ALBERT

Description: Abstract 154 Background Follicular lymphoma (FL) has an indolent course during which patients (pts) receive multiple lines of active treatments ranging from single-agent chemotherapy (CHT) or monoclonal antibodies (MoAb), to high-dose therapy with stem cell transplantation (HSCT). In relapsed patients the efficacy of salvage treatments may be affected by the type and the intensity of the previous treatments and it is currently not known whether a definite sequence of treatments throughout the course of the disease could optimize the outcome of patients. Since randomized trials can hardly be designed to answer this important clinical question, the Fondazione Italiana Linfomi (FIL) launched an observational, multicenter, retrospective study (REFOLL) to analyze if combinations of different first-line and salvage treatments could be identified, able to achieve a better long-term outcome. Patients and Methods Of 582 pts with FL at first relapse between 2000 and 2008 registered from 25 Institutions, 548 were included in the study. They had received either alkylating- (AA) (22%), or anthracycline- (AC) (61%) or nucleoside analogues-based (NA)(17%) CHT as first-line treatment, with the addition of rituximab (R) in 284 (52%). AA pts were older (PCHT with R showed a better outcome than CHT -〉CHT without R (HR:0.55, P=0.015; HR 0.61, P=0.047 after adjusting by age and stage at diagnosis). Conclusions Auto-HSCT obtained the best TTNT after relapse compared to any other regimen but its efficacy was maximized when anthracycline-containing CHT was used as first-line treatment, compared to other CHT programs. The addition of R to first-line CHT did not adversely impact on the results of any salvage. This study supports the concept that different sequences of active treatments do not necessarily obtain similar long-term results, which is important in the management of indolent diseases like FL and warrants further studies. The sequence of AC-CHT at diagnosis and auto-HSCT at relapse may be tested as the reference sequence of active treatments in FL patients. Disclosures: No relevant conflicts of interest to declare.

Description: Cancer chemotherapy may be associated with a high incidence of nausea and vomiting (CINV), which may occur acutely within 24 hours after the start of chemotherapy (acute phase) or in the following days (delayed phase). Despite the availability of several antiemetics, clinical findings show that control of nausea and vomiting continue to be a serious concern for hematological patients, mainly for those receiving multiple-day (MD) and high-dose (HD) chemotherapy (CT), for which no specific international recommendations have been formulated, due to the lack of a unanimous consensus between the main international guidelines. NEPA is the first antiemetic developed as an oral fixed dose combination of two drugs that are antagonists of two receptors involved in the control of nausea and vomiting: a new highly selective NK1-RA, netupitant, and a second generation 5HT3-RA, palonosetron, that simplify the antiemetic regimen allowing for a lower number of capsules and days of treatment. In clinical practice, NEPA is administered together with dexamethasone that contributes to CINV prophylaxis by its intrinsic antiemetic properties. However, dexamethasone also exhibits an important immunosuppressive activity, which could lead to several adverse events, such as increasing the risk of serious infections, especially in patients undergoing myeloablative treatment. The rational of this study was to explore the efficacy of multiple doses of NEPA given with an every-other-day regimen without dexamethasone in preventing CINV in patients with non-Hodgkin's lymphoma (NHL) eligible for autologous stem cell transplantation (ASCT) and treated with MD-HD-CT. The chemotherapy regimen (BEAM/FEAM) was administered for 6 days, NEPA was taken on day 1, 3 and 5, and nausea and vomiting were monitored up to day 15. No dexamethasone was given for antiemetic prophylaxis. The primary endpoint was the percentage of patients achieving a Complete Response (CR; no vomiting and no use of rescue medication) during the overall phase, defined as the period from day 1 (first day of chemotherapy) until 2 days after the last dose of chemotherapy. Seventy patients participated to the study. According to the adopted Fleming one-stage design, the primary endpoint of this study was achieved. Indeed, the number of complete