ALBERT

Description: Several authors have reported ASCT as a feasible, safe and effective treatment in HIV associated lymphoma patients (pts) receiving Highly Active Antiretroviral Therapy (HAART), particularly when being autografted with chemosensitive disease. To gain a better understanding of the usefulness of ASCT in HIV+ Lymphoma pts a retrospective comparative study (HIV+ vs HIV- lymphoma pts with ASCT) has been performed using the EBMT-LWP Registry. Methodology: Registry-based, retrospective, individually matched case-control analysis. Within the participating centres one or two HIV- controls for each HIV+ pt were selected from the registry with the following inclusion criteria: Known HIV serological status at ASCT, lymphoma (HL or NHL), ASCT performed between 1999 and 2006 and pts over 18 years of age. Two cohorts (HIV+ vs HIV-) were matched for histology, IPI at diagnosis (NHL), stage at diagnosis, disease status at ASCT, age at ASCT, year and country of ASCT. Results: 40 HIV+ lymphoma pts undergoing an ASCT were matched with 46 HIV- pts. Pts and transplant features are shown in table 1. With a median follow up of 36 mo, the differences regarding OS and PFS were not significant: 62% for HIV+ vs 69% for controls, and 56.5 vs 58%, respectively. No differences were seen regarding HL and NHL pts. An overall TRM of 10% was observed in the HIV cohort, mainly related to infections, while no cases of TRM were seen within the control arm. Since survival rates between the HIV+ and the matched HIV- lymphoma populations remained comparable, the HIV condition should not preclude these pts from being treated according to the same criteria as the HIV negative lymphoma population. Nevertheless, infectious complications should be cautiously followed within the HIV+ lymphoma pts undergoing an ASCT. Patients and transplant features HIV+ HIV- n=40 % n=46 % Age [Median (range)] in years 41.4 (29.2–62.5) 44 (16–62.4) p= NS Male sex 35 87.5 25 54.3 p=0.001 Histology     DLBCL 24 60 25 54.3 p= NS     Burkitt lymphoma 2 5 2 4.3 p= NS     T-cell NHL 2 5 3 6.6 p= NS     HL 12 30 16 34.8 p= NS Disease status at ASCT     Complete remission (CR) 21 (12 in CR1) 52.5 (30 in CR1) 20 (11 in CR1) 43.5 (24 in CR1) p= NS     Chemosensitive disease 16 40 25 54.3 p= NS     Chemorefractory disease 3 7.5 1 2.2 p= NS CD34+ cells infused mill/kg [median (range)] 4.9 (1.6–21.2) 4.8 (0.9–21.2) p= NS     G-CSF prior to engraftment 36 90 21 46 p= 0.0001     Neutrophil engraftment 39 98% 46 100 p= NS Cause of Death     Relapse/progression 9 60% 10 84% p=0.08     Secondary malignancy 1 6.7% 1 8% p= NS     Transplant-related deaths 4 26.7% 0 0% p=0.06     Other 1 6.7% 1 8% p= NS

