ALBERT

Description: Key Points Mixed, atypical, and warm immunoglobulin G plus C AIHA (∼30% of cases) more frequently have a severe onset (Hb ≤6 g/dL) and require multiple therapy lines. Infections, particularly after splenectomy, acute renal failure, Evans syndrome, and multitreatment, were predictors of fatal outcome.

Description: It is unclear whether karyotype aberrations that occur in regions uncovered by the standard fluorescence in situ hybridization (FISH) panel have prognostic relevance in chronic lymphocytic leukemia (CLL). We evaluated the significance of karyotypic aberrations in a learning cohort (LC; n = 64) and a validation cohort (VC; n = 84) of patients with chronic lymphocytic leukemia with “normal” FISH. An abnormal karyotype was found in 21.5% and 35.7% of cases in the LC and VC, respectively, and was associated with a lower immunophenotypic score (P = .030 in the LC, P = .035 in the VC), advanced stage (P = .040 in the VC), and need for treatment (P = .002 in the LC, P = 〈 .0001 in the VC). The abnormal karyotype correlated with shorter time to first treatment and shorter survival in both the LC and the VC, representing the strongest prognostic parameter. In patients with chronic lymphocytic leukemia with normal FISH, karyotypic aberrations by conventional cytogenetics with novel mitogens identify a subset of cases with adverse prognostic features.

