ALBERT

Description: Peripheral blood progenitor cells (PBPC) have increasingly become the preferred source of stem cells for autologous transplantation due to their easier accessibility, rapid engraftment and higher safety. The harvest of PBPC in paediatric patients assumes critical importance, particularly in low-weight infants, in whom optimizing the procedure allows the collection of sufficient number of cells, with a reduced number of leukapheresis. The published data of these low-weight patients are scarce, and very likely the accumulation of cases will contribute to optimize the procedure. In this single centre study we retrospectively analyzed data of 69 large volume leukapheresis (LVL) from 36 low weight (〈 20Kg) paediatric patients between January 1998 and April 2008. Primary diagnosis included several malignancies: neuroblastomas (21 cases), meduloblastomas (4 cases), acute leukaemia (4 cases), retinoblastoma (2 cases) and other 5 cases with various solid tumours. All the LVL procedures underwent with a continuous flow blood separator (COBE Spectra) after priming the extracorporeal line with red blood cells and acid-citrate-dextrose (ACD) was used as the anticoagulant. Mean body weight was 15,78kg (ranging 9–19Kg), and a median age of 44 months (ranging 7–88 months). Blood withdrawn at a mean rate of 33,8 mL/min (standard deviation [SD] 8,0), through central vein catheters and using 4 volemias (one case with 3), lasting a mean 133,43 minutes/procedure (ranging 212–101 min). A mean of 4881,78 ml of blood was processed (ranging 2101–7327mL). Leukapheresis was performed on the fifth day of G-CSF stimulation in most of the procedures (66,7%), while 21 patients were submitted to stimulation for a longer period (18,8% with 6 days, 7,2% with 7 days and 4,3% with eight). The mean G-CSF dose used was 203,06 μg/d (ranging 105–400 μg/d). The mean number of CD34+ cells in peripherical blood, before leukapheresis, was 20,4 ×106 cells (ranging 1–216 ×106 cells), while the PBPC collection yielded 2,73 ×106 CD34+/Kg (ranging 0,1–28,94 ×106 CD34+/Kg). The majority of LVL procedures (53,6%) were initiated with a peripherical blood CD34+ count inferior to 15×106 cells. Only 33,3% of each LVL procedure harvest sufficient PBPC (〉 2,5 ×106 CD34+/Kg), most of which from patients with peripherical blood CD34+ count superior to 15×106 cells (59,4%). There is a significant correlation between peripherical blood CD34+ count, before leukapheresis, and collected PBPC CD34+ (Pearson chi-square 18,212; p

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: Membrane-anchored ephrinB2 and its receptor EphB4 are involved in the formation of blood and lymphatic vessels in normal and pathologic conditions. Eph/ephrin activation requires cell-cell interactions and leads to bidirectional signaling pathways in both ligand- and receptor-expressing cells. To investigate the functional consequences of blocking ephrinB2 activity, 2 highly specific human single-chain Fv (scFv) Ab fragments against ephrinB2 were generated and characterized. Both Ab fragments suppressed endothelial cell migration and tube formation in vitro in response to VEGF and provoked abnormal cell motility and actin cytoskeleton alterations in isolated endothelial cells. As only one of them (B11) competed for binding of ephrinB2 to EphB4, these data suggest an EphB-receptor–independent blocking mechanism. Anti-ephrinB2 therapy reduced VEGF-induced neovascularization in a mouse Matrigel plug assay. Moreover, systemic administration of ephrinB2-blocking Abs caused a drastic reduction in the number of blood and lymphatic vessels in xenografted mice and a concomitant reduction in tumor growth. Our results show for the first time that specific Ab-based ephrinB2 targeting may represent an effective therapeutic strategy to be used as an alternative or in combination with existing antiangiogenic drugs for treating patients with cancer and other angiogenesis-related diseases.

