ALBERT

Description: The combination of fludarabine, cyclophosphamide and rituximab (FCR) is still currently regarded as the standard regimen for treatment of physically fit patients with chronic lymphocytic leukemia (CLL). This therapy can be associated with significant toxicity, and patient adherence to the protocol may often be difficult outside of clinical trials. This retrospective study aimed to evaluate the efficacy and safety of FCR therapy in the real life setting, with particular focus on the influence of dose reduction on treatment outcome. A total of 132 CLL patients (≤70 years of age) treated with FCR as frontline therapy from 10 medical centers, were reviewed. The majority of patients were males (73.5%, n=97) and younger than 60 years (78%, n=103). Eleven patients had Binet stage A (8.3%), 72 (54.5%) were stage B and 49 (37.1%) had Binet stage C. Results of FISH analysis were available for 99 patients, with high risk cytogenetics of del(11q) in 21 patients (21.2%) and del(17p) in 9 cases (9.1%). The majority (56.5%, n=74) received rituximab at a dose of 500mg/m2 and the rest 375mg/m2. Almost half of the patients (49.2%, n=65) were given a reduced dose of chemotherapy (

Description: The main cause of thrombosis, a major complication of essential thrombocythemia (ET), is the high platelet count. In contrast, thrombosis is rare in reactive thormbocytosis (RT), indicating that thrombocytosis can not be the sole cause of thrombosis. Moreover, thrombosis occurs in ET even after reduction of the platelet count. Tissue factor (TF) is the most potent activator of coagulation. Monocytes are a main source of TF and monocyte TF is increased in various disorders including solid tumors and polycythemia vera that are associated with increased incidence of thrombosis. The decreased incidence of thrombosis that was reported recently in ET after treatment with hydroxyurea compared to anagralide was attributed to a decrease in leukocytes that occurs only after hydroxyurea. Based on this information, we studied the capacity of monocytes from patients with ET to generate TF. Peripheral blood mono-nuclear cells (PBMC) were isolated on Ficoll-hypague from 14 patients with ET and 10 with RT due to iron deficiency. Monocytes were counted by anti CD14 and were the same in both groups (18%). Monocytes were purified from lymphocytes by adherence to plastic surface. Cells were incubated for 16 hours with and without endotoxin.TF activity was measured in the cells by modified PT and TF antigen by ELISA. TF activity and antigen were 1.4–1.7x 10−5 U/monocyte and 21–31x10−5 pg/monocyte in unstimulated PBMC from normal controls (NC), RT and ET. Stimulated PBMC from NC and RT showed a similar increase of TF activity and antigen (2.5 and 3.8 fold).However, PBMC from ET generated 12.9 and 14.4 times more TF activity and antigen (p

