ALBERT

Beschreibung: Second-generation tyrosine kinase inhibitors (2G-TKI), nilotinib or dasatinib used after imatinib failure can induce complete cytogenetic response (CCR) in 50% of chronic myeloid leukemia (CML) patients. BCR-ABL transcript levels reduction in the initial months of treatment has been associated improved outcome. Aims to evaluate the predictive value of early molecular responses, at 3 and 6 months after treatment with 2G-TKI in CML patients with imatinib failure or intolerance; to correlate these responses with CCR, overall survival (OS), progression-free survival (PFS) and event free survival (EFS). Methods Between September 2007 and August 2012, 71 consecutive patients with CML resistant or intolerant to imatinib were treated with dasatinib (n= 50) or nilotinib (n=21). BCR-ABL transcripts were measured in peripheral blood using real-time quantitative PCR (RQ-PCR) at 3 months intervals. Results were expressed as BCR-ABL/ABL ratio, with conversion to the international scale (IS). Major molecular response (MMR) was defined as a transcript level ≤ 0.1% (IS). Cytogenetic analysis was performed at baseline, 3, 6, 12 and 18 months after starting therapy with 2G-TKI. BCR-ABL mutation analysis by direct sequencing was investigated in resistant patients. Probabilities of OS, PFS and EFS were calculated using Kaplan-Meier method. An event was defined as the loss of CHR, CCR, progression to advanced phases, death or 2G-TKI discontinuation. The CCR probabilities according to molecular responses were calculated by c2 method and cumulative incidence, considering as competitive event death or progression. Results 71 patients were analyzed, median age of 47 years (15-81); Disease status before 2G-TKI was: 50 (71%) CP; 13 (18%) AP and 8 (11%) BC. Responses: 59/71 (83%) obtained CHR; 38/55 (69%) CCR and 37/60 (62%) MMR. At 3 months of therapy, 81.5% (44/54) had a BCR-ABL ratio ≤10% and at 6 months 66% (33/50) had ≤ 1%. At 3 months, CCR was obtained 65% (19/29) pts with ≤10% RQ-PCR and 16% (1/6) with 〉10% RQ-PCR (p= 0.06). At 6 months, CCR was 100% (12/12) in pts with RQ-PCR ≤ 1% and 14% (1/7) in those with 〉1% (p〈 0.0001). The probability to achieve RQ-PCR 〈 10% at 3 month was 43% (95% CI 32-54%). During treatment 3 (4%) progressed to AP and 5 (7%) to BC. The 5-year probability of OS was 78% (95% CI: 68-88%) albeit by disease status was 86% in CP, 92% in AP and 12% in BC (p〈 0.0001). OS was inferior in pts with RQ-PCR 〉 10% at 3 months (60 vs 84%, p= 0.03) and 〉1% at 6 months (68 vs100%, p= 0.006). PFS was 68% in 5-year, and was lower in BC pts (p〈 0.0001) and pts with RQ-PCR 〉1% at 6 months (p= 0.004). EFS was 53% and lower in BC pts (p〈 0.0001), in pts with RQ-PCR 〉 10% at 3 months (p= 0.005) and 〉 1% at 6 months (p〈 0.0001). RQ-PCR at 3 and 6 months were also predictive of a worse survival when patients in CP were analyzed separately. 2G-TKI was discontinued in 44% (31/71) due to: resistance (n=18), intolerance (n=5), death (n= 3), HSCT (n=3) and loss of follow-up (n=2). Eleven BCR-ABL mutations were detected in 36 pts; 3 previously 2G-TKI (L387M-1, E255K-1, M351T-1) and 9 after therapy (T315I-5, M244V-2, E255V-1, Y253H-1). OS by mutation was 45% with any mutation and 88% with no mutation (p= 0.05). Conclusion BCR-ABL transcript levels at 3 and 6 months can identify patients with worse prognosis and less chance to obtain CCR with 2G-TKI after imatinib treatment. Disclosures: No relevant conflicts of interest to declare.

