ALBERT

Description: Patients with multiple myeloma (MM) have increased bone marrow (BM) angiogenesis; however, the proangiogenic properties of myeloma cells and the mechanisms of MM-induced angiogenesis are not completely clarified. The angiopoietin system has been identified as critical in the regulation of vessel formation. In this study we have demonstrated that myeloma cells express several proangiogenic factors, and, in particular, we found that angiopoietin-1 (Ang-1), but not its antagonist Ang-2, was expressed by several human myeloma cell lines (HMCLs) at the mRNA and the protein levels. In a transwell coculture system, we observed that myeloma cells up-regulated the Ang-1 receptor Tie2 in human BM endothelial cells. Moreover, in an experimental model of angiogenesis, the conditioned medium of HMCLs significantly stimulated vessel formation compared with control or vascular endothelial growth factor (VEGF) treatment. The presence of anti-Tie2 blocking antibody completely blunted the proangiogenic effect of XG-6. Finally, our in vitro results were supported by the in vivo finding of Ang-1, but not Ang-2, mRNA and protein expression in purified MM cells obtained from approximately 47% of patients and by high BM angiogenesis in patients with MM positive for Ang-1, suggesting that the angiopoietin system could be involved, at least in part, in MM-induced angiogenesis.

Description: Among the three classic Philadelphia-negative myeloproliferative neoplasms (Phneg MPN), myelofibrosis (MF) is the most severe in terms of survival and quality of life, with very limited therapeutic options. Although the pathogenesis of Phneg MPN remains still poorly understood, aberrant megakaryocytopoiesis is a common, distinctive feature. Specifically, in MF, bone marrow megakaryocytes (MKs) are hyperplastic and show typical morphological abnormalities such as hypolobated nuclei, tendency to form tight clusters and impaired capacity to generate pro-platelets (pro-PLTs) in-vitro. Recent data proved that MF-MK hyperplasia is a consequence of both increased proliferation and reduced apoptosis of MK progenitors, likely correlated to the over-expression of the anti-apoptotic gene Bcl-xL (Ciurea et al. Blood 2007). Protein Kinase Cε (PKCε) is a novel, calcium-independent PKC isoform, capable to modulate cell proliferation, differentiation and survival. Our group showed that PKCε plays a crucial role in normal and malignant hematopoiesis (Mirandola et al. Blood 2006; Gobbi et al. Stem Cells 2007; Gobbi et al. Blood 2009). During in-vitro erythroid and megakaryocytic differentiation of normal CD34+ progenitors, PKCε levels are finely tuned with a virtually opposite kinetic: progressively increasing during erythroid maturation while peaking early and then decreasing during MK maturation. Forced expression of PKCε in the later phases of megakaryocytopoiesis delays MK differentiation, proving that PKCε silencing is required for MK full differentiation. Here we investigated the expression of PKCε in primary myelofibrosis (PMF)-MK progenitors and we tested whether PKCε modulation may affect megakaryocytic differentiation of PMF-CD34+ cells. CD34+ cells were immunomagnetically isolated from 5 PMF patients and 2 G-CSF mobilized donors (controls, C) and then cultured up to 14 days in serum-free medium supplemented with 200 ng/mL thrombopoietin, 50 ng/mL Stem Cell Factor and 3 ng/mL Interleukin-3. MK differentiation was assessed by morphological analysis and in-vitro pro-PLT generation. Consistently with current literature, also in our serum-free based culture, PMF-MKs showed impaired differentiation associated with abnormal morphology (smaller size, round and hypolobated nuclei) and reduced pro-PLT generation when compared to C (Fig. 1 panel A). First, we demonstrated by Western Blot analysis (WB), that PMF-CD34+ displayed higher levels of PCKε, phosphorylated PKCε (pPKCε), Bcl-xL and Bcl-2 (Fig. 1, panel B ). Figure 1. Figure 1. This is consistent with their augmented proliferative capacity in MK-differentiating medium [median fold increase of PMF cultures was significantly higher than C (12.91 vs 1.09, respectively, p