Description: Background: The Israel National Cancer Registry (INCR) is a population based, national passive tumor registry established in 1960. Reporting by hospitals, laboratories, and other providers has been mandatory in Israel since 1982 and most cancer cases are registered on the basis of pathology reports and hospital records. In some hematopoietic malignancies where the diagnosis was not based on tissue pathology and patients initially received no inpatient treatment, cases may not have been reported to the registry, or reporting to the INCR may have been delayed, resulting in an underestimation of the true burden of disease. One diagnosis for which there is particular concern in this regard is CLL/SLL and here we used active surveillance to estimate the true incidence of CLL/SLL in Israel. Here we present the interim results Methods: We attempted to estimate the incidence of CLL in Israel more accurately,recognizing the fact that the exact incidence may never be known. The Israel Chronic Lymphocytic Leukemia Study Group, working with the Israel Center for Disease Control of the Ministry of Health, actively documented new cases of CLL/SLL in Israel for calendar years 2011 and 2012. All flow cytometry laboratories in Israel provided lists of patients with B cell clones. Israeli hematologists diagnosing CLL were asked to verify which of the B cell clones indicated a diagnosis of CLL, SLL, PLL or MBL and to fill out an internet-based reporting form. Diagnoses based on flow cytometry were verified by medical record review. Cases identified through active surveillance were pooled with cases known to INCR in order to estimate the true annual incidence of CLL/SLL and assess the completeness of the INCR data. Results: We identified 432 and 396 CLL/SLL cases for 2011 and 2012, respectively of whom 57.4% were males. The average age was 68.8. The corresponding age-adjusted[1]incidence rates per 100,000 (ASR) were 4.26 for 2011 and 3.79 for 2012. In comparison, the INCR registered 295 new CLL cases in 2011 (ASR=2.78) and 232 in 2012 (ASR=2.19), 54.5% of them males. The average age at diagnosis was 69.9. These data indicate a gap between true and reported incidence (1.48 and 1.60/100,000 in 2011 and 2012, respectively). However, it should be noted that the INCR will be fully updated for 2012 only by the beginning of 2015. Of active surveillance cases, 157 (2011) and 152 (2012) were registered in the INCR. Most cases missing in the INCR were diagnosed based on flow cytometry, peripheral blood samples and FISH (85.9% in 2011, 89.8% in 2012) without histo-pathological confirmation. Of the CLL/SLL cases existing in the INCR dataset for 2011-12 but not detected by active surveillance (138 in 2011; 80 in 2012), most (76.8% in 2011, 63.8% in 2012) had been diagnosed earlier and the remainder were coded as diagnoses other than CLL/SLL. Omitting these cases from the INCR dataset substantially increased the observed gaps in the true and the registered annual incidence of CLL/SLL (from 1.48 to 2.80 per 100,000 in 2011 and from 1.60 to 2.37 per 100,000 in 2012). Conclusions: The true incidence of CLL is unknown, but it is clear that there is under reporting to cancer registries. Completeness of CLL/SLL data requires accurate reporting of cases by hematologists and other care providers in the community. In Israel, this issue has been addressed by publishing updated guidelines for mandatory reporting stressing the requirement for reporting of hematologic malignancies. [1] Age-adjustment made on the basis of the world standard population Disclosures Ruchlemer: Roche: Research Funding.

Description: Introduction: Chronic Lymphocytic Leukemia (CLL) is frequently accompanied by immune dysregulation. Hypogammaglobulinemia is one of the most important immune defects encountered, and all three classes of immunoglobulins (IgG, A and M) can be involved. Recently, novel heavy+light chain (HLC) immunoassays have become available that quantify the light chain types of each immunoglobulin class (e.g. IgGk and IgGl). These assays are measured in pairs and provide information on the isotype produced by a tumour (the "involved" HLC), the non-clonal ("uninvolved") HLC, and the ratio (e.g. IgGk/IgGl) - which indicates monoclonality. HLC assays have been shown to improve monitoring of plasma cell dyscrasias, but their role in CLL is yet to be studied. Methods This is a multi-center study performed in collaboration with the Israeli CLL Study Group and involved 10 medical centers. The cohort included 122 patients with CLL and 26 healthy controls. Baseline was defined as the time the blood sample was taken. Serum samples were analyzed for levels of IgG subclasses (IgG1, IgG2, IgG3, IgG4), heavy+light chains (HLC) (IgGκ, IgGλ, IgAκ, IgAλ, IgMκ or IgMλ) and free light chains (sFLC). HLC-pair suppression was defined as an abnormal HLC ratio and uninvolved HLC levels below the normal reference range (i.e. in g/L: IgGκ