Beschreibung: Several studies demonstrated the prognostic significance of an early molecular response in chronic myeloid leukemia (CML) patients (pts) treated with imatinib in first line or other tyrosine kinase inhibitors. Aims: The aim of this study was to evaluate the impact of early molecular responses, at 3 and 6 months after treatment with imatinib in CML pts and correlate these responses with CCR, MMR, overall survival (OS) and event free survival (EFS). Patients and Methods Between February 2006 and June 2012, 95  adult pts with newly diagnosed CML in chronic phase (CP) received imatinib 400mg/daily. CP was defined using WHO 2008 criteria. All pts received a short course of hydroxiurea until imatinib was available. Cytogenetic analysis was performed at diagnosis, 3, 6, 12 and 18 months after starting therapy and then every 12-24 months thereafter. BCR-ABL transcripts were measured in peripheral blood at 3-month intervals using quantitative RT-PCR (RQ-PCR). Results were expressed as BCR-ABL/ABL ratio, with conversion to the international scale (IS). Major molecular response (MMR) was defined as a transcript level ≤ 0.1% (IS). Statistical analysis: OS was measured from imatinib start until date of death or last visit. An event was defined as death from any cause. EFS was measured from imatinib start until the first event (loss of complete hematological response (CHR); complete cytogenetic response (CCR), progression to advanced phase, death or imatinib discontinuation) or last visit. OS and EFS rates were calculated using Kaplan-Meier method and log-rank test to compare its curves. The MMR probabilities according to molecular responses at 3 and 6 months were calculated by c2 method and cumulative incidence, considering as competitive event death or progression, before the event. Results 95 pts were analyzed, 57 (60%) male, with a median age of 47 years (17-79); Sokal score: high, intermediate and low was 30, 38.6 and 31.4% respectively; EUTOS scores was 81.5% low and 18.5% high. The median time from diagnosis until imatinib therapy was 1 month (0-5) and the follow-up was 39 month (3-89). Responses: 88% achieved CHR; 50% CCR and 53% MMR. One patient progressed to advanced phase during follow-up, while on imatinib treatment. 21 (22%) pts discontinued imatinib due to intolerance (47.6%); resistance (42.9%), death (4.8%) and Allo-HSCT (4.8%). At 3 months from the start of therapy, 30/64 (46.8%) achieved CCR, 15/64 (23.4%) partial cytogenetic response and 20/64 (31.2%) less than partial; by RQ-PCR, 72.3% (68/94) achieved at 3 months BCR-ABL transcripts ≤10% and 27.7% (26/94) 〉 10%. At 6 months 55.2% (48/87) had BCR-ABL transcripts ≤ 1% and 44.8% (39/87) 〉1%. The OS was 97% (95%CI: 95-99%) and EFS 63% (95%CI: 52-75%).There was no significant difference in OS and EFS in pts with RQ-PCR 〉 10% vs ≤ 10% at 3 months (figure 1), but pts with BCR-ABL transcripts 〉 10 and 〉1-10% at 6 months had an inferior EFS in comparison with pts with  BCR-ABL transcripts ≤ 1%  (41%,50%,89% respectively - p= 0.005), (figure 2). The CI showed that CCR pts at 3 months reached MMR earlier at 24 month (54% vs 18%, p=0.03), as well as CCR pts at 6 months, albeit no significance statistically (52% vs 37%, p= 0.16). For RQ-PCR at 3 months, pts with BCR-ABL transcripts 0-1% had a probability of 88% to achieve MMR, 1-10% had 52% and 〉10% 42%, p〈 0.0001 (figure 3). In conclusion, our results show that early molecular responses are predictive of achieving MMR and BCR-ABL transcripts

Beschreibung: Introduction: Angiogenesis (AG) abnormalities are crucial in pathogenesis of multiple myeloma (MM), and give support to treat patients with antiangiogenic agents. However, patients with similar clinicopathological aspects may present distinct outcome under AG inhibitors treatment. Single nucleotide polymorphisms (SNPs) in genes involved in blood vessels formation may constitute a plausible explanation for this finding. The wild-type alleles of VEGF c.-2595C〉A (rs699947), c.-1154G〉A (rs1570360), c.-634G〉C (rs2010963), c.*237C〉T (rs3025039), VEGFR2 c.-906T〉C (rs2071559) and c.889G〉A SNPs (rs2305948) SNPs, and GSTM1 and GSTT1 genes determine higher production, transcriptional activity, binding efficiency or best-characterized regulator of VEGF. This study aimed to investigate the roles of VEGF c.-2595C〉A, c.-1154G〉A, c.-634G〉C, c.*237C〉T, VEGFR2 c.-906T〉C, c.889G〉A SNPs, and GSTM1 and GSTT1 genes in outcome of MM patients treated with thalidomide-based regimens. Patients and methods: The study comprised 102 MM patients diagnosed at the Haematology and Haemotherapy Centre of University of Campinas between June 2005 and June 2013. The tumor was diagnosed by standard criteriaand staged by International Staging System. Therapeutic regimens consisted in thalidomide combined with steroids and chemotherapy, followed or not by autologous steam cell transplantation (ASCT). Response was evaluated at the end of treatment using the International Myeloma Working Group guidelines. The follow-up of patients was performed with hematological, biochemical, and immunological exams. The end of the study was February 2016. Genotypes of VEGF, VEGFR2 SNPs, and GSTM1 and GSTT1 genes were analyzed in genomic DNA by polymerase chain reaction based methods. The pairwise linkage disequilibrium (LD) was performed to ensure that markers were appropriate for inclusion in the VEGF and VEGFR2 haplotype estimates. The chi-square test and logistic regression model were used to identify variables influencing response to treatment. The Kaplan-Meier method, log-rank test and Cox hazards models served to assess the associations between event-free survival (EFS) and overall survival (OS). Results: Near half of patients enrolled in this study were male, and most of them were caucasians and with tumor at stages II or III. ASCT was performed after chemotherapy in near 40% of patients. LDs between VEGF and VEGFR2 SNPs were seen in study, and common haplotypes (frequency 〉1%) of the genes were included in further analyses. Patients with the wild-type allele of VEGF c.