ALBERT

Description: G-CSF is used to enhance neutrophil recovery after autologous peripheral blood stem cell transplantation (aPBSCT), even if the optimal timing and dose of G-CSF has not been established. Recently Peg-Filgrastim has been approved for clinical use. The clearance of Peg-Filgrastim is neutrophil-mediated with a sustained duration of action with prolonged serum concentration during neutropenia. In order to verify the efficacy and feasibility of use of Peg-Filgrastim, we administered to 10 patients (A Group, 3F, 7M, median age 46y) submitted to aPBSCT for haematological malignancies (6 NHL, 3 MM, 1 HD) a single 6 mg dose of Peg-Filgrastim subcutaneously on day +1 and we compared the engraftment of these patients to data of a group of 30 patients (B group 9F, 21M, median age 46y, 18 NHL, 6 MM, 2 POEMS syndrome, 1 Plasmacell leukemia, 3 HD) submitted to aPBSCT not receiving G-CSF. Patients were matched for sex, age, disease, disease status at transplant, conditioning regimen, transplant procedure and they received comparable CD34+ cell dose. We evaluated haematological engraftment, and other clinical outcomes, all results are expressed as a median value in the table. Peg-Filgrastim was well tolerated in all but 1 patient reporting bone pain. Neutrophil engrafment was significantly faster (72 hours) in the Peg-Filgrastim group: days +10 and +12 (500 and 1000 cells/μL) vs days +13 and +15.5 of control group; faster neutrophil engraftment was also clear analyzing number of days with absolute neutrophil count (ANC) 500/μL 10 (7–11) 13 (7–18) p 1000/μL 12 (7–15) 15.5 (10–38) p 20 x 10³/μL 11 (8–24) 12 (9–18) p=0.4 Days to Plts 〉 50 x 10³/μL 24 (12–39) 14 (10–60) p=0.39 Days to Plts 〉 100 x 10³/μL 40 (14–120) 18 (12–210) p=0.06 Days to Reticulocytes 〉1% 15 (11–16) 13.5 (10–30) p=0.59 Days to Hgb 〉10 g/dl 33 (10–84) 21 (10–210) p=0.48 Days of fever 5 (2–10) 5 (2–13) p=0.92 Days of antibiotic therapy 7 (5–20) 9.5 (5–18) p=0.72 Bloodstream infections 4/10 6/30 p=0.2 Number of pRBCu 1 (0–2) 0 (0–2) p=0.02 Number of SDu 1.5 (1–3) 1 (0–2) p=0.022 Days of hospitalization 25 (19–30) 23 (20–34) p=0.89

Description: Abstract 4911 Patients with haematological malignancies and overt hepatitis B (HB) infection defined by the presence of HB surface antigen (HBsAg) are at risk of hepatitis reactivation, and antiviral prophylaxis is generally recommended. HBV reactivation can also occur during immunosuppressive therapy in patients who are HBsAg negative, but are positive for antibodies to HB core antigen (anti-HBc) which suggests prior contact with HBV and potential occult infection. The risk of HBV reactivation for these patients who have evidence of viral clearance (HBV-DNA negative) and developed potential immunity (anti-HBs positive) is not clear, and there are no clear guidelines for prophylaxis in this subset of patients. We therefore performed a multicenter prospective observational study to determine the risk of HBV seroreversion in anti-HBc positive patients with or without anti-HBs and with hematological malignancies undergoing intensive immunosuppressive chemotherapy and/or hematopoietic stem cell transplantation (HSCT). Patients underwent monitoring of HBV serum markers including HBV-DNA serum levels, while patients who started antiviral prophylaxis concomitant to the cytotoxic therapy were excluded. Between 1/2008 and 12/2008, 25 consecutive HBsAg -/antiHBc +/antiHBs + patients (pts) from 3 hematological centers were enrolled into the study (20 pts with lymphoma, 2 pts with acute myeloid leukaemia, 3 with myeloma). Before starting anticancer therapy, all pts had undetectable HBV-DNA levels, 21 were anti-HBs positive, and 12 had also anti-HBe. Moreover, 3 pts had HCV co-infection. All patients underwent intense immunosuppressive therapy including rituximab in 15 pts, and HSCT in 10 pts (7 autologous and 3 allogeneic). HBV markers were monitored during immunosuppressive treatment and for 18 months after end of therapy. At present, 18 pts have completed the planned follow-up period, and other 7 pts have at least 12 months of post-treatment follow-up. Among the 25 patients, we observed 3 cases of seroreversion with positive HBV-DNA levels. All 3 seroversions occurred in patients following allogeneic HSCT despite