Description: Background: Philadelphia-negative Myeloproliferative Neoplasms (MPN) include Polycythemia Vera (PV), Essential Thrombocythemia (ET) and Myelofibrosis, both Primary (PMF) and secondary to PV or ET (PPV-MF and PET-MF). A MPN is frequently the underlying cause of splanchnic vein thrombosis (SVT). Ruxolitinib, a JAK1/2 inhibitor, efficiently reduced spleen volume and improved symptoms in patients (pts) with MF and PV in the COMFORT-I/II and RESPONSE phase III trials, and in ET pts in a phase II study. We reported (Blood 2014 124:3192) that ruxolitinib was safe in pts with MPN associated to SVT and effective in reducing spleen size at the planned primary endpoint analysis at 24 weeks (w) in a phase II clinical trial. Herein we present follow up data with cut off at 1 year after core period (a total of 72 w of treatment). Methods: Main enrolment criteria included diagnosis of PV, ET, PMF or PPV-/PET-MF associated with SVT, splenomegaly 〉5 cm below costal margin (bcm), active anticoagulant or antiaggregant thrombosis prophylaxis, platelet count (plt) 〉100 x109/L, neutrophils count 〉1x109/L, normal hepatic and renal function, absence of esophageal varices 〉grade 2. Pts who completed the 24 w of study treatment and tolerated well the drug and had evidence of clinically-significant improvement were allowed to enter an extension phase aimed at collecting and reviewing safety and efficacy data. The drug was provided free of charge by Novartis, that had no role in trial design nor in data analysis. Results: Diagnosis of MPN were: PMF 8 (38.1%), PV 5 (23.8%), ET 4 (19.1%), PPV-MF 3 (14.3%), PET-MF 1 (4.8%). Nineteen pts had spleno-porto-mesenteric thrombosis and 3 Budd-Chiari syndrome (BCS); one pt had both sites involved. Initial dose of ruxolitinib was 10 mg BID for PV, 25 mg BID for ET, 15 mg BID for MF pts with baseline (bl) platelet count of 100 to 200x109/L and 20 mg BID for platelet count 〉200x109/L. Currently 17/21 pts are on active treatment, 14 completed w72; final data for all 17 pts will be available at meeting. One pt with MF discontinued from the study being shifted to commercial ruxolitinib at w60, one ET and one MF pt discontinued for inefficacy at w24 and one MF pt for an unrelated adverse event after w72. Efficacy: 13/21 (61.9%) pts obtained a ≥50% spleen length (sl) reduction by palpation at w24, that was maintained at w72 in 8/14 pts (57.1%). Median sl reduction at w72 was 63% (range 0-100). No significant differences in resistive or pulsatility index of splanchnic artery were noted, nor in esophageal varices status evaluated at w72. 10/11 evaluated pts with echocardiography at w72 showed a median reduction of the cardiac output of 20.1% (range 2.3-42.2) mainly due to a reduction of heart rate and of cardiac index (-21.9%, range 8.8-44.3) due to increase in body surface area. The first effect could be attributed to decrease of proinflammatory cytokines, the second to weight gain associated with ruxolitinib. Symptomatology was evaluated by MPN-SAF up to w24, showing a median total symptom score reduction from 65 to 42. Safety: regardless of drug relationship, the most common adverse events (AE) (% any grade, % grade ≥3) were thrombocythopenia (57.1%; 14.3%) and anemia (33.3%, 19%) that were the main reasons for dose adjustments. Other AE included AST or ALT increase (42.9%, 0%), diarrhea (28.6%, 0%), abdominal pain (23.8%, 0%), ascites (19%, 0%), fever (23.8%, 0%), neutropenia, (9.5%, 9.5%), upper airways infection (19%, 0%), weight gain (14.3%, 4.8%), muscle cramps (14.3%, 0%). Three serious AE occurred: one case of hepatocarcinoma in a pts with BCS, one grade 2 pneumonia and one grade 2 haematemesis not related to esophageal varices. Median ruxolitinib total daily dose at w72, after dose adjustments, was 19.1 mg for MF, 16 mg for PV and 28.3 mg for ET. Median hemoglobin reduced from 12.9 gr/dL (range 9.4-16.7) at bl to 10.7 (8.4-14.4) at w16 and recovered at w72 (12.1, range 10.8-14.7). No pts received transfusions. Median platelet count was 212 x109/L (100-389) at bl, reached to the lowest level at w4 (139, range 48-252) and improved to 160 (69-285) at w72. Median leukocyte count decreased from 7.3 x109/L (1.8-16.4) at bl to 4.08 (1.2-21.7) at w 24, and remained substantially stable through w 72 (4.96; range 2.45-17.3). Median reduction of JAK2 allele burden at w72 was 9% (range 0-38). Conclusions: At w 72 follow up, ruxolitinib continues to be safe in pts with MPN associated to SVT and maintains efficacy against splenomegaly in 57% of the pts. Disclosures De Stefano: Roche: Research Funding; GlaxoSmithKline: Speakers Bureau; Bruno Farmaceutici: Research Funding; Novartis: Research Funding, Speakers Bureau; Janssen Cilag: Research Funding; Celgene: Speakers Bureau; Shire: Speakers Bureau; Amgen: Speakers Bureau. Barbui:Novartis: Speakers Bureau. Vannucchi:Novartis: Other: Research Funding paid to institution (University of Florence), Research Funding; Shire: Speakers Bureau; Baxalta: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Description: Abstract 2849 Background We have previously reported on the natural history of polycythemia vera (PV), focusing primarily on overall and leukemia-free survival (ASH Annual Meeting Abstracts. 2011;118(21):277-). In the current study, we present, on behalf of the International Working Group for Myeloproliferative neoplasms Resarch and Treatment (IWG-MRT), our analysis regarding risk factors for thrombosis. Methods Under the auspices of IWG-MRT, seven international centers of excellence for myeloproliferative neoplasms participated in the current study. The two principle investigators (AT and TB) reviewed all the cases and selected 1,545 patients who met the 2008 WHO criteria for PV, were age 18 years or older, diagnosed after 1970, and whose submitted data included diagnostically essential information. Results I: Presenting Features Median age was 61 years (range, 18–95; 51% females). Arterial and venous thrombosis history before or at diagnosis was documented in 246 (16%) patients and 114 (7.4%) patients, respectively. Major hemorrhage hemorrhage before or at diagnosis was documented in 17 (4.5%) patients. Other features at diagnosis included pruritus (36%), microvascular disturbances (28.5%), palpable splenomegaly (36%), abnormal karyotype (12%), leukoerythroblastosis (6%), increased LDH (50%), thrombocytosis (53%), extreme thrombocytosis (platelets 〉1 million mm3; 4%) leukocytosis (49%), JAK2 V617F (95%), other JAK2 mutations (3%), subnormal serum erythropoietin (Epo) level (81%), and endogenous erythroid colonies (EEC; 73%). History of hypertension (46%), hyperlipidemia (18.3%), diabetes (8.4%), and tobacco use (16%) was also obtained. Results II: Clinical Course To date, 347 (23%) deaths, 50 (3%) leukemic progressions, and 138 (9%) fibrotic transformations have been recorded. Overall, cytoreductive treatment was not used in 416 (27%) patients and the remaining were exposed to different agents based on physician discretion. Post-diagnosis arterial or venous thrombosis occurred in 184 (12%) and 137 (9%) patients, respectively. Results III: Risk Factors for thrombosis Arterial and venous thrombosis-free survival, from time of diagnosis, were separately analyzed using the occurrence of thrombosis as the endpoint (uncensored variable) and last follow-up or death before thrombosis as the censored variable. In univariate analysis, the following were significantly associated with post-diagnosis arterial thrombosis: advanced age, leukocyte count, presence of a leukoerythroblastic smear (LES), history of hypertension and history of arterial thrombosis before or at diagnosis; multivariable analysis using all these five parameters identified arterial thrombosis history (RR 2.5, 95% CI 1.6–4.0; p

