ALBERT

Description: Introduction Elderly non-transplant eligible newly diagnosed multiple myeloma (nte-NDMM) patients also benefit from novel therapies, however, overall survival (OS) is inferior in unfit and frail compared to fit patients as defined by the International Myeloma Working Group (IMWG) frailty index. This is caused by a high discontinuation rate due to toxicity. Therefore, a less toxic effective treatment for unfit and frail patients is needed. In view of the favorable safety profile of ixazomib (Ixa) and daratumumab (Dara), we investigated the efficacy and feasibility of treatment with Ixa and Dara plus low dose dexamethasone (Ixa-Dara-dex) in unfit and frail patients. This trial was registered at www.trialregister.nlwww.trialregister.nl as NTR6297. Methods In this prospective multicenter phase II trial, treatment consisted of nine 28 day-induction cycles consisting of Ixa 4 mg (days 1, 8, 15), Dara 16 mg/kg (cycle 1-2: days 1, 8, 15, 22; cycle 3-6: days 1, 15; cycle 7-9: day 1) and dex (in combination with Dara; cycle 1-2: 20 mg; subsequent cycles 10 mg) followed by maintenance therapy with Ixa (days 1, 8, 15, 29, 36, 43) and Dara (day 1) of 8-week cycles, until progression for a maximum of 2 years. A pre-specified efficacy analysis was planned for the first eligible 23 unfit and 23 frail patients separately at the time the data of the first 9 cycles induction therapy was available. Inclusion criteria were unfit or frail NDMM patients according to the IMWG frailty index. Main exclusion criteria were severe cardiac dysfunction, chronic obstructive pulmonary disease with an FEV1

Description: Introduction and Objective: Extranodal natural killer (NK)/T-cell lymphoma, nasal type (ENKTL-NT) is associated with Epstein-Barr virus (EBV) and is much more common in Asia and Latin America than in western countries. Data on disease presentation and outcome from European series are very limited. The objective of the study is to analyze the clinical characteristics at diagnosis, treatment received and outcome of a series of patients from Spain. Patients and Methods: Eigthy-seven patients with ENKTL-NT diagnosed from 2000 to 2017 were identified in 24 academic centers in Spain. Clinical data were collected retrospectively. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test. Variables included in the univariate analysis were: race, gender, age, previous sinusitis, nasal localization, Ann Arbor stage, ECOG performance status (PS), B symptoms, LDH, beta2-microglobulin, albumin and C-reactive protein. Multivariate analyses were performed by Cox proportional hazard regression model. Results: Clinical characteristics at diagnosis are shown in Table 1. Seventy-seven patients received active treatment, 31 (40%) with chemotherapy (CT) alone, 39 (51%) with CT and radiotherapy (RT), 7 (9%) with RT alone (median dose 50 Gy). First line therapies were: CHOP/CHOP-like in 30 (42%) patients, high-dose L-Asparaginase-containing regimens in 27 (38%), and other regimens in 14 (20%); 12 patients proceeded to stem-cell transplant in first line (10 auto / 2 allo). Response rate was evaluable in 70 patients (by PET/TC in 55%): CR 35 (50%), PR 9 (13%), SD/progression 26 (37%). Median number of CT lines was 2 (1-6). With a median follow-up of 38 months, 3 yr OS was 38% (95% CI 27-49), and 3 yr PFS 25% (95% CI 14-35). Causes of death were: progression 35 (67%), toxicity 12 (23%), second neoplasms 5 (10%). The variables at diagnosis significantly associated with poor OS were: age ≥ 60 yr, extranasal disease, Ann Arbor III-IV, ECOG PS 2-4, increased LDH, and decreased albumin. In the multivariate analysis including all the previous variables, ECOG 2-4 PS (HR 3.3, 95% CI 1.4-7.0) and low albumin (HR 3.6, 95% CI 1.4-9.3) maintained the negative influence in OS. Patients treated with regimens that included high dose L-Asparaginase had 3 yr OS of 61% (95%CI 40-82), compared with patients treated with CHOP/CHOP-like 3 yr OS of 19% (95%CI 5-32) (p=0.009). These differences were statistically significant both in patients with nasal involvement (3 yr OS 82% with L-Asparaginase vs 21% with CHOP, p=0.01) or with localized disease (3 yr OS 71% with L-Asparaginase vs 24% with CHOP, p=0.03). Differences were not statistically significant in patients with extranasal involvement (3 yr OS 48% with L-Asparaginase vs 14% with RCHOP, p=0.2), or advance disease (3 yr OS 48% with L-Asparaginase vs 14% with CHOP, p=0.2), probably because the low number of patients. Conclusion: This is the largest series reported