high anti-HBs levels at baseline. The 3 seroreverted patients showed a progressive decline in anti-HBs titers during the phase of monitoring, and HBV reactivated between the 7th and 9th month after allogeneic HSCT. The pts responded to treatment with antinucleoside analogues (entecavir in 2 cases, lamivudine in 1 case), i.e. HBV-DNA decreased of at least 1 log within three months from treatment start. Moreover, we detected one case of transient anti-HBs disappearance, and one case of persistent anti-HBe loss without seroreversion. None of the HCV co-infected pts presented acute hepatitis. No seroreversions were observed in 15 lymphoma patients undergoing immunochemotherapy including rituximab. In conclusion, patients with occult HBV infection are at risk of HBV reactivation during continuous immunosuppressive therapy following allogeneic HSCT even in the presence of anti-HBs levels at baseline, while the risk appears low in patients undergoing transient immunosuppressive therapy, as immunochemotherapy including rituximab, for the treatment of lymphoma. Disclosures: No relevant conflicts of interest to declare.

Description: Background Deep venous thrombosis (DVT) is present in about 3–15% of cancer patient. Paraneoplastic thrombosis pathogenesis is multifactorial. Antithrombotic prophylaxis frequently is not oriented to the real thrombotic or haemorragic risk of the patients. Aim Aim of our study is to define the real thrombotic risk in neoplastic patient. With this purpose we considered in our patients complement fraction C3 and C4 and circulating immune-complexes (CIC) because they activate macrophages and platelets and increase tissue factor level. Moreover we evaluated also total cholesterol and triglycerides level, because they are linked with factor VII activation. Chemotherapy dose density and chemotherapeutic agents used were also included in our investigation as pro-inflammatory/pro-thrombotic risk factors. Methods We considered C3, C4, CIC, cholesterol and triglycerides level, dose density and chemotherapeutic agents used in 119 patients with solid neoplasms (62 colon, 27 lung, 18 gastric, 12 others) and without anticoagulant prophilaxis. Of these only 105 were evaluable because in these all the data were available. Median age was 68.5 years (R 57–83). M/F ratio was 72/47. The threshold value of third quartile was chosen as risk cut-off (C3: 130mg/dl; C4: 32mg/dl; ICC: 2.9 mcg/ml; total cholesterol: 205mg/dl; triglycerides 123mg/dl). We elaborated a scoring system in which 1 point was attributed to each value inferior to the third quartile. One point was added or removed if patient received or not Irinotecan. In fact this drug was the only variable that in univariate analysis showed an high Yates corrected chi square test (4, p 0.045). The statistical analysis was conducted with Yates corrected chi square test, Odds Ratio (OR), realtive risk (RR). Furthermore Erythrocyte Sedimentation Rate (ESR) and C-reactive Protein (CRP) were also evaluated. Results 27 patients (26%) showed DVT. Of these 23(85%) had a score ≤3 and 4 (15%) ≥4. 78 patients (74%) did not show DVT. Of these 46(59%) had a score ≥4 and 26 ≤3. Yates corrected chi square test is 15.68 (p

Description: Background Hairy-Cell leukaemia (HCL) is an uncommon B-cell chronic lymphoproliferative disorder that accounts for about 2% of all leukaemias. Although the disease is generally indolent in its natural course, the majority of patients requires treatment for life-threatening infections due to pancytopenia or symptomatic splenomegaly. Remarkable progresses have been made in the treatment of HCL. Prior to the advent of nucleoside analogues, which are currently the standard initial treatment, interferon and splenectomy were the most effective therapies. Treatment with purine analogs (PNA) such as 2-chlorodeoxyadenosine (2-CdA) is associated with excellent remission rate and long-term survival. Recently, immunotherapeutic approaches which use monoclonal antibodies, like rituximab, have increased the number of therapeutic options for HCL and offer promising salvage strategies for patients who relapse or who are refractory to treatment with purine analogues. Previously rituximab, used in patients relapsing or refractory to CdA and for elimination of