ALBERT

Description: Introduction: Loss of the Y-chromosome (LOY) is frequent in myelodysplastic syndromes (MDS) and observed as a single aberration in 3-4% of male MDS patients (pts). It is often clonal and not only age associated and confers a very good prognosis and a very low risk for leukemic transformation (Greenberg et al, Blood 2012; Schanz et al, JCO 2012). But LOY does not prove a hematologic disease per se (Arber et al, Blood 2016). To facilitate a better discrimination between age-related and clonal LOY, the aim of this study was to identify molecular mutations and cytomorphological features which might be characteristic for MDS with isolated LOY. Methods: We included 291 pts in our analysis. The cohort comprised 199 pts with normal karyotype (NK) and morphologically proven MDS (excess blasts (EB) in 77/199 (38%) pts) and 92 pts with LOY. NK was defined by 20 normal metaphases or at least 10 normal metaphases and normal fluorescence in situ hybridization (FISH, Tab.1). Results from mutational analysis were available for all pts with NK and for 61 pts with LOY as single cytogenetic aberration in ≥3 metaphases. Seventeen core genes (Tab.2) were sequenced in all 260 pts by Sanger and/or next generation sequencing (NGS). In 134 pts further 28 genes (Tab.2) were analyzed using one of two NGS panels. In addition to these myeloid genes, the second NGS panel covered single nucleotide polymorphisms on the Y-chromosome which enabled determination of the LOY clone size. Detailed cytomorphology for the evaluation of dysplasia was performed by two experts (UG, UB) as previously described (Germing et al, Leuk Res 2012) in 41 pts, including pts with small LOY clones and with cytogenetic sub-clones. Results: Sequencing of 40 pts with LOY and morphologically proven dysplasia showed higher frequencies of mutations in TET2 (epigenetic regulator), ZRSR2 (splicing factor, located at Xp22.2), and CBL (kinase signaling) compared to MDS with NK (Fig.1). Amongst others, mutations in IDH1/2 (epigenetic regulators) and RUNX1 (transcription factor) were rare in MDS with LOY (Fig.1). The total number of mutated core genes did not significantly differ between MDS with LOY and MDS with NK and no EB (p=0.54), but it was significantly higher in MDS with NK and EB (p=0.014, Fig.2). To distinguish between LOY as ancestral or secondary mutation we sequenced 12 pts with MDS and cases we included as clonal cytopenia of undetermined significance (CCUS, pts with cytopenia(s) and molecular mutation and/or LOY≥75% of metaphases) (Wiktor et al, GCC 2000) using the second NGS panel that allowed determination of LOY clone size and detection of molecular mutations. Thereby, we identified four pts where LOY was most likely the founder aberration, two pts with LOY as secondary aberration in addition to ancestral molecular mutations, and six pts with co-dominance of LOY and a molecular mutation (Fig.3). Finally, we aimed to evaluate if the cut off of LOY≥75% (Wiktor et al, GCC 2000) can distinguish between age-related and clonal LOY in our cohort. In 41 pts analyzed in more detail, peripheral blood counts (hemoglobin: mean 10.4 vs. 9.7 g/dL; white blood count: 4.9 vs. 6.0x10(9)/L, platelets: 163 vs. 198x10(9)/L) and dysplasia of the individual cell lines (erythro-, granulo-, megakaryopoesis) did not differ significantly between LOY≥75% and

