ALBERT

Description: Abstract 2638 Although patients with early-stage Hodgkin's lymphoma (HL) overall have a high rate of cure, they cannot be considered as a homogeneous group. In fact, a portion of these patients are resistant to or may relapse after standard treatment. Current prognostic criteria based on clinical and laboratory parameters at diagnosis do not allow to accurately identify the subset of patients with less favorable clinical outcome. In a study aimed at defining new biomarkers for risk stratification, an increased number of tumor-associated macrophages was found to be strongly associated with shortened survival in patients with classic Hodgkin's lymphoma [N Engl J Med. 2010 Mar 11;362(10):875-85]. The aim of this study was to evaluate the clinical significance of the proportion of CD68-positive infiltrating macrophages in patients with early-stage Hodgkin's lymphoma. By using an immunohistochemistry method, we analyzed diagnostic biopsies of 63 patients followed at our institution between 2006 and 2010, and uniformly treated with ABVD (adriamycin, bleomycin, vinblastine, dacarbazine) chemotherapy. Thirty-nine (62%) patients were males and 24 (38%) were females; median age at diagnosis was 30 years (range 17–85). Histological subtype was nodular sclerosis HL in 55 cases, mixed cellularity HL in 3 cases, lymphocyte-rich HL in 3 cases, and not classified in 2 cases. Five patients had subdiaphragmatic disease while 58 had supradiaphragmatic localizations. Forty-four patients with supradiaphragmatic disease were classified in the EORTC unfavorable subset: in detail, 25 patients had B symptoms and ESR ≥30, or ESR ≥50 despite the absence of B symptoms, 29 patients had bulky disease, 7 patients were older than 50 years, and 6 patients had more than 3 nodal areas involved. Thirty-six out of 63 (59%) patients received radiotherapy as a consolidation treatment after chemotherapy. After completion of the therapeutic program, 54 out of 63 (86%) patients obtained complete remission, while 9 (14%) had refractory disease; 15 out of 54 (28%) patients in complete remission relapsed during follow up. Diagnostic biopsies were reviewed by expert hematopathologists and classified into 3 groups according to the intensity of CD68 expression [N Engl J Med. 2010 Mar 11;362(10):875-85]. CD68-positive infiltrate was lower than 5% in 14 patients (group A), between 5 and 25% in 43 patients (group B), and greater than 25% in 6 patients (group C). Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method with observation time calculated from diagnosis. Comparison between survival curves was performed by means of the Gehan-Wilcoxon test. The 2-year OS and PFS in the entire cohort were 98% and 79%, respectively. There was a difference in the 2-year PFS between patients with favorable and those with unfavorable prognosis according to the EORTC risk criteria (100% vs 72%, P

Description: Key Points Somatic indels of CALR exon 9 are present in about 20% to 25% of sporadic patients with essential thrombocythemia or primary myelofibrosis. These mutations are found also in familial cases of essential thrombocythemia or primary myelofibrosis as somatically acquired events.

