ALBERT

Description: Abstract 1658 Poster Board I-684 Introduction NHL patients with refractory disease or relapsing after autologous or allogeneic stem cell transplant (SCT) have very poor prognosis with currently available salvage chemotherapy. Sorafenib (Nexavar, BAY43-9006, Bayer) is an oral multikinase inhibitor approved by FDA for the treatment of renal cell carcinoma and hepatocellular carcinoma. Sorafenib exerts a broad range of antiproliferative, antiangiogenic, and proapoptotic effects against a variety of nonhematological tumors through the inhibition of the RAF/MEK/ERK pathway, the receptor tyrosine kinases c-kit, Flt3, RET, as well as the proangiogenic vascular endothelial growth factor receptors (VEGFRs), and platelet-derived growth factor receptor-β (PDGFR-β). Several lines of evidence suggest that Sorafenib might have a significant clinical impact in the treatment of malignant lymphomas by overcoming the cytoprotective effects of Bcl-XL, ERK, and Mcl-1 and eventually targeting additional signalling pathways relevant to lymphomagenesis. Our preclinical data demonstrating a marked cytotoxic activity of Sorafenib against NHL cell lines in vitro and in vivo in xenograft models, established the rationale for this currently ongoing phase II study aimed to determine safety and activity of Sorafenib in relapsed/refractory NHL. Methods Between March 2008 and May 2009, 21 patients (16 males and 5 females; median age, 65 years; range, 29-74 years) with relapsed/refractory diffuse large B cell lymphoma (DLBCL, n = 11), follicular lymphoma (FL, n =4), mantle cell lymphoma (MCL, n =2), lymphoplasmacitoid lymphoma (LPL, n =1), chronic lymphocytic leukemia (CLL, n =2), and peripheral T-cell lymphoma (PTCL, n =1) who have failed second- or subsequent-line salvage chemo-radiotherapy were enrolled in this phase II trial. Prior to study entry, patients received a median of 4 (range 2 - 7) lines of treatment, including autologous SCT in 15 (71%) and an additional allogeneic SCT in 5 (24%) cases. At study entry, 7 (33%) patients had relapsed and 14 (67%) refractory disease. Eligibility criteria included absence of any available treatment options of proven efficacy, at least one target lesion ≥2 cm, ECOG performance status of 0-1, and adequate bone marrow, liver and renal functions. Sorafenib (400 mg BID, per os) was administered continuously until disease progression or appearance of clinical significant toxicity probably related to study drug. Tumor responses were assessed according to the revised response criteria for malignant lymphoma of the International Working Group. NCI CTCAE v3.0 was used for toxicity assessment. Results To date, 21 patients received a median of 3 months (range, 1 – 11) of Sorafenib therapy. All patients are evaluable for toxicity and response, and 1 patient is still on therapy. Overall, therapy was well tolerated without significant adverse events. The most common drug-related non-hematological toxicities were grade 1-2 mucositis (14%), diarrhea (24%), hand-foot syndrome (24%), anorexia (29%), and fatigue (29%). Grade 3-4 hand-foot syndrome occurred in 19% of patients. Hematological toxicities included grade 1-2 neutropenia (10%) and thrombocytopenia (24%). Grade 3-4 neutropenia and thrombocytopenia were observed in 14%, and 24% of patients, respectively. Best response to Sorafenib included 1 (5%) complete remission (CR) occurring in the patient with LPL, and 1 (5%) partial remission (PR) in a patient with cutaneous DLBCL, for an overall response rate (ORR) of 10%. In both patients, response duration was 6 months. In addition, 9 (42%) patients achieved stable disease (SD) for a median of 3 months (range, 2 – 10), with 3 (14%) patients achieving SD for ≥6 months, while 10 (48%) patients progressed. Upon Sorafenib treatment, an extensive necrosis involving the central area of the tumor associated with a nearly complete disappearance of tumor vascularization was documented by computed tomography and contrast-enhanced ultrasound in two DLBCL and one FL patients bearing latero-cervical or abdominal lymphoid masses. Conclusions Sorafenib as a single agent was well tolerated. Despite limited clinical activity (10% ORR), disease stabilization was experienced by 42% of patients. The potent antiangiogenic activity of Sorafenib in NHL patients bearing highly vascularized lymphoid masses suggests that further research should focus on combinations of Sorafenib with molecularly targeted agents eventually exerting antivascular activities. Disclosures Off Label Use: The multikinase inhibitor Sorafenib has been used in a phase II trial in patients with relapsed/refractory NHL.