responders for the overall phase was 60, which is greater than the predetermined cut-off of 42, representing the minimum frequency of responders for which the treatment is considered effective. In addition to the primary efficacy result, several additional endpoints were evaluated for the study period (Figure 1). The CR values were 87.1% (primary endpoint, overall phase: days 1-8), 88.6% (acute phase: days 1-6) and 98.6% (delayed phase: days 7-8), while the complete control (CR with no more than mild nausea) was 85.7% (overall phase), 88.6% (acute phase) and 95.7% (delayed phase) (Figure 1A). Moreover, the percentages of patients that did not have any emetic episodes were 88.6% (overall phase), 90% (acute phase) and 98.6% (delayed phase) and patients that did not require a rescue therapy for controlling CINV were 94.3% (overall phase), 94.3% (acute phase) and 100% (delayed phase). Daily records taken from day 1 to day 15 showed that values for all these categories were above 85% for all the days of observation (Figure 1B). Patients also documented the grade of their nausea according to the Likert scale. Moderate and severe episodes of nausea were reported by less than 10% for the overall phase and less than 5% in both acute and delayed phase and the daily values of no nausea were above 65% for each day of the treatment (Figure 1C and 1D). Indeed, the mean patient global satisfaction for the antiemetic prophylaxis for the study period was 9.13 ± 1.59 out of 10. Regarding safety, a total of 12 Treatment-Emergent Adverse Events (TEAEs) occurred in 6 (8.6%) subjects enrolled in the study. Among these, only 1 (8.3%, constipation) was evaluated as possibly related to NEPA administration. Moreover, the only two TEAEs classified as SAE (Serious Adverse Event) were two episodes of fever that have been evaluated as not-related to NEPA. Therefore, the safety profile of NEPA was confirmed also in this setting. In conclusion, our study demonstrated that multiple alternate dosing of NEPA without the addition of dexamethasone can effectively prevent nausea and vomiting in a difficult setting, such as MD/HD-CT with a good tolerability profile. Disclosures No relevant conflicts of interest to declare.

Description: Infection of EBV has been linked to the etiology of a number of lymphoproliferative diseases, and EBV+ diffuse large B cell lymphoma (DLBCL) of the elderly has been more recently described as a distinct entity. The viral load of EBV-DNA in plasma can be an indicator for EBV-association in some lymphoma types, as NK/T-cell lymphoma and Hodgkin lymphoma, and a marker for disease activity associated with negative prognosis. Here, we studied whether EBV-DNA in whole blood (WB), mononuclear cell fraction (MNC) and plasma of patients with DLBCL at diagnosis could be an indicator for EBV-association and a prognostic marker in patients treated with immunochemotherapy (R-CHOP). We analysed 247 patients with DLBCL (median age 64 years, range 15-92 years; 118 females, 129 males), diagnosed between 2006 and 2013. All patients were HIV-negative. EBV was detected using a commercial real-time PCR kit (BioQuant EBV, Biodiversity, Brescia, Italy) in peripheral blood (PB) compartments (WB n=240, plasma n=55, and MNC n=52). Lymph node samples from 61 DLBCL patients were analyzed for EBV infection through in situ hybridization for EBV-encoded small RNAs (EBER). EBV was detected in 58 of 240 WB samples (24%). The copy number varied between 2 x 102 and 4.9 x 106 copies/ml. The presence and copy number of EBV in WB and MNC were correlated (p60 years of age) had more often EBV in peripheral blood (30% vs 17%), and the viral load was higher in patients aged 〉 60 years (p 60 years (p=0.02), we performed a logistic regression analysis including age and HCV serology as parameters determining the EBV viral load in PB. In this analysis, HCV serology, but not age remained a significant factor for EBV viral load (p=0.004). Presence and viral load of EBV in PB was not related to other characteristics as gender, stage, performance status, LDH level, and IPI. In an univariate analysis including 201 patients treated with R-CHOP, the presence of EBV-DNA in WB was associated with a significantly shorter event-free survival (EFS): 67% (50%-79%, 95% C.I.) versus 80% at 2 years (p

