ALBERT

Description: Gene expression profiles of bone marrow (BM) CD34-derived megakaryocytic cells (MKs) were compared in patients with essential thrombocythemia (ET) and healthy subjects using oligonucleotide microarray analysis to identify differentially expressed genes and disease-specific transcripts. We found that proapoptotic genes such as BAX, BNIP3, and BNIP3L were down-regulated in ET MKs together with genes that are components of the mitochondrial permeability transition pore complex, a system with a pivotal role in apoptosis. Conversely, antiapoptotic genes such as IGF1-R and CFLAR were up-regulated in the malignant cells, as was the SDF1 gene, which favors cell survival. On the basis of the array results, we characterized apoptosis of normal and ET MKs by time-course evaluation of annexin-V and sub-G1 peak DNA stainings of immature and mature MKs after culture in serum-free medium with an optimal thrombopoietin concentration, and annexin-V–positive MKs only, with decreasing thrombopoietin concentrations. ET MKs were more resistant to apoptosis than their normal counterparts. We conclude that imbalance between proliferation and apoptosis seems to be an important step in malignant ET megakaryocytopoiesis.

Description: We analyzed clinical and molecular follow-up of 16 patients with chronic myeloid leukemia (CML) relapsing after allogeneic stem cell transplantation (SCT). The median interval between allogeneic SCT and relapse was 26 months (7–162). Two patients had failed treatment with donor lymphocyte infusions prior to Imatinib; four patients had received therapy with IFN alpha. All patients were treated with Imatinib (400 or 600 mg/daily). One patient had received Imatinib before allogeneic SCT. The overall complete hematological (CHR) and cytogenetic responses (CCyR) were 100% for all patients either relapsed in CP or AP. All patients achieved complete molecular response (CMR), intended as 3 logs reduction of BCR-ABL/B2M within 18 months; 8/16 patients obtained a CMR within three months, independently of the phase of the disease at of relapse. Median follow-up after start of Imatinib therapy was 24 months (range 6–36). Chimerism status evaluated in 9 patients showed conversion to full donor chimerism after therapy in all but one of them. Imatinib has significant activity against CML in relapse after allogeneic bone marrow transplantation with durable cytogenetic and molecular remissions obtainable in all patients.

Description: Exploration of the immunomodulatory activities of the multifunctional cytokine interleukin-11 (IL-11) has prompted several therapeutic applications. The immunomodulatory effects of IL-11 on human antigen-presenting cells and on T cells were investigated. IL-11 inhibited IL-12 production by activated CD14+ monocytes, but not by mature dendritic cells (DCs) stimulated via CD40 ligation. Moreover, IL-11 did not affect either DC maturation, as demonstrated by phenotypic analysis and evaluation of cytokine production, or DC generation from progenitor cells in the presence of specific growth factors. Molecular analysis demonstrated the expression of IL-11 receptor messenger RNA in highly purified CD14+ monocytes, CD19+ B cells, CD8+, and CD4+T cells, and CD4+CD45RA+ naive T lymphocytes. In keeping with this finding, IL-11 directly prevented Th1 polarization of highly purified CD4+CD45RA+naive T cells stimulated with anti-CD3/CD28 antibodies, as demonstrated by significant increases of IL-4 and IL-5, by significantly decreased interferon-γ production and by flow cytometry intracellular staining of cytokines. Coincubation of naive T cells with DCs, the most potent stimulators of Th1 differentiation, did not revert IL-11–mediated Th2 polarization. Furthermore, parallel experiments demonstrated that the activity of IL-11 was comparable with that induced by IL-4, the most effective Th2-polarizing cytokine. Taken together, these findings show that IL-11 inhibits Th1 polarization by exerting a direct effect on human T lymphocytes and by reducing IL-12 production by macrophages. Conversely, IL-11 does not exert any activity on DCs. This suggests that IL-11 could have therapeutic potential for diseases where Th1 responses play a dominant pathogenic role.