Description: Recent trials have shown that anti-CD20 monoclonal antibody Rituximab may be effectively employed in association with high-dose (hd) chemotherapy and peripheral blood progenitor cell (PBPC) autograft in the management of high-risk B-cell lymphoma. Addition of Rituximab has a dual effect: increased tumour cytoreduction and in vivo purging prior to PBPC harvesting. We here report the results of a prospective, multicenter trial evaluating Rituximab-supplemented hd-sequential chemotherapy (R-HDS) as frontline treatment in patients with high-risk Diffuse Large B-Cell Lymphoma (DLBCL). So far, 6 Italian Centres associated to GITIL have participated to the study. Eligibility criteria included: i. biopsy-proven DLBCL, with CD20+ phenotype; ii. no previous cytotoxic treatments; iii. age between 16–60 yrs.; iv. advanced stage disease with 2–3 aaIPI score. The R-HDS regimen includes an initial debulkying (3 APO courses) and then the sequential administration, at 15–20 day intervals, of: i. cyclophosphamide (CY) 7gr/sqm (day 1) + Rituximab 375mg/sqm (day +2 and +10), followed by PBPC harvest; ii. Ara-C 2gr/sqm b.i.d. for 6 days, reinfusion of 1–3x106 autologous CD34+ve cells/kg (day 7) and then Rituximab 375mg/sqm (day +8 and day +18); iii. etoposide 2.4gr/sqm day +1 + Cisplatin 100mg/sqm day +2; iv. a final myeloablative regimen (Mitoxantrone 60mg/sqm + L-Pam 180mg/sqm), with PBPC autograft (≥5x106 CD34+ve cells/kg) + Rituximab 375 mg/sqm (day +30 and +37); v. involved-field radiotherapy on areas of previous bulky lesions or residual lesions, within 2–3 mos. following autograft. Presently, 91 patients (median age: 48 yrs.) have been enrolled and are evaluable. They all had 2 (58) or 3 (33) aaIPI score; in addition, 63 (69%) presented with disease-related symptoms, 52 (57%) had extranodal disease, and 27 (30%) had BM involvement. There were 4 early toxic deaths (three due to sepsis following CY, Ara-C and autograft, respectively, and one due to leucoencephalopathy from JC-virus infection 2 mos. after autograft); one more toxic death due to pneumonia occurred at 10 mos. after R-HDS, for an overall TRM of 5.5%. In addition, 21 patients had CMV or VZV reactivation that resolved after antiviral therapy. Overall 73 patients (80 %) reached CR. So far, at a median follow-up of 24 mos., 76 patients (83.5%) are alive and 68 (75%) are in continuous CR (CCR), with 4.3-yr OS and and EFS projections of 80% and 74%, respectively. There was a trend towards a better outcome in aaIPI 2 vs. 3, although the difference was not statistically significative. Among 27 patients with BM+, 17 (63%) are presently in CCR, at a median follow-up of 25 mos. In conclusion, R-HDS was feasible at the multicenter level although the occurrence of severe infectious complications should not be underestimated. Nevertheless, both CR rate and survival curve projections compare favorably with the poor outcome usually observed in aaIPI 2–3 patients managed with conventional chemotherapy. The results here presented urge a comparative analysis between conventional vs. intensified Rituximab-supplemented chemoimmunotherapy in younger patients with high-risk DLBCL.

