gene. Initially, she was treated with celecoxib and methylprednisolone; however, the tumor ruptured and resulted in abdominal compartment syndrome with hypertension, obstipation, bladder outlet obstruction, and bilateral hydronephrosis. She was then transitioned to VAC chemotherapy, which consisted of a 21-day cycle of vincristine (0.025 mg/kg/dose) weekly, dactinomycin (0.025 mg/kg/dose) on day 1, and cyclophosphamide (40 mg/kg/dose) on day 1, in addition to daily celecoxib therapy. She has tolerated 5 cycles of therapy with minimal side effects and occasional growth factor support. The most recent imaging reveals tumor measurements of 3.7×4.2×6.7 cm. She has had complete resolution of her hypertension, obstipation, bladder outlet obstruction, and marked improvement of her bilateral hydronephrosis. She will continue this regimen until complete resection is feasible. Conclusion: VAC used in combination with celecoxib may be a therapeutic option for inoperable ALK-1-negative IMT.

Background: Vaginal RMS is associated with a favorable prognosis, although the optimal local control approach is controversial due to the long term reproductive, musculoskeletal, and psychological sequelae of RT. A response-based local control approach has been attempted in patients with group III vaginal RMS, eliminating the need for RT. Objectives: To describe a new surgical approach for localized vaginal RMS using minimally invasive surgical resection followed by autologous buccal graft vaginoplasty reconstruction. Design/Method: Case series of 3 patients with localized vaginal botryoid RMS from 3 institutions who were treated with chemotherapy as per ARST0331, subset B. Results: All 3 patients were under 3 years of age (range 11-30 months) and had botryoid RMS. All patients received a maximum of 4.8 g/m2 of cyclophosphamide followed by vincristine/dactinomycin therapy. Surgery was performed at different times (weeks 0, 12, and 16), and all patients underwent a subtotal or total vaginectomy with autologous buccal graft vaginoplasty reconstruction. In one patient the surgical margins were positive, and in the other two the closest margins were 1 and 2 mm. No patient received RT. At a median length of follow-up of 25 months, all 3 patients remain disease-free. Background: Pure choriocarcinoma of the testis is a highly malignant tumor derived from trophoblastic cells with the potential for early metastasis. It accounts for 0.3% of all primary testicular germ cell tumors. Given its rarity and propensity in older patients, pure choriocarcinoma is often not in the differential for patients who present at pediatric oncology services. Objectives: To describe a case of pure choriocarcinoma in a peri-pubertal male patient, review pediatric/adolescent cases, and discuss the use of pubertal status in testicular tumor work up. Design/Method: We report a case of a previously healthy, normally developing, Tanner IV, 14-year-old male patient who presented with an asymmetrically enlarged right testicle following blunt trauma with subsequent right-sided chest pain, fever, and emesis. A right radical orchiectomy was performed and pathology showed pure choriocarcinoma. Imaging revealed extensive metastatic disease including to the lungs and brain. A literature search on PubMed identified previously reported cases of testicular pure choriocarcinoma in adolescents.

Results: Due to its rarity, pure choriocarcinoma of the testis mostly appears as case reports within current literature. The patients in reported cases (n = 17) range from age 18 to 63 years (mean age 31.3). Our patient is the youngest known reported case. Pure choriocarcinoma is often initially misdiagnosed given its tendency to present with symptoms secondary to lung, skin, and/or brain metastasis, as opposed to testicular swelling like other testicular tumors. Its misdiagnosis may be related to the gap in knowledge regarding peri-pubertal testicular tumor differential and workup. While puberty plays an important role in the frequency of testicular tumor types, teenage and adolescent patients, like the presented patient, often fall between pre-and post-pubertal studies in the literature. Research studies often use age cut-offs when studying preversus post-pubertal testicular tumors; yet, the variability of age of puberty onset and the variety of puberty stages suggests that age-defined cut-offs are suboptimal. Conclusion: Peri-pubertal boys are at risk for testicular cancers that are typically identified in the 15-to 35-year-old cohort. Our report of testicular pure choriocarcinoma in a 14-year-old highlights unique characteristics of this tumor and the importance of puberty status in pediatric oncology workup algorithms.

Background: Rhabdomyosarcoma (RMS) is the most common sarcoma in children.

The perianal site is unusual in occurrence and associated with lower cure rates. Cases treated with gross total surgical resection and conventional radiotherapy have been reported to be associated with sphincter dysfunction and anal ulcerations. Objectives: To describe a case of localised perianal embryonal RMS and its management using neoadjuvant chemotherapy and stereotactic radiosurgery. Design/Method: Single case report Results: Three year old boy presented with painful swelling over the right perianal region since two months. Examination revealed a 2.5 cm soft, tender, diffuse swelling over the right perianal region. Open wedge biopsy of the lesion was suggestive of embryonal rhabdomyosarcoma and immunohistochemistry was positive for desmin, Myf4, CD99 (focal), WT1, CD 56 and negative for S-100, pan, CK, CD45. FDG PET CT scan showed 2.7×1.5 cm metabolically active enhancing soft tissue mass in the right perianal region extending to perineum and right half of the gluteal cleft, with no evidence of distal metastases. He received four courses of neoadjuvant chemotherapy with IVA (Ifosphamide, Vincristine and Actinomycin D). The child was treated with stereotactic radiosurgery to a dose of 19.8Gy /3 #to CTV, 23.1Gy/ 3#to GTV to the perianal area. Subsequently he received five more courses of IVA based chemotherapy. We are presenting a case of a novel p53 mutation c.672 G>A. Mutations in this hotspot are associated with the DNA binding site resulting in a gain of function of p53. These are associated with altered cancer spectrum, deregulated metabolic pathways, increased metastases, enhanced chemotherapy resistance, and binding of ETS and MOZ involved in histone methylation and acetylation. We found no reports of this mutation but have found a missense mutation resulting in a splicing variant as well as a number of indels occurring at c.672. Synonymous mutations may play a part in cancer biology, by affecting cryptic and non-cryptic alternative splice sites, including those in TP53 (Supek et al, Cell 156:1324 , 2014 . They found thatTP53-synonymous mutations were extremely recurrent and affected nucleotides directly adjacent to splice sites.

There is no documentation of this mutation in the literature, and further work must be done to determine its relevance. One such experiment would be creating a mini gene construct to evaluate TP53 splicing and analyze cell activity. We hypothesize this synonymous mutation may affect TP53 splicing, RNA folding or codon usage and serves as a driver for the two concurrent and aggressive primary tumors. Here we describe severe, recurrent hypercalcemia responsive to denosumab after discontinuation of denosumab for metastatic GCTB in a child. Objectives: Discuss the complications associated with discontinuation of denosumab for GCTB in a child and its utility in treating recurrent, post-therapeutic episodes of hypercalcemia.

A twelve year-old male presented with episodic left-sided hip pain and difficulty weight-bearing. MRI revealed a cystic lesion in the left ischium. Treatment with monthly denosumab 120mg was initiated. Dramatic improvement was noted clinically and radiographically. After forty months asymptomatic and stable, denosumab was discontinued. One month later, he presented with nausea and vomiting, hypercalcemic at 15.5 mg/dL with acute kidney injury (serum creatinine 2.4 mg/dL). Calcitonin, hyperhydration and lasix were unsuccessful. He was treated with denosumab with rapid resolution of hypercalcemia. In the following five months, hypercalcemia recurred twice, both with resolution within 48 hours of treatment with denosumab 20mg and 10mg, respectively. Results: While GCTB is a benign histologic diagnosis, its locally aggressive nature complicates treatment. Definitive management is often surgical, which was precluded by our patient's metastatic disease. Tumor cell expression of receptor activator of nuclear factor-kB ligand (RANKL) interacts with RANK on monocytes, activating osteoclasts, their precursors and giant cells, promoting bone resorption. Denosumab, a human monoclonal antibody, binds and inhibits RANKL, suppressing bone turnover. Upon discontinuation of denosumab's inhibitory effects, osteoclast hyperactivity may cause rebound hypercalcemia. This phenomenon may be more pronounced in a skeletally immature child with increased rate of bone metabolism. Treatment with denosumab resolves these episodes of hypercalcemia. Conclusion: This patient highlights the utility of low dose denosumab in managing severe hypercalcemic episodes following long-term treatment with denosumab. Further research is needed to determine ideal dosing, effects of recurrent treatment, recommended monitoring and the potential need for gradual discontinuation of therapy.

Background: Interdigitating reticulum cell sarcoma is a rare spindle cell sarcoma of the lymph node stromal cells known as interdigitating reticulum cells. Tumor cells are positive for S-100 protein, CD 68, HLA-DR and CD45RB. Treatment regimens have been varied, with a poor overall prognosis. We were able to identify 5 cases reported in the literature from the adult population and none from the pediatric population. Objectives: To introduce a pediatric case of Interdigitating reticulum cell sarcoma Design/Method: Clinical case report Results: Our patient is a 4 year old male adoptee brought to the U.S. from an industrial region of China. He was 9 months old and still living in China when he was diagnosed with a Fibrosarcoma of his lower back. He underwent complete resection with wide margins and was treated with Vincristine and Dactinomycin adjuvant chemotherapy prior to moving to the U.S. reportedly in remission. At a follow-up visit at 3 years of age in the U.S., a right axillary mass was noted on CT scan. He underwent complete resection of this mass, as well as wedge resection of 2 left lower lobe pulmonary nodules that had been stable since age 2. Final pathology from all sites revealed an atypical spindle cell sarcoma, mostly suggestive of an Interdigitating reticulum cell sarcoma. He was treated with Ifosfamide and Doxorubicin off-study per Children's Oncology Group protocol ARST1321. Six weeks after the completion of therapy, scans remain stable from prior to therapy. He continues to have 2 sub-centimeter right upper lobe pulmonary nodules of uncertain etiology that have been stable since 2 years of age.

Since his disease has been very slow growing, parents opted to observe with scans for 3 months prior to proceeding with resection of these remaining nodules in the next month.

Conclusion: This is an exceedingly rare case of Interdigitating Reticulum Cell Sarcoma in a pediatric patient from an industrial region of China. An optimal treatment regimen is yet to be determined. The impact of exposure to this industrial region on cancer incidence is unknown.

Background: Type 1 diabetes (T1DM) is associated with other autoimmune diseases, namely thyroiditis, celiac disease and autoimmune gastric disease. Two conditions at initial presentation, however, is exceedingly rare. Here we describe a child with novel, simultaneous presentation of thrombocytopenia and hyperglycemia, leading to concurrent diagnoses of immune thrombocytopenia (ITP) and T1DM. Objectives: Describe a child with severe thrombocytopenia and hyperglycemia, leading to new diagnoses of both ITP and T1DM. Explore known co-morbid autoimmune diagnoses, and the significance behind less commonly reported pairs. Design/Method: A five year-old male presented with bruising. He had a viral URI one week prior. CBC and CMP revealed thrombocytopenia of 2 K/cmm and hyperglycemia to 457 mg/dL. Urinalysis was positive for glucose, negative for ketones. Bleeding history was negative. Physical exam revealed wet purpura and scattered bruises. Presentation was consistent with ITP, and his hyperglycemia was attributed to an acute illness stress response. He received IVIG with platelet improvement to 83 K/cmm. Elevated serum glucose persisted overnight. Hemoglobin A1c was elevated at 7.8%, indicating chronic hyperglycemia. Autoantibody testing obtained prior to IVIG demonstrated an elevated anti-glutamic acid decarboxylase antibody, diagnostic for T1DM. He started insulin therapy with stabilization of serum glucose. Results: Pleomorphic by nature, with non-specific symptomatology, autoimmune diseases can be challenging, confounded by associated conditions. Genetic and immune dysregulation disorders are considered when presented with associated conditions. Thrombocytopenia and T1DM are an unusual pair. To our knowledge, only five pediatric cases have described this association, none with simultaneous presentation. T1DM results from T cell destruction of insulin-producing pancreatic beta-cells. ITP is mediated by circulating autoantibodies to platelets. Both conditions share a basis in autoimmune dysregulation, but by independent mechanisms. These associations may have significant implications for treatment. Recent studies suggest when traditional treatments fail, rituximab (anti-CD20) therapy targeting B lymphocytes may prove beneficial for many autoimmune disorders, including T1DM and ITP.

Conclusion: Complex autoimmune disorders should be considered in patients who develop multiple autoimmune conditions. In less commonly recognized associations like ITP and T1DM, early recognition and management is critical to patient success. Response to conventional treatments, and the utility of antibody therapy in resistant cases should be considered.

Background: Synovial sarcoma is a malignant mesenchymal malignancy that most commonly originates in the deep soft tissue of the extremities, with < 3% being reported in the head and neck region. Objectives: We present a 16-year-old male with a several-month history of progressive left upper extremity pain and weakness, exacerbated after slipping and falling on his left elbow.