Description: Achieving a complete cytogenetic response (CCgR) is a major target in the treatment of chronic myeloid leukemia (CML) with interferon-α (IFN-α), but CCgRs are rare. The mean CCgR rate is 13%, in a range of 5% to 33%. A collaborative study of 9 European Union countries has led to the collection of data on 317 patients who were first seen between 1983 and 1997 and achieved CCgRs with IFN-α alone or in combination with hydroxyurea. The median time to first CCgR was 19 months (95% CI, 17-21; range, 3-84 months). At last contact, 212 patients were still alive and in continuous CCgR; 105 patients had lost CCgR, but 53% of them were still alive and in chronic phase. IFN-α treatment was discontinued permanently in 23 cases for response loss, in 36 cases for chronic toxicity (15 are still in unmaintained continuous CCgR), and in 8 cases because it was believed that treatment was no longer necessary (7 of these 8 patients are still in unmaintained continuous CCgR). The 10-year survival rate from first CCgR is 72% (95% CI, 62%-82%) and is related to the risk profile. High-risk patients lost CCgR more frequently and more rapidly and none survived more than 10 years. Low-risk patients survived much longer (10-year survival probability 89% for Sokal low risk and 81% for Euro low risk). These data point out that a substantial long-term survival in CCgRs is restricted mainly to low-risk and possibly intermediate-risk patients and occurs significantly less often in high-risk patients.

Description: Abstract 2928 Introduction. The recent development of a safe and efficient once daily oral iron chelator (Deferasirox, ExjadeÒ) made possible regular chelation therapy in transfusion dependent MDS patients. However in this category of patients the reported clinical experience is limited to selected populations. For this reason the GIMEMA group developed a phase IIIb prospective trial to test safety and efficacy of Deferasirox in a large population of patients comparable to general MDS population. Methods. One hundred and fifty-nine transfusion dependent IPSS low-intermediate1 risk MDS patients were enrolled. Analysis has been performed on 123 patients who had completed the planned year of treatment. Baseline characteristics were the following (data are expressed as median with upper and lower quartile unless specifically indicated): median age was 72 years (range 24 – 87); 48 were IPSS low risk and 75 Intermediate1; duration of transfusion dependency before treatment was 20 months (12-36) corresponding to 38 (22-70) packed red blood cells transfusions received. Baseline serum ferritin was 2000 ng/ml (1471-3000). Baseline Charlson and CIRS comorbity scores were 1 (0-1) and 0.2 (0.1-0.4), respectively. Patients started treatment with the standard 20 mg/kg Deferasirox dose but dose adjustments on clinical indications were allowed. Results. 61 patients (49%) prematurely interrupted the study (drop out), 62 (51%) patients completed the planned year of treatment. In logistic model for drop out rate high Charlson co-morbidity score showed a trend as significant risk factors (p=0.06). Drops out were related to: ten patients (8%) had progression to acute leukemia during the study; twenty patients (16%) experienced MDS related clinical problem (three had cardiac failure, seven had severe infectious diseases, four had severe bleeding, three died at home, three presented others MDS related problems); five patients underwent hemopoietic stem cell transplantation and thirteen discontinued treatment for unrelated problems. Drug related toxicity was drop out cause in 13 patients (11% of the entire population). Main causes of toxicity related drops out were increase of creatinine and gastro-intestinal disturbance. Out of 123 patients analyzed for adverse events only 4 (3%) presented grade 3–4 drug related adverse events. Severe adverse events with suspected relationship with study drug were diarrhea and increase of liver enzymes. Serum ferritin was monthly recorded in the 62 patients who completed the protocol with a statistically significant decrement during the 12 months follow up: median baseline value 2000 ng/ml (interquartile range 1471–3000), median final value 1550 ng/ml (interquartile range 775–2200) P 〈 0.001, Friedman test analyzing the entire study period. Analysis of quality of life is ongoing. One patient showed a complete erythroid response to Deferasirox treatment acquiring transfusion independence that is still ongoing after 18 months. Discussion. Preliminary results from the GIMEMA MDS0306 study confirmed feasibility of Deferasirox therapy in transfusion dependent MDS patients. Drop out rate, toxicity related drop out and severe side effects were similar to those reported in other trials even if the present population presented clinical characteristics of more advanced disease and age. The rate of progression is coherent with prolonged disease story. Serum ferritin behavior confirms Deferasirox efficacy. The serum ferritin reduction was more evident in the more heavily overloaded population indicating successful iron depletion in this group of patients as clinically requested. ClinicalTrial.gov identifier NCT00469560. Disclosures: Angelucci: Novartis: Honoraria. Saglio:Novartis: Consultancy, Honoraria; Bristol Myers Squibb: Consultancy, Honoraria.

