ALBERT

Description: Activating mutations in the Vav guanine nucleotide exchange factor 1 (VAV1) gene are reported in various subtypes of mature T-cell neoplasms (TCN). However, oncogenic activities associated with VAV1 mutations in TCN remain unclear. To define them, we established transgenic mice expressing VAV1 mutants cloned from human TCN. Although we observed no tumors in these mice for up to a year, tumors did develop in comparably-aged mice on a p53-null background (p53-/- VAV1-Tg), and p53-/- VAV1-Tg mice died with shorter latencies than did p53-null (p53-/-) mice. Notably, various TCN with tendency of maturation developed in p53-/- VAV1-Tg mice, while p53-/- mice exhibited only immature TCN. Mature TCN in p53-/- VAV1-Tg mice mimicked human peripheral T-cell lymphoma (PTCL)-GATA3 and exhibited features of type2 T helper (TH2) cells. Phenotypes seen following transplantation of either p53-/- VAV1 or p53-/- tumor cells into nude mice were comparable, indicating cell-autonomous tumor-initiating capacity. Whole transcriptome analysis (WTA) showed enrichment of multiple Myc-related pathways in TCN from p53-/- VAV1-Tg mice relative to p53-/- or wild-type T cells. Remarkably, amplification of Myc locus were found recurrently in TCN of p53-/- VAV1-Tg mice. Finally, treatment of nude mice transplanted with p53-/- VAV1-Tg tumor cells with JQ1, a bromodomain inhibitor, which targets the Myc pathway, prolonged survival of mice. We conclude that VAV1 mutations function in malignant transformation of T cells in vivo and that VAV1-mutant expressing mice could provide an efficient tool for screening new therapeutic targets in TCN harboring these mutations. We conclude that VAV1 mutations function in malignant transformation of T cells in vivo and that VAV1-mutant expressing mice could provide an efficient tool for screening new therapeutic targets in TCN harboring these mutations.

Description: Aim and Background: Renal impairment (RI) is common feature in patients with multiple myeloma (MM) and is considered as a poor prognostic factor. Improvement of renal function can lead to the improved survival in patients with MM, however little is known on the prognostic impact of reversal of RI compared to that of the patients without RI at diagnosis in the novel agent era. To address this issue, we retrospectively analyzed the impact of RI on survival of newly diagnosed multiple myeloma (NDMM) patients with or without RI seen at our Department over the past 15 years. Patients and Methods: The study population included all patients diagnosed as MM and treated during May 2000 to March 2015 at Kameda Medical Center, Kamogawa-shi, Japan. We reviewed and retrospectively analyzed the medical records of the Department of Hematology/Oncology. All statistical analyses were performed with EZR, which is a graphical user interface for R ver. 3.2.1. Results: We identified 258 patients with NDMM during this period. RI was defined as eGFR

Description: Background: Aplastic anemia (AA), paroxysmal nocturnal hemoglobinuria (PNH) and myelodysplastic syndrome (MDS) are the heterogeneous group of bone marrow failure syndrome (BMFs). AS they often show profound hypocellular marrow, the diagnosis is often difficult by bone marrow and laboratory examination alone. Red to yellow marrow conversion occurs with age in the appendicular skeleton (AS), where red marrow is converted to yellow marrow until the age of early 20s. Although abnormal distribution of red marrow in appendicular skeleton were previously reported in small series of patients with MDS, leukemia and lymphoma by MRI, no further study has published so far. Here, we examined distribution of red marrow in AS by low-dose multi-detector CT (MDCT) in BMFs patients, and analyzed the