Description: The issue of mass casualties in civilian population has lately become globally relevant and prevalent. Explosions of loaded busses by suicide bombers as well as explosions in crowded public places create a great number of casualties, many of them being children and several members of same families, who are evacuated by scoop and run method to nearby hospitals. We report on potential hazards of massive blood transfusions to multi-trauma patients, simultaneously admitted to hospital. Upon admission to the emergency room (ER) ID and personal details of patients are recorded and a temporary ID badge is issued for unidentified patients. Then, a blood sample for typing and screening is taken and required blood is ordered. Primary blood supply for patients with unstable condition, who need immediate blood transfusion, is O Rh positive packed cells (for fertile females O Rh negative) until the ABO and Rh blood groups are established. In order to avoid misidentification our routine includes presence of a blood bank representative in the ER for confirming identification of patients and correct labeling of blood samples. 2 individuals must identify patients from whom samples are taken. In the operating rooms (OR) another blood bank representative (either a transfusion medicine specialist or a hematologist) matches blood types and identification numbers, maintains contact with the blood bank, conveys information to anesthesiology team and advises them on replacement therapy. 7 terrorist attacks resulted in a total of 55 patients, evacuated to 2 hospitals in Israel. 285 packed cells units were typed and cross-matched for these patients. The amount of packed cells supplied during the first 2 hours was 47% of the total blood supplied during the first 24 hours. The cross-matched/transfused ratio varied from 1.3 to 2.19 reflecting overestimation of blood requirement during mass casualty episodes. One “near-miss” was prevented in OR when two members of the same family were operated on in adjacent rooms. Units for one of these patients were misplaced. ABO incompatibility is one of the major causes of morbidity and mortality resulting from blood transfusions. Signs and symptoms are masked in an anesthesized patient. The fact that units of blood accumulate at patient’s bedside upon being deleted from the blood bank inventory may be misinterpreted as a shortage of blood supply in the blood bank. There is also a potential for errors in matching units of blood to patients both in ER and OR. In the setup of mass casualties influx the blood bank personnel should be on alert for the following potential Achilles’ heels: misidentification of the patient when taking a blood sample for typing and screening or misidentification of the patient who needs to receive the blood product. Reasons for these may be either one digit difference in serial temporary number of unidentified patients, being operated on simultaneously in nearby rooms, or several family members undergoing simultaneous surgery in adjacent OR. Such errors can be minimized by using a 3-digit bold number in addition to the running temporary ID and thus providing 2 identification parameters. Our data suggest that the amount of blood products ordered for such patients is excessive. Surgical teams should be aware of the possibility to have blood components kept on hold in the blood bank instead of accumulating them in ER and OR and risking misidentification and suboptimal storage conditions.

Description: Abstract 4620 Chronic lymphocytic leukemia (CLL) is the most common leukemia of the elderly people in the western world. Its age-adjusted incidence rate is about 4.1 per 100,000 men and women per year. CLL increases exponentially with age and for patients above the age of 80 the CLL incidence rate increases to 〉20 per 100,000 per year. The clinical characteristics and outcome of CLL patients diagnosed at age 80 or above are unknown. The Israel Chronic Lymphocytic Leukemia Study Group reviewed retrospectively the records of 214 such patients diagnosed between the years 1979–2009 in 7 medical centers (118 males, 96 females; mean age: 84 years, range; 80–94). 153 (71%) were Ashkenazi Jews, 43 (20%) were Sephardic Jews, and 3 (1.4%) were Arabs. 104 (48%) were referred due to routine blood analysis and 80 (37%) due to disease manifestations. At diagnosis 120 (56%) had Rai stage 0, 67(31%) Rai stages I and II, and 27(13%) Rai stages III and IV. The mean hemoglobin level was 12.2g/dL (range 5.8–17.3), mean WBC 33,241/μ L (range 6,100-400,000) and mean platelets of 194,622/μ L (range 56,000-617,000). Lymphadenopathy was noted in 33% and splenomegaly in 22%. LDH at diagnosis was elevated in 26% of the patients. 161 patients (75%) were on follow-up only without any treatment. Fifty three patients received treatment for the CLL (25%). Treatment consisted of chlorambucil and or prednisone in 36 patients, COP (cyclophosphamide, vincristine and prednisone) in 6 patients, CHOP (cyclophosphamide, adriamycine, vincristine and prednisone) in 5 patients, FC (fludarabine and cyclophosphamide) in 3 patients and RCOP (rituximab and COP) in 2 patients, 1 patient received irradiation. By June 2010,155 patients (72%) have died with a mean overall survival of 68±5 months, median 56±5.4 months and 5 years survival of 47.2%±3.6. In univariate analysis a better survival was associated with younger age (the mean survival of patient age 80–84 years at diagnosis was 76±6.3 months, median 71±5.8 months compared to mean survival of 48.8±4.8 months and median 43±9.3 months for patients ≥85 years old at diagnosis, p=0.002), Rai stage (the mean survival of patients diagnosed at Rai stage 0 was79.5±8.5 months, median 62±6.5 months compared to mean of 55.7±6.2 months, median 47±7.6 months for patients diagnosed at Rai stages I and II, p=0.023), WBC count at diagnosis (the mean survival of patient with WBC count at diagnosis ≤30,000/μ L was 77±7.6 months, median 62±6.1 months compared to mean survival of 51.8±6.7 months, median 32±8 months in patients diagnosed with a WBC 〉30,000/μ L, p=0.015), β2 microglobulin levels (the mean survival of the 39 patients with β2 microglobulin level at diagnosis 〈 3mg/L was 103±19.6 months, median 70±13 months compared to mean of 50.2±7.6 months, median 39±8 months in the 28 patients with β2 microglobulin levels ≥ 3 mg/L, p=0.006), reason for diagnosis (the mean survival of patients diagnosed due to routine blood counts was 88.4±11.2 months, median 72±4.8 months, compared to 43.2±4.6 and 27±6.8 in patients diagnosed due to disease manifestations, p〈 0.001), and CD38 level (the mean survival of 87 patients with CD38 levels ≤30% was 81.1±7.9 months, median 72±4.6 months compared to 52±8.9 32±6.9 months respectively in the 24 patients with CD 38 levels 〉30 %, p=0.036). No correlation was found between overall survival and patients’ gender, receiving or not chemotherapy, year of diagnosis before or after 2000, or ethnicity (Ashkenazi Jews vs. Sephardic Jews). Multivariate analysis using Cox regression analysis found younger age, low WBC count, and routine blood test as the reason for diagnosis as 3 independent good prognostic factors (HR 1.8, 1.6, 1.9 respectively). CLL patients diagnosed at the age of 80 or more can still expect to live long life. Disclosures: No relevant conflicts of interest to declare.