Design/Method: MRI demonstrated an intraspinal extradural tumor involving the left aspect of the spinal canal, neural foramina and paraspinal soft tissue from the C2 to T2 levels. Biopsy revealed a malignant mesenchymal neoplasm with negative immunohistochemical markers for rhabdomyosarcoma and Ewing sarcoma. Molecular studies were positive for a SS18/SSX2 fusion transcript, conferring the diagnosis of synovial sarcoma. Positron emission tomography scan was negative for metastatic disease.While awaiting diagnostic biopsy results, the patient developed worsening left arm pain and swelling accompanied by increasing facial edema. Venous Doppler ultrasound revealed extensive deep vein thromboses spanning from the internal jugular vein to the proximal brachial vein. Transthoracic echocardiogram revealed an echogenic mass in the right atrium extending through the tricuspid valve into the right ventricle.

Computed tomography cardiac angiogram demonstrated contiguity between the intra-cardiac mass with the superior vena cava and left brachiocephalic and internal jugular veins. He underwent urgent surgery due to impending hemodynamic deterioration and pathology of the resected specimens from the left brachiocephalic vein and right atrium/tricuspid annulus were consistent with synovial sarcoma. Results: He subsequently received neoadjuvant treatment with chemotherapy and conventional radiation, followed by surgical resection, postoperative proton radiation boost, and adjuvant chemotherapy. He had no evidence of disease upon completion of therapy and is being monitored under regular surveillance. Conclusion: Primary synovial sarcoma involving the spine is rare, and while tumor thrombi have been described with synovial sarcoma, this is the first known report of extension into the right side of the heart. Multidisciplinary care between neurosurgery, cardiothoracic surgery, otolaryngology, oncology and radiation oncology was key in rendering this patient free of disease.

A RARE CASE OF POLYCYTHEMIA: CHUVASH POLYCYTHEMIA Nathan Hall, Ashish Risal

Background: Chuvash Polycythemia is a rare form of congenital polycythemia caused by an altered oxygen-sensing pathway. It was recognized in the 1970s in the Chuvash Republic of the Russian Federation as a clinically distinct entity from polycythemia vera and has an autosomal recessive inheritance pattern. A specific mutation in the Von Hippel-Lindau (VHL) gene results in an R200W amino acid substitution leading to an upregulation of hypoxia inducible factors (HIF-1, HIF-2) despite normal oxygen levels. This leads to a chronic increase in red blood cell production. The mutation is in the VHL gene on chromosome 3p25.4. This mutation was subsequently found in people of European, African-American, and Pakistani/Bangladeshi ethnicities. Our patient is a 9

year old female of Pakistani descent who presented to a neurologist with a longstanding history of headaches. Lab evaluation revealed a hemoglobin level of 20.5 and hematocrit of 60.6. Family history is positive for father having an undiagnosed polycythemia for which regular phlebotomies are performed, and parents are cousins. Objectives: Describe a rare case of Chuvash Polycythemia, diagnosis, treatment, and outcomes in a pediatric patient. Design/Method: Case Report Results: An extensive workup for polycythemia was conducted after confirming the hgb and hct levels for primary and secondary polycythemia. Work up for polycythemia vera (JAK2, Exon 12&14) was negative and erythopoetin levels were normal. Additionally, P50 (oxygen affinify) studies were found to be normal. Gene testing was performed and revealed a homozygous R200W mutation on the VHL gene, confirming the diagnosis of Chuvash Polycythemia. To date, there is no treatment for Chuvash polycythemia. However, symptom management with phlebotomy is thought to be acceptable. Phlebotomy can help with headaches, ruddy complexion and other morbidity but may lead to iron deficiency anemia. There is also a significant increase in stroke and other thrombotic events in these patients. Paradoxically, there is an increase in bleeding events as well, and some of the strokes are hemorrhagic. Other complications include pulmonary hypertension and hemangiomas. Conclusion: Chuvash polycythemia is a rare cause of polycythemia that should be promptly diagnosed and treated based upon clinical symptoms to prevent long term morbidity or mortality.

Background: Osteosarcoma is the most common primary bone tumor in children.

Metastatic disease is seen in 30% of patients with lungs being the most common site of metastasis followed by other boney sites. Bone marrow metastasis affecting hematopoiesis is extremely rare with only a few case reports in the literature.

We describe a case of metastatic osteosarcoma with diffuse infiltration of the bone marrow at both contiguous and distant locations. The physiological functions of the bone marrow were compromised and patient showed suppression of the hematopoietic cell lineage. Design/Method: The discussion includes clinical presentation and diagnostic features noted on initial disease evaluation such as magnetic resonance imaging, computerized tomography scan, bone scintigraphy and serial blood counts. We have provided histologic findings from biopsies of the primary tumor and bone marrow. We also compared and contrasted the symptoms and the course of the disease with those of typical metastatic osteosarcomas.

A 10 year-old Caucasian female presented with intermittent pain in her right leg for 2 weeks. Imaging showed a destructive mass in the right distal femur with local bone marrow and soft tissue involvement. Biopsy revealed a high-grade osteoblastic osteosarcoma. Metastatic evaluation demonstrated sub centimeter nodules in addition to extensive skeletal disease involving the bilateral femurs, bilateral humeri, skull, ribs and pelvis. Complete blood count done prior to biopsy was remarkable for a white blood count 6100/μl, hemoglobin 12.3g/dl and Platelets 32000/μl. Bone marrow evaluation was performed with samples from bilateral iliac crests demonstrating pleomorphic tumor cells (70% marrow involvement) with osteoid formation along with normal hematopoietic cells. With no available clinical trial, the patient received standard therapy consisting of Methotrexate, Adriamycin and Cisplatin. Her platelet count recovered after the initial course of chemotherapy suggesting that her marrow disease had responded to some extent. Unfortunately her response at other sites was poor resulting in her death from progressive disease after about 5 months of treatment. Conclusion: Bone marrow involvement impairing hematopoiesis is quite uncommon in metastatic osteosarcoma. Patients with osteosarcoma who present with abnormal complete blood counts should be evaluated for bone marrow metastases; such patients typically have a dismal prognosis.

Background: Z.R. is a 2 year old previously healthy male who presented with extensively indurated cellulitis of the right forearm and thigh, with associated right axillary and inguinal lymphadenopathy and fevers after failing oral antibiotics. He was hospitalized and started on appropriate parenteral antibiotics, with no clinical improvement. He developed palpable hepatosplenomegaly, neutropenia and mild anemia. Objectives: To report a very rare case of Subcutaneous Panniculitis-like T-cell Lymphoma. Design/Method: A bone marrow biopsy was obtained and significant for hemophagocytosis, but no blast population was observed. Due to concerns for hemophagocytic lymphohystiocytosis, work up was obtained but was non-specific. Ultimately, skin and lymph node biopsy revealed the rare diagnosis of subcutaneous panniculitis-like T-cell lymphoma (SPTCL), a mature T-cell lymphoma of extranodal cutaneous origin.

Results: This process typically presents as single or multiple focal nodules or plaques on the extremities, trunk, or face with associated fever, lymphadenopathy, hepatosplenomegaly, cytopenias, and rarely hemophagocytosis. This is an extremely rare diagnosis for which there is no defined epidemiologic incidence, and no organized treatment approach. Currently, treatment approaches include steroids alone, immunosuppressive agents, multi-agent chemotherapy and even autologous stem cell transplant. The current 5yr median survival is roughly 80%, but this depends greatly upon the phenotype of the T cell receptor (TCR). The αβ phenotype has a significantly better prognosis than the aggressive ϒδ phenotype that is often associated with hemophagocytosis. He was found to have a βϒ TCR, concerning for the more aggressive phenotype. Thus, we have begun treatment with a multi-agent chemotherapy regimen. He has received two cycles of of doxorubicin, vincristine, prednisone, and cyclophosphamide per AHOD 0431. He is now receiving methotrexate and cytarabine per AALL1231. MRI of the extremities and CT of the abdomen after 2months of therapy showed near resolution in the size and induation of his plaques. We plan to treat for at least 6 months pending response. Conclusion: This case stresses the importance of broadening your differential diagnosis when a patient does not respond to appropriate treatment and further, will provide much needed insight as to how to successfully treat pediatric patients with the rare diagnosis of SPTCL and associated hemophagocytosis.

Background: Technology is changing the practice of medicine. Practitioners have accessed e-mail and electronic medical records using desktop and laptop computers. Now, they face the challenge of thousands of healthcare mobile applications (apps) available on smart phones. An app is a self-contained program or piece of software designed to run on handheld devices to perform a specific purpose. Objectives: To identify a need for pediatric-specific apps for the pediatric hematology-oncology (PHO) community as a tool to improve workflow and enhance trainee and patient education. Design/Method: Hematology/ Oncology MeSH terms from the 2015 list were searched in the Apple iTunes Store as simple keywords in the English language. A master list of unique apps was created and the apps were divided into four categories (medical teaching, provider tools, resources and consumer) and several subcategories. Results: A search of the 51 hematology-oncology MeSH terms in the iTunes Store resulted in 689 apps for the iPhone and 476 apps for the iPad. A total of 41 iPhone apps (6%) were considered potentially useful to the PHO field. Categories of medical teaching (42%) and provider tools (31%) yielded the highest number of interesting apps. However, in resources only 12% were found to be pediatric hem/onc-oriented (staging 0%, journals 6.6%, conferences 0% and few useful handbooks). In consumer-related apps (22% potential useful) only four non-english apps (Spanish) apps were found. Conclusion: Mobile technology and apps are convenient and may lead to superior and faster clinical decision-making, improved accuracy and enhanced productivity for PHOs. However, there is clearly a need for design of pediatric hemato/oncology-specific apps. ASPHO can take the lead in coordinating a response to this fast-moving field by designing and organizing these apps and encourage PHOs for using those new PHO-specific Apps to optimize patient care and education. 

Background: Neutropenic enterocolitis occurs commonly in individuals with hematologic malignancies who are neutropenic and develop a breakdown in gut mucosal integrity as a result of cytotoxic chemotherapy. Clinical manifestations include fever and abdominal symptoms (pain, distention, cramping, tenderness, nausea, vomiting, and watery or bloody diarrhea). Diagnosis is confirmed with imaging and treatment is broad spectrum antibiotics. Tuberculous enteritis is rare in the United States (US) with non-specific signs and symptoms, often resulting in diagnostic delays. Objectives: Report AML complicated by both typhlitis and tuberculous enteritis. Design/Method: Case report Results: A 15 year-old Hispanic female with AML received treatment on Children's Oncology Group-protocol (AAML1031-Arm B). Following Induction-I, during neutropenic status, computed tomography (CT) revealed abnormal mucosal enhancement of her ascending colon. CT scans during the remainder of treatment demonstrated necrotic abdominal lymph nodes (LN) and persistent ileocecal inflammation that remained primarily unchanged despite antibiotic therapy and bowel rest. At the end of therapy, she had persistent fevers in the setting of a protracted course with typhlitis. Imaging showed a mildly prominent left supraclavicular LN and partial improvement in the colonic wall thickening with confinement to the cecum and proximal ascending colon. CT also revealed nonspecific pulmonary nodules with no lung parenchymal disease or hilar adenopathy. Excisional biopsy of the left LN showed necrotizing granulomas with rare acid-fast bacilli (AFB). AFB stains, tuberculosis (TB) polymerase chain reaction testing and stool culture were also positive. She was born in the US with family from El Salvador and reported visiting two years prior to her diagnosis. No known TB exposures. Two-weeks after starting anti-tuberculous therapy, she defervesced and neutrophil counts improved. Nine months post completion of therapy she remains in first remission with a hypocellular bone marrow. Bone marrow AFB stains and cultures are negative to date. Conclusion: Tuberculous enteritis is rarely suspected and even harder to identify in pediatric oncology populations due to the overlap in symptoms from their cancer treatment. Published reports of gastrointestinal TB in children commonly reported abdominal pain, fever and weight loss as presenting symptoms highlighting the deceptive clinical presentation of this disease in the setting of a cancer diagnosis. (13), acute lymphoblastic leukemia (9), chronic myelogenous leukemia (3), biphenotypic leukemia (2), and juvenile myelomonocytic leukemia (1) . Donor types were haploidentical (20), matched unrelated donor (4) and matched sibling donor (4). Of the patients that had MC alone, 15 of 16 (94%) responded to DLI. Three of the 15 responders (20%) developed grade II-IV acute graft versus host disease (GVHD) and 2 of 15 (13%) developed limited chronic GVHD. Of the patients with MC who were also MRD positive, 2 of 10 (20%) responded to DLI; one of the responders developed extensive chronic GVHD. Both of these responders had low-level MRD (0.04% and 0.03%) at the time of DLI. Of the nonresponders with MC and MRD positive disease, 3 of 8 (38%) developed GVHD. Neither of the 2 patients with MC and morphologic relapse had a response to DLI, nor developed GVHD. MC predated morphologic relapse by 64 and 65 days in the two patients in which DLI was delayed. Conclusion: When administered promptly after evidence of MC alone, DLI from any donor type can increase donor chimerism with a low risk of GVHD, and may prevent relapse. We advocate close monitoring of donor chimerism after HCT and early administration of DLI using a dose escalation regimen.