MRD after treatment with PNA, showed hematological CR and good MRD eradication. Patients and treatment We analysed, in a retrospective study, five consecutive patients M/F 4/1, 4 with HCL and one with HCLVariant treated at the diagnosis with one rituximab administration at the dose of 375mg/mq and 2CdA at the dose of 0.14 mg/mq/day s.c. for 5 days. Their median age was 70 years (range 41–71). All patients showed splenomegaly and thrombocytopenia (median platelet count was 65000 with range 49000–88000), four of these presented neutropenia (median count was 435/mmc with range 430–800/mmc) and one patient was severely anemic (Hb 〈 8 g/dl). Results None of the patients had severe therapy-related side effects. Four patients showed febrile cutaneous rash, although received prophyilaxis with acyclovir. The median time of recovery for neutrophil count 〉1500/mmc was 20 days (range 15–38) for platlets count〉 100000/mmc was 21days (12–21), and hemoglobin level〉 8g/dl was 31.5 days(27–36). Our median follow up at today was 264 days(range 40–570). At this time all patients are in hematological and morphologic complete remission. Conclusions The use of Rituximab together with 2CDA in first line therapy is safe and feasible. Moreover when Rituximab is used in such setting, median time of recovery in neutrophils and platelets count is significatively shorter than that obtained after therapy with 2CdA alone (8 and 4 weeks respectively). A longer follow-up is needed to evaluate the long-term results of the treatment.

Description: Abstract 317 Introduction: The novel agents bortezomib, thalidomide and lenalidomide have been successfully incorporated into autologous stem-cell transplantation (ASCT) as up-front therapy for newly diagnosed MM. However, several reports have raised concerns about the impact of novel agent-based induction regimens on PBSC collection. Furthermore, the ability to successfully collect PBSCs following initial therapy with two of these newer drugs needs to be confirmed in large phase III clinical trials. Methods: The GIMEMA Italian Myeloma Network designed a phase III study to compare VTD with thalidomide-dexamethasone (TD) as induction therapy prior to double ASCT. Primary study endpoint was the rate of complete or near complete response to each of these two induction regimens, while their toxicity profile – including the impact on PBSC mobilization and collection - was a secondary study endpoint. To address this latter issue, we performed a post-hoc analysis to compare the effect of the triplet VTD induction regimen versus the doublet TD combination on CD34+ cell collection. After three 21-day cycles of VTD or TD induction therapy, patients received intermediate dose cyclophosphamide (CTX 4 g/m2) followed by G-CSF (10 mcg/Kg/die) to mobilize and collect PBSCs. The target threshold to safely perform double ASCT was 4 × 106 CD34+ cells/Kg. Results: Patients evaluable for PBSC collection were 435 out of the 474 who received induction therapy. Of these, 223 were initially randomized to VTD and 212 to TD induction therapy. The median number of collected CD34+ cells was 9.7 × 106/Kg in the VTD arm and 10.7 × 106/Kg in the TD arm (p= n.s.). The planned yield of 4 × 106 CD34+ cells/Kg was achieved with a single harvest in more than 90% of patients in both treatment groups (96% in VTD and 92% in TD, p= n.s.). A yield of CD34+ cells 〉10 × 106 /Kg was reported in 51% and 56% of patients treated with VTD and TD, respectively (p= n.s.). Only 5 patients (2%) in VTD group and 2 patients (1%) in the TD arm failed to collect more than 2 × 106 CD34+ cells/Kg (p= n.s.). The majority of patients (86% in VTD and 82% in TD, p=n.s.) received CTX as an in-patient procedure, the median time of hospitalization being 4 days. Less than 5% of patients developed grade 3–4 infectious complications (2% in the VTD group vs 3% in TD, p=n.s.) which required hospitalization in only 2 patients. Following ASCT, no significant difference was observed between the two treatment arms in terms of hematologic recovery and non hematological toxicity. Kaplan-Meier curves of TTP and PFS were almost superimposable for patients with a CD34+ yield 〉10 × 106/Kg and in the range between 4 and 10 × 106/Kg (group 1). These curves were very similar also for