Description: Chronic lymphocytic leukemia (CLL) is a disease of elderly patients. Despite the development of novel agents and new monoclonal antibodies, FCR still remains the combination chemoimmunotherapy of choice for fit patients with CLL, yielding the longest durations of remission. When this study was first started, no established chemo-immunotherapy regimen was unanimously regarded as standard therapy for less fit elderly patients with CLL; this category of patients had clearly been underrepresented in clinical trials utilizing chemo - or chemo-immunotherapy. Patients and Methods We conducted a single arm, phase II trial to assess the efficacy and toxicity of low dose fludarabine and cyclophosphamide in combination with a regular dose of rituximab (FCR-LITE) in elderly patients with therapy naïve CLL. Our intention was to deliver 6 courses of Fludarabine which was given intravenously (IV) at 12.5 mg/m2/day together with IV cyclophosphamide 150 mg/m2/day for 3 consecutive days. IV rituximab was administered on day 0 of cycle 1 at a dose of 375 mg/m2, and at 500 mg/m2 on day 1 of cycles 2-6. Categorical variables were compared in patients with and without CR using chi-square test or Fisher's exact test and continuous variables were also compared using Mann Whitney test. Duration of follow-up was recorded using reverse censoring method. Kaplan Meier curve was used to establish PFS during clinical follow-up. All statistical tests were two sided. P