Background: Donors for patients of African descent requiring a hematopoietic stem cell transplant (HSCT) are limited in national registries. The donor pool is further limited because matched donors are disqualified if the total nucleated cell (TNC) counts of marrow grafts are below required donation thresholds. This is probably more likely in people of African descent who often have lower white blood cell counts than their European counterparts. In addition, for patients with sickle cell disease (SCD), TNC thresholds are higher than in other diseases (3.5 -5×108 TNC/kg of recipient's body weight versus 2×108 TNC/kg). This threshold was established anecdotally based on the hypothesis that higher TNC dose would decrease the rejection risk. Graft dosing is traditionally done using TNC but CD34 graft content may be a better predictor of transplant outcomes. Objectives: In a diverse population of HSCT donors, determine whether TNC concentration and CD34 percentage differ by ethnicity. Determine whether TNC or CD34 dose affects post-transplant morbidity and mortality. Design/Method: Retrospective chart review of allogeneic HSCT donors and recipients from 2000 to 2014. The Mann Whitney U test was used to compare TNC concentration and CD34 percentage between groups and a univariate logistic regression analysis was used to evaluate transplant outcomes. Results: We included 132 allogeneic HSCT patients and 134 donors. Diagnoses were: SCD (n = 35, 26.5%), leukemia/lymphoma/myeloma (n = 48, 36.4%), myelodysplastic syndrome (n = 7, 5.3%), or other (n = 42, 31%). Donors were Caucasian (37.9%), Black (37.1%), Asian (4.5%), Hispanic (9.1%), and other/unknown (12.9%). TNC concentration of bone marrow grafts was lower for Black vs. non-Black donors (n = 49 vs 85, median 0.16 vs 0.2×108/ml, p = 0.01). Median CD34 fraction was higher in Black vs. non-Black donors (1.57 vs 1.22%, p = 0.003). Time to engraftment, incidence of acute or chronic GVHD, incidence of rejection, and mortality did not vary significantly based on TNC or CD34 dose. Conclusion: Our data shows significantly lower TNC concentration but higher CD34 fraction in grafts collected from Black vs non-Black donors with no difference in outcomes. This suggests that the TNC threshold for bone marrow harvest should be lower for Black donors.

Background: Limited data exists regarding the burden of late morbidity following alloHCT for children with nonmalignant diseases. Objectives: To assess the incidence and severity of late effects in survivors of alloHCT for nonmalignant conditions. Design/Method: We conducted a prospective assessment of patients at Columbia University Medical Center who had survived ࣙ2 years disease-free after alloHCT in childhood (age ࣘ21 at transplant). Beginning in March 2015, patients participated in comprehensive clinic visits, which included objective lab and imaging tests to screen for late effects, quality of life evaluation with the Pediatric Quality of Life Inventory (PedsQL), and assessment of educational attainment. Late effects were graded with the Common Terminology Criteria for Adverse Events, version 4.0. Results: As of January 1, 2016, 34 patients (aged 3.7-29.2 years) enrolled in the study at a mean of 6.0±3.3 years after alloHCT. Diagnoses included hemoglobinopathies (n = 18, 53%), bone marrow failure (n = 8, 24%), and HLH/immunodeficiencies (n = 8, 24%). Among participants, 59% had a matched sibling donor (41% unrelated donor), 68% received bone marrow (21% cord blood, 12% PBSCs), and 44% underwent myeloablative conditioning (38% reduced-toxicity, 15% reduced-intensity). Fifty percent of the participants developed at least one chronic health condition and 12% developed a grade 3 condition. There were no grade 4 conditions. The most frequent late effects were ovarian failure (22% of females), growth impairment (12%), low bone mineral density (12%), thyroid dysfunction (9%), chronic kidney disease (9%), and treatment-related malignancies (6%). In addition, 15% had a history of chronic GVHD, 12% had a history of late acute viral infections requiring hospitalization, 15% had urine microalbuminuria, 9% had hyperferritinemia, and 27% had mild pulmonary function test abnormalities without clinical significance. Mean PedsQL scores were within 1 standard deviation of population norms in all domains, but 24% had overall scores in the impaired range (>1 standard deviation below population norms). Thirty eight percent of participants had delayed educational attainment.

In this heterogeneous cohort of long-term survivors of alloHCT for nonmalignant diseases, mild-to-moderate late effects were common, but severe late effects were infrequent. The ongoing study should be able to identify risk factors for adverse long-term outcomes.

Background: Allogeneic hematopoietic cell transplantation (HCT) remains standard therapy for various rare, inherited metabolic diseases (IMD). As survival improves, assessment of long-term outcomes is often hampered by patient attrition and distance from treating centers. Objectives: We piloted a methodology to remotely study parental and patient perspectives of behavioral and emotional functioning following HCT for IMD. Design/Method: The University of Minnesota BMT Database was queried for surviving IMD patients and disease characteristics. Parents/patients were invited for study participation. The Research Electronic Data Capture (REDCap) system was used to electronically administer and retrieve the standardized Behavior Assessment System for Children, Second Edition (BASC-2) survey tools in a one-time cross-sectional analysis. The responses for parent/patient pairs were then analyzed by paired samples t-test in the subscale areas of anxiety, depression, atypicality, and attention problems. Results: We identified 421 patients transplanted for IMD between 1982 and 2015. Of 239 survivors, 96 parents and/or patients (40%) were enrolled. Of those, 8 parent/patient pairs successfully completed the BASC-2 surveys. IMD diagnoses included Hurler syndrome (4 pairs), adrenoleukodystrophy (2 pairs), mannosidosis (1 pair) and Maroteaux-Lamy syndrome (1 pair). The median time from transplant to assessment was 9.8 years (IQR, 4.7 to 15.6, range 2.1 to 19.9). There was not a significant difference in perceptions of anxiety (p = 0.38), depression (p = 0.16), atypicality (p = 0.11) or attention problems (p = 1.0) when comparing parent and patient responses. The majority of patients performed at average level in comparison to age and gender based norms from a parent (84% of scores) and patient (88% of scores) perspective in all subscales analyzed. Conclusion: Effective, remote assessment of behavioral and emotional function via electronic methods is feasible in a large cohort of IMD patients surviving HCT. Importantly, the scores for anxiety, depression, atypicality, and attention disorders did not significantly differ between parent and patient report. This suggests that when patients are unable to provide self-reported functioning, parent perspectives may serve as adequate representation. Continued follow-up of this population is critical to provide appropriate counseling regarding long-term outcomes for patients and families considering HCT as a treatment option for IMD. Background: Infants and young children who undergo hematopoietic stem cell transplantation (HSCT) are at increased risk for late effects due to exposure of developing organs to chemotherapy and radiation therapy typically utilized as part of conditioning regimens. Busulfan (Bu)-based myeloablative conditioning regimens were developed to eliminate radiation exposure in these young children with the hope that late effects would be minimized. As most reports of late effects to date have focused on outcomes in older children and adults, there remains a paucity of data regarding late effects in very young children undergoing HSCT following Bu-based regimens.

Objectives: The aim of this single-center, retrospective study was to describe the late effects observed in a cohort of very young patients who underwent cord blood transplantation (CBT) using Bu-based conditioning regimens. Design/Method: The medical records of 102 patients who underwent CBT after chemotherapy-based cytoreduction at < 2 years of age from September 1993-August 2008 and who survived > 5 years were reviewed. Overall survival, descriptive statistics, mean height standard deviation scores, and cumulative incidences of key late effects were calculated. Cox regression models explored associations between predictors and late effects.

The median age at transplant was 1 year (range 0.1-2) and median age at follow-up was 13.8 years (range 7.7-23.8). Overall survival at 10 years post-CBT was 93% (range 84.9-96.8). Nearly all patients (98%) experienced at least one significant late effect; two or more late effects were documented in 83.3% of patients and 3 or more in 64.7%. Dental problems were documented in 92.2% of patients. Other commonly observed late effects included short stature (55.9%), cognitive (53.6%), pulmonary (18.6%), and pubertal delay/gonadal failure (14%). Short stature and cognitive deficits were more frequent in patients with inherited metabolic diseases. Conclusion: Avoiding irradiation in the very young undergoing CBT may decrease, but does not eliminate late effects. These results will inform clinical care and guidelines for long-term follow-up, as well as add to the growing information regarding late effects of HSCT in general. Long-term survivors of CBT in infancy and early childhood require regular follow-up to identify these late effects and ameliorate associated consequences. Background: Pediatric patients undergoing hematopoietic stem cell transplant (HSCT) are at increased risk for invasive fungal disease (IFD). There is no gold standard fungal prophylaxis regimen during HSCT. Cincinnati Children's Hospital Medical Center (CCHMC) utilizes three alternative dosing strategies for antifungal prophylaxis in this population: genotype-directed voriconazole, alternate-day micafungin and once-weekly liposomal-amphotericinB (L-AmB). There is limited data regarding the efficacy of these regimens or comparing superiority. Objectives: The aim of our study was to assess efficacy of these regimens in preventing IFD in pediatric allogeneic HSCT patients. Secondary aims included: safety comparison and pharmacoeconomic assessment. Design/Method: A retrospective chart review was conducted for patients ࣘ18 years who received an allogeneic HSCT between January 2010 and July 2015. Proven, probable and possible IFDs were defined using updated 'European Organization for Research and Treatment of Cancer' and the 'Mycoses Study Group' definitions and examined during the first 100 days post-transplant. Results: Of the 396 allogeneic transplants performed in 374 patients, 244 patients met inclusion criteria. Seventy-eight patients (32%) received L-AmB, 98 (40%) received micafungin and 68 (28%) received voriconazole starting day zero. Proven or probable IFD occurred in 6 patients; three in the micafungin group (Candida parapsilosis), 2 in the voriconazole group (Saccharomyces cerevisiae and Candida glabrata) and 1 in the L-AmB group (Candida glabrata) (p = 0.66). In eighteen patients, antifungal prophylaxis was changed due to 'possible' IFD, 13 (72%) of these occurred in the micafungin group. Overall, the micafungin group had only 2 adverse events (AEs) out of 103 total AEs, compared to 43 in L-AmB and 58 in voriconazole group (p < 0.0001).

Our results show that rates of proven and probable IFD were similar with all three regimens. Although 'possible' infections were increased on alternate day micafungin, overall safety and tolerability were significantly better for the micafungin group when compared to L-AmB and voriconazole groups. Sub analyses are ongoing to further delineate which of these patients had active GVHD and were on increased immune suppression. These data along with the pharmacoeconomic results will add more insight into risk and benefit balance between each of these regimens. Background: Cyclin dependent kinase 5 (Cdk5) is a ubiquitously expressed proline directed serine/threonine kinase. Preclinical and clinical data suggest that Cdk5 activity lies at the cross-roads of neuroscience, inflammation and cancer immune surveillance. Our lab has identified a novel role of Cdk5 in T-cells and acute graft-versus-host disease (aGvHD). We hypothesize that Cdk5 inhibition in donor T-cells leads to reduced migration into secondary lymphoid organs (SLOs) and reduced severity of aGvHD in murine models of allogeneic hematopoietic stem cell transplant (allo-HSCT).

Objectives: Investigate the role of Cdk5 in T-cell trafficking in syngeneic and allogeneic HSCT models. The translational goal is to use Cdk5 inhibition as a novel strategy to prevent aGvHD. Design/Method: Small molecule inhibitor (CIP5) and Roscovitine were used for in vitro and in vivo experiments for pharmacological inhibition of Cdk5, respectively. Donor T-cells from Cdk5 knockout hematopoietic chimeric mice were adoptively transferred into haploidentical mice (B6 into B6D2F1) to study the role of Cdk5 in T-cell functions and aGvHD. Lineage specific T cell Cdk5 knockout (Cdk5Tko) mice will be used for future experiments. Fluorescence activated cell sorting was used to study quantitative differences in migration of Cdk5Tko and Roscovitine treated donor T-cells versus appropriate controls. Cellular interaction patterns of differentially labeled T-cell subsets were used by real time imaging with 2-photon laser scanning microscopy. Results from our baseline syngeneic experiments will be compared with allogeneic model. Results: 1) Loss of Cdk5 expression in donor T-cells is associated with reduced migration, proliferation and differentiation of donor T-cells. 2) Cdk5 expression is important for development of aGvHD. 3) Loss of Cdk5 in donor T-cells reduces mortality and morbidity due to aGvHD. We will discuss additional results at the conference.

We identified malignant disease, total body irradiation, and chronic GvHD as significant risk factors for these findings. Larger prospective studies and long term follow up of this cohort are needed to confirm and expand on our findings.