-2595C〉A alone or plus the wild-type allele of VEGFR2 c.-906T〉C SNPs, and the CGGC haplotype of all respective VEGF SNPs had 3.55, 9.91, and 3.86 more chances of achieving better response to therapy than others. The median follow-up time of 102 MM patients enrolled in the study was 43 months (range: 1-88). The estimated probabilities of 60-months EFS and OS were 24.5% and 48.1%, respectively. At 60 months of follow-up, patients with VEGFR2 c.889GG, VEGF c.-634GG plus VEGFR2 c.889GG, and VEGFR2 c.889GGplus GSTM1 present genotypes had 2.62, 2.64, and 2.80 more chances of presenting disease relapse or progression, and 2.21, 4.88, and 4.23 more chances of evolving to death in multivariate analysis, respectively. Conclusion: Our data present, for the first time, a preliminary evidence that VEGF c.-2595C〉A, c.-1154G〉A, c.-634G〉C, c.*237C〉T, VEGFR2 c.-906T〉C, c.889G〉A SNPs, and GSTM1 gene alter outcome of MM patients treated with thalidomide-based regimens. If these findings could be confirmed in multi-center studies with larger sample size, this might constitute a promise in assisting optimal patient choice for treatment with angiogenic agents. Financial support: São Paulo Research Foundation (FAPESP). Disclosures No relevant conflicts of interest to declare.

Beschreibung: Rationale for Study Primary Myelofibrosis (PMF) mainly affects individuals in their sixth decade of life or older. It is the most difficult myeloproliferative neoplasm to be defined, as the phenotype mimics a variety of hematological and non-hematological diseases. No symptom or sign is specific for PMF. Many patients are asymptomatic at presentation and the disease is usually detected by the discovery of a splenomegaly or abnormal blood counts during a routine examination. The only treatment with curative potential for PMF is allogeneic stem cell transplantation. This should be reserved only for high-risk patients, after careful consideration, taking into account the option for participation in clinical trials of new drugs. It is therefore extremely important the early identification of poor prognosis patients, to offer the best therapy. In Brazil, we do not have sufficient data to assess a patient's journey between the first symptoms and diagnosis of PMF. Moreover, the real incidence/ prevalence of this disease is unknown and a sub-diagnosis rate is speculated in our country. Objectives Understand and identify the journey of patients with PMF (clinical characteristics, diagnosis process and therapeutics interventions) and the problems between the first symptoms and initiation of treatment. Methods Given the observational nature of the study and the lack of a specific hypothesis to be tested, the statistical analysis is descriptive. This partial analysis includes descriptive results of contents of the database. Categorical data are presented as frequencies and percentages. For continuous data, mean, standard deviation, median, minimum, and maximum values are presented. Results 103 patient disposition (2008-2012); all of them met WHO criteria 2008: median age: 69; 58% male and 13.6% had died. Based on medical history, professional or environmental exposure was related in 4%, but this information was lack in 25% of the medical charts. In almost 42% of the medical records, the family history was not available. Two patients had a positive family history (brother of one and sister from another one with the same disease). Most frequent reason (63,1%) for medical evaluation seeking was symptoms and fatigue happened in 67% of them. Time from symptoms onset date until the confirmed diagnosis took a median of 9.7 months. General physician was the most frequent specialist to do the first evaluation of the patient until confirmed or suspected diagnosis. Bone marrow aspiration and bone marrow biopsy were performed in all patients; mutation status for JAK V617F in 82.5%, PCR for BCR-ABL in 71.8% and bone marrow cytogenetics in 64.1%. According to IPSS (78 patients), 8.5 % were low risk, 63.4% intermediate-1 63.4%, intermediate-2 28.1% and none high risk. Anemia was the most frequent laboratorial finding (67%) and most of the patients were treated with hydroxiurea (75.7%). Conclusions Although most of the patients have apparently the diagnosis of PMF, it took almost 10 months to be done. An expressive number of medical reports do not show a complete history, while 20-30% of them don’t have all the laboratory tools for a precise diagnosis. It is important to know Brazilian needs to improve diagnostic and provide a better treatment, since we are facing new drugs for PMF. Disclosures: No relevant conflicts of interest to declare.