Description: In Italy the use of lenalidomide (LEN) in MDS with del(5q) is ruled by a national agency (AIFA, Agenzia Italiana del Farmaco) Registry since 2008. We conducted an observational, non-interventional, multi-centre, retrospective/prospective cohort study, registered as MORE (ClinicalTrials.gov NCT01347944), to investigate the use LEN in the context of a "real world setting". Registry eligibility: IPSS low or intermediate-1 risk MDS with transfusion-dependent anemia and 5q31 deletion. MORE integration: retrospective collection of clinical, hematological and cytogenetic data at pre-registry time, at enrollment, after 4-6 cycles and 8-12 cycles of LEN, and at the last available follow-up and/or end of treatment. Hematological and cytogenetic response was assessed according to Cheson et al (Blood 2006). Statistical analysis used PL / SQL Developer and R open source software. 190 patients (M:F 60: 130) were included in this study (Table 1). GROUP A, (149 patients, median age 75 years) with complete data sets, and GROUP B (41 patients, median age 71 years), investigated only by FISH were analyzed separately. By integration of Registry with MORE forms, including disease history and/or treatment preceding inclusion in the Registry, information was recruited over a median time of 44 months (range 0.5-237). The complete erythroid response rate was 74.6% in group A and 78.6% in group B after 4-6 cycles treatment, and 85.8% and 88.9%, respectively after 8-12 cycles. The partial response rate was 11.5% in group A and 10.7% in group B at 4-6 months cycles. The complete cytogenetic response rate (only group A ) after 4-6 cycles was 7.8%. The partial response rate was 2.3 %. After 8-12 cycles complete response increased to 13% , partial response to 9.6 %. Leukemic evolution was observed in 18 cases (9.5%). Disease progression to a higher risk MDS was found in 12 cases (6.3%). Neutropenia (grade 3-4; 59%) and thrombocytopenia (grade 3-4; 21%) were predominant in the first 6 months of treatment. Infections (21%) mostly affected the upper respiratory tract. As far as we know this is the first report on LEN administration within a national registry. Despite being a retrospective study solid information on real life management of del(5q)-MDS were obtained. The known efficacy on erythropoiesis was strongly confirmed (FIG.1A). Notably, we also found a good response in low/int-1 IPSS cases with non-isolated 5q- (70.6%), suggesting that IPSS score plays a role in the successful response. The low rate of cytogenetic response possibly reflected the high level of variations in timing and dosage of LEN as well as heterogeneity of analyses in a non-centralized study. Nevertheless, results after 8-12 cycles (22.6%; FIG.1B) were similar to the 25% found with 5mg LEN in the European cooperative MDS004 study (Fenaux P et al, Blood 2011). AML evolution was found in 18/190 cases (9.6%) after a median of 7.5 LEN cycles (range 1-30). Moreover twelve additional cases (6.3%) showed progression to RAEB1 or RAEB2 after a median of 19.5 LEN cycles (range 4-56). In the MDS004 study a similar analysis gave 25.4 % of leukemic evolution and 2.9% of disease progression. This large series of MDS with del(5q) allowed us to confirm the efficacy of LEN in a "real world setting". Biological and clinical features seem to be critical for the success of this personalized therapy. Table 1. Table 1. Figure 1. Clinical-hematological features of 190 cases (MORE Study). Figure 1. Clinical-hematological features of 190 cases (MORE Study). Disclosures Roncadori: Celgene: Research Funding. Rossi:Celgene: Research Funding. D'Emilio:Celgene: Research Funding. Di Renzo:Celgene: Research Funding. Leoni:Celgene: Research Funding. Rambaldi:Roche: Honoraria; Novartis: Honoraria; Amgen: Honoraria; Celgene: Research Funding; Pierre Fabre: Honoraria. Avanzini:Celgene: Research Funding. Visani:Celgene: Research Funding. Tura:Celgene: Research Funding. Covezzoli:Celgene: Research Funding. Mecucci:Celgene: Research Funding.

Description: In the present study, we used a polymerase chain reaction–based (PCR-based) strategy to retrospectively analyze the presence of residual myeloma cells in serial posttransplant bone marrow samples obtained from 13 patients in remission after allogeneic hemopoietic stem cell transplantation (allo SCT). For this purpose, patient-specific primers were generated from complementarity determining regions 2 and 3 of the rearranged IgH gene. The level of sensitivity of the PCR-based assay ranged from 1 in 105 to 1 in 106 normal marrow cells. Following transplantation, 9 of 12 patients who attained stringently defined complete remission (CR) remained persistently PCR− for a median of 36 months, and 4 of the patients remained PCR− up to the latest analysis, which was performed at 48, 72, 72, and 120 months, respectively, after allo SCT. None of the patients in the PCR− subgroup experienced a disease relapse, and only 1 of 4 PCR+ patients experienced a relapse. It is concluded that allo SCT has the potential ability to induce sustained serological and molecular CR in selected patients with multiple myeloma.