Description: Advances in chemotherapy have improved the prognosis of patients with acute myeloid leukemia (AML), however, high-risk patients still have a poor outcome. In this category of patients, the only therapeutic strategy with curative potential remains allogeneic hematopoietic stem cell transplantation (allo-HSCT). With the aim to improve the effect of allo-HSCT by sequential use of chemotherapy followed by reduced intensity conditioning (RIC), we conducted a prospective study in high-risk AML patient. The high-risk population included intermediate II [t(9;11)(p22;q23); MLLT3-MLL, cytogenetic abnormalities not classified as favorable or adverse] and unfavourable patients [inv(3)(q21q26.2) or t(3;3)(q21;q26.2); t(6;9)(p23;q34); t(v;11)(v;q23); MLL rearranged, -5 or del(5q); -7; abnl(17p); complex karyotype] (Dohner et al. Blood 2010), secondary AML, and patients requiring 2 induction courses to obtain CR. The chemotherapy sequential regimen consisted in fludarabine 30 mg/m², high-dose cytarabine 2 g/m², and amsacrine 100 mg/m² from days -12 to -9 (FLAMSA). After 3 days of rest, RIC consisted of 4 Gy total-body irradiation (TBI) on day -5, cyclophosphamide (40 mg/kg with HLA-identical sibling, 60 mg/kg for unrelated or mismatched donors) on days -4 and -3, and rabbit antithymocyte globulin (ATG, Genzyme) (5 mg/kg total dose) from day -3 to day -1. In a group of patients, TBI was replaced by iv. busulfan (BU) (Busilvex, Pierre Fabre) 3.2 mg/kg/d during either 4 or 2 days according to patient age (〉55 years) (from day -7 to -4 or from day -5 to -4). Peripheral-blood stem cells (PBSC) were preferred; bone marrow (BM) and cord blood (CB) were also accepted. Graft-versus-host disease (GvHD) prophylaxis consisted in cyclosporine from day -1, and mycophenolate mofetil (15 mg/kg bid), starting from day 0. In the absence of GvHD, MMF was discontinued by day+50 and cyclosporine was tapered from day +60 to +90. Except for CB transplantation, patients received 3 prophylactic increased doses of donor lymphocyte infusions (DLI) if they were in CR and GvHD-free at day +120 or 30 days after discontinuation of immunosuppressive agents starting at 1x106 CD3+ cells/kg. Between January 2007 and December 2013, 66 consecutive AML patients were included; 33 males and 33 females with a median age at allo-HSCT of 52 years (range: 19-66), 59 (89%) were de novo AML and 7 (11%) secondary AML. At transplantation, 22 (33%) patients were in CR (20 CR1 and 2 CR2) and 44 (67%) were in less than CR. Stem cell source was PBSC for 52 (79%) patients, CB for 6 (9%) and BM for 2 patients. Donors were 10/10 HLA matched siblings in 24 (36%) patients, 10/10 HLA matched unrelated in 18 (27%) patients and HLA mismatched for the rest of patients [unrelated 9/10 (n=18), CB 4/6 (n=6)]. For ABO compatibility, 32 (48%) were compatible, 13 (20%) had minor incompatibility and 21 (32%) had major incompatibility. For conditioning, 49 (74%) patients received TBI, 17 (26%) received BU. After transplantation, 59 (89%) patients engrafted, 7 patients did not engraft and died early (2 from relapse and 5 from infection). At day 90 post-allo-HSCT, among evaluated patients (N=52), 37 (71%) showed total donor chimerism, 15 (29%) had mixed chimerism. There were 24 patients with acute GvHD [10 gr I, 3 gr II and 7 gr III and 4 gr IV] with a cumulative incidence of 27% for grade ≥II; and 17 chronic GvHD [10 limited and 7 extensive], among them 5 after DLI, with a cumulative incidence of 48% at 2 years. After a median follow-up of 7 months (range: 0.1-76), the 2-years probability of overall survival (OS) and progression-free survival for the whole population were 30% (confidence interval: 24-36) and 40% (confidence interval: 37-52) respectively with a cumulative incidence of transplant-related mortality of 30% at 2 years. When stratifying on disease status at transplantation, patients in CR had significantly better OS and PFS at 2 years compared to patients in less than CR with 45% versus 18% (p=0.013) and 73% versus 22% (p=0.001) respectively. No statistical difference was found in outcomes of TBI compared to BU conditioning. Patients in CR showed very promising results and could benefit the most from this strategy. A high rate of deadly infections was observed, thus an efficient prophylactic anti-infectious strategy is recommended. Patients not in CR remain having poor outcome and maybe new transplantation strategy using haploidentical donors could be interesting to evaluate in this population. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Description: Advances in chemotherapy have improved the prognosis of patients with acute myeloid leukemia (AML), however, high-risk patients still have a poor outcome. In this category of patients, the only therapeutic strategy with curative potential remains allogeneic hematopoietic stem cell transplantation (allo-HSCT). With the aim to improve the effect of allo-HSCT by sequential use of chemotherapy followed by reduced intensity conditioning (RIC), we conducted a prospective pilot study in high-risk AML patients in first complete remission (CR1). The high-risk population included intermediate II [t(9;11)(p22;q23); MLLT3-MLL, cytogenetic abnormalities not classified as favorable or adverse] and unfavourable patients [inv(3)(q21q26.2) or t(3;3)(q21;q26.2); t(6;9)(p23;q34); t(v;11)(v;q23); MLL rearranged, -5 or del(5q); -7; abnl(17p); complex karyotype] (Dohner et al. Blood 2010), secondary AML, and patients requiring 2 induction courses to obtain CR. The chemotherapy sequential regimen consisted in fludarabine 30 mg/m2, high-dose cytarabine 2 g/m2, and amsacrine 100 mg/m2 from days -12 to -9 (FLAMSA). After 3 days of rest, RIC consisted of 4 Gy total-body irradiation (TBI) on day -5, cyclophosphamide (40 mg/kg with HLA-identical sibling, 60 mg/kg for unrelated or mismatched donors) on days -4 and -3, and rabbit antithymocyte globulin (ATG, Genzyme) (5 mg/kg total dose) from day -3 to day -1. As a new experimental approach, we replaced TBI by iv. busulfan (BU) (Busilvex, Pierre Fabre) 3.2 mg/kg/d during either 4 or 2 days according to patient age (〉55 years) (from day -7 to -4 or from day -5 to -4). Peripheral-blood stem cells (PBSC) were preferred; bone marrow (BM) and cord blood (CB) were also accepted. Graft-versus-host disease (GvHD) prophylaxis consisted in ciclosporine from day -1, and mycophenolate mofetil (15 mg/kg bid), starting from day 0. In the absence of GvHD, MMF was discontinued by day+50 and ciclosporine was tapered from day +60 to +90. Except for cord blood transplantation, patients received 3 prophylactic increased doses of donor lymphocyte infusions (DLI) if they were in CR and GvHD-free at day +120 or 30 days after discontinuation of immunosuppressive agents starting at 1x106 CD3+ cells/kg. Between August 2010 and March 2013, 26 consecutive AML patients in CR1 were included; 11 males and 15 females with a median age at allo-HSCT of 55 years (range: 24-67), 19 (73%) were de novo AML and 7 (27%) secondary AML. According to cytogenetics and molecular markers, 22 (85%) were unfavourable and 4 (15%) were in intermediate II category. Before allo-HSCT, to reach CR1, 20 (77%) patients received one induction chemotherapy and 6 (23%) needed 2 inductions. Cell source was PBSC for 23 (88%) patients, CB for 2 and BM for 1 patient. Donors were 10/10 HLA matched siblings in 9 (35%) patients, 10/10 HLA matched unrelated in 8 (31%) patients and HLA mismatched for the rest of patients [unrelated 9/10 (n=7), CB 4/6 (n=2)]. For ABO compatibility, 13 (50%) were compatible, 5 (19%) had minor incompatibility and 8 (31%) had major incompatibility. For conditioning, 6 (23%) patients received TBI, 13 (50%) received 4 days BU and 7 (27%) received 2 days BU. After transplantation, 23 (88%) patients engrafted, 3 patients died early (1 at day 1 and 1 at day 2 both from septic shock; 1 at day 8 from pneumonia and pericardial effusion). At day 90 post-allo-HSCT, 18 (78%) showed total donor chimerism and 5 (22%) had mixed chimerism and all patients were in CR. There were 6/23 (26%) patients with acute GvHD [2 gr I, 2 gr II and 2 gr III] and 5/23 (22%) chronic GvHD [4 limited and 1 extensive], all before DLI. After a median follow-up of 9 months (range: 0.03-35), the 2-years probability of overall survival (OS) for the whole population was 58% (confidence interval: 47-69) (Figure 1a) and the 2 years cumulative incidence of relapse was 18% (confidence interval: 17-19). At the latest follow-up, 16/23 (70%) engrafted patients were alive, 4/23 (17%) patients relapsed and died later and 3/23 (13%) patients died from transplant related infectious complications. No statistical difference in terms of OS and relapse incidence was found between the 3 types of conditioning, (Figure 1b). FLAMSA-RIC regimen followed by allo-HSCT showed promising results in high-risk CR1 AML patients. Because of some early severe infections, an efficient prophylactic anti-infectious strategy is recommended. The use of BU instead of TBI does not impact on transplant outcomes. Disclosures: No relevant conflicts of interest to declare.