Description: Abstract 2858 Janus-activated kinase 2 (JAK2) gene mutations and translocations are involved in the pathogenesis of a variety of hematologic malignancies. Among different translocation partners, pericentriolar material 1 (PCM1)-JAK2 fusion products have been described in rare cases of both lymphoid and myeloid neoplasms characterized by morphological (myeloproliferaton, eosinophilia, myelofibrosis) and clinical (striking male predominance, aggressive course) similarities. We recently identified a new case of the rare translocation PCM1-JAK2 in a 29-year-old man presenting with atypical chronic myeloid leukemia (aCML) and peculiar aspects of diserythropoiesis in the bone marrow (BM): abundant paratrabecular clusters of proerythroblasts associated with marked reduction of mature erythroid compartment (Sammarelli et al., S.I.E.S. 12th Meeting, 2012). For the first time we describe here the erythroid differentiation capacity of ex-vivo expanded CD34+ cells from this PCM1-JAK2 fusion case, as well as the signaling pathways activated in peripheral blood neoplastic cells (PBNC) harboring the translocation. Presence of the PCM1-JAK2 fusion transcript in PBNC was confirmed by nested RT-PCR using primers derived from PCM1 exon 25 and JAK2 exon 9 described in Reiter et al. Cancer Res. 2005 (Figure 1). CD34+ cells were isolated from the peripheral blood (PB) of the patient and cultured in serum-free medium supplemented with erythropoietin (EPO), interleukin-3 (IL-3) and stem cell factor (SCF) to induce erythroid differentiation; erythroid cell output [evaluated in terms of fold increase (FI) and glycophorin-A (GlyA) expression at day 14 of culture] was compared to the one obtained from PB CD34+ cells from a polycythemia vera patient (PV), in which JAK2 is constitutively activated by V617F point mutation, and to CD34+ cells from a G-CSF-mobilized donor (M). As shown in Figure 2, FI and GlyA expression were significantly lower in our patient compared to M and PV (FI: 0.63, 6.47 and 7.92 respectively; GlyApos cells: 4.2%, 51.6% and 64.2%, respectively) consistently with the diserythropoietic picture in the BM. We then investigated the activation of the 3 main signaling pathways associated to Receptor tyrosine kinases and most commonly turned on in cancer: Mitogen-activated protein (MAP) kinase pathway, JAK/Signal transducer and activator of transcription (STAT) pathway and phosphatidylinositol 3-kinase (PI3K)/AKT pathway, evaluating, by Western Blot analysis, levels of phosphorylation of Extracellular signal-Regulated Kinase (ERK1/2), JAK2, STAT5 and AKT in PBNC from our PCM1-JAK2 case and in PB mononuclear cells (PBMC) from 5 healthy control subjects (C1-C5). Although these signaling cascades are deeply interconnected, we surprisingly found a selective activation of the sole MAP-kinase pathway in PBNC (Figure 3). These data suggest that, while presence of JAK2V617F mutation leads to ligand-independent activation of STAT5, AKT and ERK1/2 (Laubach et al. Exp. Hematol. 2009), PCM1-JAK2 fusion product fails to activate JAK/STAT and PI3K/AKT axis. Specifically, reduced STAT5 activation might explain impaired erythroid differentiation of CD34+ cells in vitro as well as the marked aspects of diserythropoiesis in the BM. The signaling signature of PMC1-JAK2 neoplastic cells described here has also relevant implications on the treatment strategy for these patients. In particular, given the lack of activation of JAK2 and its down-stream partner STAT5, JAK-inhibitor therapy does not seem the ideal candidate in this specific setting. Disclosures: No relevant conflicts of interest to declare.