Beschreibung: Introduction The majority of chronic myeloid leukemia (CML) patients (pts) in chronic phase (CP), present satisfactory response to imatinib treatment. However, 25-30% of these pts exhibit suboptimal response or treatment failure. The probability of achieving optimal response may be related with several factors. The human organic cation transporter 1 (hOCT1, SLC22A1), an influx transporter, is responsible for the uptake of imatinib into chronic myeloid leukemia (CML) cells The aim of this study was to analyze hOCT-1 levels at diagnosis of CML patients and correlate with cytogenetics and molecular responses. Methods hOCT-1 expression was evaluated in 58 newly diagnosed CML pts. Pts were treated with imatinib 400-600mg in first line. Samples were collected from peripheral blood at diagnosis and RNA was obtained from total leucocytes. For cDNA synthesis, 3 ug of RNA was used. hOCT-1 expression was evaluated by real-time PCR with TaqMan probe SLC22A1 (Applied Biosystems) and endogenous GAPDH control. The results were analyzed using 2-ΔΔCT. Cytogenetic analysis was performed at diagnosis, 3, 6, 12 and 18 months after starting therapy and then every 12-24 months thereafter if CCR was achieved. BCR-ABL transcripts were measured in peripheral blood at 3-month intervals using quantitative RT-PCR (RQ-PCR). Results were expressed as BCR-ABL/ABL ratio, with conversion to the international scale (IS). Major molecular response (MMR) was defined as a transcript level ≤ 0.1%. Results 58 CML pts, 60% male, median age of 46 years (19-87) were evaluated, 71% in chronic phase (CP), 21% in accelerated phase (AP) and 5% in blast crisis (BC). The mean and median of hOCT-1 transcript levels in the total group was 2.03 and 0.961 respectively (0.008–19.039) and CP pts was 1.86 and 1.00 (0.008-10.34).The median duration of imatinib treatment was 27 months (1-109) and 96.6% achieved complete hematological response, 79.3% complete cytogenetic response and 69% major or complete molecular response. The regression analysis showed correlation between higher transcript levels of hOCT-1 and BCR-ABL transcripts

Beschreibung: Introduction: Burkitt lymphoma (BL) has become an AIDS-defining disease by Centers for Disease Control (CDC) definition since 1993, emphasizing the strong relationship between this subtype of non-Hodgkin Lymphoma (NHL) and the Human Immunodeficiency Virus (HIV) infection. Although it is widely recognized that the HIV-associated BL represents a distinct entity and a more difficult-to-treat disease, reported results from developed countries seem to corroborate that these regimens do not need to be tailored to the HIV-positive population. There is no available data on outcomes of this population in developing countries. In this study, we report a real-world cohort of adult HIV-associated BL patients in Brazil. Methods: This is a retrospective multicenter cohort encompassing 4 academic hospitals in Brazil. Ethics approval for the study was obtained in all centers. Patients were treated according to their local protocol, which included Hyper-CVAD, CODOX-M IVAC or CHOP-like regimens, on a clinical judgement basis. Further reductions in the dose could be done at discretion of physician in case of excessive toxicity. For all patients who were not using cART, HIV-directed therapy was promptly started and administered along with chemotherapy. A cytoreductive regimen could be administered prior to the actual regimen to minimize the risk of tumor lysis. Survival analysis was performed using the Kaplan-Meier method and log-rank test for comparison. Cumulative incidence of relapse (CIR) was calculated using death as a competitor. Results: A total of 54 patients with HIV-associated BL were included in this analysis. Median age was 39 years (range, 15 - 64) and the vast majority were male (78%). 41% of patients were using cART prior to the BL diagnosis. Advanced disease was found in 86% of patients. CNS disease was observed in 31%. Regarding the immune status at the presentation, 52% had CD4+ T-cells count lower than 200 cells/mm3 and 19% had undetectable levels of HIV viral load. Other features are summarized in Table 1. Five patients died before starting any regimen due to sepsis. Among the 49 patients, most were treated with a modified Hyper-CVAD (26/49, 53%), CODOX-M IVAC (9/49, 18%) and a CHOP-like regimen (8/49). Only 8/49 (16%) patients received rituximab in upfront therapy. Radiotherapy was used in 4/49 patients (2 cranial irradiation, 1 in initial bulky site and 1 in testicles). A treatment-related mortality of 38.7% (95% confidence interval [CI] 25.5 - 53.7) was found and the complete response (CR) rate was 44.9% (95% CI 30.9 - 59.6). Primary refractory disease was found in 