Description: Introduction TNF-related apoptosis-inducing ligand (TRAIL) is a protein functioning as a ligand that induces the process of cell death. TRAIL has been shown to kill in vitro a wide variety of tumor cells with minimal effects on normal cells. Despite its in vitro activity, recombinant soluble TRAIL has so far shown limited efficacy in vivo. In contrast, recent reports have shown that significant apoptosis can be observed both in vitro and in vivo when TRAIL is expressed on the cell membrane (mTRAIL). A further innovation might be the delivery of bioactive proapoptotic TRAIL through its expression by extracellular vescicles (EVs), the nanovesicular organelles secreted by cells. In fact, EVs are viewed as an effective tool for intercellular cross-talk and receptor discharge. The trans-membrane expression of TRAIL ligand within the double layer exosomal membrane may induce a more potent death signal when compared with the soluble molecule. Material and Methods Mesenchymal Stromal Cells (MSC) from bone marrow were cultured in vitro and used for EVs production. Cultured MSC in 75 cm2 flasks, at 80% confluence were infected with a lentivector encoding TRAIL, maintained in culture, and cell-supernatants repeatedly collected over several days, ultracentrifugated, with EVs-containing pellet harvested in PBS. EVs were produced also from uninfected MSC as control (EVs-CTRL). EVs were characterized by flow cytometry for expression of MSC markers and mTRAIL, EV size was evaluated by NanoSight technology. Total protein concentration was used to quantify EVs, Western Blot analysis was performed to characterize membrane-bound TRAIL. In vitro analysis was performed on SU-DHL-4 (human B cell lymphoma) and MEL-1300 (human melanoma) cell lines, exposed for 24 hours to 20-100 μg/ml EVs-TRAIL or EVs-CTRL. Annexin/propidium iodide assay was used to quantify apoptotic/necrotic cells. For the in vivo assessments, SU-DHL-4 and MEL-1300 cells were transduced with Luc-Lentiviral particles to obtain Luciferase positive cell lines. These cells were used to engraft NOD scid gamma (NSG) mice (2x106 SU-DHL-4 and 3x105 MEL-1300 cells for each subcutaneous injection point). To visualize tumor cells, mice were injected intraperitoneum with luciferin and analyzed with the Xenogen system. Mice bearing subcutaneous tumor nodules received single intravenous injections of 100, 200, 300 µg or multiple (x 3) 200 µg injections of either EVs-TRAIL or EVs-CTRL. Results FACS analysis showed strong TRAIL expression on EVs from TRAIL-infected MSC compared to EVs-CTRL, with a high proportion of positive particles (median 85%, range 78-93). In addition, EVs-TRAIL displayed MSC membrane markers, i.e. CD 105, CD 90, CD73 and CXCR4. Western Blot analysis under non-reducing conditions showed the presence of TRAIL ligand, with strong prevalence of dimeric TRAIL isoform (barely detectable the trimeric isoform, undetectable monomeric isoforms). NanoSight analysis revealed that EVs had a variable size, up to approximately 400 nm in diameter, with a predominant peak at 273 nm. A strong and dose-dependent cytotoxic effect was observed on SU-DHL-4 cells exposed to EVs-TRAIL (annexin/PI+ve cells: up to 87% for 100 μg/ml EVs-TRAIL), compared to EVs-CTRL exposure (15% Annexin/PI+ve cells for 100 μg/ml EVs-TRAIL). A similar, albeit less pronounced in vitro cytotoxic effect of EVs-TRAIL was observed on the melanoma MEL-1300 cell line. The anti-tumor effect was remarkably strong when EVs-TRAIL were injected in vivo in mice bearing either SU-DHL-4 or MEL-1300 nodules. A marked reduction of the tumor luminescence from 1.2x1010 photon/sec to

Description: Background. Recent reports have shown that Rituximab added to conventional chemotherapy may significantly improve the prognosis of CD20-positive Diffuse Large B-cell Lymphoma (DLB-CL). However, patients with unfavorable clinical presentation still have a poor outcome. Other studies have documented an increased anti-lymphoma activity upon addition of Rituximab to intensified treatments with autologous peripheral blood stem cell (PBSC) transplantation. Based on these premises, a prospective multicenter study has been performed on the use of a Rituximab-supplemented high-dose sequential (R-HDS) chemotherapy schedule with PBPC autografting in patients with unfavorable DLB-CL, defined as score 2 and 3 (intermediate-high or high) according to the age-adjusted International Prognostic Index (aaIPI). Methods. The R-HDS regimen included: (i) an initial