Description: OBJECTIVES Aim of this prospective study was to evaluate the risk of invasive fungal infection (IFI) in patients (pts) with acute promyelocytic leukemia (APL) and to compare APL pts with patients affected by non promyelocytic acute myeloid leukemia (npAML) in order to evaluate factors potentially linked to IFI in these two subsets of acute myeloid leukemia. PATIENTS AND METHODS From January 2010 to April 2012 all pts with newly diagnosed AML were registered in 33 Italian participating centers. A minimum follow up of 90 days after 1st induction chemotherapy was requested for all pts. A prolonged follow up until June 2014 was made only for APL. Data were collected about age, gender, AML subtype, treatment and also about post chemotherapy risk factors for IFI (duration of neutropenia, mucosal damages, vomiting, diarrhea, presence of medical devices), antifungal prophylaxis, onset of IFI, level of certainty (possible/probable/proven), and antifungal treatment. Only for APL the survey was prolonged for at least 3 months in order to analyze if these pts have an IFI risk during other than first induction phases. RESULTS 1,192 consecutive newly diagnosed adult AML pts (npAML:1,086/APL:106) were enrolled in the study. Among npAML pts, those receiving low dose chemotherapy and/or palliative treatment were excluded from the analysis; in the remaining 881 pts 214 cases (24%) of IFI were recorded. Considering APL, 3 pts were excluded from the analysis due to early death (1 pt) or bad performance status (2 pts). The remaining 103 pts received APL treatment according to local protocols: all trans retinoic acid (ATRA) plus chemotherapy (90 pts) or ATRA plus arsenic trioxide (ATO)(13 pts). Only 8 (8%) APL pts developed an IFI after the induction phase: 1 proven, 3 probable and 4 possible IFI. All cases were caused by molds. All APL were followed for a median follow up of 36 months (range 3-54). During this time only 2 other cases of IFI were observed: 1 possible IFI during consolidation at 16 weeks from APL diagnosis and 1 probable aspergillosis in a rare case of APL relapse at 132 weeks from APL diagnosis. All the IFI occurred in pts treated with ATRA plus chemotherapy. IFI was fatal in only 1 case (cerebral aspergillosis), all the other pts recovered after antifungal treatment. A comparison between npAML and APL was made in order to analyze the risk of IFI within 90 days after induction treatment among these 2 groups of patients (see table). A significantly lower number of overall IFI and systemic antifungal treatment was observed in the APL group, in spite of the fact that systemic anti mold prophylaxis was significantly less frequently utilized. Table 1Comparison between APL and npAML in induction phaseAPLnpAMLpNumber of pts103881Mean age51550.01m/f50/53448/433N.S.Performance status (WHO)0-1〉1. 76 27. 284 597.

Description: BACKGROUND: AML in the elderly is associated with low complete remission (CR) rates after induction therapy, poor survival and high treatment-related mortality. 5-Azacytidine (5-AZA) has emerged as a valid substitute of the Conventional Care Regimens (CCR) in a small subset of patient with a bone marrow blast count ranging from 20% to 30%. However, in a off-label use, 5-AZA may also be used in patients with bone marrow blast infiltration 〉30%. Furthermore, 5-AZA can be also used for the maintenance therapy after the bone marrow blast count has been reduced under the 5% cut-off. AIMS: to assess both safety and efficacy of in-label use of 5-AZA in elderly AML patients who have reached a bone marrow blast count between 5% and 30% after an induction conventional chemotherapy. METHODS: from 2010 to 2013, 13 patients (8 males; 5 females) with a median age of 74 (range 64-86) years and a newly diagnosed AML have been enrolled. At the diagnosis, the median bone marrow blast count was 45% (range 24%-95%). Cytogenetics showed: normal karyotype in 7 patients, chromosome 8 trisomy in 2, complex karyotype in 4. A DNMT3A mutation was documented in 5 cases. Neither FLT3-ITD mutations nor NPM1 mutations were present. According to age, performance status and comorbidities, all patients received a CCR induction chemotherapy. Low Dose Cytarabine, 100mg/sqm, was given subcutaneously for 5 days in 4 patients, Fludarabine (25mg/sqm intravenously for 5 days) and Cytarabine (2gr/m2 intravenously for 5 days) in 4 and the ICE schedule- Idarubicine (10mg/sqm intravenously for 3 days), Cytarabine (100mg/sqm intravenously for 5 days) and Etoposide (50mg/sqm intravenously for 3 days) in 5. At the day +31 bone marrow evaluation, no one obtained a Complete Remission, in 5 patients blast count ranged between 20% and 30%; in 4 between 15% and 20%; and in 4 between 5% and 10%. Then, all patients received 5-AZA at 75mg/sqm subcutaneously for 7 days every 28 days. The median number of cycles was 8 with a minimum of 1 cycle and a maximum of 15 cycles. Adverse hematological events were: grade III-IV neutropenia in 7 patients (54%) and thrombocytopenia in 9 patients (69%). Fever was the major non-hematological side effect during 5-AZA: fever was of unknown origin (FUO) in 4 patients, infection-related in 4 (2 pneumonias, 1 sepsis from Pseudomonas Aeruginosa and 1 from KPC). One patient died after the first cycle for septic shock due to KPC. RESULTS: Among the 12 evaluable patients the median survival was 16 months (range 2 – 44). Our data showed a longer median survival (17 months) in the 5 patients with DNMT3A mutation in comparison with those with wild-type DNMT3A (11 months). In consideration of the limited number of patients, the p-value was 0.47. In addition, a reduction of transfusion requirements as well as an improvement of quality of life were obtained. Therapy with 5-AZA was overall well tolerated as only one patient needed a long-term hospitalization and died from septic shock. In conclusion, we showed that a bone marrow blast reduction after conventional induction chemotherapy and a subsequently treatment with 5-AZA can be a valid option in elderly patients with AML and DNMT3A mutation. More patients and longer follow-up are required for confirming these encouraging preliminary results. Disclosures Off Label Use: Gemtuzumab Ozogamicin in AML.