patients who collected between 2 and 4 × 106/Kg CD34+ cells or 10 × 106/Kg CD34+ cells was in the 90% range, a value significantly better than what was seen in the remaining subgroups. In a multivariate Cox regression analysis, yields of CD34+ cells 〉10 × 106/Kg and in the range of 4 to 10 × 106/Kg were independently associated with prolonged PFS (p=0.001 and =0.027, respectively), while CD34+ cells 〉10 × 106/Kg predicted for extended OS (p=0.002). Absence of t(4;14) and/or del(17q), and ISS stage 1 or 2 were additional favorable prognostic factors for both PFS and OS, while randomization to VTD independently predicted for longer PFS. Conclusions: Results of the present analysis showed that both TD and VTD shared the advantage of no adverse impact on PBSC collection and the engraftment potential of collected PBSCs. The target for CD34+ cell collection (〉4 × 106/Kg) was achieved with a single harvest in more than 90% of patients in both treated groups and a collection failure was reported in 1% to 2% of patients. These favorable results are due to early PBSC collection, which was performed after 3 cycles of TD and VTD, and use of CTX plus G-CSF which allows better stem cell collection and less likelihood of a collection failure. Of particular note, both VTD and TD were associated with a 50% to 59% probability to collect 〉10 × 106 CD34+ cells/Kg, a variable independently associated with extended PFS and OS. Disclosures: Off Label Use: bortezomib and thalidomide used as induction therapy for newly diagnosed multiple myeloma patients. Baccarani:Bristol-Meyers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees. Cavo:Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Millennium: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria; Genzyme: Honoraria.

Description: Ethical issues are connatural with the medical activity. Moral questions regarding some medical specialities as obstetrics or pre or perinatal medicine are well known. Nevertheless few is known about ethical problems perceived as remarkable from physicians and patients in onco-hematology. This is a retrospective monocentric descriptive study. Its purpose is to recognize, in oncohematology, what are the problems perceived as ethically relevant both from physicians and patients. Ethical issues regarding onco-hematologic patients were recognized consulting clinical diary of 100 patients treated in our institution. Patients have casually been selected in the temporal period from January 2004 to June of 2008. Ethical questions were listed in two groups: those perceived as remarkable for the physicians and those for the patients. Median age of the patients was 54.5 years (R 33–86). M/F was 55/45. Sixty-one patients were affected by chronic or indolent hemopathies. Sixty-six patients received 1st line therapy, instead 34 2nd line or superior. Seventy-five patients had primary school instruction, 22 secondary, 3 had got a degree. Eighty patients were assisted by a relative. Twenty-nine patients perceived a problem as ethically relevant (5 compliance to treatments; 5 refusal of treatment; 7 intolerance to hospitalization; 9 scarce trust in caregivers; 3 difficulty to understand the therapeutic plan). In 38 cases physicians perceived a problem as ethically relevant (8 over treatment; 7 type of treatment to adopt; 8 correct timing of therapy; 11 correct use of resources; 4 adequacy of treatment). Physicians perceived these problems mainly about patients requiring 2nd line treatment or further (28 cases out of 38). In 12 cases only patients perceived a problem, in 21 cases only physicians perceived a problem, while in 17 cases a problem was perceived as ethically relevant by physicians and patients simultaneously. In our study, in onco-hematology the main issue perceived by patients as ethically relevant is the scarce trust in caregivers, while for physicians it is the correct use of resources. Physicians perceive an ethical problem mainly considering patient candidate to 2nd line treatment or further. In 24% of cases, a problem perceived as ethically relevant by patients is underestimated by physicians. In this contest the possibility of an ethical consultation within a clinical counselling might create a convergence between physician and patient perspective.