Description: Autoimmune hemolytic anemia (AIHA) is a greatly heterogeneous condition both in terms of clinical presentation and response to treatment, usually classified as warm (WAIHA), cold (CAD), mixed, and atypical forms. The aim of this study was to identify predictors of outcome and response to therapy considering in particular the serological characteristics and the severity of anemia at onset. We evaluatedretrospectively 307 patients (112 M and 195 F, median age at diagnosis 63, range 1-97), diagnosed between 1978 and 2013 and followed-up for a median of 33 months (range 12-372); 60% of cases were WAIHA, 27% CAD, 8% mixed, and 5% atypical (14 DAT- and 1 DAT+ for IgA only). Hemoglobin values were lower in mixed (median 5.8, range 2-10.7 g/dL) atypical (6.2, 3-9), and in IgG+C3 DAT+ WAIHA (6.9, 2.9-11.5). Twenty-one subjects were diagnosed with Evans’ syndrome, the majority of them WAIHA, with a severe onset. Considering anemia at onset, 27% of cases had Hb levels 10 g/dL; the most severe cases were mainly mixed and atypical forms (P=0.0001). Regarding therapy, 47% of cases were treated with one therapy line only, 26% with two, 13% with three, and 4% with four or more lines. Sixty % of WAIHA received first line steroid therapy only, 20 CAD required no treatment, and patients with IgG+C DAT+ WAIHA, mixed, and atypical forms were more frequently treated with 2 or more therapy lines (P