Description: Introduction Given the variety of highly effective therapies available for chronic lymphocytic leukemia (CLL), a tailored treatment strategy is needed. Fixed-duration chemoimmunotherapy can produce sustained and deep responses. The presence of minimal residual disease (MRD) has been studied as an independent prognostic factor for long-term survival in patients with CLL. Multiple novel agents have been recently approved for previously untreated patients, including the BTK inhibitor, ibrutinib, but its effect on MRD is still unclear. We performed a prospective clinical trial to evaluate the efficacy of maintenance therapy with ibrutinib in patients with detectable MRD after first-line chemoimmunotherapy. Patients and methods In this phase 2 clinical trial, we assessed the efficacy and safety of ibrutinib 420 mg daily as maintenance therapy, until progression or unacceptable toxicity, after achieving complete remission (CR) or partial remission (PR) with chemoimmunotherapy in previously untreated 40 patients with CLL from 9 centers in Brazil. The median age was 60 years (range: 43-85 years). Twenty-nine patients (73%) had been treated with fludarabine and cyclophosphamide (FC) ± rituximab, 10 (25%) with chlorambucil ± rituximab, and one (2%) with bendamustine + rituximab. Responses definitions were based on the 2018 iwCLL guidelines. Twenty-five patients (63%) were in CR and 15 (37%) in PR before the start of maintenance. Patients with detectable MRD within 12 months after the end of the first line chemoimmunotherapy were included. Besides, three patients with undetectable MRD were also included in order to evaluate possible effects of ibrutinib on that group. Responses were assessed monthly during the first year and every three months thereafter. MRD was assessed by 8-color flow cytometry in the bone marrow and in the peripheral blood before and after one year of maintenance therapy, and in peripheral blood every 3 months thereafter. Primary end point was progression-free survival (PFS). Results Median follow-up time was 25 months (range: 12-46 months). Among the 40 patients included, two patients withdrew consent (one just after inclusion and one after 30 days), and one patient died 7 days after ibrutinib was started due to an unrelated cause (ruptured aortic aneurysm). Thirty-seven patients were treated with ibrutinib and prospectively followed. The median PFS and overall survival (OS) were not reached. PFS and OS at 2 years were 92% and 95%, respectively. Among the 15 patients who started maintenance in PR, 8 (53%) achieved CR (3 of which had incomplete hematologic recovery), and 7 had complete nodal response, but remained in PR due to persistent lymphocytosis. Among the 22 who entered maintenance in CR, all but one remained in CR: 1 patient presented ≥ 50% increase in his baseline lymphocyte count 40 months after maintenance was started, but remains on ibrutinib with no cytopenias or clinical indication to treatment change. Among the 34 patients who had detectable MRD, 9% had at least 1-log reduction after one year and 20% after 2 years. Besides, one patient achieved undetectable MRD so far, 30 months after ibrutinib was started. All 3 patients with undetectable MRD at baseline, remained undetectable. Sustained increases from baseline values in the hemoglobin and platelet levels were observed in 30 patients (81%). Adverse events of any grade that occurred during maintenance with ibrutinib included diarrhea (23%), nausea (10%), and fatigue (8%), but only 2 patients had grade 3 diarrhea, associated with the concomitant use of metformin that resolved after discontinuation. Atrial fibrillation occurred intermittently in 3 patients during maintenance. A total of 81% of patients remain on ibrutinib. Four patients discontinued the drug: one after 8 months to perform a stem cell transplant by the decision of the treating physician, one after 10 months due to adverse events (lymphomatoid granulomatosis), and 2 after 13 months due to logistic difficulties to remain on regular follow up. Conclusions Maintenance with ibrutinib for CLL patients achieving CR or PR after chemoimmunotherapy resulted in excellent PFS and OS, and sustained improvement in hematologic variables irrespectively of achieving undetectable MRD. Efficacy of this regimen compares well to other frontline chemo-free treatments offered to patients with CLL in the United States and Europe. Disclosures No relevant conflicts of interest to declare.