Description: Gene expression alterations occurring in the bone microenvironment cells and their potential relationships with the occurrence of bone lesions in multiple myeloma (MM) patients have never been investigated. In this study, we have isolated both mesenchymal (MSC) and osteoblastic (OB) cells, without in vitro differentiation, from bone biopsies obtained by iliac crest of 24 MM patients, 7 MGUS subjects and 8 healthy donors (N) who underwent orthopedics surgery. Bone status was evaluated in all MM patients by total X rays scan and MRI for the spine. Firstly, we evaluated cell proliferation in relationship with growth substrate (bone and glass) and cell phenotype by flow cytometry and immunohistochemistry. We found that both MSC and OB cells have higher cell doubling rate in MM patients as compared to N. Higher expression of alkaline phosphatase and Runx2 was observed in OB as compared to MSC cells in both N and MM patients without osteolytic lesions, but not in osteolytic ones. We performed a gene expression profiling analysis of isolated MSC and OB cells using GeneChip® Affymetrix HG-U133A oligonucleotide arrays. An unsupervised analysis of the most variable genes across the dataset generated a hierarchical clustering with the two major branches containing respectively MSC and OB samples. A multiclass analysis of N, MGUS and MM patients identified 33 differentially expressed probe-set (specific for 27 genes) in MSC cells, and 19 differentially expressed probe-set (13 genes) in OB, and the identified transcripts mainly characterized N versus MM and MGUS samples. A supervised analysis between N and MM samples identified 65 probes (56 genes: 17 up-regulated and 39 down-regulated) differentially expressed in MSC and 35 probes (29 genes, 12 up-regulated and 17 down-regulated) in OB. Notably, genes encoding the Homeobox class proteins, such as HOXB2-6-7, were up-regulated in both MSC and OB of MM patients as compared to N. As regards the bone status, a total of 60 probe-sets (3 up-regulated and 57 down-regulated genes) were found differentially expressed in MSC from osteolytic vs. non-osteolytic MM patients, whereas MGUS-MSC exhibited an intermediate transcriptional profile between osteolytic and non-osteolytic MM patients. A distinct pattern of gene expression profiling was also observed in MSC versus OB when osteolytic and non-osteolytic MM patients were compared (26 vs. 94 differentially expressed probe-sets, respectively), including transcription factors related to MSC osteogenic differentiation belonging to Runx2 pathway (HEY1) or Wnt and BMP signaling On the other hand, few genes were found differentially expressed in OB cells in relationship with the presence of bone lesions. In conclusion, we identified a distinctive transcriptional fingerprint in isolated MSC and OB cells of MM patients as compared to N subjects, which mainly correlated with cell proliferation. Moreover, a different gene expression profile was observed in MSC cells of MM patients according to the presence/absence of bone lesions, highlighting the critical role of the block of the osteogenic differentiation.