14%. Regarding the patients who achieved a CR at the end of treatment, 3-year CIR was 6.2% (95% CI 1.6 - 15.7%). There was no recommended regimen for salvage, and most patients received an alternate classic regimen for BL if feasible. Only one relapsed patient proceeded to autologous stem-cell transplantation, but eventually died after a second relapse. Median follow-up time was 4.4 years. A 4-year OS of 36.1% (95% CI 25.2 - 51.8) for total cohort and 39.8% (95% CI 28.1 - 56.5) for those patients who received any regimen was calculated (Figure 1). A univariate analysis for CR and OS did not show any statistically significant difference regarding sex, age, staging, CD4+, viral load, prior cART, extranodal infiltration, blood counts, lactate dehydrogenase (LDH), employed regimen or use of rituximab. All relapsed and primary refractory patients eventually died in our cohort. Aside from those patients who died from disease progression per se, remaining patients died from infections (24/34), despite intensive antimicrobial prophylaxis and associated cART. Conclusion: Outcomes of HIV-positive BL population are scarcely reported worldwide. While HIV patients seem to have a higher relapse rate in other studies, our early mortality and overall survival were far worse than those reported in developed countries and with more selected cohorts. In comparison with literature, our patients experienced higher toxicity with classic regimens and higher refractoriness rate. Therefore, these findings warrant further cooperative multicenter studies in developing countries, aiming at improving supportive care and optimizing regimens locally feasible. Disclosures Delamain: Novartis: Honoraria.

Beschreibung: Introduction: Multiple myeloma (MM) is a plasma cell neoplasm, characterized by plasma cell infiltration inside the bone marrow, secretion of monoclonal immunoglobulin (paraprotein), and end organ damage including lytic lesions in the bones. About 80-90% of myeloma patients suffer from osteolytic lesions during the course of the disease. 18F-FDG PET/CT is an imaging technique capable to detect active disease in patients in multiple myeloma (MM) and can be helpful in staging and prognosis. However, its routine use is still hampered by several factors, including high cost, reimbursement issues, lack of cost-effectiveness studies and limited availability. 99mTc-sestamibi (MIBI) has also been proposed as a potential tracer in MM evaluation and is more accessible with lower costs. The aim of this study was to compare these two imaging modalities at staging disease and their relation with clinical data. Materials and Methods: Sixty-four patients with newly diagnostic MM (30 male; 34 female) were submitted to 18F-FDG PET/CT and 99mTc-Sestamibi SPECT/CT before treatment. Whole body PET/CT images were acquired 60 minutes after FDG administration and anterior and posterior whole-body scans (WBS) plus SPECT/CT of chest and abdomen were obtained 10 minutes after MIBI injection. Number of focal lesions, bone marrow involvement, contiguous soft tissue impairment and extra osseous lesions were recorded. Number of focal lesions was classified in 3 groups: 0 (no lesions); 1 (1-3 lesions); 2 (4-10); 3 (more than 10). A visual degree of uptake was defined for bone marrow involvement: comparison to liver on PET/CT and to myocardium on MIBI. Standardized uptake value (SUVmax) of the hottest lesion of each patient was registered. Potentials factors contributing to progression-free survival (PFS) were assessed with Cox regression model combining baseline clinical data (including renal function, anemia, hypercalcemia, LDH, bone marrow plasma cell percentage and ISS (I, II or III)) along with PET/CT and MIBI scan status. Results: PET/CT was positive in 61 patients (95%) and MIBI in 59 subjects (92%; P = 0.15). WBS was positive in 56 patients while WBS plus SPECT/CT was positive in 59 (p= 0.08). PET/CT detected extra osseous lesions in 4 patients and sestamibi in 1 subject. Contiguous soft tissue involvement was found in 29 and 24 patients on PET/CT and MIBI, respectively (p=0.05). PET/CT detected much more focal lesions than MIBI: 13, 11, 16 and 24 patients were in group 0, 1, 2 and 3 on PET/CT and 30, 18, 6 and 10 were on the same groups respectively on MIBI (p: 0.0001). In the figure below, a comparison between 99mTc-Sestamibi WBS (A) and 18F-FDG PET/CT (B) at staging in a 67 years-old male. SUVmax were statistically different in subjects who presented elevated LDH (p= 0.02). Seventy-five percent and 100% of patients with elevated LDH had contiguous soft tissue involvement on MIBI and PET/CT respectively. More focal lesions on PET/CT were found in patients with hypercalcemia (p=0.02), however this correlation was not