Description: Background: Autologous Transplantation with intermediate or high doses of Melphalan is the most effective therapy in patients with Multiple Myeloma being 〈 65 years old, although this procedure is limited by an high percentage of relapses. Recent advances knowledge of the molecular mechanisms, allowed the development of novel targeted therapies. Several studies have shown that the synergic effect of Bortezomib and Talidomidomide, in association with conventional chemotherapies, induces a more pronounced reduction of tumour mass, an enhancement of global responses and an improvement of Progression Free Survival (PFS). Aims: The present study is aimed at the evaluation of effectiveness and toxicity of MVTD conditioning therapy with stem cell support in Multiple Myeloma relapsed patients. Patients and Methods: From January 2005 to August 2007, 15 patients (7 males and 8 females: median age 62 yrs (46–70)) have been subjected to Autologous Transplantation therapy with MVTD conditioning therapy (Melphalan 100 mg/sqm days - 6 and - 3, Bortezomib 1.3 mg/sqm days - 6 and - 3, Talidomide 200 mg from day - 6 to day - 2, Desametazone from day - 6 to day - 3, CSP infusion at day 0). All patients were in CS III A; median performed therapies 3 (1–5); all had received previously a therapy with Talidomide, two Talidomide + Velcade, one PEG-IFN. Results: 100% of patients obtained a response: 4 patients (26.7%) obtained CR, 5 (33.3%) a nCR, 4 (26.7%) a VGPR and 2 (13.3%) a PR. One patient in CR was subjected to 2 therapeutic lines and 3 patients in CR were subjected to more than 1 therapeutic lines, 5 in nCR from 2 to 4, 4 in VGPR from 2 to 4 and 2 in PR more than 2. At the moment, with a median of 7.5 months (1–21), 11 (73%) are alive, 8 (53%) still keep the obtained response, 3 (20%) after progression are in rescue therapy, 4 patients (27%) died because of progression. PFS median since MVTD beginning is of 6 months (1–24). None of the patients have developed a significant neurotoxicity. All patients have developed grade 4 thrombocytopenia and neutropoenia, with a median of 3 days (1–10) and 6 days (4–12), respectively. 54% of patients had neutropoenia with fever with a median of 2 days (0–8). The median units of platelets and red cells infused was 3 (2–11) and 2 (0–11), respectively. Conclusions: In our experience, Autologous Transplantation therapy with MVTD conditioning, appeared to be effective in relapsed patients with Multiple Myeloma. Although in a small series of patients the response obtained was independent from the number and type of previous therapies, from the clinical state, and β2 microglobulin. No significant neurotoxicity has been observed, whether the haematological toxicity was overlapping to that due to conventional Autologous Transplant. Further studies, in larger series of non pluritreated patients are required.

Description: ASCT has been reported as a feasible, safe and effective treatment in HIV-Ly patients (pts) receiving Highly Active Antiretroviral Therapy (HAART). We hereby present an updated analysis of the EBMT experience on HIV-Ly pts treated with an ASCT since 1999. Sixty eight pts from 20 institutions [56 (82%) males, median age of 41 (29–62) years] were included. Twenty-two pts met AIDS criteria (other than lymphoma) at the time of HIV-Ly diagnosis. Forty-nine pts were diagnosed of NHL (31 DLBCL; 8 Burkitt/Burkitt-like; 4 plasmablastic; 3 anaplastic, 3 PTCL), 80% of them presenting with stage 〉II and 18 pts of HL, 61% of them presenting with stage 〉II. Median (range) lines of therapy before ASCT was 2 (1–5). Thirty-five pts were autografted in CR (16 in CR1), 25 in chemosensitive disease and 8 in chemoresistant disease. Sixty-five pts received the BEAM protocol as a conditioning regimen and the remaining three received TBI-based protocols. Two pts received more than 1 ASCT (censored at time of 2nd ASCT). At the time of ASCT the median number of CD4+ cells was 162 (8–1159)/mcl and 34 pts had undetectable HIV viral loads. HAART was given in 55/57 pts during conditioning but withdrawn in 25% of them. The median number of CD34+ cells infused was 4.5 (1.6–21.2) ×106/kg and G-CSF was used until engraftment in 60/67 pts for a median of 8 (2–21) days. All pts but one who died on day +15 reached neutrophils〉500/ml at a median time of 11 (8–36) days. Platelet count 〉20.000/ml was reached in 61 pts at a median time of 14 (6–455) days. Twenty three pts (34%) died: disease-progression (n=15), acute ASCT-related complications (n=6) [bacterial infections (n=4), multi-organ failure (n=1), other complications (n=1)] and 2 pts died from HIV-related complications. Cumulative incidence of NRM was 4.4% (95%CI 1.5–13.3) and 7.6% (95%CI 3.3–17.6) at 3 and 12 months, respectively. Age 〉 50 years at ASCT [RR 4.37 (95%CI 1.01–18.89), p = 0.05] was the only independent adverse prognostic factor for NRM. Relapse occurred in 19 (28%) pts giving a cumulative incidence of 23.6% (15.2–36.9) and 29.6% (20.0–43.8) at 12 and 24 months, respectively. Median time to progression was 4.5 (0.5–32) months. Histology (NHL other than DLBCL) [RR 3.2 (95%CI 1.0–9.6), p = 0.04], the use of 〉2 previous treatment lines [RR 2.7 (95%CI 1.0–7.2), p = 0.05] and not being in CR at ASCT [RR 3.5 (95%CI 1.2–9.7), p = 0.02] were significantly associated with a higher risk of relapse post-ASCT. With a median follow up time of 32 (2–81) months, PFS and OS were 56% (CI95% 43–70) and 61% (CI95% 48–74) at 3 years, respectively. Pts with refractory disease showed a poorer OS [RR 5.1 (95%CI 1.8–14.6), p = 0.002] and PFS [RR 5.3 (95%CI 2.0–13.7), p = 0.001]. One pt developed an in-situ epithelioma and myelodisplastic syndrome (+4y) and another one a kidney adenocarcinoma (+3y). The results of the largest experience on ASCT for HIV-Ly indicate that this approach is a useful treatment in terms of NRM, long-term OS, and PFS, with significantly better results in patients autografted with chemosensitive disease.