Description: The aim of the present study was to compare thalidomide-dexamethasone (THAL-DEX) and vincristine-doxorubicin-dexamethasone (VAD) as primary therapy for newly diagnosed multiple myeloma (MM). For this purpose, we performed a retrospective matched case-control analysis of 200 patients who were treated with THAL-DEX (n=100) or VAD (n=100) on two consecutive studies from 1996 to 2003. Thalidomide was given orally at the daily dose of 200 mg, while VAD was administered by continuous infusion. Pulsed dexamethasone combined with thalidomide or vincristine-doxorubicin was given at the monthly dose of 40 mg/d for 4 days (1 to 4), with courses repeated on days 9 to 12 and 17 to 20 on odd cycles. By design of both studies, THAL-DEX and VAD were planned to be given for 4 months in an attempt to reduce tumor cell mass before collection of peripheral blood stem cells (PBSC) and subsequent autologous transplantation. Matching criteria were age (within 2 years), clinical stage and serum β2-microglobulin (within 1 mg/l). In addition to the above mentioned criteria, all other relevant baseline patient characteristics were comparable between the two groups. Response to therapy was evaluated using an intent-to-treat approach and stringently defined criteria (EBMT). In comparison with VAD, THAL-DEX resulted in a significantly higher ≥ partial response rate (76% versus 52%, respectively; P=0.0004) and effected more profound reduction in serum IgG (P=0.002) and IgA (P=0.01) M protein levels. Nine patients treated with THAL-DEX and 9 patients who received VAD did not proceeded to PBSC mobilization, mainly because of death while on study treatment (THAL-DEX=5 patients; VAD=6 patients) or nonfatal toxicity (THAL-DEX=3 patients; VAD=2 patients). The median number of CD34+ cells collected following high dose cyclophosphamide 7 g/m2 was 7.85 x 106/kg in the THAL-DEX group and 10.5 x 106/kg in the VAD group. Considering 4 x 106 CD 34+/kg as the minimum number of stem cells required to safely perform double autologous transplantation, adequate cell yields were obtained in 83% of patients with prior exposure to THAL-DEX and in 88% of patients treated with VAD (P=0.3). In conclusion, results of the present study (to the best of our knowledge, the first comparing THAL-DEX with VAD as initial cytoreductive therapy in preparation for autologous transplantation) extend and confirm prior observations by our group and others showing that THAL-DEX is an effective and relatively well tolerated induction regimen for previously untreated patients with MM. In comparison with VAD, THAL-DEX significantly augmented tumor cytoreduction without increasing the toxicity or interfering with subsequent collection of PBSC. Based on these data, thalidomide-dexamethasone may be considered an oral, and easy to administer, alternative to the more complex, and cumbersome to administer, combination of vincristine-doxorubicin-dexamethasone as front-line therapy for MM patients who are candidates to subsequent autologous transplantation.

Description: We have previously reported that 3′-azido 3′-deoxythymidine (AZT) can possess a significant antineoplastic activity when combined with drugs that disrupt de novo thymidylate synthesis, such as 5-fluorouracil and methotrexate (MTX). The aim of the present study was to evaluate the efficacy and the tolerance of the combination AZT + MTX in human immunodeficiency virus (HIV)-related non-Hodgkin's lymphoma (NHL). Twenty-nine patients (22 men and 7 women), either newly diagnosed or pretreated, have been enrolled in the trial; the median age was 34 years, 45% had acquired immunodeficiency syndrome before lymphoma and 19 patients had less than 100 CD4 lymphocytes/μL. Histologic diagnoses were mainly Burkitt (27%) and diffuse large B-cell lymphoma (45%); extranodal involvement was present in 20 patients. The treatment plan included three weekly courses of MTX at 1 g/m2 (days 1, 8, and 15) plus oral AZT at 2 g/m2 (days 1, 2, and 3), 4 g/m2 (days 8, 9, and 10), and 6 g/m2 (days 15, 16, and 17), plus leucovorin rescue. From the eleventh patient on, in case of complete or partial remission, the treatment was continued with three additional courses, using AZT at the maximum dose. In 26 evaluable patients, the total (complete + partial) response rate was 77% (95% confidence interval, 58% to 89%), with complete remission (CR) in 46% of the patients (95% confidence interval, 29% to 65%). The median CR duration was 12.8 months. Grade III-IV neutropenia and anemia were observed in 52% and 31% of the courses, respectively. There was one therapy-related death due to bacteremia followed by septic shock; the only other recorded infection was a herpes vaginalis. In conclusion, we suggest that AZT + MTX is an effective and well-tolerated regimen in HIV-related NHL.