debulkying with 3 APO courses; (ii) a high-dose (hd) phase consisting in the sequential administration, at 15–20 day intervals, of hd- cyclophosphamide (7gr/sqm, with two Rituximab doses at 375 mg/sqm), hd-Ara-C (2gr/sqm b.i.d. for 6 days with Rituximab), and hd etoposide + Cisplatin; (iii) a final myeloablative phase (hd-Mitoxantrone + L-Pam) with PBSC autografting and 2 more doses of Rituximab. Involved-field radiotherapy was scheduled on areas of previous bulky disease or residual lesions. Six Centers affiliated to the GITIL group (Gruppo Italiano Terapie Innovative nei Linfomi) participated in the multicenter study. Patient enrollment started in November 1999 and was closed in September 2004. Results. Overall, 112 previously untreated patients aged ≤ 60 years, with CD20-positive DLB-CL and aaIPI score 2 (74 pts) or 3 (38 pts), entered the study protocol and are evaluable. There were 5 early toxic deaths (3 sepsis in the hd-phase, 1 pneumonia and 1 leucoencephalopathy from JC-virus infection after autografting) and one late toxic death due to pneumonia which occurred at 10 mos. after R-HDS. The TRM was 5.3%. Ninety patients (80 %) achieved Complete Remission (CR). At a median follow-up of 24 mos, 90 patients (80%) are alive and 83 (74%) are in continuous CR (CCR), leading to a 5.3-yr event-free survival (EFS) projection of 71%. There was a trend towards a better outcome in aaIPI 2 vs. 3, although the difference was not statistically significant. Conclusions. The CR, OS and EFS rates observed after R-HDS compare favorably with the poor outcome anticipated in aaIPI 2–3 patients managed with conventional chemotherapy. The results of this phase II study prompted an ongoing phase III GITIL multicenter study to compare R-CHOP vs. R-HDS in younger patients with high-risk DLB-CL.

Description: Introduction A randomized multicenter study of 134 Follicular Lymphoma (FL) patients, selected for age less than 60 yrs. and poor prognostic features according to age-adjusted IPI (2-3) and IIL-score (3 or greater) was conducted between March 2000 and May 2005, among 30 Italian Centers. The study compared efficacy and tolerability of CHOP-R vs. R-HDS with autograft as primary treatment in poor-risk FL. Initial results have been already reported (Ladetto M et al, Blood 2008), showing superior disease control with R-HDS without any survival advantage. We have recently updated the long-term outcome and the results at long-term are here presented at a median follow-up of 9.5 yrs. Patients and Methods Of the original 134 randomized patients, the long-term outcome has been updated for 125 patients, 61 of CHOP-R and 64 of R-HDS arms. Clinical characteristics at study entry and treatment schedules have been already reported. Briefly, the main features of the updated patients included: median age 51 yrs. (22-60), M/F ratio 74/51, aaIPI 2-3 90%, FLIPI 〉2 (retrospectively assigned) 60%, high LDH 49%, bulky disease 62%, B-symptoms 45%, BM involvement 86%. Clinical characteristics were balanced among the two arms. Treatment schedule consisted of: i. standard arm: 6 courses of cyclo-phosphamide/doxorubicin/vincristine/prednisone followed by 4-weekly rituximab courses (CHOP-R); ii. experimental arm: rituximab-supplemented high-dose sequential chemotherapy with autografting (R-HDS). The analysis was intention to treat with event-free survival as the primary endpoint. Minimal residual disease was evaluated post treatment in 58 patients with a bcl-2/IgH MBR or mcr translocation confirmed at diagnosis by nested PCR. The trial was registered at www.clinicaltrials.gov as no. NCT00435955. The long-term outcome has been updated in July 2013 by 28 out of 30 participating Centers accounting for 125 patients (93% of the whole series). Results Complete remission (CR) was achieved by 88 (70.4%) patients, including 35 (57%) with CHOP-R and 53 (83%) with R-HDS (p 〈 .001); in addition, 37 out of 58 (64%) patients achieved a Molecular Remission (MR). At a median follow-up (MFU) of 9.5 yrs., 88 patients (70.4%) are alive. Overall, 19 patients died for lymphoma progression (11 in the CHOP-R, 8 in the R-HDS arms), there were nine deaths for secondary malignancy (3 in the CHOP-R, 6 in the R-HDS arms), nine more patients died for other causes, including four early toxic deaths. The overall survival projection for the whole series is 78% and 70% at 5 and 10 yrs., respectively. As shown in Figure 1, there were no main differences in the long-term OS between the two arms, with 5 and 10 yrs projections