Description: Introduction: Despite the improvement of outcome of aggressive B-cell lymphomas in the rituximab treatment era, central nervous system (CNS) relapse continues to pose a significant management problem. It remains a challenge to select patients (pts) in whom specific diagnostic procedures to identify CNS disease at diagnosis should be performed and to target a high risk group in whom a CNS prophylaxis strategy is warranted. The German High-Grade Non-Hodgkin Lymphoma Study Group (DSHNHL) recently proposed a new prognostic model incorporating the 5 IPI factors (age 〉 60 y, LDH 〉 N, stage 3 or 4, extranodal (EN) sites 〉 1) in addition to kidney/adrenal gland involvement to predict the risk of secondary CNS disease in pts with aggressive B-cell lymphoma. This model effectively stratified patients into 3 risk groups: low risk (0-1 factors, 2 y CNS relapse risk .6% (95% CI 0.0-1.2); intermediate risk (2-3 factors, 2 y CNS relapse risk 3.4 %( 95% CI 2.2-4.6)) and high risk (4-6 factors, 2 y CNS relapse risk of 10.2% (95% CI 6.3-14.1)) (Schmitz et al. Hematol. Oncol. 2013: 31, 047a). Herein, we sought to validate this model in an independent cohort of DLBCL treated with R-CHOP chemotherapy at the British Columbia Cancer Agency (BCCA). Methods: The DSHNHL dataset on which the model was initially developed was comprised of 2164 patients with aggressive B-cell lymphomas (n= 1735, 80.2% diffuse large B-cell lymphoma (DLBCL)), 18-80 years of age who were treated with rituximab with (CHO(E) P-like chemotherapy on prospective studies. The BCCA Lymphoid Cancer Database was screened to identify all patients with DLBCL treated with curative intent R-CHOP chemotherapy. Results: In total, 1597 patients were diagnosed with DLBCL at the BCCA and received at least one cycle of curative intent R-CHOP chemotherapy. The median follow-up for living patients was 4.2 years. Pts in the BCCA population-based DLBCL cohort were more likely to have poor risk features including PS 〉1, advanced age and a high IPI score (Table 1). Applying the 6 factor model, very similar risk groups were identified: low risk (0-1 factors 2 year CNS relapse risk .8% (95% CI 0.0-1.6%).; intermediate risk (2-3 factors 2 year CNS relapse risk 3.9% (95% CI 2.3-5.5%); and high risk (4-6 factors 2 y CNS relapse risk 12% (95% CI 7.9-16.1%) (Figure 1). The median time to CNS relapse was 6.7 months from the time of diagnosis in the BCCA group and was 7.2 months in the DSHNHL group highlighting that this event typically occurs early in the disease course. In both datasets kidney/adrenal involvement was highly associated with CNS relapse (2 year CNS risk BCCA 33%; 14% DSHNHL), the difference likely reflecting the higher risk pts in the BCCA population-based setting. Conclusions: We have validated the proposed DSHNHL prognostic model for CNS relapse in an independent dataset. The model identifies a high risk group in which diagnostic procedures to rule out CNS disease are highly recommended at diagnosis including MRI head, and cerebrospinal fluid analysis by cytology and flow cytometry and consideration of CNS-directed therapies. Kidney/adrenal involvement is consistently associated with a high risk of CNS relapse in the rituximab treatment era for which CNS prophylaxis should be incorporated into front-line therapy. Table 1 Clinical factor BCCA N=1597 DSHNHL N=2164 Age 〉 60 years * Median age 1035 (65%) 65 years (16-94) 974 (45%) 58 years (18-80) Median follow-up 4.6 years 2.9 years Male sex 915 (57%) 1244 (57.5%) PS 〉 1* 584 (37%) 247 (11%) Elevated LDH 1147 (53.0%) 737 (49.0%) EN 〉 1 396 (25%) 479 (22%) Stage 3 or 4 916 (57%) 1148 (53%) IPI * 0,1 2 3 4,5 463 (31%) 359 (24%) 350 (23%) 329 (22%) 1009 (47%) 523 (24%) 398 (18%) 231 (11%) Bulky disease 〉 7cm 636 (41%) 1027 (47.5%) * P〈 0.05 Figure 1 Figure 1. Disclosures Savage: F Hoffmann-La Roche: Other. Villa:F Hoffmann-La Roche: Other. Sehn:Roche: Research Funding. Pfreundschuh:Roche: Advisory Board Other, Research Funding. Gascoyne:Hoffman La-Roche: Research Funding. Connors:Seattle Genetics, Inc.: Research Funding; Roche: Research Funding.

Description: Key Points The results of this retrospective analysis do not support intrathecal prophylaxis or radiotherapy to ECFI patients in complete remission/unconfirmed complete remission.