Description: Background: Philadelphia-negative Myeloproliferative Neoplasms (MPN) include Polycythemia Vera (PV), Essential Thrombocythemia (ET) and Myelofibrosis, both Primary (PMF) and secondary to PV or ET (PPV-MF and PET-MF). A MPN is frequently the underlying cause of splanchnic vein thrombosis (SVT). Ruxolitinib, a JAK1/2 inhibitor, efficiently reduced spleen volume (SV) and improved symptoms in patients (pts) with MF and PV in the COMFORT-I/II and RESPONSE phase III trials, and preliminary evidence of efficacy in ET pts has been obtained in a phase II study. A few pts with SVT treated with ruxolitinib were reported in the literature, but the safety and efficacy of ruxolitinib has not been systematically evaluated. Study Hypothesis: We hypothesized that by decreasing the enlarged spleen, treatment with ruxolitinib could result in reduction of local pressure in splanchnic vessels producing both improvement of splanchnic circulation and splenomegaly-related symptoms. We designed an investigator-initiated multicentre phase 2 study of Ruxolitinib in pts with splenomegaly in the setting of SVT associated with MPN. The drug was provided free of charge by Novartis, that had no role in trial design nor in data analysis. Study Design: Primary objective was to evaluate the proportion of pts achieving ≥ 50% reduction in spleen length from left costal margin (LCM) by palpation at any visit and at w24, or a ≥ 35% reduction in SV by magnetic resonance imaging (MRI) or computed tomography (CT) at w24. SV has been measured with a semi-automatic segmentation method by using OsiriX software. Secondary objectives, with measurements done at w24 versus (vs) baseline (bl), included evaluation of: safety of treatment, splanchnic circulation by echo-Doppler analysis, hyperdynamic arterial circulation by echocardiography; stiffness of hepatic/splenic parenchyma by fibroscan; status of esophageal varices, Quality of Life using MPN-SAF questionnaire. Exploratory objectives included: changes in JAK2V617F or MPLW515 allelic burden and in cytokine and microRNAs profiles; correlation of bl mutations with response to treatment; quantification of circulating endothelial progenitor cells (EPCs). Results: At the time of abstract submission enrolment has been completed; 16/21 pts completed the w24 of treatment. Last patient last visit is planned in next October, therefore final trial data will be available at ASH meeting. Diagnosis of MPN were: PMF 8 (38.1%), PV 5 (23.8%), ET 4 (19.1%), PPV-MF 3 (14.3%), PET-MF 1 (4.8%). Nineteen pts had spleno-porto-mesenteric thrombosis and 3 BCS; one pt had both sites involved. All pts were under oral anticoagulation therapy. Initial dose of Ruxolitinib was 10 mg BID for PV, 25 mg BID for ET, 15 mg BID for MF pts with bl platelet count of 100 to 200x109/L and 20 mg BID for those with bl platelet count 〉200x109/L. Median values at enrolment were: hemoglobin 12.9 gr/dL (9.4-16.7), platelet count 212 x109/L(100-389), white blood cell count 7.3 x109/L(1.8-16.4). Eleven of 16 pts (69%) obtained a ≥50% spleen length reduction by palpation; 5/16 pts (31%) achieved a SV reduction ≥ 35% by imaging, comparable to previous studies in MF/PV pts without SVT. Spleen stiffness was evaluable in 4/16 pts due to values over the instrument upper limit of detection in the remaining twelve. All the 4 evaluable pts obtained a reduction from a mean value of 55.2 to 45.8 kilopascals. No significant differences in resistive or pulsatility index of splanchnic artery were noted, nor in esophageal varices status. Eleven of the 16 pts obtained a reduction of the cardiac output from mean value of 5.9 to 4.7 L/min. The median total symptom score calculated with MPN-SAF was reduced from 65 at bl to 42 at w24. Preliminary results of JAK2 allele burden did not show significant changes, while the absolute number of peripheral blood EPCs decreased in pts with PMF at w24 vs bl, in particular for Syto+CD34+VEGFR-2+ and Syto+CD45dimCD34+VEGFR-2+ cells (p

Description: We examined the prevalence and prognostic relevance of bone marrow reticulin fibrosis in 526 patients with World Health Organization–defined polycythemia vera evaluated at the time of initial diagnosis. Seventy-four patients (14%) displayed mostly grade 1 reticulin fibrosis, with only 2 cases showing higher-grade fibrosis. Presenting clinical and laboratory characteristics, including JAK2V617F allele burden, between patients with and without fibrosis were similar for the most part, with the exception of a higher prevalence of palpable splenomegaly in patients with fibrosis (P 〈 .01). Patients with fibrosis were less prone to experience thrombosis during their clinical course (1.1 vs 2.7 per 100 patient-years; P = .03) and more prone to develop post-polycythemia vera myelofibrosis (2.2 vs 0.8 per 100 patient-years; P = .01). There was no significant difference between the 2 groups in terms of overall or leukemia-free survival. The present study clarifies the incidence, degree, and prognostic relevance of bone marrow fibrosis obtained at time of initial diagnosis of polycythemia vera.

Description: Abstract 1780 Background: Biological features related to the development of autoimmune hemolytic anemia (AHIA) in patients with chronic lymphocytic leukemia (CLL) are crucial insights in the understanding of the pathogenesis of autoimmune phenomena in the course of the disease. Design and Methods: We retrospectively analyzed 585 CLL patients with available immunoglobulin heavy-chain variable (IGHV) gene status and B-cell receptor (BCR) configuration (HCDR3). Of them, 73 developed AIHA. The clinical characteristics at CLL diagnosis and follow-up were available in all patients, while cytogenetic analysis at the time of diagnosis was available in 409 patients. Results: Occurrence of AIHA was significantly associated with an IGHV unmutated (UM) status (p