observed on MIBI (p=0.45). Renal insufficiency was a negative prognostic factor for PFS (HR: 2.25). The same was observed with advanced ISS staging (HR: 4.29). However, only advanced ISS staging (III) and extramedullary disease detected by MIBI were independent predictors of worse PFS. Conclusion: There was no difference in the detection of active disease when comparing FDG PET/CT and MIBI SPECT/CT in MM staging, although the first one detected more number of lesions. Including SPECT/CT to planar images on MIBI did also not improve the number of positive scans. Elevated LDH and hypercalcemia were the only clinical parameters related to higher number of bone lesions while ISS staging (III) and extramedullary disease detected by MIBI were independent predictors of worse PFS. Our study demonstrated that sestamibi WBI detects less volume of disease compared to PET/CT, however it may substitute PET/CT in centers where it is not available or there is no reimbursement for MM staging. Figure. Figure. Disclosures No relevant conflicts of interest to declare.

Beschreibung: Several trials have demonstrated the feasibility of discontinuation of tyrosine kinase inhibitors (TKI) treatment in chronic myeloid leukemia (CML) patients (pts) with deep molecular response. Aims: to report the results of two Brazilian imatinib (IM) discontinuation trials and to evaluate factors impacting in treatment-free remission (TFR) and treatment-free survival (TFS) after IM discontinuation. Methods:Between September 2016 and January 2019, 60 CML pts were included in two ongoing phase II, single arm, prospective Brazilian discontinuation trials: Pilot Study of Discontinuation in Patients With Chronic Myeloid Leukemia With Deep Molecular Response - Evaluation of Pioglitazone in Treatment-free Remission (TFR) (EDI-PIO UNICAMP)(NCT02852486)and Imatinib Discontinuation in Patients With Chronic Myeloid Leukemia Chronic Phase With Sustained MR4log(USP) (NCT03239886). Inclusion criteria: age 〉18 years, chronic phase, minimum of 3 years of IM therapy, deep molecular response for ≥ 2 years (confirmed by 4 tests in the last 2 years, defined as MR4.0 in USP trial and MR4.5 in EDI-PIO). Patients participating in EDI-PIO trial used pioglitazone 30 mg/day plus IM for 3 months before IM discontinuation (n=30). After discontinuation, pts were monitored by quantitative RQ-PCR monthly in the first year, every 2 months in the second year and every 3 months in the third year. Criteria for IM re-initiation: loss of MMR (in one test), loss of cytogenetic response, loss of hematologic response, disease progression or confirmed loss of MR4.0 (this criteria used only in EDI-PIO trial). TFR was calculated from the date of discontinuation until first event (loss of MMR; IM reintroduction; death any cause or last follow-up); TFS was calculated from the date of IM discontinuation until reintroduction or last follow-up (censoring deaths not related to CML). Adverse events after IM discontinuation were reported according to CTCAE. Results:Data cut-off for analysis was February 2019. In the 1stanalysis 48 pts who discontinued IM in MR4.5 were analyzed. Patient's characteristics from EDIPIO (n=30) and USP (n=18) trials were: 57% vs. 67% male, median age of 55 (29-77) and 56 (33-95) years (29-95) at discontinuation; 16% and 33% had used previously Interferon; median duration of IM treatment of 10 (3-16) vs. 10 (5-15) years; median duration of MMR 95 (30-149) vs. 93 (57-130) months; MR4.0 was 90 (26-135) vs. 89 (30-123) months; and MR4.5 was 76 (23-135) vs. 75 (30-102) months; none variable had statistical difference.One patient died in MMR due to cardiac failure. TFR was 61% (95% CI 47-75) at 20 months. Sixteen (33%) out 48 re-initiated IM (2 with confirmed loss of MR4.0 and 14 with loss of MMR) in a median time of 20 (1-26) months. All relapsed pts recovered MMR after IM reintroduction, in a median time of 2 months (0-4). There was no transformation to advanced phases. No serious adverse events were reported during pioglitazone treatment. In the Cox regression the duration of MMR was associated with a longer TFR HR: 0.96 (beta-) (CI 95%:0.94-0.99, P= 0.006). Gender, age at diagnosis, age at discontinuation, treatment with pioglitazone, Sokal and EUTOS scores, BCR-ABL transcripts type, duration of IM therapy, duration of MR4.0 and MR4.5 and previous use of Interferon did not affect TFR.In the second analysis all 60 pts were included. TFS was 56% and was higher in pts who discontinued IM in sustained MR4.5 vs. MR4.0 (63% vs. 33%, P=0.04)(Figure). The independent factors for TFR in the multivariate analysis by Cox-regression were the duration of MMR [HR: 0.97 (beta-), 95%CI: 0.95-0.98, P=0.001] and intermediate/high risk Sokal [HR 3.14 95%CI: 