of Caucasian patients with ENKTL-NT. Patients are young at diagnosis and one fourth had a previous history of chronic sinusitis. This population has a poor outcome, being progression the main cause of death. Poor clinical condition at diagnosis (high ECOG PS and low albumin level) is the main factor related with poor survival. Therapies with high dose L-Asparaginase improve the survival in this western population compared with the classical CHOP regimen. Disclosures González-Barca: Roche: Speakers Bureau; Celtrion: Consultancy; Gilead: Consultancy; janssen: Consultancy, Speakers Bureau. Martín:Celgene: Consultancy, Honoraria, Other: Travel expenses; Roche: Consultancy, Honoraria, Other: Travel expenses; Janssen: Honoraria, Other: Travel expenses; Servier: Honoraria, Other: Travel expenses. Panizo:BMS: Membership on an entity's Board of Directors or advisory committees; Celgene: Speakers Bureau; Janssen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Acerta Pharma: Research Funding; Roche: Consultancy, Speakers Bureau. Sanchez Blanco:Gilead: Honoraria; Roche: Honoraria; Janssen: Honoraria. Marin Niebla:Roche: Consultancy, Other: Medical education of Staff, Speakers Bureau; Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Medical education of Staff, Speakers Bureau; Celgene: Other: Medical education of Staff, Speakers Bureau; Amgen: Other: Medical education of Staff, Speakers Bureau. Queizan:Janssen: Consultancy. Lopez:Roche: Research Funding.

Description: Background: Acute myeloid leukemia (AML) is an aggressive hematological malignancy which has an incidence of 40 children on average per year in the Netherlands and Belgium combined (population of 28 million). Despite the fact that almost all children achieve complete remission (CR), 30-40% of patients eventually relapse. Since survival after relapse is poor (35-40%), the overall survival (OS) of pediatric AML remains relatively low (~70%) compared to the increasing remission rates. The most effective strategy to improve the dismal outcome of AML patients is thus to prevent relapse. Over the last decades accumulating evidence is suggesting that AML develops in a hierarchical structure; originating from hematopoietic stem cells which are transformed to leukemia initiating cells, also referred to as leukemic stem cells (LSC). LSC possess self-renewal capacity and are more resistant to therapy. Therefore, LSC are supposed to be responsible for outgrowth of both the initial leukemia and the relapse. This holds true for adult AML, where the frequency of LSC at diagnosis has shown to be of importance for clinical outcome. However, while it has been shown that a high number of immature cells (CD34+/CD38-/CD45-/low) associates with an increased risk of relapse in pediatric AML, relatively little is known about the prognostic impact of LSC within this compartment. RAEB-t. Flow-cytometric LSC characterization was performed on either bone marrow (BM) or peripheral blood (PB) from AML patients collected at diagnosis. Purified white blood cells (WBC) were obtained after lysing the red blood cells using lysing solution (Pharm Lyse or FACSLysing, BD Biosciences) and were subsequently incubated with monoclonal antibody combinations and analyzed using an 8-color flow cytometer approach. LSC were defined as CD34+ CD38- cells with aberrant expression of CD123, CD7, CD56 or CD2. Results: Data were available from 103 patients and patient characteristics are listed in Table 1. In this cohort relapse-free survival (RFS) was 59.4%. Fortunately 56.4% of relapsed patients achieved a second CR and OS was 85.4%. LSC-load is defined as % of aberrant CD34+ CD38- cells within the CD34+ compartment. In our pediatric cohort, 17 patients (16.5%) had no expression of CD34 on blast cells at all (CD34null) and consequently no aberrant CD34+ CD38- LSC could be detected. Absence of CD34 has often been associated with good prognosis in literature. In our cohort relapse-rate seemed to follow this trend (4 out of the 17 CD34null patients (23.5%) vs. 34 out of the 83 CD34positive patients (41%)) but did not differ significantly (Plogrank = 0.196). ROC curve analysis showed that a cut-off of 17.2% LSC at diagnosis was associated with the occurrence of developing relapse with a specificity of 92%. Kaplan-Meier survival analysis, as depicted in Figure 1, showed a significant association between a high LSC-load and impaired RFS (34% relapses in LSClow vs. 64% relapses in LSChigh) (Plogrank= 0.027). Univariate analysis showed that next to LSC percentage, FLT3 