Description: Background: Combined treatment with all-trans retinoic acid (ATRA) and anthracycline-based chemotherapy regimens has remarkably contributed to improve treatment outcomes in patients with Acute Promyelocytic Leukemia (APL) patients leading to cure rates above 80%. However, information is lacking on how these patients might recover in the long-term period. Objective: The primary objective of this study was to investigate long-term health-related quality of life (HRQOL) and symptom burden in APL and to examine factors predicting better long-term HRQOL outcomes. Patients and Methods: Patients with APL treated within two large GIMEMA trials (i.e., AIDA0493 and AIDA 2000) were considered. All patients received ATRA plus Idarubicin (AIDA) for induction followed by consolidation that was risk-adapted in AIDA2000 and in most cases, maintenance for 2 years . The main inclusion criterion was having survived the initial diagnosis for more than 5 years and being in complete remission (CR) at the time of study inclusion. The SF-36 was used to assess generic HRQOL. This questionnaire consists of 36 items covering eight generic health status/QoL domains: physical functioning (PF), role limitations due to physical health (RP), bodily pain (BP), general health perceptions (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (RE) and mental health (MH). Mean SF-36 scores were compared between APL patients and those from general population. To minimize bias, all comparisons were performed between APL patients and corresponding propensity score-matched peers from general population, further adjusting for education, family status and geographical area using a multivariate linear mixed model. For descriptive purposes, a cut-off of 30 years was considered to distinguish between younger and older patients at the time of diagnosis and the corresponding HRQoL profiles were compared using multivariate linear regression analysis to adjust for key potential confounders. Also, M.D. Anderson Symptom Inventory (MDASI) was assessed to investigate the profile and prevalence symptom burden Results: Of the 307 patients, potentially eligible for this analysis and invited to participate in the study, 244 completed a HRQOL questionnaire (compliance 79.5%). No differences were found in the main socio-demographic and clinical characteristics between patients with or without a HRQOL evaluation. Mean age of patients was 52 years (range 20-90) and there were 47% males and 53% females. Median time from diagnosis was 14 years (range: 4-20). There were 81% of patients reporting at least 1 comorbidity at the time of HRQOL evaluation. APL long-term survivors reported a HRQOL profile broadly similar to that of their peers in the general population. However, the RP scale was statistically (P=0.016) and clinically meaningful worse in APL patients. Fatigue was the most prevalent symptom with 70% of patients reporting it with any level of concern, as well the most frequently reported moderate to severe symptom by 29 % of patients. Being distressed and problem with remembering things were the other two most prevalent symptoms reported by 65% and 62% of patients respectively. Being diagnosed at a younger age (

Description: Hypoxia is a common feature of solid tumors associated to angiogenesis and malignant phenotype. Tumor adaptation to hypoxia is mainly due to the hypoxia-inducible factor (HIF)-1α, a key transcription factor that regulates angiogenesis and tumor progression. As known multiple myeloma (MM) is a hematological malignancy characterized by the accumulation of malignant plasmacells into a hypoxic microenvironment as the bone marrow (BM) that critically supports their growth and survival. However the effect of hypoxia on MM cells and the role of HIF-1α in MM-induced angiogenesis actually are not known. Recently we have demonstrated that the tumor suppressor gene ING4 may exert an anti-angiogenic effect through the inhibition of HIF-1α activity in MM cells in hypoxic condition suggesting a role of HIF-1α in MM-induced angiogenic switch. To go further insight this issue, in this study, first we checked the level of BM oxygen tension in a cohort of MM patients (n°=25) at the diagnosis as compared to healthy donors and MGUS subjects. The mean pO2 ± SD was 52.3±9 mmHg (p=NS) in MM patients similar to that observed in the controls, confirming that MM cells are exposed in vivo to hypoxic microenvironment. Thereafter HIF-1α protein expression by MM cells was checked by immunohistochemistry on bone biopsies showing the presence of HIF-1α stabilization at nuclear level in malignant plasmacells as well as in BM stromal cells (BMSC) into the BM. Consequently the effect of hypoxia and HIF-1α in both MM and BMSC cells was checked. Human myeloma cell lines (JJN3 and RPMI-8226) and BMSC were transfected with a pool of siRNA anti-HIF-1α to knockout HIF-1α and then exposed to low oxygen tension. A gene expression profiling evaluation was performed by microarray analysis using Gene Chips U133plus 2.0 (Affymetrix). Data were then validated by real time PCR. We found that hypoxia significantly upregulated the expression of the pro-angiogenic molecules in both MM and BMSC cells including Vascular Endothelial Growth Factor (VEGF), Osteopontin (OPN) and Interleukin-8 (IL-8) blunted by siRNA anti-HIF-1α. Genes belonging to glycolysis and HIF-1α regulating signal pathways were found to be also regulated by HIF-1α in MM cells in hypoxic condition. These observations were confirmed in purified CD138+ MM cells (n°=11) exposed to hypoxia that induced a significant up-regulation of the pro-angiogenic molecules and the modulation of glycolysis and ubiquitin mediated proteolysis signal pathways. Finally, the potential expression and role of HIF-1α in MM cells was also investigated in normoxic condition. Whereas the presence of HIF-1α mRNA was observed in all HMCLs and primary MM cells tested, HIF-1a protein stabilization and activity was observed at nuclear level in 2 out of 6 HMCLs and in about 38% of MM patients evaluated suggesting that a hypoxia independent stabilization of HIF-1α may occur in MM cells. Consistently, in normoxic condition, HIF-1α knock out by siRNA significantly affected in HMCLs either pro-angiogenic molecules as VEGF or several genes belonging to cell cycle regulation. In conclusion our data underline the role of hypoxia in the regulation of the angiogenic signature of MM cells and the BM microenvironment and suggest that HIF-1α could be a potential target in MM.