respectively of 75% and 70% for CHOP-R and 81% and 70% for R-HDS (p=0.96). Response to primary treatment had a major impact on the OS, with 5 and 10 yr survival projections respectively of 90% and 80% for patients achieving CR, and of 49 and 43 for those with less than CR (p 〈 .001) (Figure 2A). Similarly, MR achievement was associated with prolonged overall survival, with 5 and 10 yr survival projections respectively of 89% and 83% for patients with PCR-ve on BM cells, and of 76 and 57 for those with persistent PCR-positivity (p = .03) (Figure 2B). Conclusion The long-term follow-up of the randomized CHOP-R vs. R-HDS trial indicate that: i. poor risk FL may now experience a prolonged survival, with approximately 70% of patients alive at 10 yrs., due to the combined efficacy of both primary chemo-immunotherapy and salvage treatments; ii. the superior disease control of R-HDS compared to CHOP-R does not translate in any survival advantage, with analogous OS regardless of which treatment is used; iii. also in FL like in other lymphoproliferative malignancies, achieving CR and MR is crucial not only for the disease control but also for long-term overall survival; iv. lymphoma progression remains the major cause of death, while secondary neoplasms, in particular secondary leukemias represent the second cause of treatment failure. Thus, efforts are still needed in order to increase the anti-tumor efficacy while reducing any potential late effect in treatment options for FL. Disclosures: Tarella: Roche Co.: support and honoraria for Conference participation Other. Ladetto:Roche: Honoraria, Research Funding, Speakers Bureau.

Description: Introduction. High-dose (hd) therapy with stem cell autograft is an effective treatment for both non-Hodgkins (NHL) and Hodgkins Lymphoma (HL). However, the occurrence of secondary myelodysplastic syndrome/acute leukemia (sMDS/AL) is a critical issue, representing a major cause of failure in patients potentially cured after hd-therapy. Aim of the study. To evaluate incidence and risk factors of sMDS/AL in a large series of lymphoma patients, treated with the hd-sequential (HDS) chemotherapy approach, followed by peripheral blood progenitor cell (PBPC) autograft. Patients and Methods. Data have been collected on 1,347 lymphoma patients treated in the last two decades at 11 Centers, associated to GITIL (Gruppo Italiano Terapie Innovative nei Linfomi). The series included 234 HL and 1,110 NHL (276 low-grade); median age was 46 yrs; 771 were male; 640 (47.5%) patients received HDS front-line, 707 as salvage treatment. All patients received either the original or the modified HDS regimen: 152 (13%) patients were unable to complete the program with autograft; among 1,171 autografted patients, only 79 received a TBI-conditioning regimen. Nearly all patients (97%) were autografted with PBPC (median CD34+ cells: 8 × 106/kg), only a few received BM cells; PBPC were usually collected after hd-cyclophosphamide, or, in a subgroup (28%), after a 2nd round of mobilization, with hd-Ara-C; there were no significant differences in the amount of infused cells between PBPC of the 1st vs. the 2nd mobilization course. HDS was supplemented with Rituximab in 525 (39%) patients. Results. At a median follow-up of 5.5 yrs, Overall Survival projections at 5 and 10 yrs are, respectively, 62% and 54% for the whole series, 69% and 61% for patients treated at diagnosis. Overall, 46 (3.4%) patients developed s-MDS/AL, with a cumulative incidence of sMDS/AL of 3.2%, 4.7% and 8.4% at 5, 10 and 20 yrs, respectively. Median time of s-MDS/AL occurrence was 35 months since autograft. In competing risk univariate analysis, a few clinical parameters, including age 〉 45 yrs, male sex, advanced stage, Rituximab administration, autograft with PBPC of 2nd round of mobilization, displayed a variable increase in the cumulative incidence of sMDS/AL; however, on multivariate analysis, only male gender and reinfusion of PBPC of the 2nd mobilization course were associated with sMDS/AL occurrence (SDHR: 2.93, p=0.007 for male gender; 2.54, p=0.004 for graft with PBPC collected at the 2nd round). Conclusions. Overall incidence of sMDS/AL in HDS-treated patients is analogous to that reported in other recent surveys on lymphoma patients treated with hd-therapy and autograft, with a higher risk recorded among males; furthermore, the study suggests that the quality of CD34+ve cells employed for autograft may be critical for the post-graft development of sMDS/AL.