mutation status and WBC count were significantly associated with RFS. After multivariate adjustment (taking into account cytogenetic risk groups and mutational status) LSC frequency was the only independent predictor of relapse or RFS (HR 2.3, 95% CI 1.1-4.8, p=0.032). Conclusion: Our results confirm data from adults and reveal that the frequency of LSC at diagnosis in pediatric AML patients can distinguish patients more likely to fail current treatment regimens as these patients develop significantly more relapses). Identifying this patient group creates opportunities for more personalized medicine and the development of therapies directed against LSC, sparing normal hematopoietic stem cells. Disclosures Kaspers: Janssen-Cilag: Research Funding. Cloos:Takeda: Honoraria.

Description: S100A9 belongs to a family of low-molecular-weight calcium-binding proteins and is involved in many biological processes including inflammation, cell migration and angiogenesis. It has been reported that S100A9 knockdown reduced myeloid-derived suppressor cell (MDSC) accumulation and Multiple Myeloma (MM) cell growth in MM models. MDSC are a heterogeneous population of immature myeloid cells and contribute to MM disease by immunosuppression, induction of angiogenesis and secretion of cytokines and growth factors. S100A9 is therefore proposed as an attractive drug target and compounds inhibiting the interaction of S100A9 with its receptors RAGE and TLR4 have been developed. In this study we evaluated the therapeutic relevance of S100A9 inhibition in MM using the preclinical immunocompetent murine 5T33MM model and two different small molecule inhibitors for S100A9 interactions (Active Biotech AB, Sweden). The presence of S100A9 was investigated in different cell populations. S100A9 is expressed in monocytic and granulocytic MDSC in murine and MM patient derived bone marrow (BM) samples, as demonstrated by western blot analysis and flow cytometry. S100A9 levels were higher in granulocytic MDSC compared to monocytic MDSC. Human MM cell lines and patient derived MM cells demonstrated low S100A9 expression, while no expression could be observed in 5T33MM cells. Treatment of 5T33MM mice with 30 mg/kg/day ABR-215757 (paquinimod) (quinoline-3-carboxamide analog) or ABR-238901 (N-(heteroaryl)-sulfonamide derivate) significantly diminished tumor cell percentages in the BM with ABR-238901 being the most potent one (27% relative reduction, p

Description: Introduction: Second-Harmonic Generation microscopy (SHG) has provided progresses in extracellular matrix research, mainly regarding automated analysis of collagen fibers. Nodular sclerosis-classical Hodgkin lymphoma (NS) often has a rich collagen deposition, which remains poorly explored in its biological significance and potential prognostic role. The aim of this study was to characterize the collagen component of NS using SHG, and to investigate its clinical value. Methods: Hematoxylin and eosin stained slides from 53 consecutive samples of paraffin embedded NS tissue were analyzed by SHG imaging in an Inverted Zeiss LSM 780-NLO. HIV-positive individuals were excluded. For comparative purposes, 11 reactive lymph nodes (RL) were also randomly selected. In each slide, 3 capsular areas and 3 sclerotic regions (perinodular septa - PS - in NS and fibrotic foci around germinal centers in RL) were chosen. Collagen near blood vessels was not considered. We evaluated quantity, uniformity and organization of the fibers with ImageJ and OrientationJ plug-in in 4 hotspots from each image. Shapiro-Wilk test was used to assess data normality, while t-tests and Pearson correlations were performed to analyze collagen parameters between two groups. Overall survival (OS) was defined as time from diagnosis until death from the disease or last follow-up. Event-free survival (EFS) was set as time from diagnosis until progressive disease, death from the disease or last follow-up. Collagen data were used in survival analyses as continuous variables (in Cox-hazards model) or categorical ones (by choosing the mean value as a threshold for Kaplan-Meier curves and log-rank test). Significance was set at p 3). The first-line treatment was ABVD in 40 cases (75.5%) and BEACOPP in 13 patients (24.5%). Radiotherapy was performed in 27 (50.9%) patients. Tumor PS presented more dense (p