Description: Imatinib (IM) is a cornerstone in the treatment of chronic myeloid leukemia (CML). Dose change or discontinuation of IM in patients who experience sustained molecular response is a subject of debate. We retrospectively studied 142 CML patients in chronic phase (Table 1) treated with IM and followed-up during 2000-2013 at our institution. Dose changes, discontinuation of therapy, cytogenetic and molecular analyses were regularly recorded during follow-up. Patients’ history was subdivided into 483 treatment time-periods at constant dosage. Response was evaluated at the end of each treatment period. We assessed whether the probability of observing a complete cytogenetic response (CCyR) or a molecular response (MR: complete, CMR or major, MMR) or a progression were influenced by treatment dose and/or duration. We applied generalized estimating equation (GEE) logistic models for the analysis of longitudinal panel data. These models are designed to account for individual patient variation due to repeated measurements during each patient’s follow-up. Out of 483 time periods at constant IM dose, 236 were followed by dose modification, 116 by IM discontinuation, 29 by a change to other treatments due to tolerability issues or non-response; 102 were still ongoing without dose changes. Treatment response: 74% of time periods resulted in a CCyR and 2.3% showed no response; 31.9% showed a CMR, 29.6% showed a MMR (MR3, MR4, MR4.5), 35.6% a suboptimal response, 2.9% no MR. CMR+MMR was observed in 61.5% time periods. Periods at standard dose showed a higher response rate, both when considering CCyR (response rate after low, standard, high dose: 69.3%, 79.6%, 68%, respectively, P=0.023) and when considering MR (CMR after low, standard, high dose: 27%, 40.5%, 15.4%, respectively, P

Description: This study investigated Thiotepa (TT) and Fludarabine (Fluda) as a preparative regimen for allogeneic peripheral stem cell transplantation in patients with myelodysplastic syndrome (MDS) or acute leukemia from MDS (MDS-AML) older than 50 or with comorbidities contraindicating standard conditioning. Patients were prepared with TT, given over 3 hours as an i.v. infusion at a dose of 10 mg/kg over two days (day -8 and day -7) and Fluda at the dose of 125 mg/m2 i.v. over five days ( from day -7 to day -3). Fresh or cryopreserved allogeneic peripheral stem cells were infused on day 0 or +1. Graft-versus-Host Disease (GvHD) prophylaxis consisted of cyclosporine A (CyA) at the dose of 1.5 mg/kg day as a continuous iv infusion from day -5 until engraftment. The CyA was then administered orally at the dose of 3 mg/kg twice a day. Doses were adjusted to maintain plasma level concentrations between 150–350 mg/dL. From day +60, in the absence of acute GvHD, the CyA was tapered down by 20% every 2 weeks until withdrawal. In addition, patients received methotrexate 10 mg/m2 on day +1, and 8 mg/m2 on days + 3, +6 and +11 after transplantation. At the time of transplantation, patients were classified in two risk groups (low vs high risk) according to IPSS score (low/intermediate-1 vs. intermediate-2/high) for MDS patients, and disease status (CR vs. not CR) for MDS-AML. Kaplan-Meier survival analysis was carried out to compare Overall Survival (OS), Transplant-Related Mortality (TRM) and probability of relapse. Fifty patients (29 males, 21 females) entered the study; the median age was 54 years (range 38–71). Sixteen MDS patients had a low/intermediate 1 score according to the International Prognostic Score System (IPSS), 16 had an intermediate 2/high IPSS score, 18 had MDS-AML. Thirty patients underwent transplantation as front-line therapy, 20 received one or more cycles of chemotherapy before transplant. Among the latter, nine with MDS-AML were in complete remission at the time of their transplant, while four were in a partial remission. The interval from diagnosis to transplantation ranged from 1 to 52 months (median value 11 months). Contraindications to a standard conditioning regimen were liver disease, hypertrophic cardiomyopathy secondary to hypertension or valvular stenosis, cardiac arrhythmia, diabetes mellitus, hypothyroidism, previous CNS bleeding, and a history of sepsis. All but one patient achieved engraftment, with full donor chimerism by day +30. Patients were followed up for a median time of 21 months (range 0.2–87). TRM at 1 and 2 years after transplantation was 25% and 33%; the 5-year probability of relapse was 27%. Twenty-six patients are alive in complete remission, and the 5-year OS is 50%. The 5-year OS was 73% and 28% in low- and high-risk patients respectively (p=0.002). TRM at 1 and 2 years after transplantation was 13% and 21% in the low-risk group and 39% and 45% in the high-risk group (p=0.046); the 5-year probability of relapse was 10% and 50% in the low- and high-risk group respectively (p=0.015). In a multivariate Cox regression, risk group retained a borderline significance (HR=2.6, p=0.07) when adjusted by age at transplantation (p=0.03) and interval from diagnosis to transplant (n.s.). The combination of Thiotepa and Fludarabine is an effective and well-tolerated conditioning regimen in patients with MDS or MDS-AML who are poor candidates for standard myeloablative transplantation, particularly in MDS patients with low/intermediate-1 IPSS score and MDS-AML patients in CR.

