ALBERT

Description: Abstract 2793 Background: DLBCL is the most frequent aggressive non Hodgkin's lymphoma in adults. The International Prognostic Index (IPI) is currently the most used tool to identify different risk patients. The role of an interim PET to early identify patients with bad response to chemotherapy is still controversial. Aims: The aim of this analysis is to evaluate the predictive value for event-free survival of an interim PET (after 2 chemotherapy cycles) and at the end of therapy (after 6 chemotherapy cycles) of dose-dense R-CHOP in patients with DLBCL. Methods: This is a prospective clinical trial for patients with DLBCL older than 65 with IPI 0–5 or younger than 65 with IPI 0–2. Treatment consists on 6 cycles of R-CHOP administered every 14 days followed by pegfilgrastim (6 mg per cycle) on day 2. In this sub-analysis we have included 69 patients who completed the 6 cycles of chemotherapy and who have PET evaluation at diagnosis, after 2 cycles of R-CHOP and at the end of treatment. All evaluations were made by combined PET/CT, except for 14 patients who were evaluated by PET alone. PET was determined to be positive or negative based on the local radiology reports. Interim PET results did not change the planned treatment. Results: 124 patients were included in the trial, 19 (15.3%) did not finish 6 cycles of treatment: 2 due to serious adverse events, 2 due to progression disease/stabilization, 7 due to investigators decision and 8 due to death. Over 105 patients who completed 6 cycles of treatment, 69 patients with complete PET evaluation (at diagnosis, after 2 cycles and at the end of treatment) were included in the analysis. Median age was 61.6 years old (range 18.2–82.8), 34 (49.3%) were older than 65 yo, 37 (53.6%) were male, 59 (85.5%) had ECOG 0–1. Characteristics of the disease at diagnosis were as follows: stage III-IV: 45 (65.2%), bulky disease: 17 (24.64%), 〉2 extra-nodal sites involvement: 4 (5.8%), B symptoms: 18 (26.1%), elevated LDH: 36/67 (53.7%), elevated beta-2-microglobulin: 23/62 (37.1%), IPI 3–5: 23 (33.3%). The median relative dose intensity (RDI) for cyclophosphamide and adriamycin calculated according to 3-week interval as a reference was 139.8% (≥130% in 75.2% of patients): 141.6% in younger patients and 138.6% in the elderly. Thirty-five (50.7%) patients achieved a negative PET evaluation after 2 R-CHOP cycles and 57 (82.6%) at the end of therapy. Patients with bulky disease had a positive interim PET more frequently (64.7% vs 44.2%), but most of them turned negative at the end of treatment (positive end-of-treatment PET for bulky disease: 11.7%). With a median follow-up of 28 months (limits 2.3–49), event-free survival (EFS) was 70.6% for patients with positive interim PET and 92.9% for patients with negative interim PET (p=0.14). The negative predictive value (NPV) of a negative interim PET was 94.3% and the positive predictive value (PPV) of a positive interim PET was 14.7%. EFS was 47.6% for patients with positive end-of-treatment PET and 95.6% for patients with negative end-of-treatment PET (p

Description: Introduction Management of B-cell chronic lymphocytic leukemia (CLL) is currently undergoing profound changes. Accordingly, new treatment options with an expected less toxicity than standard regimens are been explored. Recent results show that chemoimmunotherapy may improve the life expectancy of CLLpatients and has proven to be more efficient than chemotherapy alone in depleting malignant cells. Despite its efficacy, little is known about its precise immunomodulatory effects. Aim To evaluate the effects of chemoimmunotherapy with bendamustine plusrituximab (BR) on the distribution of normal residual leucocyte populations in peripheral blood (PB) from advanced-stage CLL patients, with special emphasis on maturation-associated B-cell subsets (immature, naïve, memory IgM/IgG/IgA and plasma cells). Material and Methods Distribution of PB neoplastic cells and residual normal immune cell subpopulations were analyzed in 72 CLL patients with advanced disease (Binet B/C), before therapy (M0) and after 1 course of BR (M1). The same analysis was repeated 3 months after completing treatment (M3) in 31/72 patients. PB leucocyte cell subsets were identified at each time-point by 8-color flow cytometry with monoclonal antibody reagents against CD3, CD4, CD5, CD8, TCRgd, CD19, CD20, CD27, CD38, CD45, CD56, sIgM, sIgA, sIgG, sIgLambda and sIgKappa. Results After the first BR course, absolute counts of all PB myeloid subsets were significantly decreased as compared to time M0, including neutrophils (2,744±1,830 vs 4,764±2,906 cells/uL, p