relationship between the abnormal medullary pattern in AS and laboratory variables. The relationship between the MDCT pattern and subsequent development of leukemic transformation on survivals was analyzed in patients with BMFs. Patients: We retrospectively reviewed the medical records of 138 untreated patients (AA n=36, PNH n=5, and MDS n=97) with BMFs diagnosed in the Department of Hematology/Oncology at Kameda Medical Center, Kamogawa, Japan, from July 2008 to June 2014. Follow-up MDCTs were evaluated in 28 MDS patients when they were diagnosed as overt AML (MDS/tAML). Retrospective review of clinical and laboratory features including complete blood count, % of bone marrow blast, chromosomal analysis, and International Prognostic Scoring System (IPSS) at diagnosis was performed. WHO classification of patients with MDS was as follows: RCUD (n=21), RARS (n=2), RCMD (n=26), RAEB (n=43), and, MDS unclassified (MDS-U) (n=5). Leukemia-free survival (LFS) and overall survival (OS) were analyzed in 73 patients with MDS who were ≥65 years of age and ineligible for allogeneic stem cell transplantation (allo SCT) by the Kaplan-Meier. CT image acquisition and Image analysis: Non-enhanced CT examinations were performed from the skull to the knees by MDCT scanner (Aquilion 64, Tohshiba, Tokyo, Japan). Bony canal of humeral and femoral bone were visualized by coronal and sagittal axis image reconstruction. Medullary CT density of humerus and femurs were measured and the results were expressed as Hounsfield unit (HU). As the normal adult bone marrow was composed of rich adipocytes and called yellow marrow, it is represented by low density CT value between -30 to -100 HU. The value above -30 HU observed in long bony canals was considered as high density. Medullary pattern of AS were categorized as follows: (1) fatty pattern; showing a low signal density marrow (2) focal pattern; showing abnormally focal high density lesions (3) diffuse pattern; showing uniformly high density marrow. Results: All 36 patients with AA showed a fatty (n=13, 36.1%) or focal (n=23, 63.9%) pattern in medullary AS on MDCT, and none of them showed diffuse pattern. Five patients with PNH showed as follows: fatty/focal/diffuse, 1/3/1. Ninety-seven patients with MDS showed as follows: fatty/focal/diffuse, 24/46/27. Patients with MDS who showed diffuse pattern had a significantly low hemoglobin concentration compared to those with fatty or focal pattern (p=0.03). Among the patients with MDS, most of the patients with RCUD (n=21), RARS (n=2), RCMD (n=26), MDS-U (n=5) showed the fatty or focal pattern (fatty or focal/diffuse pattern; RCUD (18/3), RARS (2/0), RCMD (21/5), MDS-U (5/0)), but approximately half (46%) of patients with RAEB showed diffuse pattern (fatty/focal/diffuse pattern; 7/17/19). In addition, patients with transformed to MDS/tAML showed either focal (n=10, 35.7%) or diffuse (n=18, 64.3%) pattern and none of them showed fatty pattern. In 73 patients with MDS who were ≥65 years of age and ineligible for allo SCT, the group with focal or diffuse pattern had significantly shorter LFS and OS compared to the group with fatty pattern (p=0.01, p=0.05, respectively). Patients with focal pattern in AS showed longer LFS than those with diffuse pattern (p=0.05), but difference was not statistically significant in OS (p=0.22). Conclusions: This study showed that MDCT imaging of the appendicular skeletons provided important information for the diagnosis and prognosis of patients with BM. In patients with MDS, focal or diffuse pattern on MDCT showed negative prognostic impact on LFS and OS, and these patterns appeared to reflect the status of disease. Figure 2. Figure 2. Figure 3. Figure 3. Disclosures No relevant conflicts of interest to declare.