Description: Salvage chemotherapy followed by high dose therapy (HDT) and autologous stem cell transplantation (ASCT) is the standard of treatment for chemosensitive relapses in diffuse large B cell lymphoma. Improvement of salvage chemotherapy was suggested with the association rituximab, Ifosfamide, etoposide, carboplatinum, R-ICE. What is the optimal chemotherapy regimen and can we reduce the post ASCT relapses rate? The ongoing CORAL trial was designed to answer these questions. DLBCL CD 20+ in first relapse or pts refractory after first line therapy were randomized between rituximab plus DHAP and R-ICE. Stratification was made on centers, prior rituximab exposure and refractory/12months, 108 refractory/early relapses; 97 pts with prior exposure to rituximab; Stage 3-4 107 pts; elevated LDH 88 pts; secondary IPI 0–1 112 pts; sIPI 2-3 63pts. The two arms were well balanced. In the prior rituximab cohort exposure more pts had refractory disease and adverse prognostic factors. However, at inclusion patients characteristics were not significantly different in the stratified subgroups. The overall response rate was 68%, with 41% complete remission rate. Toxicity was similar to what is expected with intensive therapy, 72 SAE were reported with 12 deaths during the initial salvage regimens. In univariate analysis factors significantly affecting response rate (p1 54% vs 77% and prior exposure to rituximab 54% vs 82%. In a logistic regression model only refractory/early relapse and secondary IPI remain significant for response rate. Intent to treat 2 yrs EFS and OS were 50% (CI 42–57%) and 69% (CI 61–75%) respectively. Only 107 pts in this prospective study received, per protocol ASCT. For patients transplanted, 2 yrs EFS was 75% (CI 63–84%) with OS 89%. Two yrs EFS was affected by: prior treatment with rituximab, 34% vs 66% (p=.0001); refractory/early relapse 36% vs 68% (p

Description: Abstract 3379 Poster Board III-267 Background: Allogeneic stem cell transplantation ( SCT ) is increasingly being used to treat relapsed lymphoma. We reasoned that patients with high – risk ( chemorefractory disease, short time interval between first – line therapy and relapse ) aggressive lymphoma need vigorous debulking ( myeloablative conditioning ) and a strong GvLymphoma effect (early T–cells transferred with the graft: Glass et al., BMT 2004 ) ) in order to obtain optimal results Patients and Methods: Younger patients ( 18 to 65 yrs ) with aggressive NHL and primary progressive disease, early relapse with at least one IPI risk factor, or relapse after HDT /ASCT were included into the study. They received myeloablative conditioning (Fludarabine 125 mg/m2, Busulfan 12 mg/kg and cyclophosphamide 120 mg/kg) followed by GVHD prophylaxis with short term mycophenolat mofetil plus tacrolimus. After an amendment in July 2008 anti-thymocyte globulin (ATG) was given to all patients prior to transplantation. Patients were randomized to receive two courses of rituximab ( 4 × 375 mg/ m2) post transplant starting on day +21 and day +175 or no additional GVHD prophylaxis. From June 2004 to July 2009, 84 patients with aggressive NHL were enrolled and 81 were eligible for toxicity analysis (median age 49 years). 71 patients had follow up allowing for a meaningful survival analysis. Forty - one pts had diffuse large B cell NHL, 6 patients follicular lymphoma grade 3, 8 pts blastic mantle cell lymphoma, 2 pts aggressive marginal zone lymphoma, 4 patients lymphoblastic B cell lymphoma, and 20 pts suffered from T cell lymphoma. Forty-five (54%) pts received at least one cycle of HDT and autologous SCT prior to alloSCT; 75% had early relapse (〈 12 months) or primary progressive disease, 59% chemo-refractory disease and 24% had progressive disease with high or high intermediate age adjusted IPI immediately prior to conditioning. Mobilized blood was obtained from HLA-identical siblings in 24 pts, from matched unrelated donors in 40 pts and from one locus mismatched unrelated donors in 17 pts. Fifty – five patients did receive ATG. Median observation time of surviving patients is 1.9 years. Forty – one pts died, in 26 patients death was treatment related. After one year, estimated overall survival is 52% (95% CI 39% to 63%), progression free survival is 46% (95% CI 33% to 57%), relapse rate is 29% (95% CI 43% to 10%), non relapse mortality is 37% (95% CI 26% to 50%). The incidence of acute GVHD 〉 grade 1 is 66% (95% CI 49% to 82%). The last documented lymphoma progress occurred at day 288 after alloSCT. Patients with high-intermediate or high IPI at transplant did not differ significantly in PFS from patients with low and low-intermediate IPI (PFS at 2 years 34% vs 41%, p=0.144). There are no significant differences in OS, PFS and GvHD for pts receiving Rituximab or not. Conclusion: This alternative myeloablative conditioning followed by T - replete allogeneic SCT is an effective treatment option in patients with high risk features like active disease at transplantation and high – tumor burden. Although the incidences of GVHD ( uninfluenced by the administration of Rituximab ) and non-relapse mortality were relatively high, relapse rates were low and OS and EFS are promising While further optimization of conditioning by using lymphoma – specific drugs in high doses and improvement of GvHD – prophylaxis by adding optimal doses of ATG are certainly possible we do not believe that minimal conditioning and in vivo T – cell depletion will cure patients with high – risk aggressive lymphoma. Disclosures: Glass: Roche: Honoraria, Research Funding. Off Label Use: Rituximab will be used as prophylaxis for graft-versus-host-disease. Schmitz:Roche: Honoraria, Research Funding.