Divya Devadasan, Chiao-Wang Sun, Tim Townes, Frederick Goldman

Background: Hematopoietic stem cell transplantation (HSCT) for patients with sickle cell disease (SCD) is curative, though significant toxicity from myeloablative conditioning has limited its utility. We have previously developed knockin mice producing normal (AA) or sickle (SS) human hemoglobin recapitulating severe anemia, hyposthanuria and limited lifespan found in SCD patients. Reduced intensity preparative regimens decrease transplant toxicity and are preferable in non-malignant disorders. Newer agents under development include Treosulfan, an alkylator, and anti-c-kit antibodies (ACK2), which create bone marrow (BM) niches by blocking c-kit function.

Objectives: To optimize non-myeloablative conditioning in a murine model of SCD that allows for sufficient donor RBC chimerism and disease amelioration. Design/Method: Mice received varying conditioning regimens (+/-rescue with control AA marrow), including irradiation (2-8 Gy, TBI), Treosulfan (2-5g/kg; IP), or ACK2 (100-500ug; IP). The hematologic effects of respective treatments were determined by assessment of marrow cellularity, peripheral CBCs, and erythroid donor chimerism (by Iso-electric focusing). Urine concentrating ability, a surrogate of renal tubular function, was also assessed. Results: Erythroid hyperplasia was noted in the BM of SCD mice. ACK2 and Treosulfan, independently and in a dose-dependent manner, decreased BM cellularity and induced cytopenia in control and SCD mice. Overall, SCD mice were able to tolerate ß50% dosing of Treosulfan (and TBI), relative to controls. While all Treosulfan-treated SCD mice (3g/kg) had evidence of donor erythroid engraftment 2 weeks post-transplant, only 25% had sustained donor erythroid chimerism. Normalization of reticulocytes and urine osmolality was found in SCD mice with sustained donor erythroid chimerism, while non-engrafted mice remained hyposthanuric. These animals are being followed long-term for fertility and survival. Conclusion: SCD mice closely mimic human disease in phenotype and ablative conditioning intolerance. Treosulfan alone was unable to sustain erythroid chimerism in the majority of SCD-transplanted animals, suggesting that current dosing is non-myeloablative. Nonetheless, animals with at least 50% donor erythroid chimerism had normalization of urine osmolality and CBCs. This is consistent with the clinical experience with SCD transplants where incomplete donor erythroid engraftment is sufficient to ameliorate the disease phenotype. Current studies are now assessing the combinatorial effect of ACK2 and Treosulfan. Background: Transplant-associated thrombotic microangiopathy (TA-TMA) occurs in around 30% of hematopoietic cell transplant (HCT) recipients. However, TA-TMA in pediatric patients receiving HCT for hemoglobinopathies has largely been undescribed. Herein, we report three patients with hemoglobinopathies whom developed sequelae from severe progressive TA-TMA despite treatment with eculizumab. Patient 1: 2 year old male with sickle cell disease (SCD) presented with TA-TMA related massive pericardial effusion, tamponade and uncontrolled hypertension 70 days post myeloablative matched related umbilical cord blood transplant. Despite discontinuation of tacrolimus, the effusion worsened and he required polypharmacy anti-hypertensive therapy. After treatment with eculizumab, his effusion resolved, hypertension improved, and TMA labs normalized. He is now 20 months post-transplant and continues to have chronic kidney disease (estimated GFR 45 ml/min/1.73m2). Patient 2: 25 year old male with SCD developed posterior reversible encephalopathy syndrome (PRES) with seizures 18 days following reduced-intensity matched sibling bone marrow transplant. Despite discontinuation of tacrolimus, one month later he presented with refractory status epilepticus requiring six anti-epileptics and hypertension. Imaging confirmed recurrence of PRES with left temporal hemorrhage. Laboratory testing was consistent with TA-TMA. Post treatment with eculizumab, his seizures abated and TMA labs normalized. He is currently 15 months post-transplant and has residual neurocognitive defects. Patient 3: 7 year old Asian female with beta-thalassemia major received a myeloablative matched unrelated bone marrow transplant. Six months post-transplant she presented with TMA related intractable hypertension, acute kidney injury requiring dialysis, and seizures. Renal biopsy and MRI brain showed changes consistent with TMA. She had minimal response to discontinuation of tacrolimus and therapeutic plasma exchange. Following eculizumab therapy, her hematological parameters normalized and she was taken off dialysis. However, she developed severe chronic kidney disease (estimated GFR 35ml/min/1.73m2) and hypertension. She died sixteen months post-transplant due to respiratory failure caused by RSV.

In patients with hemoglobinopathies, ongoing endothelial dysfunction may place them at greater risk for TA-TMA. The latter can have long-term devastating clinical consequences. Further investigation is needed in order to determine if pre-emptive eculizumab may be warranted for treatment of TA-TMA in this seemingly high-risk population. Objectives: The use of a reduced-intensity conditioning regimen and a CD34+ selected, T-cell-depleted peripheral blood stem cell (PBSC) graft will allow engraftment with a low incidence of graft-versus-host disease (GVHD). Design/Method: Between 2009-2015, ten pediatric SCD patients underwent CD34+selected, T-cell-depleted transplantation from alternative donors. Indications for transplantation included vaso-occlusive pain crisis (n = 6), concurrent Kostmann's (n = 1), stroke (n = 2) and conditional transcranial Doppler, developmental delay with nocturnal hypoxia (n = 1). Patients received a median of 26 pRBC transfusions (range 4-31) within three years prior to transplantation. Conditioning regimen consisted of melphalan 140mg/m2, thiotepa 5mg/kg x 2, fludarabine 40mg/m2×5, and rabbit-ATG 2.5mg/kg x 4 without post-transplant immunosuppression. Six patients received rituximab during conditioning. Seven patients received a planned donor lymphocyte infusion (DLI) between days 33 and 42 with methotrexate IV for GVHD prophylaxis on a companion study. Two patients received therapeutic DLI infusions post-transplant. Results: Median age at transplantation was 14.7 years (range 5-23). Eight patients had mismatched-related and two had matched unrelated donors. Median PBSC dose was 18×106 CD34+/kg (range 9-25) and all patients received <1×104 CD3+/kg. All patients engrafted with an ANC>500 at median 14.5 days (range 10-17). Nine out of ten patients (90%) are alive with median follow-up of 33 months (range 4-60). Three patients had EBV-related post-transplant lymphoproliferative disorder (PTLD), and one died as a consequence of treatment for PTLD. No other serious viral disease was observed. No acute grade II-IV GVHD developed after transplant and before DLI and only one case occurred after DLI. No patient had chronic GVHD. Conclusion: A reduced-intensity conditioning regimen followed by a T-cell-depleted alternative donor transplantation provided reliable engraftment and a low incidence of GVHD. This approach may increase the availability of transplantation for pediatric patients with SCD who do not have a matched sibling donor.

Background: Existing literature shows mixed conclusions regarding the impact of ABO incompatibility on outcomes following hematopoietic cell transplantation. As the future for umbilical cord blood (UCB) expansion technologies is bright, we assessed whether this typically-overlooked graft characteristic impacted various outcomes following UCB transplantation (UCBT) for non-malignant disorders (NMD). Objectives: To determine the impact of ABO match status on outcomes of interest in patients undergoing first UCBT for NMD. Design/Method: A prospectively maintained institutional BMT program database was queried for all patients undergoing first UCBT for NMD and their demographic, disease and transplant-related characteristics. UCB and recipient ABO compatibility was considered (1) matched, (2) major mismatched (recipient isoagglutinins against UCB antigen), (3) minor mismatched (UCB isoagglutinins against recipient antigen), or (4) bi-directional mismatched. In double UCBT, compatibility status of the dominant unit was considered. The impact of ABO incompatibility was assessed on the following: overall survival, graft failure, aGvHD (grade II-IV and III-IV), cGvHD, times to neutrophil and platelet recovery, post-transplant pRBC transfusion requirements, and donor hematopoietic chimerism. Results: Through December 2014, 270 patients have undergone first UCBT for various NMD. Sixty-one percent had an underlying storage disorder; 26% had marrow failure; 13% had another indication. Among all four ABO compatibility groups, no significant difference was seen in age, gender, NMD diagnosis category, conditioning intensity, HLA-matching, cell dose, number of UCB units, transplant era, performance score, GvHD prophylaxis, or CMV serostatus. ABO compatibility status did not appear to impact any outcomes assessed, though a trend toward increased grade III -IV aGvHD was seen in recipients of major mismatched units. In multivariable and initial subgroup analyses, ABO compatibility did not significantly impact study end-points, including post-transplant pRBC transfusion burden. Conclusion: ABO compatibility status did not appear to impact selected post-transplant outcomes following UCBT for our large NMD cohort. 

Background: For BL patients who relapse, the prognosis is dismal due to chemo-immunotherapy resistance. Our group has successfully modified expanded peripheral blood Natural killer cells (exPBNK) with an anti-CD20 CAR to target CD20+ BL cells in vitro and in NSG mice. Romidepsin is a histone deacetylase (HDAC) inhibitor that increases the expression of NKG2D ligands in BL.

We investigated the effect of romidepsin alone and in combination with anti-CD20 CAR modified exPBNK cells against CD20+ BL cells in vitro and in humanized BL NSG mice. Design/Method: Anti-CD20 CAR modified exPBNK cells were produced as we have described. Daudi, Raji, Raji-2R and Raji-4RH cells were treated with 10ng/ml romidepsin, generously provided by Celgene. Raji-Luc engrafted mice were injected with romidepsin (2.2mg/kg) or PBS followed by anti-CD20 CAR exPBNK cell or mock exPBNK cell injections 24hrs later. Tumor regression and/or progression were monitored weekly. Results: HDAC 1, 3, 6 levels were significantly increased in BL cells compared to white blood cells. Total H3K9 acetylation was enhanced in Raji, Raji-2R, and Raji-4RH following romidepsin. More importantly, romidepsin significantly inhibited BL cell proliferation (p<0.001), induced apoptosis only in rituximab sensitive BL cells and cell cycle arrest in resistant BL cells (p<0.001). Romidepsin significantly inhibited in vivo Daudi, Raji and Raji-2R cells growth in xenografted NSG mice with reduced tumor burden (p<0.05) and bioluminescence (p<0.05).

In vitro cytotoxicity of anti-CD20 CAR exPBNK cells was significantly enhanced against romidepsin treated BL cells compared to the untreated at E:T = 3:1 (P<0.001; n = 4), or compared to the mock exPBNK (P<0.05; n = 4). In humanized Raji xenograft NSG mice, survival time in romidepsin+CAR exPBNK treated mice was significantly extended compared to the untreated mice (median 28 days, P<0.001), the CAR exPBNK treated mice (median 42.5 days, P<0.05), the romidepsin treated mice (median 30 days, P<0.001). Additionally, we observed the enhanced MICA/B expression in Daudi xenograft mice after romidepsin treatment. Conclusion: These results suggest the therapeutic potential of the combination of anti-CD20 CAR modified exPBNK cells and romidepsin against chemo-immunotherapy resistant BL. We are continuing investigating whether the enhanced MICA/B expression in mice is associated with the extended survival.

donor and conditioning regimen received. However, B cell and myeloid donor chimerism at last follow up was best following low toxicity or myelo-ablative conditioning regimen with matched related (MRD) or matched unrelated donor (MURD) compared to unconditioned and matched sibling donor (MSD) recipients. Most haplo-identical donor recipients have poor myeloid chimerism (<5% donor cells), despite receiving MAC conditioning. Sixteen patients are off IVIG (10 B and myeloid chimerism>50% donor, 6 B and myeloid chimerism <50% donor). Thirteen patients with B and myeloid chimerism <50% donor continue IVIG. The mean CD3+ count at last follow up is highest for those who received MSD and unconditioned transplants. Recipients of low toxicity conditioning have higher CD3+ counts compared to RIC and MAC conditioning, across all types of donor. MSD with unconditioned transplants have the best thymic output at last follow up, followed by MRD and MURD with low toxicity myelo-ablative conditioning. Conclusion: T cell donor chimerism is not influenced by conditioning or donor types. However, conditioning with MRD or MURD demonstrated better myeloid cell chimerism compared to unconditioned MSD or haplo-identical donor recipients with MAC. Sustained CD3+ output is seen after 20 years post-HSCT for of IL2RG/JAK3 SCID and even though unconditioned MSD recipients have poor myeloid chimerism; they have highest thymic output at last follow up.