Description: DVT is present in about 3–15% of cancer patients. Paraneoplastic thrombosis pathogenesis is multifactorial. Chemotherapy is frequently involved in DVT genesis as pro-inflammatory/pro-thrombotic factor. There are few data about incidence of DVT in patients treated with Irinotecan. Aim of our study is to define if thrombotic risk in patients treated with Irinotecan is increased and then which mechanism is probably involved. For this purpose we considered in our patients the complement fractions C3 and C4 and the immune circulating complex (ICC), because they activate macrophages and platelets and increase tissue factor level. Moreover we evaluated also total cholesterol and triglyceride level, cause linked with factor VII activation. We considered C3, C4, ICC, cholesterol and triglyceride level, dose density and chemotherapeutic agents used in 116 patients with solid neoplasms (62colon, 26lung, 18gastric,) and not receiving anticoagulant prophylaxis. Median age was 68.5 years (R 57–83). M/F ratio was 66/40. The threshold value of third quartile was chosen as risk cut-off (C3: 130mg/dl; C4: 32mg/dl; ICC: 2.9 mcg/ml; total cholesterol: 205mg/dl; triglycerides 120mg/dl). The statistical analysis was conducted with Yates corrected chi square test, Fisher’s exact test, Odds Ratio (OR), relative risk (RR). Twenty-four patients (20%) developed DVT. The patients treated with Irinotecan were 42. DVT occurred in 14 of these patients (32%) and in 10 of the 74 patients treated without Irinotecan (14%), with a Yates corrected chi square test of 4.6 (p=0.03), a Fisher’s exact test with p=0.03, an OR of 2.98 (95%CI 1.2–7.3) and a RR of 2.35 (95%CI 1.1– 4.8). C-Reactive Protein and Erythocyte Sedimentation Rate at Pearson’s test were not related with C3, C4, ICC, total cholesterol and triglyceride levels. All patients treated with Irinotecan had advanced stage colon cancer. High levels of triglycerides (〉120mg/dl) were present in 17 out of 42 patients treated with Irinotecan (40%) and in 17 out of 74 patients treated without Irinotecan (23%) with a Yates corrected chi square test of 3.1 (p=0.07), a Fisher’s exact test with p=0.05, an OR of 2.2 (95%CI 1–5) and a RR of 1.7 (95%CI 1–3). Although most patients developing DVT have an advanced stage colon cancer and so receiving Irinotecan, the influence of chemotherapy in DVT pathogenesis in our study cannot be excluded. Probably Irinotecan could contribute to DVT increasing triglyceride levels that are linked with in vivo factor VII activation. This relief suggests also that risk factors, other than classical, should be considered in the thrombosis onset; then other drugs (i.e. hypolipemizing drugs) could be useful in paraneoplastic DVT prevention. Nevertheless these data should be confirmed in a larger cohort of patients.

Description: Abstract 2971 Introduction: Bendamustine is a bifunctional alkylating agent approved for the treatment of several lymphoproliferative disorders. Studies have evidenced its efficacy in multiple myeloma (MM), but data so far available in this setting are scarce. We performed a retrospective analysis of Italian patients with relapsed/refractory MM, who had received bendamustine as salvage therapy within a national compassionate use program. Patients and methods: Seventy-eight patients (42 males, 36 females) were collected in 19 hematological centers. Mean age was 64.2 years (range 38–84). ISS was equally distributed, with about one third of patents being represented in single stages. Twenty-three of 43 analyzed patients had cytogenetic abnormalities, the most frequent being del13q (14 patients); t(4;14) and t(11;14) were observed in 4 and 2 patients, respectively, while t(6;14), del17p or complex karyotype occurred in single patients. The median number of prior lines of therapy was 4 (range 1–10). Ninety-seven percent of patients had previously received bortezomib, 94% IMIDs, 85% melphalan, 74% cyclophosphamide, 45% anthracyclines, 26% other drugs, 33% radiotherapy. Sixty percent of patients had undergone autologous and 4% allogeneic stem cell transplantation. The last treatment before bendamustine was a bortezomib-based regimen in 31%, an IMIDs-based regimen in 42%, a combined bortezomib/IMIDs-based regimen in 9%, while 18% of patients had received other therapies. Seventy-three percent of patients were resistant to last therapy received, while 27% had relapsed. Median