Description: Abstract 3951 Poster Board III-887 Background An increased incidence of second cancers has been reported in some lymphoproliferative disorders. Whether the predisposition to other malignancies is due to disease-related immune-suppression rather than to the carcinogenic role of therapy given to treat the hematologic disease is still poorly understood. Purpose The aims of this study were to assess the frequency, characteristics and factors predicting second cancers in patients with WM and to evaluate whether WM patients are at increased risk of developing other malignancies as compared to an age- and sex-matched control population. Patients and methods The clinical records of 220 consecutive WM patients seen in two Hematologic centres of Northern Italy from 1980 to 2008 were reviewed. All cancers, with exception of non-melanoma skin cancers, were considered for this analysis. Standardized incidence ratios (SIRs), defined as the ratio between observed and expected cases, were used to compare the incidence of second cancers in WM with that of the general population. The number of expected cancers was obtained from age, sex and calendar-specific incidence rates reported by AIRTUM (Associazione Italiana Registri Tumori) for Northern Italy. A multivariate Cox proportional hazards regression model was used to examine risk factors for the development of second cancers. Therapy was analyzed as a time-dependent covariate. Results The median age of patients was 61 years (range: 26-86), 131 (60%) were males and 89 females (40%). The median follow-up was 4.8 years (range: 0.5-25). Overall, 136 patients (62%) with symptomatic WM received therapy, whereas a watch-and-wait policy was adopted in 84 patients (38%) with asymptomatic WM. Among treated patients, first-line therapy consisted of chlorambucil in 93 cases (68%), cyclophosphamide-based regimens in 15 (11%) and nucleoside analogs-containing regimens in 17 (13%). Rituximab was associated to chemotherapy in 19 patients (14%). Details on therapy were not available in 11 cases (8%). Overall, 52 second cancers were observed in 49 patients (22%). Forty-six patients (94%) had one malignancy and 3 (6%) developed two cancers. The types of cancer were: gastrointestinal (n=9, 17%), lung (n=8, 15%), breast (n=7, 13%), urinary tract (n=6, 11%), prostate (n=5, 10%), diffuse large B cell lymphoma (n=5, 10%), myelodysplastic syndrome/acute leukemia (n=3, 6%), brain (n=3, 6%), thyroid (n=2, 4%), mouth (n=2, 4%), other cancers (n=2, 4%). The diagnosis of cancer preceded that of WM in 13 cases (27%), was concomitant (within 3 months) in 6 (12%) and subsequent in 30 (61%). The median time from diagnosis of WM to the occurrence of a subsequent cancer was 4.3 years (range: 0.2-12.9). The cumulative probability of developing a second cancer after WM was respectively 11% at 5 years, 21% at 10 years and 33% at 15 years. As compared to the control population, the risk of second cancer in WM was 1.66 times higher than expected (95% CI: 1.16-2.37, p=0.005), without significant difference between males and females (p=0.7). In multivariate analysis, the risk of second cancer was not influenced by age (p=0.91), sex (p=0.45), reduction of IgG (p=0.91) or IgA (p=0.58) levels. In a time-dependent analysis, therapy given for WM did not increase the risk of developing a second malignancy (hazard ratio: 1.12, p=0.76). Conclusions This study shows that WM are at higher risk of developing second cancers as compared to the general population. We did not find an association between the occurrence of second cancers and treatment of WM. Disease-related immune-suppression may predispose WM patients to develop other malignancies. Disclosures: No relevant conflicts of interest to declare.