Description: Acute myeloid leukemia (AML) is a malignant disease characterized by abnormal proliferation of clonal precursor cells. Although different strategies have been adopted to obtain complete remission, the disease actually progresses in about 60–70% of patients. Bortezomib has documented antitumor activity in multiple myeloma and other lymphoid malignancies. TRAIL is a member of the TNF family that induces apoptosis in tumor cells while sparing normal cells. Here we examined the sensitivity to Bortezomib alone or in combination with TRAIL of bone marrow cells from AML patients (34 patients: 25 newly-diagnosed, 4 relapsed, 5 refractory). Immunofluorescence analysis showed that NF-κB was located in the nuclei of the AML blasts and it did not translocate after exposure to Bortezomib. Bortezomib induced cell death in blasts from each patient sample. The cytotoxic effect was dose- and time-dependent (concentration from 0.001 to 10 μM for 24 and 48 hours) and was associated with down-regulation of Bcl-xL and Mcl-1, up-regulation of TRAIL-R1, TRAIL-R2, p21 and activation of executioner caspases. Moreover, low doses of Bortezomib primed TRAIL-resistant AML cells for enhanced TRAIL-mediated killing. Thus, the combination of proteasome inhibitors and TRAIL is effective for treating AML patients, even patients who are refractory to conventional chemotherapy.

Description: Paroxysmal Nocturnal Hemoglobinuria (PNH) is an acquired disorder characterized by the emergence and expansion of a GPI-defective clonal haematopoiesis. Its clinical features are haemolytic anaemia, cytopenia and thrombosis. Several data suggests the pathogenetic relevance for auto-immune-mediated mechanisms in the expansion of the mutated clone. Since HLA genes represent a susceptibility factor for autoimmunity, we have investigated HLA genotypes in 42 Italian patients with PNH. This study analyzed the HLA class I and class II genes in a cohort of 42 Italian PNH patients. Data indicate the occurrence of a significant increase of A*33 (9.5% in PNH patients versus 2.3% in controls; p