Description: Bendamustine is an purine analog alkylating agent with marked efficacy in haematological malignancies either when given as monotherapy or in combination with rituximab. The efficacy and safety of this drug was investigated in heavily pretreated patients (pts) with hematological malignancies. A total of 44 patients (median age 63 years ranging from 22–87) from 6 Italian centers treated with bendamustine alone or in combination with rituximab were analyzed in this retrospective study. The diagnoses were multiple myeloma (n=2), chronic lymphocytic leukemia or small lymphocytic lymphoma (n=19), diffuse large B cell lymphoma (n=7), follicular lymphoma (n=8), mantle cell lymphoma (n=4), marginal zone lymphoma (n=2), Hodgkin’s disease (n=1) and peripheral T cell lymphoma (n=1). All pts received bendamustine 60–90 mg/m2 at day 1+2, alone or in combination with rituximab 375 mg/m2 (n=35) at day 1 of each cycle given every 21 or 28 days. The pts were heavily pretreated with a median of 3 previous treatments (range 1–8); 37 pts had previously received rituximab and 9 pts had undergone autologous transplantation. Prior to receiving bendamustine, 14 pts had relapsed disease, 7 had refractory disease and 23 were progressing during therapy. The median number of bendamustine cycles was 3 (range 1–8); 11 pts were still on treatment at the time of this analysis. Patients who completed therapy with at least 1 cycle of chemotherapy were evaluated for response and toxicity; pts in continuous therapy were evaluated for toxicity only. Of 33 pts evaluable for response 7 pts achieved a CR (21%) and 14 a PR (42%) resulting in an ORR of 64%. The remaining 12 pts were non-responders. No differences in the results were observed between groups with different bendamustine doses or scheduling. The best results were obtained in 10 evaluable pts with indolent lymphoma (4 CR, 6 PR) and in 9 pts with chronic lymphocytic leukemia (1 CR, 6 PR). Two evaluable pts with mantle cell lymphoma obtained a response (1 CR, 1 PR). By contrast, only 1 pt with diffuse large B cell lymphoma of 6 patients evaluable for response obtained a CR: the other 5 were non-responders. No pt with myeloma, Hodgkin’s disease or T cell lymphoma achieved a response. After a median follow-up of 4 months, 80% of pts were alive. During 150 treatment cycles, 2 pts experienced grade 4 thrombocytopenia and 1 experienced grade 4 neutropenia; non-hematological toxicity was mild. In conclusion, this retrospective analysis shows that treatment with bendamustine, alone or in combination with rituximab, is a safe and effective regimen in heavily pretreated pts. The best results were obtained in indolent lymphoma: the data in mantle cell lymphoma were also encouraging. No lack of efficacy can be inferred in pts with diffuse large B cell lymphoma, due to the refractory nature of their disease and the advanced age of this particular group (median age 76 years ranging from 67–87).

Description: Gentuzumab Ozogamicin (GO) is an anti-CD33 antibody linked to the cytotoxic antibiotic calicheamycin and it is effective as single agent in the treatment of poor risk acute myeloid leukemia (AML) patients. In 3 Italian Hematology Departments from September 2003 to December 2004, we treated 26 AML patients, both untreated (12 cases) and resistant (14 cases) with the following protocol: rhG-CSF(5 μg/kg, on days 0 through 8), Aracytin as continuous perfusion (100 mg/m2 on days 4 through 8) followed by GO (6 mg/m2 iv over 2 hours on day 9) (G-GOA). Inclusion criteria were: 1) CD33+ de novo or secondary AML (except M3 AML; 2) Primary refractory AML or relapse of AML in patients between 61 and 80 years; 3) Untreated patients 〉70 years or not eligible for aggressive chemotherapy. There were 13 male and 13 female with a median age of 69 years (range 58–77). FAB classification was 5 M0, 5 M1, 7 M2, 2 M4, 1 M5, 6 AML post-MDS. Ten patients presented a secondary AML. The median duration of first complete remission (CR) of 9 patients with relapsed AML was 48 weeks (range 8–76). Cytogenetic study was performed in all patients; karyotype was intermediate in 13 cases, unfavourable in 7 cases. In 6 patients no metaphases were observed. All patients performed the CD33+ evaluation on BM, the median percentage of CD33 positive blasts was 90% (range 25%–95%). Fourteen patients (56%) achieved a CR and 1 patient had CR with delayed platelet recovery (CRp) with an overall response (OR) of 58% (7 untreated AML and 8 resistant patients). One patient obtained a partial remission with only a transient hematologic improvement, characterized by a peripheral increase of all hematological parameters and by a 50% reduction of the bone marrow blast count. Five patients (19%) resulted refractory to treatment and 5 patients died during the aplasia period post induction treatment. The most common adverse event was myelosuppression, as expected. Median durations of neutropenia and thrombocytopenia in patients reaching CR were 19 days (range 15–62) and 16 days (range 10–37) respectively. No VOD was recorded. Six patients (23%) developed documented infection (including pulmonary aspergillosis in 3 cases). Notably, in 2 cases we observed a grade III/IV bleeding consisting in CNS haemorrhage. Two patients died while in CR, 1 due to bladder cancer relapse and 1 to ischemic stroke. Seven patients (27%) relapsed; the median CR duration was 20 weeks (range 8–41+). At March 2005 10 patients (38%) were alive of whom 6 are still in CR (27%). The median overall survival was 17,5 weeks (1–60 weeks). On the basis of our results the G-GOA protocol could be considered an useful approach for poor risk elderly AML also in consideration of the low reported side effects. We did not observe any case of VOD, which characterized other trials using GO at higher dosage. Unfortunately the CR duration was brief. Probably it could be improved with the addition of more aggressive consolidation schedule (i.e. Intermediate doses of Ara-C).