Description: Myelodysplastic syndromes (MDS) occur mainly in older persons, and these patients are likely to have comorbidities. We studied the impact of comorbidities on non-leukemic death (NLD) and overall survival (OS) in MDS patients with the aim of developing a specific prognostic index. Eight hundred forty consecutive patients receiving a diagnosis of MDS at Policlinico San Matteo, Pavia, Italy, between 1992 and 2006 were retrospectively evaluated. One or more comorbidities were present in 455/840 (54%) patients: the older the age, the higher their prevalence (P

Description: Polycythemia vera (PV) is a chronic myeloproliferative disorder with a propensity to develop myelofibrosis, a condition named post polycythemia vera myelofibrosis (post-PV MF). Survival and prognostic factors after transition to MF remain to be defined. We studied 68 patients with post-PV MF to define survival and prognostic factors for survival at diagnosis of post-PV MF. We also developed a dynamic prognostic model to predict survival at any time from diagnosis of post-PV MF. The median interval between the diagnosis of PV and that of post-PV MF was 13 years (range, 4–29.6 years). Patients with post-PV MF were observed for 181 person-years of follow-up. At diagnosis of post-PV MF, 43 (63%) of 68 patients had less than 65 years. During the follow-up, the incidence of thrombosis was 42 × 1000 person-years (95% CI: 19–93.5) and the incidence of leukemia was 50.3 × 1000 person-years (95% CI: 26–115). The median survival was 5.7 years. Multivariable Cox proportional hazard regression including age, hemoglobin value, platelet count, leukocyte count, and spleen size, showed that hemoglobin 〈 10 g/dL (P 〈 .001) and platelet count 〈 100 × 109/L (P= .026) were independent risk factors for survival. We stratified patients at diagnosis of post-PV MF, according to these factors, obtaining two risk groups with significantly different survival (P = .003): low risk (Hb 〉 10 g/dL and platelet count 〉 100 × 109/L) with a median survival of 7 years, and high risk (Hb 〈 10 g/dL or platelet count 〈 100 × 109/L) with a median survival of 2 years. The prognostic model retained significance after adjustment for age in a multivariable Cox proportional hazard regression (HR: 4.3, 95% CI: 1.6–11.4; P= .003). To assess whether this prognostic model may predict survival at any time from diagnosis of post-PV MF, we evaluated in a time-dependent analysis 64 patients who had longitudinal blood cell counts during follow-up. As first step, we evaluated univariate survival analysis with hemoglobin value 〈 10 g/dL and platelet count 〈 100 ×109/L as time-dependent covariates. Both time-dependent parameters affected survival (HR for hemoglobin 5.8, 95% CI: 2.2–15.2, P 〈 0.001; HR for platelets 4.5, 95% CI: 1.67-12, P=.002). As second step, we evaluated the prognostic model assessed at diagnosis as time-dependent covariate, to define whether the acquisition of one risk factor during follow-up may affect survival. The HR was 7.5 (95% CI: 2.4-23.4; P 〈 .001). The time-dependent prognostic model retained statistical significance after adjustment for age (P 〈 .001). In conclusion, in patients developing post-PV myelofibrosis, a prognostic model based on hemoglobin level 〈 10 g/dL and platelet count 〈 100 × 109/L may predict survival at diagnosis of post-PV MF and at any time thereafter.

Description: In splenic marginal zone B-cell lymphoma (SMZL) no specific genetic alterations are known. Abnormalities of chromosome 7p and of p53 are reported as adverse prognostic factors. In a recent multicentre study (Arcaini et al Blood 2006), a prognostic model based on hemoglobin, albumin and LDH identified 3 risk categories. HCV infection was present in nearly 20% of patients (pts). At now, no data are available on genetic alterations in the HCV-positive subset of SMZL and in the different prognostic categories. The aims of the study were: a) to analyze copy number alterations (CNAs) by means of array comparative