Description: Central retinal vein occlusion (CRVO) and central retinal artery occlusion (CRAO) are common disorders mainly associated with traditional risk factors for atherosclerosis. There is no clear correlation between thrombophilia and CRVO. However it was suggested that hyperhomocysteinemia and the presence of antiphospholipid antibodies are risk factors for the development of CRAO. Protein Z is a vitamin K dependent cofactor for the inactivation of activated factor X (Xa) by the protein Z dependent protease inhibitor (ZPI). Protein Z deficiency presumably promotes thrombosis, in particular arterial thrombosis, as suggested by an association between low plasma protein Z levels and ischemic stroke. The similarity between risk factors for ischemic stroke and CRVO / CRAO and the fact that low protein Z levels are associated with an increased risk for ischemic stroke has led us to assess protein Z levels in patients with CRVO and CRAO. Plasma samples from 29 patients with CRVO and 7 patients with CRAO (total study group= 36, mean age 60±11) were screened for protein Z levels by ELISA. Study group was also screened for the presence of lupus anticoagulant (LAC) by the kaolin clotting time (KCT) index and the dilute Russells’ viper venum test (DRVVT), for activated protein C resistance (APCR) and anticardiolipin antibodies (ACA). Levels of protein Z were compared with a control group of 42 healthy individuals (mean age 43±11). Patients with CRAO and history of ischemic stroke or an embolic source were excluded. Thirty patients in the study group had traditional risk factors for atheroscalerosis including hypertension, diabetes mellitus, hyperlipidemia and smoking and 6 patients had none. There was no significant difference in protein Z levels between the whole study group patients and controls (1995±810 vs. 2010±603 ng/ml p=0.922). However, patients with no risk factors for CRVO/CRAO had significantly lower protein Z levels than controls (1379±682 vs. 2010±603 ng/ml p=0.022) and patients with risk factors (1379±682 vs. 2118±785 ng/ml p=0.04). In the study group three patients had abnormal APCR and 6 had positive LAC. There was no correlation between low protein Z levels and the presence of LAC, APCR or ACA, or a correlation between low protein Z levels and the specific diagnosis (CRVO or CRAO) or age. The data show that low protein Z levels may be an additional risk factor for CRVO and CRAO in patients without traditional risk factors for these disorders. The association should be explored in a larger group of patients.

Description: In autoimmune diseases the production of auto reactive antibodies is related to activation of normal B-lymphocytes. The high incidence of autoimmune disorders (AID) in CLL is well known, but the origin of auto antibodies is controversial. In the present study we postulate that Chronic Lymphocytic Leukemia associated with autoimmune diseases discloses activated phenotype pattern. Out of the 891 CLL patients registered in the Israeli Study Group, we found 72 patients (8%) who presented at least one clinically expressed autoimmune disease at diagnosis. Median age was 67 years old (range 45–87). 44% were male, 45 patients were at Binet`s stage A, 17 patients at Stage B and 4 at Stage C, and six patients were diagnosed with de novo PLL. The autoimmune disorders were as follows: Hashimoto`s disease (25), AIHA (11), Sjogren`s syndrome (10), rheumatoid arthritis (9), vasculitis (8), Grave’s disease (5), Evan’s syndrome (4), ITP (4), multiple sclerosis (2) and pernicious anemia, pure red cells aplasia, Raynaud`s syndrome, systemic erythematous lupus, ulcerative colitis (each-one). We found also 19 cases of positive direct antiglobulin test, 7 cases of positive rheumatoid factor, 4 cases with positive antinuclear antibodies, and 7 cases of hypocomplementemia. In 16 patients (22%) the morphology cell was consistent with activated lymphocytes (more than 30% of prolymphocytes). Immunophenotype analysis revealed increased expression (〉30%) of activation markers CD38 or FMC7 in 27%. IgG was higher than 1000 mg/dl in 57%, while 5 cases found with IgM paraproteinemia. Increased Beta2- microglobulin level, described by us correlating the activation of B-CLL cells, was increased in 78% of tested cases. The new marker ZAP 70 analyzed in seven patients and found positive in 5. Interestingly, Beta2m and CD38 wich usually define agressive disease were found predominatly in stage A patients with AID. Our results suggest that in B- CLL associated with autoimmune disorders, the B CLL cells present some degree of activation. It is well known that B-lymphocytes in CLL are in a preactivated state and can be induced to differentiate into plasma cells and to stimulate residual normal B cells to produce high-affinity polyclonal autoantibodies with restricted specificity and pathogenic properties. This possibility would be in keeping with our observation. Conclusion: our data showing activated lymphocytes morphology and /or increased expression CD38 or FMC7, high level of IgG and of Beta2-m in most of the cases, suggests that a state of activation of B-cells may correlate with the occurrence of autoimmune complication in B-CLL.