Description: [Introduction] It has been reported that clonal circulating plasma cells (cPC) were detected in patients with multiple myeloma (MM) and other plasma cell dyscrasias (PCD), and their detection has been shown to be a risk in newly diagnosed MM and shortened progression free survival in patients smoldering MM (sMM). It is unclear that the detection of cPCs in peripheral blood may be a simple reflection of tumor burden of bone marrow plasma cells or may represent different. This study was performed to evaluate the clinical utility of quantifying clonal cPC using 6-color FCM in patients with MGUS, SMM, and symptomatic MM (symMM) at diagnosis (Dx). They were compared with bone marrow samples (BM PCs) simulatneously analyzed in the same way. Besides we evaluated the transition of quantification of clonal cPC of PB samples at various stages after treatment. [Materials and Methods] We analyzed 280 peripheral blood (PB) samples from 194 patients with PCD (MGUS, SMM, and symMM; n  = 34/39/121, respectively) diagnosed at the Department of Hematology/Oncology, Kameda Medical Center and Kanazawa University Hospital from January 2012 to July 2015. Similarly, we analyzed 30 PB samples from 30 healthy controls. Mononuclear cells (MNC) were isolated from PB by density gradient centrifugation and stained with antibodies to CD45, CD38, CD19, CD138, CD56, and cytoplasmic kappa and lambda immunoglobulin (Ig) light chains. The cells were collected using a Beckman-Coulter NAVIOS and analyzed using Kaluza software. The gating strategy employed was expression of CD38, CD45, CD138, and cytoplasmic Ig light chains. Clonal cPC was defined as the population of CD138+, CD38+ CD45-~±, and CD19-. To confirm the clonality of these cells, light chain restriction of cytoplasmic Ig was used (κ/λ〉4 or  2×106 total events. At least ≥ 20 clonal cPC were required for the analysis. [Results] We analyzed clonal cPC of 194 PB samples with MGUS, SMM, and symMM (n  = 34/39/121, respectively) at diagnosis (Dx). The mean values of clonal cPC were: MGUS, 2.67×10-5/MNC (range, 0 - 3.0×10-4); SMM, 2.43×10-4/MNC (range, 0 - 3.6×10-3); symMM, 6.99×10-3/MNC (range, 0 - 1.5×10-1). The number of clonal cPC was significantly higher in SMM than MGUS, and in symMM than SMM (P  

Description: Background: Myelodysplastic syndrome (MDS) and aplastic anemia (AA) comprise a heterogeneous group of bone marrow failure disorders. As both show profound hypocellular marrow with minimal morphological atypia, differentiation of MDS and AA is often difficult by bone marrow and laboratory examination alone. Red to yellow marrow conversion occurs with age in the appendicular skeleton (AS), where red marrow is converted to yellow marrow until the early 20s. Although an abnormal distribution of red marrow in AS has previously been reported in small numbers of patients with MDS, along with leukemia and lymphoma by MRI, there have been no further reports to date. Here, we examined the distribution of red marrow in AS by low-dose multi-detector CT (MDCT) in AA and MDS. We analyzed the relationships between the abnormal medullary pattern in AS and laboratory variables, subsequent development of leukemic transformation, and survival in MDS patients. Patients: We performed low-dose MDCT of the humerus and femur in 103 untreated adult patients with AA (n = 32) and MDS (n = 71). We retrospectively reviewed the medical records of patients with AA and MDS diagnosed in the Department of Hematology/Oncology at Kameda Medical Center, Kamogawa, Japan, from July 2008 to June 2014. A retrospective review of clinical and laboratory features, including complete blood count, % bone marrow blasts, chromosomal analysis, and International Prognostic Scoring System (IPSS), was performed. WHO classification of MDS patients was as follows: RA (n = 22), RARS (n = 2), RCMD (n = 17), RAEB 1 (n = 18), RAEB 2 (n = 11), and MDS unclassified (n = 1). Overall survival (OS) and leukemia-free survival (LFS) were analyzed in 71 MDS patients by the Kaplan–Meier method and differences between curves were calculated by two-sided log-rank test. CT image acquisition and image analysis: Non-enhanced CT examinations were performed from the base of the skull down to the knee joint with an MS-CT scanner (AQUILION 64; Toshiba, Tokyo, Japan). The bony canals of the humeral and femoral bones were visualized by coronal and sagittal axis image reconstruction. The effective radiation dose associated with whole-body MD-CT was 10.1 mSv (ICRP 26). The dose was comparable to whole-body CT (2.4 mSv). Medullary CT density of the humerus and femur were measured and the results are expressed in Hounsfield units (HU). As the normal adult bone