Description: Background: In multiple myeloma (MM) patients (pts) undergone high dose therapy, the outcome of the transplant is better if a good response is achieved before the procedure. Therefore, different attempts have been made in intensifying pre-transplant chemotherapy to improve the response. Aim of the study was to evaluate the safety and efficacy of Thal-Dex in improving the response rate after initial VAD therapy. Methods: 61 untreated MM pts aged ≤65 years were addressed to high dose program with a debulking therapy with 3 pulse-VAD cycles followed by Thal-Dex for 3 months at the following schedule: Thal 100 mg/d orally at bed time, continuously for 3 months, Dex 20 mg/d orally on days 1–4 and 14–17 every 28 days. Response at the end of each phase was defined as follows: complete remission (CR), disappearance of serum and urine monoclonal component (MC) by immunofixation and bone marrow plasmocytosis (BMPC)

Description: Abstract 1662 Poster Board I-688 Introduction Bendamustine is an alkylating agent with a nitrogen mustard group and a purine like benzimidazol group. Recently this drug was introduced in Italy. We analized all pts treated in sixteen haematological Italian centers with Bendamustine alone or in combination with anti-CD20 antibody. Patients and methods On an intention to treat basis pts who have received at least one complete cycle were evaluable for response and toxicity. The treatments consisted of: Bendamustine 60-90 mg/m2 days 1,2 alone or in combination with Rituximab 375 mg/m2 day 0, every 21 or 28 days. 173 pts were analized, median age was 67 (range 31-87), 114 were male, 63 chronic lymphatic leukaemia 41 indolent non-follicular lymphoma, 26 diffuse large B cell lymphoma, 26 follicular lymphoma, 15 mantle cell lymphoma, 2 Peripheral T cell lymphoma. Pts were heavily pretreated, the median number of previous treatments was 3,5 (range 1-8), 121 pts have experienced more than three chemotherapy schemes. One hundred and twenty-seven pts were previously treated with Rituximab and 24 performed an autologous peripheral blood stem cell transplantation. The Bendamustine pre-treatment condition was: 70 relapsed pts, 40 with refractory disease and 63 with a progressive disease after partial response. The median number of Bendamustine cycles was 4.3 (range 1-11). Results All patients were evaluable for response: 48 pts (28%) obtained a complete remission, 78 (45%) a partial response or stable disease with an overall response rate of 73% and 47 were non responders. According to histotype we observed that 10/15 pts (67%) with mantle cell lymphoma obtained a response (6 CR;4 PR), 37/41 (9 CR; 28 PR) indolent non follicular lymphoma and 25/26 (96%) follicular lymphoma obtained a response (12 CR;13 PR), 46/63 CLL obtained a response and 8/26 (31%) DLBCL obtained a response to therapy (4 CR;4 PR), none of the two T lymphoma pts responded to therapy. With a median period of observation of 12 months (1-46) 121 (70%) pts are alive and 83 pts are in complete remission or with stable disease without any other treatment. The overall survival was 82%, 72%, 68% and 27% respectively for indolent, CLL, mantle cell and diffuse large B cell lymphoma. The progression free survival was 31%, 27%, 15% and 10% respectively for indolent, CLL, mantle cell and diffuse large B cell lymphoma. Fifthy-two pts died, 47 for progressive disease, 11 due to infection and sepsis (6%) and 2 due to other causes not related with therapy or disease. In this group of heavily pretreated pts 760 cycles were performed. The extrahematological toxicity was mild the most important problem were infections (Herpes Zooster, pneumonia, enteritis) reported in 16 pts, hepatic in 4 and cardiologic in 2 pts. The hematological toxicity was trombocytopenia grade 3-4 in 20 pts (12%), neutropenia grade 3-4 in 40 pts (23%) and anemia grade 3-4 in 19 pts (11%). Discussion In conclusion this retrospective study shows that treatment with Bendamustine alone or in combination with Rituximab is a safe and efficacy regimen in a subset of pluriresistent patients. This data shows also that the best results could be obtained in indolent lymphoma and CLL incouraging data in mantle cell lymphoma are reported. Disclosures No relevant conflicts of interest to declare.