Description: Background: Since survival in AL mainly depends on the extent of organ involvement of patients at presentation, early diagnosis and risk stratification are key to improve patients' outcome. Therefore, together with surrogates of organ involvement, biomarkers identifying patients with MGUS or MM at greater risk of developing AL would be highly valuable to prevent organ damage, to maximize therapeutic efficacy and to improve outcomes in AL. Aim: To investigate the value of multidimensional flow cytometry (MFC) for simultaneous fast diagnostic screening of plasma cell (PC) clonality and risk stratification, as well as to identify immunophenotypic markers useful for the selection of patients with monoclonal gammopathies candidates for monitoring of pre-symptomatic organ damage related to AL. Methods: We used MFC to characterize a large series of patients with newly-diagnosed (ND) AL (N=94) vs MGUS (N=20) and NDMM (N=52), as well as age-matched healthy adults (HA, N=30). For each patient with AL, automated risk stratification was performed using principal component analysis (PCA) based on the relative frequency of bone marrow (BM) PCs, plus the percentage of clonal and normal PCs within the whole BM PC compartment, vs a database containing information on the same three parameters from a total of 1,774 patients, including 497 MGUS and 1,227 NDMM. In parallel, immunophenotypic protein expression profiles (iPEP) of AL patients were clustered using t-SNE, and the comparison between the iPEP of clonal PCs from patients with AL vs MGUS and MM cases was performed using canonical-correlation analysis (CCA). To identify additional immunophenotypic hallmarks of AL, the BM cellular composition in HA, MGUS, AL and MM patients was compared using 2-dimensional minimum spanning tree (MST) force-directed classification to determine the distance among individual cases. Results: PC clonality was detected by MFC in 93/94 (99%) AL patients, whereas an M-component was detectable in 96% of cases by electrophoresis, immunofixation and sFLC. PCA as defined above, identified AL patients displaying an MM-like (n=6) and an MGUS-like (n=38) signature, as well as 49 cases with an intermediate signature between the MGUS and MM reference datasets. Multivariate analysis of baseline prognostic factors for survival, including patients' age, number of organs involved, Mayo staging, the percentage of BM PCs based on cytomorphology and eligibility for ASCT, showed that having an intermediate- or an MM-like profile had an independent adverse effect on patients' progression-free (PFS) and overall survival (OS) (HR:3.4; P≤.02). t-SNE based on the iPEP of clonal PCs revealed two major clusters of AL patients with significantly different PFS, defined by opposite patterns of expression for CD45, CD56 and CD138 (P≤.02). CCA of tumor iPEP showed partial overlap between AL vs MGUS and MM, with progressively higher percentages of cases with a CD38lo, CD45-ve, CD81-ve and CD138lo iPEP being observed from MGUS to AL and MM. In contrast, AL patients displayed significantly lower reactivity for CD56 (P≤ .03). Further characterization of the BM cellular composition allowed the systematic assessment of 16 cell populations and 18 phenotypic parameters that, by MST, mapped AL in between MGUS and MM. Of note, while AL patients displayed a predominantly-clonal PC compartment in the absence of an MM-like tumor PC expansion, the percentage of B-cell precursors was consistently lower in AL patients than in HA, MGUS and MM (P=.004). Thus, using optimal cut-off values to discriminate between AL vs MGUS and MM, we built a scoring model based on the presence of

Description: Introduction: Over the last few years, novel agents-based combinations have been incorporated into the treatment of MM patients, particularly in relapse setting. However, these novel combinations have been evaluated in clinical trials and patients included represent a selected population. Patients in real life are usually older with comorbidities and disabilities and not allowed to be included in the trials, so, in real setting, is expected worse outcomes and shorter survival. The information about treatment burden in real life is scarce. The aim of our study was to analyze the outcome of MM patients in the real life outside clinical trials, in terms of treatment lines in a single institution setting, and to analyze the influence of comorbidities on the treatment burden. Material and methods: Medical records of MM patients treated at Txagorritxu hospital (Spain) between 2009 and January 2017 were retrospectively evaluated with the aim of mapping the course of patients as well as to investigate the factors that influence treatment-decisions