Description: Introduction: Incidence of fungal infections is reducing in the last years due to wider use of effective antifungal prophylaxis. On this basis, we evaluated clinical characteristics and outcome of patients (pts) with hematological malignancies (HMs) and fungal bloodstream infections (FBSI). Patient and Methods: This retrospective/prospective study gathered consecutive documented FBSI observed among HMs diagnosed between January 2011 and June 2015 in 19 Italian Hematology Departments that refer to SEIFEM (Sorveglianza Epidemiologica Infezioni Fungine Emopatie Maligne) group. Results: We collected overall 100 patients including retrospective pts and those observed in the first six months of the prospective study with FBSI among 16 centers; further 3 centers reported no cases of FBSI. Regarding patients' characteristics male/female ratio was 1, median age was 55 yeras. (IQR 18-88). Two-third of FBSI were detected in AML (43 - 43%) and NHL (27 - 27%); the remaining pts were affected by ALL (9 - 9%), MM (6 - 6%), MDS (5 - 5%), MDS/MPN (5 - 5%), CLL (3 - 3%) and HL (2 - 2%). Thirty-five pts had FBSI at the onset of HM or after the first induction, 47 after treatment for refractory/relapsed disease, 13 when in remission, 28 pts during transplant procedures (17 from allogeneic donor, 11 from autologous cells). Fifty-nine pts were receiving antifungal prophylaxis at FBSI breakthrough: 26 posaconazole, 16 fluconazole, 6 itraconazole, 3 amphotericin B, 3 caspofungin, 1 voriconazole, and 4 combination of amphotericin B/azoles; 4 pts were treated with secondary prophylaxis after previous fungal infection. Eighty-nine pts had a central venous catheter. Eighty-four pts presented a neutrophils count 〈 500/mmc for a median time of 7 days before FBI onset (0-70 d); 50 pts received steroids and other 17 immunosuppressive treatment for allo-HSCT. Yeasts were the most common agent detected. Candida spp. represent the most represented yeast, counting for 77% of all infections; (21 albicans and 56 non albicans); 8% of FBI were due to 8% Geotrichum, 3% Trichosporon and 2% Rhodotorula, Molds were rare but not infrequent: 8% were caused by Fusarium and 1% by Scedosporium. Three patients died before starting any antifungal. Fifty-two received echinocandins (49 caspofungin and 3 anidulafungin), 22 liposomal amphotericin B (L-AmB), 15 azoles (7 fluconazole, 3 posaconazole, 3 voriconazole and 2 itraconazole) and 8 pts combo therapy (5 posa+L-AmB, 2 Caspo+L-AmB, 1 vori+caspo). Thirty-eight pts died within 30 days from FBSI diagnosis, 28 (74%) of whom due to infection. Among these 12 (43%) suffered from AML (1 in induction, 1 in CR, 10 had refractory/relapsed disease), 2 (7.2%) from ALL (all with refractory/relapsed disease), 7 (25%) from NHL (2 in induction, 2 in CR, 3 with refractory/relapsed disease), 4 (14%) from refractory/relapsed MM, 1 (3.6%) from MDS in remission, 2 (7.2%) from newly diagnosed MDS/MPN. In 8 pts (21%) for whom we cannot discriminate if death was subsequent to FBSI only or to uncontrolled HMs, fungal isolates were all rare yeast or molds except 2. Mortality was related only with advanced phase of underlying HM (p