genomic hybridization (array-CGH) with a resolution of ∼100 kb; b) to compare CNAs in HCV-positive and HCV-negative pts; c) to identify potential genetic alterations related to the clinical features and to the prognostic categories. We analyzed marrow and blood samples from 34 pts with SMZL: 22 were HCV-negative (serology and HCV-RNA) and 12 were HCV-positive (genotype 2a/2c in 10 pts, genotype 1 in 2). DNA was extracted from bone marrow (16) and peripheral blood lymphocytes (18) and was hybridized with pooled blood lymphocyte reference DNA on Agilent’s 44K oligonucleotide microarray (kit 44B). Images and data were analyzed using Agilent’s Feature Extraction (v9.1) and CGH analytics (v3.4.27) softwares. Ten cases (4 HCV+ and 6 HCV-) did not show CNAs. A single alteration was present in 7 pts, 2 to 5 alterations in 11 and 〉5 in 6. All CNAs were detected in mosaicism (from 20% to 90%). A median of 5.6 (range 1 to 20) and 3.8 (range 1 to 13) CNAs were detected in HCV+ and in HCV- cases, respectively. The most frequent CNAs were hetereogeneous in size with the following common regions: losses of 1p36.21-p35.3 (3 pts), 7q31.1-q32.3 (7 pts), 8p21.3-p12 (6 pts), 13q14.2-q14.3 (6 pts), 14q32.12-q32.13 (4 pts) and 17pter-p12 (8 pts); gains of 3q21.1-q29 (5 pts), 12q13.1-q21.31 (5 pts), 17q24.1-qter (4 pts), Xpter-p11.23 (4pts). A homozygous 13q14.2 deletion, overlapping that found in CLL and including Rb1 gene, was found in one HCV- pt. The del(7)(q31.1-q32.3) was the more frequent and it ranges from 14,1Mb to 34Mb. No difference in number of CNAs and in specific common regions alterations was found between HCV+ and HCV- cases except for dup(X)(pter-p11.23) (p=0.01, 4 HCV+ pts and none HCV- pt). High-risk prognostic category was significantly associated with del(7)(q31.1-q32.3) (p=0.01) and del(17)(pter-p12) (p=0.02). Mutational status of immunoglobulin variable heavy-chain gene was related to del(7)(q31.1-q32.3) (p=0.04) and dup(12)(q13.1-q21.31) (p=0.03). The presence of villous lymphocytes was associated with del(1)(p36.21-p35.3) (p=0.02); del(8)(p21.3–p12) was related to an autoimmune background in the HCV+ subset (p=0.04). The number of CNAs was associated to leukemic disease (p=0.02) and to the presence of villous lymphocytes (p=0.04). In conclusion, array-CGH in SMZL does not show specific genetic abnormalities for pts with HCV-positive or HCV-negative SMZL. 7q and 17p deletions are significantly associated with the high-risk prognostic category, clinically and biologically identifying a group of pts with aggressive disease.

Description: We evaluated the impact of World Health Organization (WHO) classification and WHO classification–based Prognostic Scoring System (WPSS) on the outcome of patients with myelodysplastic syndrome (MDS) who underwent allogeneic stem cell transplantation (allo-SCT) between 1990 and 2006. Five-year overall survival (OS) was 80% in refractory anemias, 57% in refractory cytopenias, 51% in refractory anemia with excess blasts 1 (RAEB-1), 28% in RAEB-2, and 25% in acute leukemia from MDS (P = .001). Five-year probability of relapse was 9%, 22%, 24%, 56%, and 53%, respectively (P 〈 .001). Five-year transplant-related mortality (TRM) was 14%, 39%, 38%, 34%, and 44%, respectively (P = .24). In multivariate analysis, WHO classification showed a significant effect on OS (P = .017) and probability of relapse (P = .01); transfusion dependency was associated with a reduced OS (P = .01) and increased TRM (P = .037), whereas WPSS showed a prognostic significance on both OS (P = .001) and probability of relapse (P 〈 .001). In patients without excess blasts, multilineage dysplasia and transfusion dependency affected OS (P = .001 and P = .009, respectively), and were associated with an increased TRM (P = .013 and P = .031, respectively). In these patients, WPSS identified 2 groups with different OS and TRM. These data suggest that WHO classification and WPSS have a relevant prognostic value in posttransplantation outcome of MDS patients.