Background: Many studies have demonstrated evolution of immune-reconstitution, but there are scarce data considering long-term quality of life (QoL), with one study suggesting poor function compared to healthy controls (1). Objectives: We objectively assessed QoL of SCID survivors at our centre according to their genetic diagnosis. Design/Method: All SCID patients more than 2 years post-transplant attending the post-transplant clinic follow up were invited to answer the Pediatric Quality of Life Inventory (PedsQL), Generic Score Scale v4.0 questionnaires as part of the routine psychology assessment. The PedsQL questionnaires consist of parent and patient reports, both have 6 domains (physical, emotional, social, school, psychosocial and total). Results: Fifty-nine of 88 (67%) patients responded; comprising 45/73 (62%) patients aged >5 years and 49/77 (64%) families. Fourteen children aged <5 years old were excluded from the child questionnaires. Twenty-eight patients were not contactable and three refused. The median interval post-HSCT was 11 years (range, 2-27). The proportions of responder according to SCID genotypes were IL2RG/JAK3 SCID (20 of 31, 65%), IL-7Ra Deficiency (10/14, 71%), Adenosine Deaminase (ADA) (12/16, 75%), Artemis (5/7, 71%). QoL for patients with IL2RG/JAK3, IL-7Ra Deficiency and Artemis SCID were not significantly different to published UK norm (Patient Report) in all domains, in contrast to a previous study (1) . However, ADA SCID survivors had significantly lower QoL, across all except the emotional components. Parents of IL2RG/JAK3 SCID reported significantly lower QoL in 3 domains compared to UK normal, whilst parents of ADA SCID reported significantly lower QoL across all except the emotional domain. The QoL scores were not significantly different between IL-7Ra and Artemis deficient SCID (all domains). Parents and children of RAG1/2 SCID reported significantly lower QoL in school domain. Parents of IL2RG/JAK3 SCID with on-going intravenous immunoglobulin therapy reported lower QoL compared to those without the therapy. Conclusion: In contrast to previously (1), a number of SCID genotypes were associated with normal QoL. Particular risk factors include ADA SCID and need for ongoing medication. Larger qualitative studies are needed to clarify QoL differences in SCID survivors.

Hemorrhagic AEs (any severity) occurring in ࣙ2

AEs led to discontinuation in 7 (6.9%) patients. Two (2.0%) deaths were at least possibly defibrotide-related. Conclusion: Day+100 survival (77.0%) in patients (80% pediatric) developing VOD/SOS post-chemotherapy without HSCT is clinically encouraging. In this study, defibrotide was generally well-tolerated, with 2 possibly treatment-related fatalities and 6

Forty patients (59%) developed GVHD with 36 (53%) having Grade I-IV acute GVHD and 4 having de novo chronic GVHD occurring after day 100. Seventeen patients (25%) with acute GVHD had active GVHD extending past day 100. In patients with prior GVHD, presence of active GVHD was 29% (8/28), 13% (3/24) and 0% (0/22) at 1, 2 and 3 years post-transplant with 68% (19/28), 33% (8/24) and 9% (2/22) of patients remaining on immunosuppressive therapy, respectively. Survival of those diagnosed with GVHD was 70% (28/40) at 1 year, 60% (24/40) at 2 years and 55% (22/40) at 3 years post-UCBT. Twenty patients with prior GVHD had interpretable post-transplant PFTs with 15 (75%) demonstrating normal or stable lung function. Performance scores in 21 patients at 3 years post-transplant showed 17 (81%) with scores of 90 or 100 and 4 (19%) with scores of 70 or 80. Conclusion: GVHD following UCBT is not associated with increased mortality

United States Background: Increased numbers of human leukocyte antigen (HLA)-mismatched allogeneic hematopoietic stem cell transplants (HSCTs) are now being performed

Anti-HLA antibodies in the recipient are routinely tested prior to stem cell transplant, and may be donor-specific or non-donor specific. There are few data regarding general anti-HLA antibodies and their role in stem cell transplant outcomes. Objectives: To determine the incidence and risk factors for the development of anti-HLA antibodies in stem cell transplant recipients and association with outcomes

We reviewed all allogeneic transplant patients at our institution from 2009-2013. Data collected included anti-HLA antibody presence, strength, and specificity. Transplant recipients were screened for panel reactive antibodies for class I and class II HLA and mean fluorescence intensity (MFI) was calculated. Additional data collected included demographic information, prior transfusions, pregnancies, transplant type, conditioning regimen used, overall survival (OS), event-free survival

1% of patients had an unrelated donor, and 81.5% of patients had an HLA-matched donor. Forty-five recipient patients (28.7%) had detectable anti-HLA antibodies prior to transplant, including 37 (23.6%) patients to class I, 24 (15.3%) to class II, and 16 (10.2%) to both. Only one patient (0.6%) in our cohort had a donor-specific anti-HLA antibody. Significant risk factors for the development of anti-HLA antibodies included any prior pregnancy (odds ratio (OR)=8.0) and >20 blood transfusions (OR=9.4). OS for the entire cohort was 50.0% at 4.26 years follow-up. OS, EFS, and TRM were similar in recipients both with and without anti-HLA antibodies. Outcomes remained similar when broken up by anti-HLA antibody type and titer. Graft failure rate was identical among those with and without detectable anti-HLA antibodies

Conclusion: Our preliminary data identifies Cdk5 inhibition in T-cells as a novel approach to prevent aGvHD. Nonspecific Cdk5 inhibitors, such as R-roscovitine, are in early clinical phase trials while specific small molecule inhibitors are under development. Our project will have major translational implications for treatment of numerous diseases where T-cells play a crucial role in inciting inflammation and organ damage. Background: VOD/SOS is typically considered an unpredictable, potentially life-threatening hematopoietic stem cell transplantation (HSCT) complication; however, there is a known risk post-chemotherapy without HSCT. Severe hepatic VOD/SOS (with multi-organ dysfunction [MOD]) may be associated with >80% mortality. Defibrotide is approved for severe hepatic VOD/SOS treatment in adult and pediatric patients in the EU. In the US, a new drug application was filed in 2015; there are no approved treatments. Objectives: Describe updated efficacy and safety results of defibrotide in patients with VOD/SOS post-chemotherapy. Design/Methods: Defibrotide is available in the US through an ongoing expanded-access protocol for patients with hepatic VOD/SOS (Baltimore/modified Seattle criteria or biopsy) post-HSCT or -chemotherapy, with/without MOD (renal and/or pulmonary dysfunction). Dosing: 25 mg/kg/d, 4 divided doses, recommended for ࣙ21 days. Results: Of 857 patients developing VOD/SOS with ࣙ1 defibrotide dose through April 18, 2015, 101 (11.8%) received chemotherapy without HSCT; 49 (49%) had MOD. Median age: 7 years (range, 0 months-69.0 years); 81 patients (80%) were ࣘ16 years (59 aged 2-11); 55% were male. Most common primary diseases: acute lymphocytic leukemia (49%), acute myelogenous leukemia (13%). Chemotherapeutic agents received by >30% of patients: vincristine, cyclophosphamide, cytarabine, doxorubicin, methotrexate, and PEG-L-asparaginase. Gemtuzumab and inotuzumab were received by 2 and 0 patients, respectively. Kaplan-Meier estimated Day+100 survival was 77.0% overall (95% CI, 67.5-84.1%), 71.4% (56.6-82.0%) for patients with MOD, and 82.3% (68.7-90.4%) for patients without MOD. Sixty-two patients (61.4%) reported ࣙ1 adverse event (AE): 22 (21.8%) assessed as at least possibly defibrotide-related, most commonly hypotension (4.0%); nausea (3.0%); and vomiting, epistaxis, hematochezia, gastrointestinal, and pulmonary hemorrhages Conclusion: Significant hormonal (growth, thyroid, gonadal) late effects are noted after intense induction followed by myeloablative consolidation chemotherapy with triple ASCR. In our patient cohort there were minimal renal and cardiac long term effects. Survivors treated for HR-NBL require life-long follow-up to ensure appropriate surveillance for and treatment of such sequelae.

Background: There is data to suggest that childhood cancer survivors are at risk for melanoma and nonmelanoma skin cancer. However, late effects of the skin after pediatric hematopoietic stem cell transplantation (HSCT) have not been well described Objectives: The primary objective of this study was to characterize nevi and associated risk factors in pediatric HSCT recipients. We also examined the incidence of cancerous and precancerous skin lesions in this cohort. Design/Method: This study was a single-center cross-sectional cohort study of pediatric HSCT recipients and controls matched by age, gender, and Fitzpatrick skin type. All study participants underwent a full skin, hair, and nail examination by a pediatric dermatologist. Medical records were reviewed to obtain demographic and clinical data. 

Background: There is no FDA-approved treatment for hepatic VOD/SOS, a potentially life-threatening complication of conditioning regimens for stem cell transplantation (SCT). Severe cases, defined by multi-organ dysfunction (MOD), may result in >80% mortality. Objectives: Present updated day+100 survival and complete response (CR) analyses from the pivotal phase 3 trial on defibrotide in VOD/SOS with MOD, including data obtained in response to US health authorities. Design/Methods: Multicenter, open-label, phase 3 historical control (HC) study. Eligible patients: Baltimore criteria ࣘday+21 post-SCT, plus MOD (renal and/or pulmonary dysfunction) ࣘday 28 post-SCT. Exclusion criteria: severe liver or gut graft-versus-host disease, clinically significant bleeding, or need for ࣙ2 pressors. A blinded medical review committee determined unequivocal VOD/SOS with MOD in HC patients' medical charts. DF dose: 25 mg/kg/d, 2-hour IV infusions q6hx4. Recommended treatment duration: ࣙ21 days. Primary endpoint: day+100 survival. Key secondary endpoint: day+100 CR. Survival and CR rate differences, and 95% confidence intervals, were calculated using propensity score-adjusted estimates. Number needed to treat (NNT): absolute risk reduction reciprocal (1/ARR); ARR equals the control minus experimental event rates. Results: Patients: 102 defibrotide-treated and 32 HCs. Baseline characteristics were similar. Day+100 survival in the defibrotide and HC groups was 38% and 25%, respectively (propensity-stratified difference in survival: 23.0% [95.1% CI, 5. 2-40.8 ], P = 0.0109), for an NNT of 5 (1/0.23). Observed day+100 CR rates were 25.5% and 12.5% (propensity-stratified difference in CR: 19.0% [95% CI, 3.5-34.6], P = 0.0160), respectively, for an NNT of 6 (1/0.19). In the defibrotide-treated group, 45% had an adverse event (AE), 21% had a serious AE at least possibly related to defibrotide. Patients with ࣙ1 AE leading to death were similar between defibrotide and HC patients (64% and 69%), as were hemorrhagic AEs (64%, 75%) and hypotension (39%, 50%). Conclusion: Defibrotide-treated patients had a 23% improvement in day+100 survival and 19% improvement in day+100 CR rate. Based on these numbers, the expected NNTs to prevent one death or achieve one CR are 5 and 6, respectively. Overall hemorrhage and fatal AE incidences were similar between groups; AEs were consistent with those expected in this critically ill population.

Stephan A. Grupp Background: VOD/SOS is an unpredictable, potentially life-threatening complication of conditioning for HSCT. Severe VOD/SOS (with MOD) is associated with >80% mortality. Defibrotide is approved for treatment of severe VOD/SOS post-HSCT in the EU. In the US, a new drug application for defibrotide proposed for the treatment of hepatic VOD/SOS with MOD post-HSCT was filed in 2015. In the US, defibrotide has been available through an ongoing, expanded-access study. Objectives: Investigate the impact of time-to-defibrotide treatment initiation (TI) in patients with VOD/SOS with/without MOD post-HSCT. Design/Method: In the expanded-access study, patients with VOD/SOS (Baltimore/modified Seattle criteria or biopsy) with/without renal/pulmonary MOD received defibrotide 25 mg/kg/d in 4 divided doses for a recommended ࣙ21 days.Day+100 survival in HSCT patients was examined post hoc based on time from VOD/SOS diagnosis to defibrotide TI. Two analyses were conducted: (1) survival rate by TI for all patients before or after days 1, 2, 3, 4, 7, and 14 (Fisher's exact test) ; (2) survival rate for those patients with TI on a particular day: 0, 1, 2, 3, 4, 5, 6, 7, [8] [9] [10] [11] [12] [13] [14] , and ࣙ15 (Cochran-Armitage test for trend across days). Results: Among HSCT patients enrolled through April 18, 2015, who received ࣙ1 defibrotide dose, TI date was available for 755 patients (426 with MOD). Defibrotide was started on the day of diagnosis in 31.7% of patients; 93.0% of patients started defibrotide on or before day 7 post-diagnosis. In the population-wide analysis of initiation before/after days 1, 2, 3, 4, 7 , and 14, earlier defibrotide TI was associated with higher survival rates, and was statistically significant for all cut-points except day 14 (with only 2.8% of pts with TI post-day 14). In the analysis of relationship between Day+100 survival and TI day, there was a statistically significant trend over time for higher Day+100 survival with earlier initiation (P<.001). Conclusion: Data indicate decreased Day+100 survival associated with longer treatment delays, confirmed by the Cochran-Armitage test (P<.001). Thus, consider defibrotide initiation as soon as possible after VOD/SOS diagnosis (with/without MOD), as no day post-diagnosis provides a viable cut-point for better outcome.