Description: Abstract 1978 Background: Autologous stem cell transplantation (ASCT) is the treatment of choice for patients with relapsed diffuse large B-cell lymphoma (DLBCL). However, in the rituximab era, patients with persistent disease receiving ASCT have a very poor outcome. Recent studies including radioimmunotherapy as part of the conditioning treatment suggest an improved outcome for this group of patients. Methods: We have evaluated, in a prospective phase 2 study, the safety and efficacy of yttriumm-90-ibritumomab tiuxetan (Zevalin) combined with standard BEAM in refractory DLBCL patients. Thirty patients with induction failure (primary refractory; n=18) or refractory to salvage immunochemotherapy at relapse (n=12) were included in the study. Patients' response was evaluated with PET-CT according to 2007 Cheson's revised response criteria. Results: Patients with a median age of 53 years (range, 25–67) received Zevalin at a fixed dose of 0.4mCi/kg (maximum dose 32 mCi) 14 days prior to standard BEAM. Histology included de novo DLBCL (22) and transformed DLBCL (8). Patients received a median of 3 (range, 2–6) prior therapies before ASCT. All patients had active disease at the time of ASCT, with 25 patients considered to be chemorefractory to the last treatment. Median CD34+ cell dose infused was 3.9 × 106/kg (range, 2–18.3). All patients engrafted. Median time to neutrophil recovery (〉500/μl) was 11 days (9–21), and to platelet recovery (〉20.000/μl) was 13 days (11–35). Overall response at day +100 was 70% (95% CI, 53.6–86.4) with 60% (95% CI, 42.5–77.5) complete responses. Eleven patients have died. One due to a cerebral hemorrhage before ASCT and 1 due to sepsis immediately post-transplant. Seven patients died of disease progression, and 2 patients died due to late complications: bacterial sepsis and secondary acute leukemia. One patient developed a myelodysplastic syndrome (refractory anemia with excess blasts-2) 33 months after TASP, while being in CR of its lymphoma. After a median follow-up of 22.7 months for alive patients (range, 12.2–39.0), 2-year overall and progression-free survival is 65% (95% CI, 47.8–82.8) and 63% (95% CI, 45.5–80.4), respectively. Conclusion: ASCT with conditioning including Zevalin radioimmunotheray plus BEAM is safe, and results in a very high response rate with promising survival in this very poor prognosis group of refractory DLBCL patients. Disclosures: No relevant conflicts of interest to declare.

Description: Introduction: Cerebrovascular disease (CVD) is a multifactorial disease caused by the interaction of genetic and environmental factors. The atherosclerotic plaque, the pathological hallmark of CVD, is an inflammatory process, where pro-inflammatory cytokines, such as tumor necrosis factor alpha (TNFα). TNFα secretion shows a high degree of interindividual variability, which is at least partly genetically determined. We have analysed the prevalence of −238 G/A and −308 G/A polymorphisms in the regulatory region of the TNFα gene promoter in CVD. Patients and methods: Genotypic analyses were performed on 308 consecutive unrelated patients diagnosed with ischemic CVD, 147 women and 161 men, mean age 70±0.8 years, who were diagnosed according to the Trial of Org 10172 in Acute Stroke Treatment. All included cases were age and sex matched to a control from the same geographic area who had no history of vascular disease. Patients and controls completed a questionnaires including blood pressure, diabetes status, total serum cholesterol level and smoking history. The TNFα variants were detected by PCR using primers containing a single base-pair mismatch to introduce a restriction site into the wild-type nucleotide sequences after amplification. PCR products were digested with NcoI and MspI to detect −308 and −238 variants, respectively. The strength of the association of the polymorphisms with the occurrence of CVD was estimated by calculation of the OR and its 95%CI by exact method. P values less than 0.05 were considered significant. Logistic regression analysis was applied to estimate the risk in a multivariable predictive model with dependent variable (case/control) and all independent variables significant in the bivariate analysis. SPSS 9.0 was used for the statistical analysis. Results: Genotype analysis showed a significant higher prevalence of the G/A and A/A genotypes of −238 G/A TNFα in patients (p〈 0.01;OR= 2.16;95%CI= 1.40–3.34). The prevalence of the A allele was also significantly increased in the group of CVD patients than in the controls (13.6% vs 7.0%; p