Description: Patients (pts) with mature (peripheral) T-cell lymphoma are known to have a poor prognosis when receiving standard conventional chemotherapy. This leads many physicians to regard high dose chemotherapy (HDT) followed by autologous stem cell transplantation (ASCT) as standard therapy for these pts. We here present a retrospective analysis on 424 pts with mature T-cell lymphoma who have received HDT and ASCT in EBMT centres between 2000 and 2005. Patients with primary cutaneous or immature (lymphoblastic) lymphoma were not included. Histological subtypes were anaplastic large cell lymphoma (ALCL, n=98, 23.1%; 19 anaplastic large cell kinase (ALK) positive, 42 ALK negative and for 37 pts the ALK status was unknown), peripheral T-cell lymphoma (PTCLu, n=176, 41.5%), angioimmunoblastic T-cell lymphoma (n=120, 28.3%) and aggressive T-cell lymphoma unspecified (n=30, 7.1%). Median age at ASCT was 51 years (17.2–73.5), median time from diagnosis to ASCT was 9 months (4–99), and median follow up for surviving pts was 36 months (0.4–99). 268 pts (63%) were male. 1/3 received HDT and ASCT after only one previous treatment line. 35% of the pts were treated in CR1, and 52% in chemosensitive disease worse than CR1. At the time point of ASCT only 12 pts (2.8%) had a poor performance status. 9% of the pts received total body irradiation as part of the conditioning regimen. At 3 years after ASCT non relapse mortality (NRM) was 7.4% and the relapse rate (RR) was 43.1%. In multivariate COX analysis for NRM refractory disease (p

Description: High dose therapy (HDT) followed by autologous stem cell support has poor outcome in patients with primary progressive lymphoma or relapse after primary HDT due to high relapse rates and failure free survival below 20%. Allogeneic SCT may help these patients by exerting an GVL effect. Its use however, is followed by high incidence of severe GVHD and treatment related mortality (TRM) in this population. The anti-CD20 monoclonal antibody rituximab has been claimed to solve this problem. We initiated a randomized phase II study using intermediate conditioning (Fludarabine 125 mg/m2, Busulfan 12 mg/kg and cyclophosphamide 120 mg/kg) followed by GVHD prophylaxis with short term mycophenolat mofetil plus tacrolimus. Patients were randomized to receive two times four doses of rituximab (375 mg/m2) post transplant starting day +28 and day +175 or no further GVHD prophylaxis. Here we report the results of a first interim analysis. From January 2005 to August 2007 sixty patients (pts) with aggressive NHL were enrolled. Thirty one pts had diffuse large B cell NHL, 9 patients follicular lymphoma grade 3, 8 pts blastic mantle cell lymphoma, one patient aggressive marginal zone lymphoma and 11 patients peripheral T cell lymphoma. The median number of prior treatment regimens was 3 (range 1 to 6). 43 (72%) pts received at least one cycle of high-dose therapy and autologous SCT prior to alloSCT; 79% had early relapse (〈 12 months) or primary progressive disease, 58% chemo-refractory disease and 52% had progressive disease with high or high intermediate age adjusted IPI immediately prior to conditioning. Allo-PBPC were obtained from HLA-identical siblings in 16 pts, from fully matched unrelated donors in 32 pts and from 1 locus mismatched unrelated donors in 12 pts. Engraftment of leukocytes was rapid (median 10 days, range 8–27) and all patients achieved complete (〉 95%) donor type chimerism after alloSCT. Median observation time is 8 months (range 1–35 months). 32 pts died, in 20 patients death was attributed to treatment related causes. After one year, estimated overall survival is 47%, failure free survival is 43%, TRM is 37%, relapse rate is 33% and incidence of GVHD 〉 grade 1 is 57%. With an observation time precluding final analysis, there are no significant differences between patients randomized to receive rituximab post transplant and those who were not. There was a trend to lower relapse rates in patients with GVHD 〉 grade 1 (25% vs 44%, p=0.14). Intermediate intensity conditioning followed by allogeneic SCT is a valuable treatment option in patients with high-risk relapse of aggressive NHL. The basic incidence of GVHD and TRM is high. Due to the short observation time, a definitive conclusion regarding the impact of post transplant Rituximab cannot be drawn. The study will be continued.