marrow was composed of rich adipocytes and called yellow marrow, it is represented by a low-density CT value between –30 and –100 HU. A value above –30 HU observed in long bony canals was considered to indicate a high-density lesion. The medullary pattern of the appendicular skeleton was categorized as follows: (1) fatty, showing a low signal density marrow; (2) focal, showing abnormally focal high-density lesions; (3) diffuse, showing uniformly high-density marrow. Results: All 15 patients with AA showed a fatty (n = 12, 37.5%) or focal (n = 20, 62.5%) pattern in medullary AS on MDCT, and none showed a diffuse pattern. Among the 71 patients with MDS, 22 (30.9%) had a fatty pattern, 32 (45.1%) had a focal pattern, and 17 (23.9%) had a diffuse pattern. Seventeen patients with diffuse infiltration pattern on MDCT had significantly shorter LFS (P 

Description: Introduction: Endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) is considered the procedure of choice for the diagnosis and staging of intra-abdominal non-Hodgkin’s lymphoma (NHL) without accessible peripheral lymphadenopathy. However, diagnosis and subclassification lymphoma by FNAB is often challenging due to variable cellularity and lack of architecture. Recent advances of ancillary techniques such as immunohistochemical staining, flowcytometry (FCM), fluorescence in situ hybridization (FISH) analysis and molecular analysis allowed classify lymphoma more precisely, although sufficient information can be obtained through this procedure remained undetermined. The present study was performed to evaluate the yield of EUS-FNAB using a standard 19 or 22-gauge needle for diagnosis and subclassification of lymphoma, assessing the feasibility of immunohistological, FCM, molecular and cytogenetic assessments. Methods: Between April 2008 and July 2014, 90 patients with malignant lymphoma who had an intra-abdominal mass without accessible peripheral lymphadenopathy underwent EUS-guided fine needle aspiration biopsy at our hospital. All patients received positron emission tomography/computed tomography and had 2-deoxy-2-(18F)fluoro-D-glucose-avid lesions in abdomen before examination. The aspirated materials were processed for flowcytometry (FCM), molecular analysis of immunoglobulin heavy (IgH) and T-cell receptor (TCR) gene rearrangement, cytogenetic analysis by conventional G banding, and FISH analysis, in addition to standard histopathological studies. Patients’ baseline data, including age, sex, laboratory examinations, imaging studies, and final diagnosis of lymphoma, were collected and examined to determine the feasibility and sensitivity for diagnosis and subclassification of lymphoma. Results: The mean of the diameter of mass was 37mm (9.7-149mm). Among the 90 patients, conventional G banding, FCM analysis, standard cytogenetic analysis, and FISH were successfully performed in 67 (74%), 78 (87%), 44 (49%), and 58 (64%) cases, respectively. G banding analysis were successful in 45 patients (67%) that showed normal karyotype in 5 cases (7%), t(14;18)(q32;q21) in 7 cases (10%), t(8;14)(q24;q32) in one case, and complex abnormality in 32 cases (48%), respectively. FCM analysis showed immunoglobulin light chain restriction in 48 cases (62%) and were diagnosed as B-cell lymphoma. FCM could not determine the T-cell clonality. Molecular analyses for TCR and/or IgH receptor rearrangements were successful in 35 patients (83%), 31 rearranged in IgH and 4 rearranged in TCR, respectively. There were 32 cases with IgH/Bcl2 fusions by FISH analysis, 26 cases in follicular lymphoma (FL) and 6 cases in diffuse large B-cell lymphoma (DLBCL), respectively. IgH/Bcl6 fusion was seen in 2 case of DLBCL and IgH/C-myc fusion was seen in 1 case of Burkitt lymphoma (BL). Finally, our cohort included 82 B-cell lymphomas (91%) and 8 T-cell lymphomas (9%). Subclassification of lymphoma in accordance with WHO system included 40 cases of FL, 39 cases of DLBCL, one case of BL, 2 cases of lymphoblastic lymphoma, 7 cases of peripheral T cell lymphoma not specified, and one case of angioimmunoblastic lymphoma. Although all of the outpatients were hospitalized until the day after biopsy, there were no serious complications related to this procedure like bleeding, perforation, ileus, and infection. Conclusions: EUS-FNAB using a standard 19 or 22-gauge needle is safe and feasible and has high diagnostic value for subclassification of intra-abdominal lymphoma without accessible peripheral lymphadenopathy. With the use of simultaneous immunophenotyping, molecular, and cytogenetic studies, lymphoma subclassification was possible in most of the cases. Disclosures No relevant conflicts of interest to declare.