Description: Abstract 4157 In spite of the progress in the therapy of advanced stage classic Hodgkin lymphoma (cHL), still a significant proportion of patients fail to respond or relapse after complete remission. MicroRNAs (miRNA) are essential regulators of cell differentiation, emerging as robust predictor and prognostic markers. Specific miRNA signatures from the Hodgkin and Reed Sternberg cells (HRS) cells and their microenvironment have been proposed, but the potential prognostic role of them remains unclear. Here, we investigated whether miRNA signatures can allow to a better understanding of cHL pathogenesis and being applied in patient outcome prognostication.We have used mirRNA gene expression data from 32 samples of advanced cHL patients and 5 cHL derived cell lines (L540, L1236, L428, HDLM2, and KHMZ) to identify specific miRNA profiles from the tumoral cells and their non-tumoral microenvironment. A miRNA signature was identified in the cHL cell lines, probably reflecting functional properties of the HRS, whereas the others informed from properties of the reactive infiltrate. Selected miRNAs were further validated by performing laser capture microdissection using frozen samples in order to look for specific miRNAS preferentially expressed for either HRS cells and their surrounding microenvironment. In addition, logistic regression and Cox analysis allowed us to identify a set of 102 miRNAs differentially expressed (p

Description: Myeloablative transplant has been investigated in poor prognosis indolent lymphoma; although recurrence rate is low it is associated with high mortality; the use of non-myeloablative conditioning regimens could reduce TRM maintaining the GVH effect. Up to May 2006, 35 patients with follicular NHL received a Non Myeloablative related allogeneic according to two prospective multicenter trials; conditioning regimen consisted of Fludarabine 150 mg and Melphalan 70–140 mg. GVHD prophylaxis consisted of CSA plus short-course MTX. All patients received filgrastim-stimulated peripheral blood stem cells from a HLA related identical donor. Median age at transplant was 50 years (34–62) and 16 (46%) had received a previous autologous transplant. At transplant, 5 patients (14%) were in CR1 (after several lines of chemotherapy), 9 (25%) in 〉CR1, 12 (34%) in PR, 1 (3%) had stable disease (after 3 chemotherapy lines) and 8 (23%) progressive disease. All patients engrafted. Acute GVHD developed in patients 19 (54%) (17patients (48%) grade II-IV). Chronic GVHD developed in 18 out of 27 patients at risk (67%), being extensive in 11 (41%). Disease was evaluated at day +100 and at that moment 23 patients were in CR, (85%) 1 (4%) in PR, two (7%) had stable disease and 9 patients ( 26%) have died. With a median follow up of 60 months (range: 32–80 months), 20 patients (57%) are alive disease free, and 14 (43%) have died, 12 of them (37%) due to transplant toxicity and 2 patients (6%) due to progression. Overall Survival (OS) and Event Free Survival (EFS) are 57 and 54 % respectively. Analysing variables which influence on OS and EFS, patients 55 years have a OS significantly shorter than those

Description: Abstract 1596 Background: The IPI, which takes into consideration both host and tumor factors, is the standard method used to stratify aNHL into different risk categories. The IPI was derived in the pre-rituximab era and confirmed as valid in the Rituximab (R) era. The major mechanism of action of R appears to be through the host's immune system. Host factors related to the immune status have been recently recognized as significant in predicting outcome. The ALC, AMC, and ALC/AMC ratio were identified by Wilcox et al. as having an impact on both progression free survival (PFS) and overall survival (OS) (Leukemia 2011;25:1502-09). In order to confirm these findings in a different population of aNHLs we have studied 402 patients with aNHL treated in the R era at 5 centers: 1 in Puerto Rico, 4 in Spain (1 Barcelona, 2 Madrid, 1 Valencia). Methods: 402 patients diagnosed between December 2000 and April 2011 with aNHL were included. ALC and AMC were obtained from pretreatment CBC. All patients received anthracycline and R based chemotherapy. ALC was divided in quartiles (Q): 1st Q ALC ranged between 277 and 950, 2nd Q ALC 951–1352, 3rd Q ALC 1353–1870, and the 4th Q ALC 1871– 5400. The lower Q ALC of 950 and the median of 1353, as well as the lower Q AMC of 366 and the median AMC of 504 were assessed as cutoffs to divide patients into groups with low or high ALC and AMC. Results: Median age was 64 (17–92) and 55% were females. Median follow up was 50 months. FFS and OS at 4 years were 73% and 79% respectively. FFS was superior for patients with an ALC 〉950 vs