Background: Invasive fungal infection in the setting of profound immune suppression is often lethal. A 2 year-old female with severe aplastic anemia, following 6 months of neutropenia unresponsive to granulocyte-colony stimulating factor presented with Rhizopus sinusitis obliterating her nasal septum and invading her cribriform plate despite prophylactic therapy with voriconazole for 5 months and 1 month of micafungin.Objectives: Demonstrate the effectiveness of a multi-modal approach to Rhizopus infection including surgical debridement, systemic and topical anti-fungal medications, granulocyte infusions and allogeneic hematopoietic cell transplantation (alloHCT); the importance of tailoring pharmacotherapy based on fungal susceptibilities and pharmacokinetic monitoring; and the short-term safety of intravenous posaconazole and isavuconazole in a profoundly immunocompromised pediatric patient. Design/Method: The patient was treated with twice daily intranasal amphotericin B irrigations, periodic surgical sinus debridement with topical amphotericin B washes and tissue sampling. Her initial culture growing Rhizopus revealed susceptibility to posaconazole and amphotericin B. Treatment with oral posaconazole and liposomal amphotericin B preceded alloHCT conditioning (cyclophosphamide, fludarabine, anti-thymocyte globulin) and radiation by one month. Posaconazole was held during cyclophosphamide administration and restarted as intravenous therapy. During her conditioning regimen and until neutrophil engraftment, the patient received 7 donor granulocyte infusions. After 7 weeks of therapy, the patient's Rhizopus demonstrated resistance to posaconazole and increased amphotericin B MIC. As such, posaconazole was discontinued and amphotericin B dose increased. After isavuconazole was confirmed susceptible, treatment was initiated to achieve a minimum goal trough level of 4 ug/ml. Studies thus far have found no correlation between trough levels and efficacy/safety and no report to date of use in a pediatric patient. The patient engrafted neutrophils on day +14 following alloHCT. Background: Outcomes for high-risk neuroblastoma (HR-NBL) remain sub-optimal. Modern treatment protocols utilizing intense induction followed by myeloablative consolidation chemotherapy with autologous stem cell rescue (ASCR) have improved survival rates, but long-term sequelae emerge over time.

Objectives: To evaluate the late effects of high dose chemotherapy induction followed by myeloablative consolidation chemotherapy with triple ASCR in pediatric HR-NBL, in the following organ systems: endocrine, renal, and cardiac. Second malignant neoplasms in this cohort have been reported. Design/Method: We retrospectively reviewed data from 63 patients who were treated on or following the Chicago Pilot 2 protocol; 58 patients who received contemporary standard intensive NBL chemotherapy followed by triple ASCR between 1991 and 2011 were evaluable. Triple ASCR conditioning chemotherapy included: two cycles of carboplatin/etoposide and one cyclophosphamide/thiotepa. All received focal radiation to the primary site of disease; none received total body irradiation. Data included: age at diagnosis, gender, chemo-radiotherapy prior to and post ASCR, height, weight, blood pressure, BUN/Cr, ejection and shortening fractions, fT4/TSH, and gonadal status. Results: Twenty-three patients (40%) are alive; 19 with complete data. Focal radiation sites included: whole abdomen, left flank, right flank, mediastinum, chest, pelvis, focal brain and spine. Short stature, defined as either failure to reach mid-parental height 3 (16%) or growth <5th% 12 (63%), occurred in 15 (79%). Seven patients have hypothyroidism (37%), including 2 with surgical hypothyroidism due to papillary carcinoma. Gonadal failure occurred in 6 (32%; 5 females, 1 male); there were no cardiac morbidities. All had normal renal function as calculated by CKD-EPI Creatinine Equation ( (UCBT= 25, haplo=4) . Acute GVHD complications were the cause for 15 admissions (UCBT=11, haplo=4). Relapse was the etiology of admission in 10 patients (UCBT=8, haplo=2). In both groups, the first readmission and the number of subsequent readmissions did not have an influence on outcome.Conclusion: There was a trend towards more readmissions in the UCBT group. However, significant differences were not reached in number of readmissions caused by each source in this cohort. The leading cause of admissions was documented infections in both groups. Larger and multi-institutional collaborative studies are warranted. (3), 5/6 unrelated cord blood(CB) (8), 6/6 MSD CB (1), 6/6 matched sibling CB plus bone marrow (BM) (1), 10/10 MUD BM (4), 6/6 matched sibling BM (13), and 9/10 MUD BM (4). Conditioning regimens included both myeloablative (n=18, 51%) and non-myeloablative (n=17, 49%) regimens. Median time to myeloid and platelet engraftment was 15 and 30 days, respectively. Probability of grade II-IV and grade III-IV acute GVHD was 22.8% (CI95: 5.2-47.9) and 5.7% (CI95: 0-48.9), respectively. Probability of extensive and limited chronic GVHD was 22.6% (CI95: 3.4-52.2) and 12.2% (CI95: 0.3-45.7), respectively. Probability of 1-year OS was 82% (CI95: 64.1-99.8). MAC was predictive of a significantly higher risk of aGVHD in the univariate analysis (p = 0.01, HR = 6.6, CI95:0.91-48).

This study demonstrated a very low incidence of aGVHD and cGVHD in a diverse cohort of CAYA AlloHPT recipients following tacrolimus and MMF Q8H prophylaxis compared to our prior study utilizing Q6H dosing of MMF1.

Background: Lower intensity conditioning regimens for haploidentical bone marrow transplantation (BMT) are safe and efficacious for adult patients with hematologic malignancies. Objectives: We report the first data for pediatric/young adult patients with high-risk hematologic malignancies (n=40) treated with nonmyeloablative haploidentical BMT with post-transplantation cyclophosphamide (PT/Cy). Design/Method: The majority of patients (n=36) received a preparative regimen of IV fludarabine (30 mg/m2/day) days -6 to -2, IV low-dose cyclophosphamide (14.5 mg/kg/day) days -6 and -5, and total body irradiation (200 cGy) day -1. Two patients received the above along with alemtuzumab, and two patients received IV busulfan (0.8mg/kg IV every 12 hours) days -6 to -3 instead of Cy. All patients received haploidentical, T-cell replete bone marrow (n=37) or peripheral blood stem cells (n=3) on Day 0. Post-transplant immunosuppression consisted of IV cyclophosphamide (50 mg/kg/day) days +3 and +4, mycophenolate mofetil through day +35, and tacrolimus through days +60 to +180. Results: Median age was 20 years (range 1-25) and diagnoses included AML (n=9), ALL (n=9), mixed-lineage leukemia (n=1), MDS (n=5), CML (n=1), Hodgkin lymphoma (n=14), and NHL (n=1). Seventeen patients (43%) had undergone prior myeloablative BMT. Donor engraftment occurred in 29/32 (91%) of patients evaluable at Day 60. Median time to neutrophils >500/μL was 16 days (range 13-22) and platelets >20,000/μL without transfusion was 18 days (range 12-62). Cumulative incidences of acute GVHD grades II-IV and grades III-IV at day 100 were 33% and 13%, respectively. Cumulative incidence of chronic GVHD was 23%, including 7% moderate-severe chronic GVHD. Transplant related mortality (TRM) at 1 year was 13%; causes included infection (n=3) and diffuse alveolar hemorrhage (n=1). Cumulative incidence of relapse at 2 years was 52%. With a median follow-up of 20 months (range 3-148), actuarial overall survival is 58% and event-free survival is 43% at 2 years. Conclusion: We demonstrate excellent rates of engraftment, GVHD, and TRM in pediatric/young adult patients treated with this regimen, comparable to published adult data. This approach is safe and feasible for young patients with high risk hematologic malignancies, including those with co-morbidities that preclude eligibility for myeloablation. Clinical trials are warranted to directly assess the benefit of preparative regimen intensity. Background: Hematopoietic stem cell transplantation (HSCT) can halt the progression of Krabbe disease (KD) via engraftment of donor-derived, enzyme-producing cells in the bone marrow, brain, and other organs. While HSCT prior to the development of symptoms is associated with improved survival, there remains a paucity of information regarding the long-term function and quality of life for surviving patients.

Objectives: The aim of this study is to report long-term functional outcomes following HSCT in a series of presymptomatic infants with infantile KD, in order to inform guidelines for early intervention with HSCT and long-term follow-up care following HSCT for infantile KD. Design/Method: The records of 19 patients followed by the Duke Pediatric Blood and Marrow Transplant Program after HSCT for KD at < 2 months of age were reviewed for information regarding long-term functional outcomes. Overall survival and descriptive statistics were calculated. Functional outcomes were compared between those transplanted at <30 days (n = 12) and >30 days of life (n = 7). Results: All patients were diagnosed due to family history (n = 16) or via newborn screening (NBS, n = 3). Median age at transplant was 27 days (range 19-61). Five and 10 year overall survival (OS) post-HSCT were 84.2% (95% CI: 58.7-94.6%) and 78.6% (95% CI: 52.5-91.4%). Median time from transplant was 11.3 years (range 0.01-18.2). One death due to disease progression occurred 15 years post-HSCT. Sixteen patients survived > 5 years post-HSCT. Nine patients (56%) were able to communicate normally. Eleven patients (69%) attended school at the appropriate grade level. Twelve patients (75%) were able to feed themselves independently. Ten patients (63%) remained ambulatory. Poorer outcomes occurred more frequently in those who were transplanted at >30 days than those transplanted at <30 days in the domains of communication (P=0.01), feeding (P=0.01), and mobility (P=0.004). Conclusion: Improved functional outcomes were observed in patients with presymptomatic infantile KD for whom HSCT was performed in the first month of life. Defining this critical period for early intervention emphasizes the need for accelerated pre-HSCT evaluation and decision-making, and will influence public policy regarding NBS. UCBT when compared to other alternative donor sources and has shown that GVHD following UCBT has no impact on overall survival. Objectives: We aimed to define the course and long-term outcomes of GVHD following UCBT. Design/Method: Eighty-one patients were enrolled on an IRB-approved, UCBT trial between January 1996 and July 2007. Thirteen patients were excluded from analysis due to death prior to engraftment (7), graft rejection (4), or re-transplantation (2) . GVHD activity, use of immunosuppressive therapy, and overall survival were collected at 1, 2 Conclusion: Anti-HLA antibodies are detectable in a significant portion of stem cell transplant recipients. Prior pregnancy and >20 prior transfusions are both significant risk factors for the development of anti-HLA antibodies. The presence of general anti-HLA antibodies in the recipient does not correlate with patient outcomes after stem cell transplantation. Background: Reduced intensity conditioning (RIC) is increasingly used for hematopoietic stem cell transplantation (HSCT) with the goal of maintaining therapeutic efficacy while limiting toxicity. Current understanding of late endocrine effects using RIC HSCT is extremely limited. While the risk of infertility after myeloablative HSCT is known to be high (>80%), there is currently no data regarding infertility risk with RIC HSCT. Objectives: Longitudinally evaluate gonadal function and fertility potential in young men after RIC HSCT.

Design/Method: Children and young adults, ࣙ 1 year after a single RIC HSCT regimen were followed in a prospective cohort study to evaluate late endocrine effects and fertility potential. Subjects were evaluated for pubertal development, hormonal status, and some subjects had a semen analysis performed. Results: Preliminary results were obtained from 14 subjects. Most subjects received Fludarabine and Melphalan +/-Campath, without total body irradiation. Five of 14 subjects (36%) had received prior chemotherapy for malignancy. The median age at time of HSCT was 13.6 years (range 3.4-24.3). The average age at time of evaluation was 20.3 years (range 15.6-25.2), with a median time from HSCT of 5.6 years (range 1.9-10.0). Eleven subjects were pubertal. Of the 9 pubertal subjects with available laboratory testing, only one (11%) had abnormally elevated gonadotropins (LH and FSH). Similarly, only one (11%) had an abnormally low testosterone level. The remainder had normal testing for Tanner stage. Four of 9 (44%) had abnormally low inhibin B levels, suggestive of reduced fertility and Sertoli cell dysfunction. Semen analysis was abnormal in all 8 subjects tested: 7 had azoospermia and 1 had oligoteratospermia. Conclusion: Results suggest that RIC HSCT may be associated with a high risk of infertility. However, gonadotropin and testosterone levels appear to be normal in most young male after RIC HSCT, therefore, normal pubertal development does not ensure normal fertility potential. Our data suggests that inhibin B levels could be a useful screening test; however semen analysis remains the gold standard to test fertility potential. Risk of infertility should be included in counseling about RIC HSCT, and fertility preservation should be discussed and offered prior to HSCT.