at different stages of the disease. Results: 176 patients with MM were diagnosed from jan-2009 to jan-2017. Baseline patient's characteristics are presented in Table 1. The median age at diagnosis was 71 years (range 33.2-93), main of the patients where non-transplant eligible newly diagnosed MM (NTENDMM): 114 (65%). With a median follow-up of 25 months, 90.6% of newly diagnosed MM patients transplant-eligible (TENDMM) remain alive versus 65% NTENDMM patients (p value: 0.000)(figure 1). Overall, patients received a median of 2 lines of treatment, it should be noted that 86% of patients had received 3 or less lines of treatment and only 14% of the patients could receive more than 3 lines of therapy. To better evaluate treatment burden, we focused on deceased patients. At the time of analysis, 19% of TENDMM (12 patients) and 51.4% of in NTENDMM (57 patients) has died with a median time to death of 29.6 months and 18 months to death, respectively. Median lines of therapy for death patients TENDMM was 3.5 (range 1-8), with a 75 percentile of 5 lines of therapy, by contrast, death NTENDMM patients received a median of 2 lines of therapy (range: 1-6), with an 80 percentile of 3 lines of therapy (figure 2). In order to evaluate the influence of comorbidities in treatment burden for NTENDMM patients, CIRS score was estimated retrospectively. Median CIRS score was 5.5 (1-19). CIRS scale did not predict progression free survival (PFS) among the different groups: CIRS 8: 30.6 months (p: 0.819), however, interestingly CIRS scale predicted overall survival (OS): CIRS 8: 12.3 months, (p: 0.012) (figure 2). Analyzing treatment burden for each CIRS score group 63% of patients with CIRS〉 8 received only one line of treatment before death, compared to 39.5% and 37.5% of patients with CIRS4-8 and CIRS

Description: We recently described that simvastatin effectively induced apoptosis in myeloma and lymphoma tumor cells by inhibition of proteingeranylgeranylation resulting in the reduction of the anti-apoptosis protein Mcl-1. In addition low concentrations of simvastatin had a chemosensitizing effect in combination with dexamethasone or doxorubicin. Based on these observations we initiated a Phase I study of dose escalating simvastatin combined with chemotherapy in patients with end-stage Myeloma and Lymphoma. Starting dose level of simvastatin was 5 mg/kg/day for 7 days, divided in 2 doses orally, followed by VAD chemotherapy in patients with myeloma and CHOP in patients with lymphoma. Three patients were included per dose level. In the absence of side effects WHO grade III/IV in 3 patients the dose of simvastatin was escalated with 2.5 mg/kg. Twenty-one heavily pretreated patients all refractory to at least 3 lines of chemotherapy (14 myeloma patients and 7 lymphoma patients) were included. No toxicity beyond WHO 2 was recorded with dose level 1–4 (5 mg–12.5mg/kg/day/7days). One patient treated at dose level 5 (15 mg simva/kg/day/7 days) became severely depressed and performed an unsuccessful suicide attempt. Two patients treated at dose level 6 (17.5 mg/kg/day/7 days had severe gastro-intestinal side effects (WHO 3; vomiting, diarrhoea, dehydration), necessitating interrupting simvastatin after 3 and 4 day respectively. The third patient treated at dose level 6 had moderate gastro-intestinal complaints but died on day 13 (2 days after VAD, deeply neutropenic) from overwhelming Gram-Septicaemia although prophylactic antibiotics had been prescribed. Three additional patients were then treated at dose level 5 again without side effects beyond WHO 2. None of the patients complained about muscle pain. No signs of rhabdomyolysis were registered. Although response was not the primary endpoint of the study, it could be evaluated in 16 patients who completed at least 2 cycles of simvastatin with chemotherapy. Six patients (4 myeloma and 1 transformed low grade lymphoma) responded (32 %) including 5 patients with a Partial Response (〉 50 tumor reduction) and 1 patient with a minor response. Four of 8 evaluable (myeloma) patients treated at dose level 4 and 5 responded. Due to toxicity all 3 patients at dose level 6 were not evaluable for response. In patients treated at dose level 4 and 5, in vivo down regulation of Mcl-1 (〉 50 %) was observed in PBMC collected after 7 days of simvastatin treatment. These data show that in vivo downregulation of Mcl-1 by high dose (simva) statin in combination with chemotherpy may be a promising new modality for patients with drug resistant myeloma and lymphoma.