Description: Splenic marginal zone B-cell lymphoma (SMZL) is a rare clinical and pathological entity recognized by the WHO classification. SMZL usually presents with isolated splenomegaly, bone marrow involvement, and leukemic picture. Nodal disease is generally rare at diagnosis. When lymphocytes with villous projections are found in peripheral blood, the disease is termed splenic lymphoma with villous lymphocytes (SLVL). High HCV-seroprevalence is frequently reported in SMZL. The disease commonly pursues an indolent course; however, about a third of pts follow a more aggressive course. SMZL is also heterogeneous with respect to the preferential usage of IgVH genes, as well as the percentage of mutation load. No previous studies correlated IgVH rearrangement features with the clinical characteristics of SMZL. The aim of the present study was to determine the tumor-related IgVH gene rearrangement and compare the gene usage and the mutation status with clinical features of 59 pts. Diagnosis was made according to the WHO classification and to the diagnostic criteria for SMZL (Matutes et al., Leukemia 2008). Paraffin sections from lesional tissues (14 spleens, and 59 bone marrow trephines) were available for all pts. Histology and blood smears were reviewed. Total RNA was extracted from PB (n=13) or BM (n=46) mononuclear cells. IgVH gene rearrangements were amplified using 6 family-specific VH leader primers coupled with a 3′ heavy chain joining (JH) primer or with a constant region of cμ chain primer. The sequence obtained from direct sequencing of the clonal PCR product was compared with germline in the IMGT database. Sixty VDJ rearrangements were amplified and 54 were functional. VH1 family was used in 19 rearrangements (32%), VH3 family in 33 (55%) and VH4 family in 8 (13%). The most frequent VH genes were VH1-02 (n=13), VH3-23 (n=15), VH3-30 (n=7) and VH4-34 (n=5) (67% of all sequences). VH was unmutated in 25%. DH segments were assignable in 56/60 rearrangements (all of the VH unmutated and 41/45 of VH mutated). The most frequent DH families were DH2 (n=9) and DH3 (n=21); the most frequent DH genes were DH3-03 (n=8), DH3-22 (n=6) and DH2-02 (n=6). Most rearrangements used JH4 family (n=21), JH5 (n=8), and JH6 (n=19), accounting for 80% of all rearrangements. JH4b (n=14), JH6b (n=10), and JH6c (n=8) were the most common JH genes. Median length of HCDR3 region was 17 aa (range 11–32). For antigen selection analysis P value was 〈 0.05 in 41% for CDRs and in 55% for FRs. No correlation was found among VH and DH families (p=0.1), among VH and JH families (p=0.09) and among DH and JH families (p=0.4). Forty-two % of pts were unmutated in VH1 family, 15% in VH3 family and 25% in VH4 family (p=0.09). Unmutated cases were 7% in VH3-23 group, 46% in VH1-02 group and 14% in VH3-30 group (p=0.03). For clinical correlations we considered only the 54 functional rearrangements. Villous lymphocytes 〉10% were detected in 53% of VH1 pts, in 57% of VH4 pts, and in 17% of VH3 pts (p=0.01). Villous lymphocytes 〉10% were detected in 21% of VH3-23 pts, in 50% of VH1-02 pts and in no VH3-30 pt (p=0.05). Liver involvement was present in 9% of VH3-23 pts, in no VH1-02 pt and in 50% of VH3-30 pts (p=0.009). HCV serology was positive in 7% of VH3-23 pts, 17% of VH1-02 pts and 50% of VH3-30 pts (p=0.04). Serum MC was detected in 50% of VH3-23 pts, in 9% of VH1-02 pts and in 17% of VH3-30 pts (p=0.06). BM was involved in 86% of VH3-23 pts, in 100% of VH1-02 pts and in 50% of VH3-30 pts (p=0.02). A sinusal localization was detected in 67% of VH3-23 pts, in 20% of VH1-02 and in 100% of VH3-30 (p=0.03). Unmutated status was significantly related to a higher percentage of BM infiltration (p=0.003). The proportion of intermediate and high risk patients according to the SMZL score (Arcaini et al. Blood 2006) was higher in the unmutated respect to the mutated group (69% vs 32%, p=0.05). After a median F-UP of 3 yrs, 10 pts died (7 of lymphoma, 3 of causes non related to lymphoma). The median OS was 12 yrs and the median PFS was 2 yrs. OS did not differ among VH families (p=0.9). Median PFS was 2 yrs for mutated pts and 1 yr for unmutated pts. We performed clustering of pts by applying a 2-means clustering algorithm, using as parameters nodal disease, villous lymphocytes 〉10%, HCV serology positive, BM involvement: in cluster 1 VH1 family pts accounted for 20%, VH3 family for 71%, VH4 family for 9%; in cluster 2 VH1 family pts accounted for 47%, VH3 family for 29% and VH4 family for 24% (p=0.01). In conclusion, VH rearrangement analysis in SMZL reveals a non-random preference for VH1-02, VH3-23 and VH3-30 genes, whose use differs according to distinctive clinical features at presentation.