1.08-9.11, P= 0.035]. Twenty-four out of 60 pts (40%) re-initiated IM (2 with confirmed loss of MR4.0 and 22 with loss of MMR).Adverse events occurred in 38 (63%) pts, 30% attributed to withdrawal syndrome. Some pts presented more than one event. Grade 1-2: arthralgia or muscular pain (17), hyperglycemia (4), hypertriglyceridemia (2), polycythemia (2), hypertension (3), and others (11). Four pts had grade 3-4 event: arthralgia (1), death for cardiac failure (1), abortion and hypertriglyceridemia (1). Conclusions:both trials demonstrated the feasibility and safety of IM discontinuation in pts in sustained deep molecular response. The duration of MMR was associated with a higher TFR and TFS rate. Imatinib discontinuation was more successful in pts in stable MR4.5. Figure Disclosures Pagnano: Pint Pharma: Consultancy; Abbvie: Consultancy; Sandoz: Consultancy. Delamain:Novartis: Honoraria.

Beschreibung: Preliminary reports demonstrated that pioglitazone, an antidiabetic drug that is agonist of peroxisome proliferator-activated receptor gamma (PPAR-γ) was able to reduce expression of STAT5 and its downstream targets HIF2α and CITED2, which are key guardians of the quiescence and stemness of chronic myeloid leukemia (CML) leukemia stem cells (LSCs). Leaving quiescence would turn the LSCs more sensitive to imatinib (IM) and cause an erosion of the LSCs. This was demonstrated in vitro and in vivo in CML patients that achieved complete molecular response after pioglitazone use. This was the rational for the design of EDI-PIO trial (Pilot Study of Imatinib Discontinuation in Patients with Chronic Myeloid Leukemia with Deep Molecular Response - Evaluation of Pioglitazone in Treatment-Free Remission) (NCT02852486). In this trial, pioglitazone was given in association with IM, with the aim to pull out the LSCs from the quiescence and sensitizing them to IM effect, increasing treatment-free remission (TFR) rates after treatment interruption. Aims: to evaluate PPAR-γ, STAT5, HIF2α and CITED2 gene expression before and after pioglitazone use in CML patients with criteria for IM discontinuation Patients and methods: EDI-PIO is a prospective, phase II trial. Inclusion criteria: CML in chronic phase, treated with IM for at least 3 years, with stable deep molecular response (MR4.5) for at least 2 years. Patients received pioglitazone 30 mg/day, orally, for 3 months before IM discontinuation. BCR-ABL levels were measured by real-time quantitative PCR monthly in the first year after discontinuation, every two months in the second year, and then every 3 months during the subsequent follow-up. Imatinib was reinitiated at molecular relapse (loss of major molecular response or confirmed loss of MR4.0). Total RNA was extracted from peripheral blood leukocytes, pre and post pioglitazone, and at 3 and 6 months after IM discontinuation. After cDNA synthesis, an aliquot was used for gene expression analysis by reverse transcriptase quantitative polymerase chain reaction (RT-qPCR), using specific primers for PPAR-γ, STAT5, HIF2α and CITED2. The relative gene expression was calculated using the equation, 2-ΔΔCT. GAPDH was used as control gene. Statistical analysis was performed using ANOVA. Treatment-free remission (TFR) was calculated from IM discontinuation until molecular relapse, reintroduction of IM by any cause, progression to advanced phases or death to any cause. Results: The study is closed for enrollment. Between June 2016 and January 2019, 32 chronic phase CML patients were recruited, of which 30 patients were included in gene expression analysis. Median age was 55 years at trial initiation; 56.7% were men, 50% low risk Sokal and the median time of IM treatment was 117 months (41-191). The median follow-up time was 20 months. TFR was 60% at 24 months. Eleven patients relapsed and IM was reintroduced, but none presented hematologic relapse or progression to advanced phases. There was no significant difference in STAT5, PPAR-γ, HIF2α and CITED2 expression pre and post pioglitazone, at 3 and 6 months after IM discontinuation. No difference was found in the comparison of the relapsed vs. non-relapsed group. Conclusions: pioglitazone did not affect STAT5, PPAR-γ, HIF2α and CITED2 gene expression in this group of pts with deep molecular response. The ACTIM trial demonstrated a reduction in STAT5 expression in bone marrow cells 6 months after pioglitazone exposure, but pioglitazone was given to pts with MMR, without MR4.0. There was no difference in gene expression in the groups with or without molecular relapse. TFR rates remains similar to those reported in other discontinuation trials. Disclosures Delamain: Novartis: Honoraria. Pagnano:Sandoz: Consultancy; Pint Pharma: Consultancy; Abbvie: Consultancy.