Description: Introduction: Sickle cell anemia (SCA) is a chronic inflammatory disease with heterogeneous clinical features and the reasons for the heterogeneity of the clinical manifestations has not been fully elucidated. New mediators of the pathogenesis of SCA described recently include the formation of Neutrophil Extracellular Traps (NETs), which may contribute to the amplification of inflammation via the production of pro-inflammatory mediators. Peptidylarginine Deiminase 4 (PADI4) is a critical regulator of NETosis by mediating histone citrullination, an essential step for the generation of NETs. There appears to be a relationship between PADI4 gene polymorphisms and the pathophysiology of other inflammatory diseases in which NETosis seems to be relevant. Our aim was to investigate the association of PADI4 gene polymorphisms [rs874881(G〉C), rs1748033(T〉C), rs11203366(G〉A), rs11203367 (T 〉C), rs2240340 (T〉C)], which have been previously associated with increased PADI4 mRNA stability and with some clinical manifestations in cohorts of SCA patients. Methods: The study included 194 SCA patients (93 males and 101 females with mean age 33.29 ± 9.54 years) being followed up at the Hematology and Hemotherapy Foundation of Pernambuco (HEMOPE), Recife, Brazil. PADI4 gene polymorphisms were performed by Polymerase Chain Reaction (PCR) and their products were sequenced using the Big Dye Terminator Cycle Sequencing Ready Reaction Kit v3.1 (Applied Biosystems, CA, USA). These results obtained were compared with the clinical data obtained from the patients' records. Ethical approval was obtained from Ethics Committee of HEMOPE and all patients gave informed consent. Results: The frequencies of the genotypes found were as follows: rs874881 (22.2% GG, 50.5% GC, 27.3% CC); rs1748033 (17% TT, 42.3% TC, 40.7% CC); rs11203366 (21.1% GG, 50% GA, 28.9% AA); rs11203367 (20.6% TT, 49.5% TC, 29.9% CC); rs2240340 (24.7% TT, 46.4% TC, 28.9% CC). The distribution of the genotypes was in accordance with the Hardy-Weinberg equilibrium (p 〉 0.05). Twenty-four patients (12.4%) presented with a history of acute chest syndrome (ACS), 27 (13.9%) with stroke, 168 (86.6%) with vaso-occlusive crisis (VOC), and 81 (47.8%) with leg ulcers (LU). No association was observed between the polymorphisms studied and the history of LU, VOC and stroke in the patients (p 〉 0.05). However, for rs 874881 and 1748033 with the G and T alleles, respectively, were associated with a higher risk of ACS (OR: 2.96, p = 0.02 and OR: 4.75, p = 0.01, respectively). Conclusion: In the present study, we found an association between the wild type alleles (rs874881G and rs1748033T) and a history of ACS in our cohort of SCA patients. There is need for future studies on these polymorphisms in larger cohorts of SCA patients to affirm this association. Disclosures No relevant conflicts of interest to declare.