Description: Background The outcome of Diffuse Large B Cell Lymphoma (DLB-CL) has been definitely improved by the addition of the anti-CD20 rituximab to conventional chemotherapy. However, despite the advantages offered by rituximab, results are still disappointing in patients presenting with adverse prognostic factors. For these patients, rituximab-supplemented intensive programs with autograft might represent a suitable option. Thus, a prospective multicenter study has been performed using first-line the Rituximab-supplemented high-dose sequential chemotherapy program delivered with multiple autologous peripheral blood progenitor cell (PBPC) support (R-HDS-maps regimen), in DLB-CL patients with score 2 or 3 according to the age-adjusted International Prognostic Index (aaIPI). Preliminary results have been already reported (ASH 2005; Leukemia2007, 21: 1802). Updated results after a prolonged follow-up are here presented. Methods. R-HDS-maps includes: 3 APO courses; sequential administration of hd-cyclophosphamide (CY), hd-Ara-C, both supplemented with Rituximab, hd-etoposide/Cisplatin, with PBPC harvests following hd-CY and hd-Ara-C; hd-Mitoxantrone/L-Pam + 2 further Rituximab doses; involved-field radiotherapy. PBPC rescue was scheduled following Ara-C, etoposide/Cisplatin and Mitoxantrone/L-Pam. Six GITIL Centers participated in the multicenter study, with patients enrolled between November 1999 and September 2004. Results. Overall, 112 consecutive patients (74 score 2, 38 score 3) entered the study protocol. There were 5 early toxic deaths (3 sepsis, 1 pneumonia, 1 JC-virus leucoencephalopathy) + one late toxic death due to pneumonia, at 10 mos.; two more patients died for secondary myelodysplastic syndrome at 3.4 and 3.6 yrs. As reported in Figures 1–2, at a median follow-up of 59 mos., 86 patients (77%) are alive; 79 (70%) are in continuous CR, with a 5-yr event-free survival (EFS) projections of 69%; no significant differences in OS and EFS between subgroups with Germinal-Center and Activated B-cell phenotype were observed. Conclusions. R-HDS-maps regimen: is feasible in a multicenter setting, with a toxicity similar to that of other dose-intense/high-dose regimens; offers prolonged survival to most patients with aaIPI 2–3 DLB-CL. Its comparative efficacy versus R-CHOP-14 is being tested in an ongoing GITIL phase III study. Figure 1 . Overall Survival of 112 aaIPI DLB-CL Figure 1. . Overall Survival of 112 aaIPI DLB-CL Figure 2. Event-free Survival according to GC and ABC phenotype Figure 2. Event-free Survival according to GC and ABC phenotype

Description: We reported that the clinical efficacy of dendritic cell–based vaccination is strongly associated with immunologic responses in relapsed B-cell non-Hodgkin lymphoma (B-NHL) patients. We have now investigated whether postvaccination antibodies from responders recognize novel shared NHL-restricted antigens. Immunohistochemistry and flow cytometry showed that they cross-react with allogeneic B-NHLs at significantly higher levels than their matched prevaccination samples or nonresponders' antibodies. Western blot analysis of DOHH-2 lymphoma proteome revealed a sharp band migrating at approximately 100 to 110 kDa only with postvaccine repertoires from responders. Mass spectrometry identified heat shock protein-105 (HSP105) in that molecular weight interval. Flow cytometry and immunohistochemistry disclosed HSP105 on the cell membrane and in the cytoplasm of B-NHL cell lines and 97 diagnostic specimens. A direct correlation between HSP105 expression and lymphoma aggressiveness was also apparent. Treatment of aggressive human B-NHL cell lines with an anti-HSP105 antibody had no direct effects on cell cycle or apoptosis but significantly reduced the tumor burden in xenotransplanted immunodeficient mice. In vivo antilymphoma activity of HSP105 engagement was associated with a significant local increase of Granzyme B+ killer cells that very likely contributed to the tumor-restricted necrosis. Our study adds HSP105 to the list of nononcogenes that can be exploited as antilymphoma targets.