Beschreibung: Background: Marginal zone Lymphomas (MZL) are indolent B cell non hodgkin Lymphoma (NHL) and include splenic, nodal and extranodal subtypes (SMZL, NMZL, ENMZL). When therapy is needed in symptomatic patients, standard treatment usually requires systemic immunochemotherapy (ICT). Although the outcome of MZL is generally measured in decades a high heterogeneity of clinical behaviour exists that warrants the identification of accurate prognostic features to better estimate the risk of relapse, progression or death in the individual patient. Recently the analysis of progression free survival (PFS) was used to identify clinically useful endpoints in B-cell NHLs, with PFS at 24 (PFS24) months identified to stratify overall survival (OS) in follicular NHL. Here we examined the ability of PFS24 to predict subsequent OS in a large, multinational MZL cohort as part of the NF10 observational multicentric international study promoted by Fondazione Italiana Linfomi (FIL). Methods: The NF10 Project was started in 2010 as a prospective registry specifically conceived to investigate the prognosis of Indolent Non-Follicular B-Cell Lymphomas (INFL). The registration of clinical, laboratory data, treatment and outcome details of consecutive adult patients with newly diagnosed INFL was available at a dedicated website. All patients with a histologic confirmed diagnosis of INFL also including MZL were eligible with no exclusion criteria. Patients were followed based on local institution guidelines, and PFS was defined as time from the date of pathologic diagnosis to progression, re-treatment, or death due to any cause. PFS24 was calculated only for patients requiring immediate therapy and was defined as being alive and progression-free 24 months from diagnosis. Subsequent OS was defined as time from achieving PFS24 or time from progression in patients failing to achieve PFS24 (progression within 24 months of diagnosis). Results: Between July 2010 and July 2018, 1.253 INFL cases have been registered by 65 centres in Europe and South America. MZLs were 677 (54%): 283 ENMZL (43%), 221 SMZL (32%), 69 NMZL (10%); 104 cases were classified as disseminated MZL (Diss-MZL 15%) due to the lack of a clear pattern of organ involvement. Median age was 66 years (range 27-93); Ann Arbor stage was III-IV in 79%; 14% had B symptoms, 6% had ECOG performance status (PS) 〉1, lactate dehydrogenase (LDH) and β2-microglobulin were above upper normal limit (UNL) in 26% and 56% of cases respectively. Bone marrow involvement was present in 67%, positive HCV and HBV serology was found in 8% and 18% of cases respectively. For the current study we identified 400 patients with MZL for whom immediate therapy was planned right after lymphoma diagnosis. Patients with immediate therapy were 59% of all MZL. Rituximab (R) combined with chemotherapy was used in 332 (82%): R plus bendamustine (RB) in 142 (36%), R plus alkylating agents (R-alk) in 101 cases (25%) (mostly ENMZL), R plus CHOP in 50 (12%) (mainly NMZL and DissMZL); R monotherapy was used in 36 (9%). The median follow-up was 38 months (range 1-83). For treated pts 3y-PFS was 79% and 3y-OS was 90%; progressive disease was the cause of death in 47% of all cases. The percentage of patients who failed to achieve PFS24 was 20% with a lower frequency in the subtypes NMZL and ENMZL (13%) compared to the group of SMZL and DissMZL (24%, p=0.015). Three-year OS for patients with progression within the first 24 months was 46% (95%CI 28-63%) with a HR of 28.3 (95%CI 10.6 - 75.6) when compared with patients without early relapse (96%, 95%CI 91-98%). When PFS24 was adjusted by IPI in all cases and by HPLL (Montalbán et al, BJH 2012) in SMZL, the PFS24 retained its prognostic role (p