Background: Radiation therapy induces chronic oxidative stress in hematopoietic stem cells (HSC) leading to impairment of HSC self renewal ability, induction of senescence and increase in oxidative DNA damage. This results in premature exhaustion of HSC reserves with subsequent development of late bone marrow injury. Sirtuin 3 (SIRT-3) is a mitochondrial protein deacetylase which reduces cellular reactive oxygen species (ROS) level by activating mitochondrial antioxidant enzymes like superoxide dismutase and isocitrate dehydrogenase. Though mitochondria is the seat of cellular respiration and the main source of cellular ROS, it has yet to be proven whether mitigating mitochondrial ROS can play an essential role in HSC maintenance under stress conditions like radiation. Objectives: To determine whether radiation induced chronic oxidative stress can be ameliorated by Sirtuin 3 overexpression. Design/Method: Sirtuin 3 overexpressing transgenic (T3TG) and cre mice strains were used. Each strain of mice was divided into 2 groups. One group was exposed to 6.5 Gy X-ray total body radiation, while the other group was not radiated. All mice were sacrificed 4 weeks later and the HSC population (Lin-ckit+Sca-1+CD150+ ) was isolated. ROS levels were detected after incubating HSCs with 2',7' dichlorohydrofluorescein diacetate (H2DCFDA) for 30 min. Data was collected with LSRII flow cytometer and then analyzed using FlowJo (TreeStar). Results: On comparing the HSC population between the irradiated and unirradiated cre mice, we noted a 1.6 fold increase in ROS level after radiation. Similarly in the SIRT3 overexpressed mice the HSC population exhibited a 1.5 fold increase in ROS level after radiation. HSCs in both mice strains demonstrated persistent oxidative stress a month after radiation; however the ROS levels of T3TG mice were not significantly lower than in the cre mice. Conclusion: Our study was limited by its small sample size and failure to optimize radiation dose according to the body surface area of the mice. Though we were unable to demonstrate the protective effect of Sirtuin 3 overexpression in significantly decreasing radiation induced chronic oxidative stress, yet our results did show this interesting trend and we aim to explore it further in future experiments after correcting for the aforementioned factors. developed protracted disseminated adenovirus (nasopharynx, gastrointestinal tract, blood) 7 months after HSCT. Due to persistent positive infection and continued concern for GVHD flare of the GI tract, the patient continued on weekly cidofovir for 8 months total, at which time she presented with 2 week history of injected and irritated eyes without other symptoms of infection or GVHD. Patient was referred to ophthalmology. Design/Method: Differential diagnosis included infectious etiologies which were ruled out by chart review and ongoing surveillance as part of standard BMT care (adenovirus pcr, CMV pcr). Results: Diagnosis was chronic bilateral uveitis though complete exam was hindered from poor dilation as a result of iris synechaie. Vitreous was clear and ultrasound of eyes within normal limits. She was treated with cessation of cidofovir and steroid drops, which was feasible at the time due to recent negative blood adenovirus PCRs and absence of diarrhea despite positive stool test.

Review of the ophthalmology literature shows that after 8 doses of cidofovir (2 months) , patients are at a significant risk for developing uveitis that could result in vision loss, an underappreciated fact in HSCT literature and practice. In discussion with ophthalmology experts, the recommendation was made to involve ophthalmology for any patient requiring chronic cidofovir therapy for greater than 8 doses and any HSCT patient who presents with injected and irritated eyes. Objectives: We hypothesized that chemotherapy preparative regimen was the source of cardiac injury and subsequent LVSD seen in the first 100 days after SCT in pediatric patients. Design/Method: We retrospectively assayed cardiac biomarkers cardiac troponin-I (cTn-I) and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) from stored specimens in 12 patients with new LVSD and 13 controls, at six time points peri-transplant. LVSD was defined as ejection fraction less than 55% or shortening fraction less than two standard deviations below the age adjusted mean, newly occurring during the first 100 days post-SCT.Results: Among 145 samples tested for cTn-I, elevation ࣙ0.03 ng/mL occurred in 49 samples (33.8%), and 15 of 25 patients (60%) had at least one sample with elevated cTn-I. Among 143 samples tested for NT-proBNP, elevation ࣙ450 pg/mL occurred in 80 samples (55.9%), and 21 of 25 patients (84.0%) had at least one sample with elevated NT-proBNP. Among patients with LVSD by day 100, on day 7, 50% had cTn-I ࣙ0.03, whereas only 8% of controls had elevated cTn-I (p=0.03). In our cohort, cyclophosphamide preparative chemotherapy (CPC) was associated with new LVSD (8/12 with LVSD v. 2/13 control; p=0.02). No association was seen with previous anthracycline use, cell source, bacteremia, total body irradiation, thrombotic microangiopathy, or acute graft versus host disease. Conclusion: Cardiac injury occurs frequently in patients undergoing SCT as evidenced by elevated cTn-I in up to 34% of patients. In those who develop LVSD in the first 100 days post-SCT, an association with CPC and day 7 cTn-I is evident. We are now prospectively monitoring patients receiving CPC with cTn-I measurements during and after infusion. aGVHD occurred in 25 patients post-HCT -14 with skin only and 9 with GI aGVHD. Fecal calprotectin levels were not significantly different at preconditioning, D+14, and D+28 post-HCT in those that developed aGVHD, those with any GI aGVHD, or with severe (> grade 2) aGVHD. Pre-conditioning and D+14 albumin levels were not significantly different in those with and without aGVHD. At D+28 post-HCT, those with GI aGVHD had a median albumin of 3.0 and those with >Grade 2 aGVHD had a median albumin 2.7 compared with a median of 3.65 in those with non-GI aGVHD and those with less severe aGVHD (<grade 2) (p= 0.04 and p=0.01, respectively).

Higher fecal calprotectin at onset of aGVHD was predictive of steroid refractoriness (116 versus 31 ug/g, p=0.046). Conclusion: Although fecal calprotectin was unable to predict occurrence of aGVHD or differentiate between GI and non-GI aGVHD, it was able to predict steroid refractory GI aGVHD at the onset of symptoms. Low albumin was a better predictor of GI and >grade 2 aGVHD. These markers may help identify patients with more aggressive disease and guide management of aGVHD.

Background: Donor lymphocyte infusion (DLI) is one strategy to potentially stabilize or reverse waning donor chimerism. Little is reported of the utility of donor DLI following hematopoietic stem cell transplantation (HCT) for non-malignant disorders (NMD). Objectives: We describe outcomes of DLI for insufficient donor chimerism after HCT in a large pediatric NMD cohort.

We queried the Institutional BMT Database for patients with NMD receiving DLI for insufficient post-HCT donor chimerism. Human leukocyte antigen (HLA) typing, graft selection and original conditioning were per institutional guidelines. The use, timing and dosing of DLI was at the discretion of the treating physician. Donor chimerism values on the myeloid fraction of peripheral blood at pre-DLI and most-recent time-points were reviewed. Patients were considered best responders if donor chimerism improved (pre-DLI to most-recent) and most recent chimerism was ࣙ80%. Results: Twenty-four patients (46% female) were identified who underwent 56 total DLIs and a median 2 DLI cycles per patient (IQR, 2 -3; maximum, 5). The median cumulative CD3+ dose per-patient was 11.5 x 106/kg. The median zenith chimerism post-HCT (but pre-DLI) was 84% (IQR, 39 -99%), observed at a median 28 days post-HCT. The median chimerism just prior to first DLI was 40%. The median time to first DLI was 90 days. Five patients (21%) were best DLI responders. At a mean 3.6 years post-HCT, they retained mean chimerism of 94% (mean increase from pre-DLI of 37% 

Background: Allogeneic hematopoietic cell transplant (HCT) offers a curative therapy for several non-malignant conditions. However, rates of graft failure in non-malignant populations exceed those of patients with malignant indications for HCT. Salvage conditioning regimens and outcomes for second allogeneic HCT for graft failure vary immensely in the literature. Objectives: We sought to evaluate the feasibility and outcomes of a reduced intensity busulfan-based conditioning regimen for patients with non-malignant diseases requiring a second allogeneic HCT for graft failure. Design/Method: We report 19 consecutive patients with non-malignant diseases who underwent a second allogenic HCT for graft failure at the University of Minnesota Children's Hospital from January 2000 to July 2014 using a single reduced intensity regimen. Median time to second HCT was 85 days (IQR 67-119 days). For their second HCT, patients received intravenous busulfan 1.6 mg/kg/day divided Q6H (2.0 mg/kg/day if <4 years of age) on day-8 and day-7 (total 3.2 mg/kg or 4 mg/kg, respectively), intravenous fludarabine 40 mg/m2/day on days -6 to day -2 (total 200 mg/m2), and a single fraction of 200 cGy total body irradiation on day-1. Cyclosporine and mycophenylate mofetil began on day-3 for GvHD prophylaxis. Graft sources included umbilical cord blood in 68%, unrelated bone marrow in 21% and unrelated peripheral blood stem cells in 11% of the patients. Results: Seventy-nine percent of patients (15 of 19) achieved stable donor hematopoiesis, with a 3 year overall survival of 74% (95% CI, 47-88%). Transplant related mortality was 26%, including death attributable to sepsis, pneumonitis and multi-organ failure. The cumulative incidence of neutrophil recovery by 42 days after second HCT was 74% (95% CI, 53-90%), with a neutropenic graft failure rate of 21%. A third allogeneic HCT was performed in 2 of the 4 individuals with failed donor engraftment. Infectious complications following second HCT included viral reactivation (35%) and invasive fungal infections (26%). The incidence of grade II-IV acute graft-versus-host disease was 33% with 6% grade III-IV.

In summary, we demonstrate the excellent overall survival and acceptable toxicity of a novel, reduced intensity low-dose busulfan-based conditioning regimen for second HCT to salvage initial HCT graft failure in patients with non-malignant conditions.

Background: Chediak-Higashi syndrome (CHS) is a rare autosomal recessive disease due to mutation in the lysosomal trafficking regulator gene LYST, characterized by oculocutaneous albinism, immunodeficiency, platelet aggregation disorder, and microscopic findings of large granules in hematopoietic and other cells. Patients with CHS experience a life-threatening hemophagocytic lymphohistiocytosis (HLH)-like disorder termed accelerated phase (AP). Allogenic hematopoietic stem cell transplantation is the sole curative therapy to prevent AP. Objectives: Describe the clinical course of a CHS patient who underwent HLA-matched unrelated donor bone marrow transplant (MUD BMT) with successful outcome despite very low donor T cell chimerism. Design/Method: Case report. Results: Patient underwent a myeloablative 10/10 MUD-BMT at the age of sixteen months. Preparative regimen included IV busulfan (4.4 mg/kg/day x 4 days with targeted pharmacokinetics) and cyclophosphamide (50 mg/kg/day x 4 days). He received an unmanipulated bone marrow (BM) graft of 5.21 x 108 TNC/kg. GVHD prophylaxis consisted of cyclosporine and methotrexate. Initial course was complicated by engraftment syndrome and coronavirus requiring intubation and steroids. He had engraftment of neutrophils on day +21 and platelets on day +33. BM donor chimerism was 98% at day +30 but fell to 88% at day +60. Subsequent peripheral blood (PB) monitoring showed T-cell sorted chimerism stable at 89-92%. BM donor chimerism at day +90 was only 43%. Despite an early cyclosporine taper, PB T-cell sorted chimerism continued falling to 41% on day +224 when he began donor lymphocyte infusions (DLI). He received a total of 7 DLIs with CD3 doses ranging from 1 x 106/kg to 1 x 108/kg. At the completion of DLI, PB T-cell sorted chimerism was 20%, and whole blood chimerism was 12%. These levels have remained stable for one year. He has had occasional fluctuating mild neutropenia and several viral infections without evidence of AP. Conclusion: Despite recurrence of his underlying disease, the patient is currently alive and well with no episodes of AP during viral infections for 2 years post-BMT. Similar to HLH, very low levels of T-cell donor chimerism may be sufficient for prevention of AP.

Background: Allogeneic hematopoietic stem cell transplantation (HSCT) remains standard treatment for Hurler syndrome and other inherited metabolic disorders (IMD). Though transplant-related complications are common in patients with Hurler syndrome, we have observed infrequent hemorrhagic cystitis (HC) in this patient population. Furthermore, medical reports suggest a therapeutic effect on severe HC from intra-vesicular administered glycosaminoglycans (GAG). Interestingly, GAG accumulate in high levels in untreated Hurler patients due to impaired catabolism. Objectives: We aimed to determine the incidence of hemorrhagic cystitis following HSCT for Hurler syndrome and compare it to that following HSCT for other IMD. Design/Method: We identified all patients with IMD transplanted at our center between 1995 and 2013 following a myeloablative regimen containing cyclophosphamide and/or TBI. Allograft sources varied. The incidence of HC was determined for patients with Hurler syndrome and compared to that in patients with other IMD. Results: 190 patients were included for analysis: 27% with Hurler syndrome; 44%, cerebral adrenoleukodystrophy (cALD); 17%, globoid cell leukodystrophy (GLD) or metachromatic leukodystrophy (MLD); 12%, other IMD. The observed frequency of HC in each disease was as follows: Hurler syndrome, 2%; cALD, 37%; GLD/MLD, 27%; other IMD, 14% (p < 0.001). There were no significant differences between patients with Hurler syndrome and those with non-Hurler IMD with respect to the following characteristics: allograft source, the use of serotherapy, or exposure to TBI. As the median age at transplant between Hurler (1.4 years) and non-Hurler IMD (8.1 years) was significantly different, an age-matched non-Hurler IMD sub-cohort was identified from the larger group (n = 30 patients, median age at HSCT of 1.6 years; p = 0.02, difference in median age at HSCT compared to patients with Hurler syndrome). This age-matched non-Hurler IMD sub-cohort continued to demonstrate a higher incidence of HC compared to patients with Hurler syndrome (14% versus 2%; p = 0.04, difference in observed frequencies).