duration of response to last treatment received before bendamustine was 9 months (range 2–46). Median Hb value was 10.1 g/dl (range 7.6–14.9), WBC count 2.700/μl (range 550–15.200), PLT count 130.000/μl (range 6.000–410.000). Serum creatinine, calcium, beta2-microglobulin and LDH levels were increased in 12 (15%), 4 (5%), and 44 (56%) patients, respectively, while albumin levels were decreased in 27 patients (35%). The median percentage of marrow plasma cells (as evaluated in 57 cases) was 60% (range 1–100). Seventy-six percent of patients had osteolytic bone involvement and 78% extramedullary localizations, with 13% showing secondary plasma cell leukemia and 7% documented amyloidosis or proteinuria. Finally, 45% of patients presented with at least one severe comorbidity, mainly cardio-vascular, liver or pulmonary dysfunction, and diabetes. Results: A total of 236 cycles was administered (median 3, range 1–9). In 47% of patients bendamustine was variously associated to bortezomib (23%), or IMIDs (21%), or to a combination of both (3%). In 80% of patients receiving bendamustine +/− steroids, a median dose of 90 mg/sqm for two consecutive days every 28 days was employed; the median dose was 80 mg/sqm when bendamustine was combined with bortezomib, 60 mg/sqm with IMIDs (total range: 40–140 mg/sqm). The remaining patients received single, monthly doses ranging from 60 to 150 mg/sqm. According to IMWG uniform response criteria, 21 out of 73 evaluable patients achieved a response after a median time of 3 months. In particular, there were 16 PR, 1 VGPR, 1 sCR, and 3 CR; overall response rate (ORR) was, therefore, 29%. Response rate was 10% (4/39) in bendamustine single agent +/− steroids, 38% (5/13) in bendamustine + bortezomib and 62% (10/16) in bendamustine + IMIDs subgroups, respectively. Responders had received a lower number of previous treatments than non responders (median 3 vs 4). Response rate was higher in relapsed (12/21, 57%) than in resistant patients (10/57, 17%). The time to best response ranged from 1 to 8 months. After a median follow-up of 8 months, median PFS duration was 6 months, with 13 out of 21 responding patients not yet progressed. Median OS of the entire cohort was 6.2 months (7 months in responders and 4 months in non responders, range 0–27). Grade 3–4 hematological and non-hematological toxicities occurred in 56% and 15% of patients, respectively, causing three interruptions of the treatment. Conclusions: Though with the clear limits due to the high heterogeneity of treatments applied and of population analyzed, our data indicate that bendamustine may be a therapeutic option in heavily pretreated MM, suggesting a possible non cross-resistance with other agents. Its earlier use with appropriate doses and combinations might further improve the results obtained in this study. Disclosures: Musto: Mundipharma: Honoraria. Off Label Use: Bendamustine in relapsed/refractory myeloma. Fragasso:Mundipharma: Honoraria. Baldini:Mundipharma: Honoraria. Storti:Mundipharma: Honoraria.

Description: The Combination of Rituximab and CHOP (R-CHOP) is the golden standard in young and elderly NHL therapy, safe and effective. We included pegylated lyposomial Adriamycin (Caelyx®) instead of conventional Adriamycin in R-CHOP regimen in order to reduce myocardic and organ toxicity and to enhance doxorubicin uptake in tumour mass in advanced stage DLBC-NHL of elderly patients with comorbidity. This study is a retrospective study including patients of two haematology centers. We analyzed 34 DLBCNHL patient treated with R-CCOP (Rituximab 375mg/sqm day 0, Caelyx® 30 mg/sqm day 1, cyclophosphamide 750 mg/sqm day 1, Vincristine 1 mg/sqm day 1, Prednisone 100 mg/day, days 1–5, recycle every 21 days). The median number of administered cycles was 6 (Range 4–11). G-CSF was administered according to international guidelines Their median age was 74.5 years old (Range 65–87), M/F:20/14, 19/34 (55%) patients presented stage III– IV disease. 