Description: The essential thrombocythemia (ET) is characterized by thrombohemorrhagic risk. ET patients receiving HU and anti-aggregants show normal platelets but present platelet coagulant and endothelial aggregation. Anagrelide (ANA) is a platelet-lowering drug that inhibits platelet aggregation. Therefore, we evaluated platelets, platelet factor 4 (PF4), prothrombin fragment 1+2 (F1+2), thrombin antithrombin complex (TAT) and d-dimer (DD) and von Willebrand factor (vWF) as markers of platelet coagulant and endothelial aggregation, respectively, in ET patients treated either with HU or ANA. All measurements were performed before treatment and when complete response, defined as platelet 〈 400 x109/L for more than 1 month, was achieved. Prolonged thrombocytosis causes thrombohemorrhagic risk. Hence, we investigated the cytoreduction time. The study comprised 36 patients (19 men, 17 women; mean age 65 years) who fulfilled PVSG and WHO. The mean duration of disease was 6 years. 17 patients received HU and 19 patients were on ANA. The average dose of HU was 0.5 g/d. ANA was initially administered at a dose of 0.5 mg/d. The dose was increased by 0.5 mg/d every week until the platelets had decreased to below 400 x 109/L. The average maintenance was 1.7 mg/d. All patients were on aspirin at dose of 100 mg/d and 50 mg/d in HU and ANA group, respectively. None of the patients had acquired or inherited thrombotic risk factors or had inherited coagulopathy. Eleven out of 17 HU patients (5 men, 6 women; mean age 68.6 years) developed thrombosis including six transient ischemic attack (TIA), three myocardial infarct (MI) and two deep venous thrombosis (DVT). The thrombosis occurred at a median time from diagnosis of 2 years. The ANA group did not experience thrombosis. Platelets were determined by automated analyser. PF4, F1+2, TAT and DD and vWF were assayed by ELISA and immunoturbidimetric assay, respectively. Before treatment, all patients had high platelets (1027±297 x 109/L) and elevated PF4, F1+2, TAT and DD (134±48 IU/mL vs 6±2 IU/mL, 3±2 nmol/L vs 0.6±0.2 nmol/L, 25±34 μg/L vs 2.7±1 μg/L, 224±172 μg/L vs 197±43 μg/L, respectively) (p〈 0.0001, p

Description: Background. Bortezomib, Melphalan and Steroids are among the most effective drugs for treatment of myeloma, and their combination has already been tested in elderly myeloma patients. However, in order the take full advantage of the synergy among these drugs, we designed a protocol for previously treated multiple myeloma patients consisting of six monthly courses of concurrent intravenous administration of the three drugs. Methods Bortezomib was given at dosage of 1.3 mg/m2, Melphalan 5 mg/m2 and Dexamethasone 40 mg i.v. on days 1, 4, 8, 11 plus dexamethasone 40 mg per os on days 2, 5, 9, 12 (VMD). In total, 21 previously treated patients have been enrolled in this study, 9 males and 12 females. Median age was 64.5 (range 53–82). All patients had been already treated with a median of 2 previous lines of treatment (range 1–6), including HDT with ASCT in 7 patients and Bortezomib, alone or in combination, in 5 patients. Fourteen patients were resistant to previous therapies and 7 were relapsed. All patients were ineligible for transplant procedures. Results After a median follow up of 9 months (range 3–14), 12/21 (57%) patients were considered responders: according to International Myeloma Working Group Criteria. 4 patients achieved a complete remission (M-protein not detectable at IFE), 4 patients a very good partial remission, 4 patients a partial remission, 7 achieved a stable disease, 2 were not evaluable. The most common grade 3/4 adverse events included hematological toxicity: thrombocytopenia (30%), anemia (8%), leucopenia (7%), neutropenia (3%) peripheral neuropathy (14%), diarrhea (14%) and infection (5%). So far, 4 patients have stopped treatment for toxicity after 1, 3, 3, 4 courses. PFS at 10 months was 67% and survival at 12 months 94%. Since VMD is an effective treatment but limited by haematological toxicity, we have modified the schedule of the combination using concurrent intravenous administration of bortezomib, melphalan and dexamethasone on days 1, 8, 15, 22 and restarting at day 35. So far, 9 patients with a median age of 69 ys (range 48–79), (5 patients in 2nd line and 4 in 3th line of treatment) were enrolled, and after a median of follow up of 4 months (range 2–5), 8 patients are evaluable. After a median number of two cycles, 6/9 (67%) patients were considered responders: 3 patients achieved CR, 1 patients VGPR, 2 patients PR, 1 was in stable disease and 1 in PD (died after 2 courses). With the new schedule we have obtained a significant reduction of grade 4 haematological toxicity (0% vs 18%, p