Description: Introduction: With the development of novel therapeutic agents, more than 30% of patients with multiple myeloma (MM) achieve complete response (CR) as defined by the International Myeloma Working Group (IMWG). However, most patients that achieve CR ultimately die due to relapse, suggesting the presence of minimal residual disease (MRD) in these patients. Multicolor flow cytometry (MFC) allows the detection of

Description: Background: Multiple myeloma (MM) is characterised by the production of monoclonal immunoglobulin (Ig) and clonal proliferation of neoplastic plasma cells in bone marrow. The emergence of oligoclonal bands (OB) in serum and/or urine immunofixation electrophoresis (IFE) that is different to that observed at diagnosis has been reported with varying frequency in patients with stem cell transplantation (SCT) or favourable response to chemotherapy, although its prognostic relevance remains unclear. Here, we retrospectively analysed clinical records and results serial serum and/or urine IFE to determine the frequency, clinical characteristics and prognostic impact of OB that developed after treatment. We also analysed the effects of OB on the results of free light chain (FLC) assay that may affect the stringent CR (sCR) criteria proposed by the IMWG. Patients: We retrospectively reviewed 180 patients with MM admitted to the Department of Hematology/Oncology at Kameda Medical Center, Kamogawa, Japan, from January 2006 to May 2014.Seventeen patients were excluded from the analysis due to lack of appropriate follow-up data. Method: An OB was defined as the presence of a serum and/or urine IFE monoclonal spike that was different from the original myeloma protein in heavy and/or light chains, as well as a different IFE migration pattern. IFE was performed at least every three months after obtaining very good partial response (VGPR) and then until the disease progression or relapse was confirmed. Overall survival (OS) and progression free survival (PFS) were analyzed in 173 MM patients by the Kaplan–Meier method, and differences between the curves were calculated by two-sided log-rank test. Free light chain (FLC) and minimal residual disease measurement by multicolour flowcytometory (MFC) were performed to evaluate the response to treatment. Results: Myeloma response more than VGPR and CR were achieved in 87 (53.3%) and 54 (33.1%) patients, respectively. None of the patients with less than PR developed OB, and OB developed in 36.3% (12/33) and 51.9% (28/54) of the patients with VGPR and CR, respectively. Among the 30 patients who received SCT, 18 patients (60.0%) developed OB, whereas only 12 of 133 patients who did not receive SCT developed OB. The emergence of OB was significantly higher in patients receiving SCT (P 

Description: Introduction: Positron emission tomography combined with computed tomography (PET-CT) is functional imaging test and has been widely used in malignant lymphoma (ML) for initial staging and monitoring response to treatment. Interim PET-CT (iPET) and post-therapy PET-CT (ePET) is also used to assess the early response and guide subsequent treatment, although its role is still controversial other than in Hodgkin's disease and diffuse large B cell lymphoma. Peripheral T cell lymphoma (PTCL) and natural killer (NK) cell lymphomas are relatively rare and heterogeneous types of ML. The prognosis of T and NK (T/NK) cell lymphoma is poor and no standard treatment is available. Therefore, there is a need to find better prognostic factors or tools for these patients. PET-CT is both sensitive and specific for initial staging of T/NK cell lymphoma, although there have been few studies using i- and ePET in these lymphomas. We investigated the prognostic value of i- and ePET in T/NK cell lymphoma in a retrospective single-center study. Methods: Between June 2006 and June 2015, 79 patients with T/NK cell lymphomas had iPET after 2 to 4 courses of treatment and at the end of treatment at Kameda Medical Center, Japan. iPET was performed just before the next cycle of treatment. Treatment responses were scored according to the Deauville score using a 5-point scale (DS). We defined DS scores 1 - 3 as complete metabolic response (CMR). Standardized uptake value (SUV) measurement was normalized relative to the injected dose and lean body mass. The SUV was measured for all lesions and the highest value for each scan was recorded as maximum SUV (SUVmax). These lesions were identified as indicator lesions. For mid- and end-treatment scans, we recorded the change in SUVmax (DSUV), comparing the index lesion and the highest SUVmax in the scan regardless of the index lesion. Differences in overall survival (OS) and progression-free survival (PFS) were calculated by two-sided log-rank test. PET-CT status was assessed for its ability to