Hurler patients appear less susceptible to HC following HSCT compared to patients with other IMD diagnoses. A protective benefit from excess urinary GAG in Hurler syndrome is a plausible reason.

Children's National Medical Center, Washington DC, United States Background: Increased risk factors for invasive mold infections led to a change in primary fungal prophylaxis from fluconazole to voriconazole for allogeneic stem cell transplant patients at our institution. Due to wide inter-patient variability from polymorphisms and variable bioavailability within the pediatric population, therapeutic drug monitoring of voriconazole is essential to assess safety and efficacy. Previously all patients received a standard dose of 4mg/kg every 12 hours. Currently voriconazole is dosed 12mg/kg every 12 hours for patients <2 years and 8mg/kg every 12 hours for patients <2 years in addition to dual anti-fungal therapy with caspofungin until the trough is therapeutic (ࣙmcg/mL). Results of a study evaluating alterations in voriconazole dosing practice to determine the effect on attaining therapeutic troughs and incidence of breakthrough fungal infections are reported. Objectives: The primary objective was time to first therapeutic voriconazole trough, and secondary objectives included corresponding dose at therapeutic trough, concomitant dosing factors, incidence of breakthrough fungal infections, and adherence to protocol changes. Design/Method: A retrospective single-center chart review of pediatric patients admitted to the BMT service, receiving voriconazole for primary antifungal prophylaxis between July 1, 2011 and August 31, 2014 was performed. Patients were divided based on dosing: weight based versus age-and-weight based. Results: Fifty-seven patients were included for analysis. Baseline characteristics were not significantly different between groups. Age-and-weight adjusted dosing increased the probability of reaching a therapeutic trough level by more than six-fold (29 days vs. 16 days; p = 0.05). Higher dosage ), drug-drug interactions ) and the oral formulation of voriconazole ) were associated with a lower probability of achieving a therapeutic level. The incidence of fungal infections was not statistically significant between groups. Overall, protocol adherence also decreased after the institution change.Conclusion: Age-and-weight based dosing is superior to weight based dosing in achieving therapeutic voriconazole trough levels. Due to limitations of the study, we are unable to conclude a definitive association between dose and time to therapeutic trough. Larger, prospective studies should be performed to determine optimal dosing in pediatrics, specifically in children ࣘ2 years of age.

A In 25 patients enrolled on these two studies, 16 patients experienced CMV, EBV, or adenovirus viral infections/reactivations before or immediately after mCTL infusion. Nine patients remained infection/reactivation-free. Eight of the patients had a complete response post-mCTL and 5 had a partial response, most coinciding with an increase in virus-specific T-cells. Three patients did not respond to therapy. The overall the response rate in both groups was 81%-even in patients with drug-resistant viral disease. This study demonstrates that mCTL derived from the PB of seropositive donors as well as the CB of virus naive donors expand in vivo and are active against multiple viruses. Conclusion: By restoring immunity to multiple viruses simultaneously, prophylaxis with pharmacotherapy is eliminated, thus, improving the efficiency and cost-effectiveness of protecting recipients from these potentially-lethal viruses. Design/Method: Twenty one children with a median age of 12 years who had refractory (11 of them after allogenic stem cell transplantation) acute leukaemia (6 B cell lymphoblastic leukaemia, 8 T cell lymphoblastic leukaemia and 7 acute myeloid leukaemia) were treated with rescue chemotherapy followed by the infusion of fresh activated and expanded NK cells obtained from haploidentical donor peripheral blood followed by three times a Hjek subcutaneous administration of low dose of IL-2.

Rescue chemotherapy consisted in Cy-Flu (4 patients), clofarabinebased (7 patients), FLAG-IDA (3 patients) or nelarabine-based (7 patients).Results: To date, we have infused 52 NK cell products containing a median of 11.74x106 /kg. All infusions were well tolerated. Thirteen patients have completed treatment and this is ongoing in 3; in 5 additional patients treatment could not be completed because of leukaemia progression (n = 2) or chemotherapy-related toxicities (n = 3). Among the 13 patients who completed the treatment, 6 achieved negative minimal residual disease, 5 had cytological remission and 2 had disease progression. All patients that achieved negative minimal residual disease received an allogenic stem cell transplantation. 

Background: Haploidentical hematopoietic stem cell transplantation using T-cell depleted grafts is a valid option for pediatric patients with hematological malignancies in need of an allogeneic transplantation and lacking an HLA-identical donor. The use of CD3/CD19 depletion as a graft manipulation method helps retain large numbers of important immune cells in the graft as well as "unaltered" CD34+ cells.Objectives: The aim of this prospective study was to analyze the outcomes and risk factors for survival of pediatric patients who received an allogeneic transplant from a mismatched and/or full haploidentical relative donor using a CD3/CD19-depleted graft. Objectives: Haploidentical stem cell transplantation (haplo-HCT) has become an interesting strategy to avoid this problem, but the required T-cell depletion produce a profund and long-lasting inmunosupression, as well as graft failure and rejection. As naïve T-cells (identified by CD45RA expression) are believed to cause graft versus host disease (GvHD), while memory T-cell (CD45RA-) provide inmediate anti-infection, anti-leukemia and anti-rejection effects, allogeneic HCT using CD45RA depletion arises as a novel approach to haplo-HCT. Design/Method: Six children, 5 of them with high-risk malignancies and 1 with a immunodeficiency were transplanted following nonmyeloablative conditioning regimen. Each patient received two cell products, one created by CD34 selection and the other through CD45RA depletion from the CD34-fraction by CliniMACS device. Results: Graft consisted in a mean of 7x106/kg CD34+ cells/kg (4,5-9,89x106/kg), 3x105/kg CD3+ cells/kg (6,9x103-1x106/kg), 1x106/kg CD45RA+ cells (1x104-4,98x106/kg) and 7x108/kg CD45RO+ cells (3,8x108-1,9x109/kg). CD45RA depletionresulted in a mean of 3 log (2,2-4,29 log). All six patients engrafted with a mean of 11 days (10-12) and rapidly achieved 100% donor chimerism. No graft failure was observed. Only one patient developed GVHD>II that was sensible to steroids. T-cells led immune recovery. They achieved values higher than 700 cells/mcL and 1000 cells/mcL at day 30 and 60 respectivelly. Most of T cells were both CD8+CD45RAand CD4+CD45RA-T cells (median of 395x106/mm³ and 243x106/mm³, respectively), while the number of CD8+45RA+ and CD4+45RA+ cells remained low (median of 0.7x106 and 0.07x106 respectively), recapitulating the CD45RA depleted graft composition. A total of 4 patients presented CMV reactivation, but none progressed to disease. With a mean of 100 days of follow up two patients relapsed, both had minimal residual disease positive at haplo-TPH and two patient died, one debt to leukemia progression and one because cardiogenic shock. Conclusion: CD45RA depleted haplo-HCT is well tolerated with a rapid engraftment, minimal risk of GvHD and an accelerated inmunologic reconstitution.

Background: Hematopoietic stem cell transplantation (HSCT) is proven to be curative for severe combined immunodeficiency (SCID). Objectives: We discuss the outcome of donor chimerism and thymic output for IL2RG/JAK3 SCID post-transplantation at our centre. Design/Method: A cross-sectional study of IL2RG/JAK3 SCID patients who underwent HSCT from 1987-2012. The conditioning regimens used were reduced intensity conditioning (RIC) (Fludarabine/Melphalan), low toxicity myelo-ablative conditioning (Treosulphan/Fludarabine or Treosulphan/Cyclophosphamide) and myelo-ablative conditioning (MAC) (Busulphan/Cyclophosphamide). CD4+ naïve cells (CD3+CD4+45RA+) measurement was used as an indicator of the thymic output post-transplantation. Background: Reports indicate that pediatric patients undergoing hematopoietic stem cell transplantation (HSCT) are frequency afflicted by vitamin D deficiency. Whether vitamin D deficiency affects HSCT outcomes in pediatric patients is yet to be proven. Objectives: To report the prevalence of Vitamin D deficiency in pediatric patients that underwent HSCT and to determine its short term impact on survival. Design/Method: We reviewed serum 25-hydroxyvitamin D levels performed prospectively before starting HSCT (baseline) and at 100 days after transplantation in children that presented for HSCT from January 2011 to December 2014. We also abstracted demographic, laboratory, co-morbidity and treatment data. Results: Seventy-two children (39 males and 33 females), with a median age of 9 (range 0.25-22 years) were assessed. At the pre-HSCT stage, the median serum 25-hydroxyvitamin D level 25.5ng/ml (range: 19-34ng/ml) with only 2 patients on supplemental therapy. Forty-five of 72 patients (62.5%) had a suboptimal vitamin D level (< 30 ng/mL) before HSCT and about half had severe vitamin D deficiency (<20 ng/mL). Prevalence did not change after hematopoietic stem cell transplantation (p-value = 0.7) with 63% of the patients having suboptimal (< 30ng/mL) vitamin D levels and 45% having severe vitamin D deficiency (<20ng/mL) at 100 days after transplantation despite supplemental therapy in 74% of subjects. There were no statistically significant associations between low Vitamin D levels prior to HSCT and the development of acute or chronic GVHD, infectious rates or immune recovery. However, severe vitamin D deficiency (<20 ng/mL) at pre-HSCT was associated with decreased overall survival after transplantation (P = .007, 1-year rate of overall survival: 65% versus 92.6%). Conclusion: Majority of pediatric patients that come to transplant have vitamin D deficient. Vitamin D may play a role in outcomes of pediatric HSCT. Further studies investigating its impact are needed. 

Background: SCIDs are T-, +/-Band NK-cell maturation/function disorders presenting with life-threating infections in infancy. HSCT is curative but there are few data on long-term immune function, physical status and quality of life (QoL) outcomes. Objectives: To gather these missing data. Design/Method: 183 European SCID patients (using PIDTC definitions1, and including reticular dysgenesis) transplanted > 20 years ago were identified from SCETIDE registry. Results: Median age at diagnosis of 0,2 months (range 0-12), at transplant 6,1 months (range 0,4-13,7). 53 had CgC, 17-ADA, 16-JAK3, 14-Artemis, 8-RAG 1/2, 8-AK2, 6-IL7Ra, 2 -other known, 59 -unknown defects. 68 received conditioning (52 with pre-transplant infections), 115-unconditioned HSCTs. 126 had haploidentical, 42-MRD, 9-mMRD, 6-URD. Median last FU was 23,28 years (10,4-42,7). OS was 0,58 (95% CI 0,5-0,66). EFS (deaths, re-transplant considered as events) was 0,46 (95% CI 0,34-0,57). No significant difference in OS (p=0,26) and EFS (p=0,04) in conditioned and unconditioned transplants. 40 patients required second (11 after unconditioned, 29 after conditioned) and 7 third transplants. 69 died <5 years post-transplant (57 had pre-transplant infections), 4 died late after first but early after second and third HSCTs. TRM was 0,32 (95% CI 0,26-0,4) (no difference in conditioned and unconditioned transplants)49 patients (26,7%) had aGVHD grade 2-4. 26 (14,2%) had cGVHD.60 were alive with >20 years follow up:-11 had impaired immune function (8 after conditioned, 3 after unconditioned transplants) with low lymphocyte levels or TRECs or required IVIG/antimicrobial prophylaxis.19 had persistent warts (CgC/JAK3 12 as previously reported2, but also 2 ADA, 1 RAG2, 1 Artemis, 1 IL7Ra, 1 T-B+NK-and T-B-phenotypes). 1 developed malignancy (meningeoma). 4 had autoimmunity (SLE, hemolytic anemia, vitiligo, autoimmune hepatitis).7 had QoL considered as below normal, 17 patients had university/college education (10 -unknown). Conclusions: There is no significant difference in OS, EFS and TRM after conditioned and unconditioned HSCTs. Despite missing follow-up data, preliminary analysis demonstrates requirement of further estimate of risk factors for impaired immune function, physical status and QoL in SCID patient's long-term post-HSCT.