Description: Background: The outcome of B-cell lymphoma has definitely improved since the introduction of the anti-CD20 Rituximab, which can be effectively combined into conventional chemotherapy regimens. Rituximab can also be added to high-dose chemotherapy programs with autograft. However, the clinical benefit of combining Rituximab and autograft-based programs has not been proved yet. This issue is addressed in the present study. Patients and Methods: Data have been retrospectively collected on 957 B-cell lymphoma patients receiving a high-dose sequential (HDS) chemotherapy program, at 10 Italian Centers associated to GITIL (Gruppo Italiano Terapie Innovative nei Linfomi). Although the HDS schedule has been introduced almost 20 yrs. ago, most patients were treated in the last decade. They received most frequently either the HDS scheme adapted for follicular lymphoma (Tarella C et al. Leukemia 2000) or the hd-Ara-C-supplemented scheme developed for mantle-cell and diffuse large cell lymphoma (Magni M et al, Blood 2000; Cuttica A et al., Cancer 2003); overall, Rituximab was added to HDS (R+) in 483 (50.5%) patients, the remaining 474 (49.5%) received Rituximab-free HDS (R−). All patients entered the HDS-protocols due to high-risk prognostic features, their median age was 49 yrs. (range 17–70). The series included 403 patients (232 R+) with low-grade and 554 (251 R+) with intermediate/high grade B-cell lymphoma subtypes; HDS was delivered to 542 (259 R+) patients at diagnosis and to 415 (224 R+) at first or subsequent relapse. Results: at a median follow-up of 5 yrs, the 5-yr Overall Survival (OS) and Event-free Survival (EFS) projections were 66% and 55%, respectively, with a significantly better outcome for patients treated at diagnosis (5-yr OS: 72%, EFS: 61%) compared to patients at relapse (5-yr OS: 56%, EFS: 45%). In all instances, Rituximab addition was associated with significant improvements; in particular, the 5-yr EFS projections were:patients at diagnosis: 68% for R+ vs. 57% for R−;patients at relapse: 59% for R+ vs. 34% for R−;low-grade subtypes: 65% for R+ vs. 41% for R− (Figure 1A);intermediate/high-grade subtypes: 64% for R+ vs. 52% for R− (Figure 1B). In the Cox multivariate survival analysis, two factors had a significant impact on the EFS, i.e. relapse status at HDS (HR: 1.74, c.i.: 1.43–2.13) and Rituximab addition to HDS (HR: 0.60, c.i.: 0.49–0.75). Conclusions: the addition of Rituximab to high-dose programs with autograft may improve response and long-term outcome in high-risk B-cell lymphoma patients. Figure 1. EFS according to Rituximab [R] administration, in (A) low-grade and (B) intermediate/high-grade, B-cell lymphoma patients treated with a HDS program Figure 1. EFS according to Rituximab [R] administration, in (A) low-grade and (B) intermediate/high-grade, B-cell lymphoma patients treated with a HDS program