Description: Introduction It is currently well-known that B-cell chronic lymphocytic leukemia (CLL) patients have an impaired immune function -particularly in advanced disease-, which significantly contributes to a higher risk of infections. The introduction of new effective therapeutic agents, such as the purine analogues (or alkylating agents with concomitant properties of purine analogues) plusanti-CD20 monoclonal antibodies, have significantly increased the rate of complete responses in CLL, but so far their impact on the overall immune function and the spectrum of infections occurring in CLL patients after therapy, remains to be fully understood. Aim To evaluate the effect of the number of treatment lines received on the different normal circulating leucocyte cell populations, including normal B-cell subsets, in advanced-stage treated CLL. Material and Methods The distribution of peripheral blood (PB) leukocytes was analyzed in 85 untreated CLL patients, and compared to that of 63 patients who had previously been treated with 1 line of treatment (n=39) or 〉1 line of treatment (n=24), and who failed to respond. Analysis was performed by 8-color flow cytometry with monoclonal antibodies against CD3, CD4, CD5, CD8, TCRgd, CD19, CD20, CD27, CD38, CD45, CD56, sIgM, sIgA, sIgG, sIgLambda and sIgKappa. Results The absolute count of circulating malignant B cells was not significantly different (p〉0.05) in the untreated vs. previously treated patients who received 1 or 〉1 line of treatment (77,627±84,211 vs 67,994±72,087 vs 59,282±74,206 cells/uL; respectively). In contrast, as compared to untreated patients, PB normal B cells were found to be reduced in patients who had received either 1 line or 〉1 line of treatment (89±142 vs 36±57 and 23±32 cells/uL, p=0.004 and p0.05). When dissecting the normal B-cell subsets, therapy-related decreased B-cell numbers were mostly due to a reduced number of circulating memory B cells (67±98 vs 21±45 and 15±26 cells/uL; p=0.001 and p0.05) B cells, nor for circulating plasma cells (3±18 vs 5±21 and 2±6 cells/uL; p〉0.05), regardless of the therapy status. As compared to untreated patients, the absolute count of CD4+ T cells and CD4/CD8 double negative TCRαβ cells were significantly lower in patients with 〉1 line of treatment (1,836±1,340 vs 1,256±1,027 and 131±165 vs 56±97 cells/uL, p=0.03 and p=0.007 respectively) but not in those who had received only 1 line (1,477±1,349 and 201±747 cells/uL; p〉0.05). In contrast, therapy did not show a significant impact on the absolute count of PB T CD8+ and TCRgd cells. No statistically significant differences were observed in the number of PB innate immune subpopulations including, neutrophils, eosinophils, basophils, monocytes, NK cells and dendritic cells. Conclusions While there are no differences regarding the number of leukemic cells, previously treated patients have significantly reduced counts of total and memory (all isotypes) normal B-cell subsets when compared to untreated patients. Together with this, CD4+ helper T cells could also be compromised after more than 1 line of treatment. Monitoring of these therapy-related immune defects could contribute to a better management of infectious complications in advanced-stage CLL patients. Disclosures: No relevant conflicts of interest to declare.

Description: Phase II trials have shown that lenalidomide alone is active in relapsed and refractory CLL. When the initially dose is reduced from 25mg to 5-10mg associated toxicities as the tumor lysis syndrome (TLS) or tumor flare reaction (TFR) nearly disappeared (J Clin Oncol 2006,24:5343). There is synergistic activity between rituximab and lenalidomide against CLL and non-Hodgkin lymphoma cells in vitro, and recently a Phase II study demonstrated that the combination of lenalidomide and Rituximab is active in patients with recurrent CLL (J Clin Oncol, 2012,31: 584). However neither the dose of lenalidomide nor the optimal schedule of administration has been defined. Furthermore since median age of CLL patients is high the emergence of a nonchemotherapy containing regimen with a lower toxicity seems an attractive approach for them. In 2008 we designed a trial that explore the optimal doses of lenalidomide in combination with rituximab for patients with relapsed or refractory CLL and analized also its safety and efficacy (ClinicalTrials.gov:NCT01185262). Our primary endpoint was to define the recommended dosage regimen for the combination of lenalidomide plus rituximab in patients with relapsed/refractory CLL. From June 2009 to November 2012 a dose escalation study was performed starting at a lenalidomide daily dose of 2,5mg and rituximab (375mg/m2 cycle 1 and 500mg/m2 cycles 2-6/28 days) with cohorts of 3 patients (if no DLT move to a higher dose; if one DLT ocurred in the cohort expand 3 more patients)(Tables 1 and 2). 29 patients has been registered in the trial. 4 of them were screening failures either because did not fullfilled criteria (2) or early withdrawal of patient consent before receiving treatment(2). Median age was 75 years (45-86). Median number of previous lines of treatment were 2 (1-4) and all but 2 patients were treated previously with fludarabine. In the first cohort of 2.5 mg we treated 6 patients and because of persistent neutropenia (more than 7 days grade 4) MTD ocurred. This was because the original protocol did not accept the prohylactic use of G-CSF. From that moment the use of G-CSF was free and based on the investigator criteria but mandatory for all those patients that started with less than 1000 neutrophils/mm3. A total of 33 SAEs were recorded among the 25 patients included in the two periods of the study (before and after the free use of G-CSF)(7/26 respectively) and during all the treatment. Main SAEs were as follows: Infections (23 SAEs with one case of Multifocal leukcoencephalophaty), constipation (2), autoimmune hemolytic anemia (1), allergic reaction to rituximab infusion (1), amyotrophic lateral sclerosis (1), gastrointestinal bleeding(1) and others (4). No case of TLS has been reported and only one case of mild TFR. By June 1st 2013 9/29 patients included has died and one is still receiving treatment. Causes of death were disease progression (5) and infection (4). In our experience the combination of lenalidomide and rituximab was a well tolerated regimen for this old (median age 75y) and heavely pre-treated population. In our experience lenalidomide at 15 mg was defined at the MTD. Neutropenia was the main adverse event associated with the regimen and nearly all patients needed G-CSF support. Clinical eficacy data is on evaluation.Table 1Dose LevelDose of lenalidomideTotal dose of rituximab (Cycle1/Cycle2 & subsequently)I2,5 mg/day375/500 mg/m2II5 mg/day375/500 mg/m2III10 mg/day375/500 mg/m2IV15 mg/day375/500 mg/m2V20 mg/day375/500 mg/m2VI25 mg/day375/500 mg/m2Table 2N patientsDLT2,5 mg3No5 mg4No10 mg4No15 mg82 Disclosures: Tomas: Celgene: Research Funding.