Description: Background: Low CD34+ cell mobilization in P.B. has been found in a quota of AML patients (10–30%). Contrary to what has been observed in CD34+ mobilization in other haematological afflictions, in AML no features pertaining to the disease or to the patient have been found to be predictive of CD34+ cell mobilization failure. A possible explanation for this particular aspect of CD34+ mobilization in AML patients could be an intrinsic abnormality of non leukemic hematopoietic cells determining an increased chemo-sensitivity to anti-neoplastic drugs. To test this hypothesis we assessed, in AML patients, frequency of various types of clonable precursors (CFUs) present in BM at the time of CR and their in vitro chemosensitivity. We also correlated this data with the efficiency of CD34+ cell mobilization in P.B. Methods: 31 consecutive patients, affected with AML and a group of 15 normal BM donors were prospectively studied. Baseline CFU-GEMM, BFU-E, CFU-GM, CFU-E as well as the sensitivity of these precursors to two chemotherapeutic agents (ASTA-Z and VP-16) were assayed on BM cells obtained in first CR after consolidation chemotherapy. Chemo-sensitivity (100 - normalized residual CFU) was studied after short term in vitro incubation of bone marrow precursors at various drug concentrations. All pts underwent a CD34+ mobilization attempt and, as measure of mobilization strength, peaks of CD34+ cells reached in P.B. were determined. Results: In AML patients, after induction and consolidation schedules, a reduced number of all types of CFUs were found in BM compared to normal controls. The frequency of any types of CFUs and the chemo-sensitivity of CFU-GEMM, BFU-E and CFU-E were not correlated to CD34+ peak reached in P.B. However, in AML patients, an inverse correlation was found between chemo-sensitivity of CFU-GM and maximum CD34+ cells peak reached in P.B. during mobilization (r= − 0.807 and p=0.0001, when ASTA-Z was used at 100 mcg/ml). In univariate and multivariate logistic regression, chemo-sensitivity to ASTA-Z of CFU-GM was the only factor significantly associated with mobilization failure (P=0.02), independently of age and cytogenetical risk. Chemosensitivity of CFU-GEMM, BFU-E and CFU-E after in vitro incubation with chemotherapeutic drugs was not different in AML patients compared to CFU obtained from normal control. The contrary was found for CFU-GM and, overall, CFU-GM from AML patients had a significantly higher chemosensitivity to ASTA-Z compared to CFU-GM of normal controls (p= 0.01 at 50 mcg/ml). Conclusions: We found that an abnormal high chemo-sensitivity of CFU-GM to some chemotherapy drugs in AML patients is associated with a high risk of CD34+ cell mobilization failure. This abnormality of non leukaemic bone marrow cells, present in CR, is restricted only to CFU-GM and is not evident in other CFUs. Figure Figure

Description: Deficiency of glycosylphosphatidylinositol (GPI)–anchored molecules on blood cells accounts for most features of paroxysmal nocturnal hemoglobinuria (PNH) but not for the expansion of PNH (GPI−) clone(s). A plausible model is that PNH clones expand by escaping negative selection exerted by autoreactive T cells against normal (GPI+) hematopoiesis. By a systematic analysis of T-cell receptor beta (TCR-β) clonotypes of the CD8+ CD57+ T-cell population, frequently deranged in PNH, we show recurrent clonotypes in PNH patients but not in healthy controls: 11 of 16 patients shared at least 1 of 5 clonotypes, and a set of closely related clonotypes was present in 9 patients. The presence of T-cell clones bearing a set of highly homologous TCR-β molecules in most patients with hemolytic PNH is consistent with an immune process driven by the same (or similar) antigen(s)—probably a nonpeptide antigen, because patients sharing clonotypes do not all share identical HLA alleles. These data confirm that CD8+ CD57+ T cells play a role in PNH pathogenesis and provide strong new support to the hypothesis that the expansion of the GPI− blood cell population in PNH is due to selective damage to normal hematopoiesis mediated by an autoimmune attack against a nonpeptide antigen(s) that could be the GPI anchor itself.