Description: Patients (pts) suffering from mature (peripheral) T-cell lymphoma are known to have a poor outcome compared to pts with aggressive B-cell lymphoma when receiving conventional therapies. However, case reports and single centre experiences show promising results of allogeneic stem cell transplantation (allo SCT) for these pts. We here present a retrospective analysis of 103 pts with mature T-cell lymphoma who received an HLA-identical allo SCT in EBMT centres between 2000 and 2005. Histological subtypes of the patients were anaplastic large cell lymphoma (n=25; 4 anaplastic lymphoma kinase [ALK] positive, 11 ALK negative, 10 ALK unknown), peripheral T-cell lymphoma unspecified (n=51), angioimmunoblastic T-cell lymphoma (n=18) and aggressive T-cell lymphoma unspecified (n=9). Patients with primary cutaneous T-cell lymphoma or T-lymphoblastic lymphoma were excluded. Median follow up for surviving patients was 40 months (6–98), median age at allo SCT 42 years (18–68) and median time to allo SCT 17 months (3–233). 39 pts had failed a prior autologous SCT; 68 pts had chemosensitive disease at allo SCT (of these 15 in CR1) and 30 pts had chemorefractory or untested relapsed or progressive disease. Donors were HLA identical siblings for 73 and matched unrelated donors for 30 pts; 82 pts received peripheral blood stem cells. 54 pts were treated with reduced intensity conditioning before SCT. The cumulative incidence (CI) of acute graft versus host disease (GvHD) 100 days after SCT was 52% and had no effect on non-relapse mortality (NRM) or relapse rate (RR). 34 of 74 evaluable pts experienced chronic GvHD (14 limited, 20 extensive), CI 46% at 2 years. Introducing chronic GvHD as a time dependent covariate, this factor was associated with a higher NRM (p

Description: Veno-occlusive disease (VOD) is a serious complication of intensive chemotherapy regimens used in hematopoietic stem cell transplantation (HSCT). Incidence ranges from 10–60% (Chopra et al., 2000). Despite numerous therapeutic attempts described such as rtPA, TIPS and defibrotide mortality remains 80% (Fried et al., 1996). Risk factors for developing VOD are previous high-dose chemotherapy, unrelated donor transplants and busulfan-based conditioning regimens. In face of the frequency and high mortality due to absence of effective therapeutic options there is need for prophylaxis. We incorporated defibrotide into the supportive regimen for high risk patients undergoing a HSCT with busulfan containing conditioning regimens. From 01/2003 to 08/2004 44 patients (median age 52y, 24 male) receiving a busulfan containing regimen for HSCT (2 autologous, 42 allogeneic, 23 unrelated donors) were treated prophylactically with defibrotide as 800mg/24h continuous infusion from start of conditioning chemotherapy up to day +21 (group 1). Underlying diseases were: 10 AML, 24 NHL, 3 HD, 6 MM, 1 CML. Median number of previous regimens were 3. 27 patients had high-dose chemotherapies followed by autologous HSCT as prior therapy. From 07/2001 to 12/2002 16 patients (median age 45y, 11 male) receiving busulfan-based conditioning for allogeneic HSCT (7 unrelated donors) received heparin (300IE/h) for prophylaxis of VOD and catheter related thrombosis (group 2). Disease entities were 7 AML, 7 NHL, 1 HD, 1 ALL. Median number of previous regimen was 3. 11 patients had high-dose therapies followed by autologous HSCT as prior therapy. While in the latter group 1/16 patients developed and finally died of VOD, 3/44 in the defibrotide group did so. Date of VOD diagnosis in the patient not prophylatically treated with defibrotide was day +13 after HSCT compared to day +21, +25 and +27 in patients who received defibrotide prophylaxis. There were no serious adverse events (e.g. bleeding) attributable to defibrotide. Overall incidence of VOD in both groups is low (6,8% group 1; 6,3% group 2). Although patients in group 1 were at high risk of VOD, no VOD occurred during the period of defibrotide prophylaxis. We conclude that defibrotide is save and efficient in prevention of VOD. Defibrotide delayed the onset of VOD beyond its application. However, with defibrotide prophylaxis late onset of VOD has to be encountered. The optimal application period has to be determined.