Description: Abstract 3692 Poster Board III-628 Background DLBCL is the most frequent aggressive non Hodgkin's lymphoma in adults. The International Prognostic Index (IPI) is currently the most used tool to identify different risk patients. The role of an interim PET to early identify patients with bad response to chemotherapy is controversial. However end of therapy PET correlates strongly with progression free survival. Aims The aim of this analysis is to evaluate the results of an interim PET (after 2 chemotherapy cycles) and PET at the end of treatment (6 chemotherapy cycles of dose-dense R-CHOP) in patients with DLBCL. Methods This is a prospective clinical trial for patients with DLBCL older than 65 with IPI 0-5 or younger than 65 with IPI 0-2. Treatment consists of 6 cycles of R-CHOP administered every 14 days followed by pegfilgrastim (6 mg per cycle) on day 2. 63 patients, who completed all 6 cycles of chemotherapy and have had both PET evaluations after 2 cycles of R-CHOP and at the end of treatment, have been selected for this sub-analysis. All evaluations were made by combined PET/ CT, except for 14 patients who were evaluated by PET alone. PET was determined to be positive or negative based on the radiology reports. Interim PET results did not change the planned treatment. Results 109 patients were analyzed for response. 17 patients (15.5%) did not finish 6 cycles of treatment: 2 due to serious adverse events, 3 due to progression disease / stabilization, 5 due to investigators decision and 7 due to death. Over 92 patients who completed 6 cycles of treatment, 63 patients who had both a PET evaluation after 2 cycles of treatment and at the end of treatment, were included in this analysis. Median age was 60 years old (range 18.2-78.9), 30 (47.6%) were older than 65, 32 (51%) were male. Fifty-four (85.7%) had ECOG 0-1. Characteristics of the disease at diagnosis were as follows: stage III-IV: 39 (61.9%), bulky disease: 15 (23.8%), 〉 2 extra-nodal sites involvement: 4 (6.4%), B symptoms: 15 (23.8%), elevated LDH: 31 (49.2%), elevated beta-2-microglobulin: 20/57 (35.1%), IPI 3-5: 19 (30.2%). Thirty-one (49.2%) patients achieved a negative PET evaluation after 2 R-CHOP cycles and 53 (84.1%) at the end of treatment. Twenty-nine (93.6%) patients with an interim negative PET remained negative at the end of therapy. Among the 32 patients with a positive PET after 2 cycles of therapy, 24 (75%) turned negative at the end of therapy. Patients with bulky disease had a positive interim PET more frequently (66.7% vs 45.8%), but most of them turned negative at the end of treatment (positive PET 6.7%). Conclusions An early positive PET is not predictive of a persistent positivity at the end of treatment. In fact, patients with bulky disease more frequently have an early positive PET, but most of them turn negative after 6 cycles of R-CHOP14. On the other hand, an early negative PET is highly predictive of a negative end-of-treatment PET. In conclusion, our data do not support an early intensification of patients with DLBCL with a positive interim PET, although a longer follow-up is necessary to confirm these results. Disclosures: No relevant conflicts of interest to declare.