Description: Abstract 3922 Backgrounds The therapeutic activity of Bendamustine ± Rituximab in CLL patients and, in particular, its effect in relationship to clinical and biologic prognostic factors has been analysed only in few studies. Purpose To evaluate in the contest of everyday practice the efficacy and safety of Bendamustine ± Rituximab in CLL patients according to different clinical and biological risk groups. Patients and Methods Nine hematological centers from the North-East of Italy reported retrospectively their experiences regarding the use of Bendamustine in CLL. Outcome and survival analyses were stratified according to the patients' clinical characteristics, previous treatments and cytogenetics. Response status and toxicity were assessed according to IWCLL (Hallek 2008) and to CTCAE V 4.0. Results Clinical data of 142 patients affected by CLL (median age 70 years, range 31–88; 92 males) treated with Bendamustine between January 2005 and June 2012, were analyzed. The investigated series included 39% go-go, 69% slow-go and 2% no-go patients (according to Eichhorst 2009); 11%, 46% and 43% of patients had Binet stage A, B and C, respectively. 19 slow-go patients (13%) were untreated; for the remaining patients, the median number of previous treatments was 2 (range 1–8); 60% of patients previously received a Fludarabine containing regimen; 11% of patients each had stable disease or no response to the last previous treatment. Cytogenetic data was available in 108 patients, being positive for 11q- and 17p- in 27% and 22%, respectively; 70% of patients had an unmutated IGHV status. Bendamustine was administered on day 1 and 2 for a median number of 4 cycles (range 1–6) every 28 days at a dosage of 60–70 mg/m2 in 56% of patients and at 80–100 mg/m2 in 44%; Bendamustine was combined with Rituximab in 84%. 132 patients were valuable for efficacy. Overall 69% responded to Bendamustine; Table 1 summarizes the efficacy results considering different clinical and biological risk groups. Higher response rates were observed among patients with early Binet stage, less number of previous treatments, non 17p- cytogenetic, and in those who received Bendamustine in combination with Rituximab. Median follow up was 9.5 months; overall 1 year estimated PFS and OS were 51%±5% and 76%±2%; significant better 1 year PFS was achieved in patients with previous response to Fludarabine containing regimen, ≤ 2 previous lines of therapy, absence of 17p-, mutated IGHV status, Rituximab combination. Grade 3–4 neutropenia, infectious complications, thrombocytopenia and anemia occurred in 40%, 13%, 11% and 12% of patients, respectively; extra-hematological toxicity was nearly absent. 37 patients died, 23 for causes strictly related to disease progression, 8 because of infections, 1 for colon carcinoma and 5 for other unrelated reasons. Conclusions Although the main clinical and biological prognostic factors which influence the response to Fludarabine containing regimens and, in particular, the presence of 17p- seem not to be overcome by Bendamustine therapy, this drug appeared an active and safe agent for the treatment of patients with CLL (including those with 11q-) in everyday practice, thus suggesting its role as an alternative therapeutic option particularly for “slow-go” patients. The addition of Rituximab to Bendamustine improves response rate and PFS. Disclosures: Zaja: Mundipharma: Honoraria. Fanin:Mundipharma: Honoraria.

Description: Stromal cells are essential components of the bone marrow (BM) microenvironment regulating and supporting the survival of different tumors, including B-cell acute and chronic lymphocytic leukemia (B-ALL and CLL), and acute myeloid leukemia (AML). In this study, we investigated the role of Notch signalling in human BM-mesenchymal stromal cell (hBM-MSC)-promoted ALL, CLL and AML survival and chemoresistance. The block of Notch signalling through γ-secretase inhibitor (GSI) XII reverted the protective effect mediated by co-culture with BM-MSC. The treatment with combinations of anti-Notch neutralizing Abs resulted in the decrease of B-ALL cell survival, either cultured alone or cocultured in presence of BM-MSC from normal donors and B-ALL patients. The inhibition of Notch-3 and -4 or Jagged-1/-2 and DLL-1 resulted in a dramatic increase of apoptotic B-ALL cells by 3 days, similar to what is obtained by blocking all Notch signaling with the GSI XII. The same Notch receptors are involved in CLL survival except for Notch-1 that, in CLL, mediates a synergistic effect with other Notch receptors in inducing the anti-apoptotic phenotype. Some preliminary data showed that Notch system is involved in survival and chemoresistance of acute myeloid leukemia blasts. Overall, our findings show that stromal cell-mediated Notch signaling has a role in promoting ALL, CLL and AML survival and resistance to chemotherapy. Therefore, the target of Notch pathway activation may represent a useful strategy to overcome drug resistance and improve the efficacy of conventional treatments. Disclosures: No relevant conflicts of interest to declare.