8 (23%) had B symptoms and 11 (32%) extranodal disease.12/34 (35%) patients had IPI high-intermediate and 11/34 (32%) high. 17/34 (50%) showed comorbidity (hepatitis C, NIDDM, severe hypertension, aortic valve disease, atrial fibrillation, chronic renal failure). Median follow-up was 26 months (Range 9–36). Overall (OS) and progression-free survival (PFS) at 36 months were calculated using Kaplan-Mayer method. After R-CCOP therapy we obtained the complete remission in 24/34 (70%) of patients, a very good partial remission in 2/34 (5%). The disease progressed in 3/34 (8%). Five out of 34 (14%) dead (3 of these for disease progression). No severe treatment-related toxicities were observed, except G3-G4 WHO neutropenia in 17 patients (50%) and cardiotoxicity in 2 patients (6%) with pre-existing cardiopathy (bradycardia and atrial fibrillation with high heart rate respectively). Myocardial function was evaluated by 2D echocardiogram before and after chemotherapy treatment and was not impaired by pegylated lyposomial Adriamycin administration. 3% of patients presented severe mucositis and 9% non-fatal infections. We did not observe any thrombocytopenia, In our study OS and EFS at 36 months were respectively 83.7% (95%CI 70.4–97%) and 56% (95%CI 27–85%).Non-responding patients had extranodal, stage IV disease with B symptoms. Nevertheless, they maintained chemosensitivity to a second-line therapy. In elderly B-NHL patients with advanced stage of disease and comorbidity, R-CCOP seems to be safe, feasible and effective. These results confirm and improve in a larger cohort of patients those reported by Zaja, Tulpule and Coiffier in their previous series (see table). Zaja et al Tulpule et al Giordano et al Coiffier et al Treatment R-COP-Caelyx x6 R-COP-Caelyx x8 R-COP-Caelyx x4-11 R-CHOP x8 * in 2 pts with preexisting cardiopathy Patients 29 19 34 202 Caelyx mg/sqm 30 40 30 Doxorubicin mg/sqm 50 Age (median) 69 51 74.5 69 IPI (L/IL) 38% 47% 32% 46% IPI IH/H 62% 53% 68% 54% OR 76% 100% 76% 82% CR 59% 80% 71% 76% 2y EFS 65.5% NA (56% 3y) 60% TRM 0 0 0 12/202 (6%) Grade III/IV toxicity Neutropenia 86% 68% 50% 91% Thrombocytopenia 3% 5% 0% NA Mucositis 3% 0% 3% 3% Infection 3% 0% 9% 12% Cardiotocicity 0% 0% 6%* 8%

Description: We have previously demonstrated that clonal hemopoiesis in female ET patients was significantly associated to the risk of thrombosis. When data on JAK2 V617P mutation became available we aimed to evaluate the incidence of this mutation according to clonality status. Ninety-two female patients, median age 32 (19–65) with a diagnosis of ET according to PVSG criteria were studied for clonality with X-CIP, 83 patients were evaluable for endogenous erythroid colonies (EECs) growth and 44 patients were evaluable for JAK2 V617P mutation. Twenty episodes of thromboses (21.7%) were detected and they include splanchnic (11), CNS (5), limb (3) thromboses and pulmonary embolism (1). Thromboses were mainly detected at diagnosis. Thirthy-seven patients showed clonal hemopoiesis (40%), 27 had polyclonal hemopoiesis (29.5%) and 28 were considered uninterpretable due to constitutional skewing (30.5%). Thromboses were overrepresented in the monoclonal group in respect to the polyclonal one (15/37 vs 2/27, p=0.003). DNA for analysis of JAK2 V617P by allele-specific PCR was available for 44 of these patients. Thirty-two patients of 44 (73%) showed JAK2 V617P mutation; JAK2 V617P was found in 16/21 patients with monoclonal hemopoiesis (76%), in 9/13 in the polyclonal group (69%) and in 7/10 (70%) in patients with constitutional skewing. Thirteen of the 32 patients with JAK2 V617P mutation (41%) had thromboses while no thrombotic event was recorded in wild type patients (p=0.008); among the 13 patients with thrombosis and JAK2 V617P mutation, 9 (69%) had monoclonal hemopoiesis, 2 (15%) had polyclonal hemopoiesis, and 2 had constitutive skewing. Thus there was a significant increase in thrombotic events in patients with JAK2 V617P mutation and monoclonal hemopoiesis (p=0.04). JAK2 V617P mutation was also significantly associated to the presence of EECs (p=0.02); in fact 22/26 patients with EECs growth showed JAK2 mutation (85%). Finally when patients with splanchnic thromboses were analyzed 9/11 had a monoclonal X-CIP (81.8%) and 7 of them who were evaluable for JAK2 V617P mutation were invariably carriers of the mutation. Thus we confirm that X-CIP in young female ET is correlated to the risk of thrombosis. JAK2 V617P mutation is significantly associated to the development of thrombosis and is present in the vast majority of patients with monoclonal hemopoiesis. The mechanisms underlying monoclonal hemopoiesis in the absence of JAK2 V617P mutation are unclear, notwithstanding these patients are clinically characterized by both absence of EECs and thrombosis.