Description: Introduction:Diffuse large B cell lymphoma (DLBCL) is the most common type of Non-Hodgkin lymphoma (NHL). Treatment has improved over the years and can achieve 70% of survival (OS) in five years. Despite all progress in this field, central nervous system infiltration (CNSi), which is a devastating complication, still occurs with an incidence of 2-10%. Therefore, defining high-risk patients who consequently need prophylaxis seems to be the most adequate approach. Objective: Evaluate central nervous system international prognostic index (CNS-IPI) score regarding reproducibility and validity of the model in a heterogeneous cohort outside of clinical trial. Patients and methods: This retrospective research study was approved by the Santa Casa de Misericórdia de São Paulo Medical School (SCMSP) and Ac Camargo Cancer Center (ACCC) Ethics Committee. Patients were eligible if they were sequentially diagnosed with primary DLBCL, between January 2007 and January 2016. Also, if patients had complete chart data, pathological review and had started treatment at the respective institution (SCMSP or ACCC). Lymphoma staging was defined according tothe Ann Arbor system and patients were also categorized by the international prognostic index - IPI at baseline All patients were treated with rituximab-based chemotherapy, mostly R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone).CNSi was diagnosed by liquor (positive cytology and/or immunophenotype), computerized tomography, magnetic resonance image and/or fluorodeoxy-glucose-positron emission tomography, requested only in symptomatic patients when CNSi was clinically suspected. Confirmed cases were classified as parenchymal, leptomeningeal or both. Validation of the CNS‐IPI was assessed by graphical comparison between our results of Kaplan‐Meier curves (risk stratification groups: low, intermediate and high risk) and those previously defined by CNS‐IPI. Results:After inclusion and exclusion criteria 322 patients were available for the analysis (55% at ACCC vs. 46% at the SCMSP). Median follow-up was 60 months and median age was 58 years. There was similar distribution between male and female (47.8 vs. 52.2, respectively), and also similar distribution between localized (stage I-II) and advanced disease (stage III-IV), 47.2 vs. 51.2%, respectively. More than half of patients were low or low-intermediate IPI (59.6%) and low and intermediate CNS-IPI 0-3 (77.6%). The minority was submitted to CNS prophylaxis (19.9%), and the majority achieved complete response at the end of therapy (73.3%). Seven patients experienced CNSi, characterizing an incidence of 2.17% (7/322). The median time from diagnosis of DLBCL to CNSi was six months (range 2-52 months), while the median time of CNSi to death was 19 days (range 0 days -9.3 months). In our cohort, given the small number of events (7/322), an univariate model for risk factors was not possible, even though we statistically compared the groups of patients without and with CNSi. In univariate analysis at baseline LDH, number of extranodal sites, IPI, kidney/ adrenal were statically different in patients without and with CNSi (Table 1). Furthermore, regarding treatment, absence of complete response was also statistically different. CNS-IPI model stratified patients in a three-risk group model (low [0-1 points], intermediate [2-3 points] and high risk [4-6 points]) and demonstrateda 2-year rate of CNS relapse of 0.6%, 3.4% and 10.2%, respectively. In our cohort, using the same stratification, we obtained the2-year rate of CNS relapse of 0.0%, 0.8% and 13.8%, respectively. There was a statistical survival difference between the cohort of patients without or with CNSi. Median OS for patients without CNSi was not reached (average: 9.0 years [95% CI:8.5-9.5]) while median OS for patient with CNSi was of 8 months (95% CI: 2.8- 13.1). Log-rank p=0.000. Conclusion:CNSi in patients with DLBCL treated with rituximab based chemotherapy remains a rare but devastating complication. Our study reinforces the validity and reproducibility of CNS-IPI, specific outside of clinical trials. Also guarantee the safety of CNS-IPI use in daily practice. Our results demonstrate that almost 80% of patients are low or intermediate risk of CNSi with no need of interventions. Those considered high risk would benefit from more intensive diagnosis and prophylaxis approach. Table 1 Disclosures No relevant conflicts of interest to declare.