predict PFS and OS. Results: The study population consisted of 48 men and 31 women with a median age of 70 years. The most frequent lymphoma diagnoses were peripheral T cell lymphoma-not otherwise specified (PTCL-NOS) (n  = 29), angioimmunoblastic T cell lymphoma (AITL) (n  = 21), anaplastic large cell lymphoma (ALCL) (n  = 6), adult T cell leukemia/lymphoma (ATLL) (n  = 12), enteropathy-associated T cell lymphoma (EATL) (n  = 2), and NK/T cell lymphoma (NKTCL) (n  = 9). Most patients except for ATLL and NK cell lymphoma were instituted with the CHOP-like regimen. Baseline PET scan was positive in all cases and median SUVmax was 13.7 (range, 2.6 - 37.4). iPET results were negative in 17 cases (26%), and ePET results were negative in 22 of 46 (48%) cases. With a median follow up of 30 months, 5-year PFS rate was 66% for obtaining CMR vs. 9.2% for not obtaining CMR (P   62% and 〉 85% were predictive of better PFS and OS (sensitivity 96%, specificity 67%, area under the curve (AUC) 0.89, 95% confidence interval (CI) = 0.82 - 0.97 and sensitivity 49%, specificity 97%, AUC 0.80, 95% CI = 0.70 - 0.90, respectively). We examined the positive and negative predictive values (PPV and NPV) and accuracy in predicting PFS and OS in 66 patients who underwent iPET. Of 35 iPET-positive patients, 31 (89%) showed progression, and 26 (74%) died during the follow-up. On multivariate Cox regression analysis, obtaining CMR at iPET emerged as an independent prognostic factor for PFS and OS (P

Description: Background: 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) has been widely used for the initial staging and monitoring of the response in patients with malignant lymphomas, including peripheral T-cell lymphoma (PTCL). FDG PET/CT performed during a course of chemotherapy (interim PET, iPET) indicates early response and has been found to have prognostic value in various lymphoma subtypes. In addition to early treatment response, baseline characteristics including tumor burden and metabolic activity also significantly impact outcomes. Recently, volume-based metabolic assessments using PET/CT, including the total metabolic tumor volume (TMTV) and total lesion glycolysis (TLG), have emerged as new assessment tools. In this study, we investigated the predictive value of baseline TMTV and TLG in PTCL, and ascertained whether iPET response can be combined with these parameters to improve risk stratification. Methods: Patients with confirmed PTCL treated at Kameda Medical Center were retrospectively analyzed. The inclusion criteria included: a confirmed histological diagnosis of PTCL; pretreatment PET/CT and iPET evaluation; and anthracycline-based chemotherapy as first-line treatment. TMTV was defined as the volume of lymphoma visualized on PET/CT with a standardized uptake value (SUV) greater than or equal to the fixed absolute threshold of 2.5. TLG was calculated as the sum of the product of the average SUV (SUVmean) and MTV of all lesions. The computer-aided analyses of the PET/CT images for TMTV and TLG calculations were performed using an open-source software application Metavol (Hokkaido University, Sapporo, Japan). All iPET scans were defined as PET/CT scans performed after 2-4 cycles of chemotherapy. Response on iPET was assessed using the Deauville 5-point scale, with a score of 4-5 reflecting positivity. Results: Of the 107 patients with PTCL in our lymphoma cohort, we excluded adult T-cell leukemia/lymphoma, extranodal NK/T cell lymphoma, and cutaneous T-cell lymphoma, due to the different treatment strategies. Finally, 63 patients were enrolled in this study, including 30 with PTCL not otherwise specified (PTCL-NOS), 28 with angioimmunoblastic T-cell lymphoma (AITL), 4 with ALK-negative anaplastic large cell lymphoma (ALCL), and one with ALK-positive ALCL. The median age was 73 (range: 46-88) years. The majority of patients were treated with CHOP or CHOP-like chemotherapy. Consolidation therapy with stem cell transplantation was performed only in seven patients (11%) as our patients had a relatively higher age. After a median follow-up period of 35 months, the 5-year progression-free survival (PFS) and overall survival (OS) for all patients were 30% and 51%, respectively. First, we assessed the prognostic value of the TMTV and TLG. The median baseline TMTV and TLG values were 423 cm3 (range, 21-3012 cm3) and 1980 (range, 56-21400), respectively. The optimal cutoff values determined using ROC curve analysis were 389 cm3 for TMTV and 875 for TLG. A high baseline TMTV was associated with worse PFS (hazard ration [HR], 2.244; 95% confidence interval [CI], 1.195-4.212; P = .01) and OS (HR, 3.358; 95% CI, 1.502-7.503; P = .002). Moreover, high baseline TLG were highly predictive of worse PFS (HR, 3.767; 95% CI, 1.666-8.517; P = .0005) and OS (HR, 4.722; 95% CI, 2.032-10.97; P