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Background: Core-binding factor (CBF) AML with RUNX1/RUNX1T1 (AML1/ETO) and CBFB/MYH11 fusion genes is known as a heterogenous group, accounting for about 10% to 15% of AML. In the Phase II Trial REL AML 001 (EudraCT Number 2017-002094-18; ClinicalTrials ID: NCT 03686345) adult CBF leukemia patients treated with a continuation therapy with Midostaurin were included, and the measurable residual disease (MRD) was performed by molecular MRD assessment (qPCR) and multiparametric flow cytometric-MRD (MCF-MRD) assay. The findings of MCF-MRD assay were compared to qPCR. Methods: 31 patients with AML1/ETO (n=15) and CBFB/MYH11 (n=16) were evaluated between December 2018 to July 2022 with both techniques. A total of 145 determinations (n. AML1/ETO = 56 and n. CBFB/MYH11= 89) were performed. MCF panel included 2 10-color tubes: CD15 FITC/ CD56 PE/ CD34 PerCP-cy5.5/ CD117 PE-cy7/ CD7 APC/ CD13 APC-R700/ CD19 APC H7/ HLADR V450/ CD45 V500C/ CD33 BV630, specific for RUNX1/RUNX1T1 cases and CD64 FITC/ CD2 PE/ CD34 PerCP-cy5.5/ CD117 PE-cy7/ CD200 APC/ CD13 APC-R700/ CD14 APC H7/ HLADR V450/ CD45 V500C/ CD33 BV630, specific for CBFB/MYH11 cases. A mean of 1,733,240 CD45 positive events were acquired, with a mean lower limit of detection (LLOD) of 0.001% (ranging 0.01-0.0003%). In 10 cases (6 RUNX1 and 4 CBFB/MYH11) the molecular and phenotypical features at onset were not available. MCF analyses were performed by InfinicytTM software and reference image tool was used wherever possible. Results: We found a concordance of 76% between MCF cases and RUNX1/RUNX1T1 qPCR, and a concordance of 83% between MCF cases and CBFB/MYH11 qPCR (Tables 1a and 1b). In relapsed cases we observed a dynamic and continuous increase of abnormal MCF events, that was not found in cases without clinical relapse although with positive qPCR (Table 2). The HLADR expression evaluated as the geo mean intensity at presentation and/or at relapse resulted higher in RUNX1/RUNX1T1 patients than in CBFB/MYH11 cases (29845 vs 8979, respectively, p=0.0039 Figure 1). Interestingly, we found in a single case with atypical CBFB/MYH11 fusion gene a high value of HLADR geo mean (44522). The down-regulated expression of HLADR in CBFB/MYH11 blasts may be a useful clue to distinguish AML blasts from the scarcely represented normal CD2 positive myeloid precursors, and from the strongly HLADR positive elements that are found in a regenerating bone marrow background. Conclusion: Although MCF-MRD assay showed lower sensitivity than CBF qPCR, MCF offered interesting informations about the dynamics of the abnormal clone size with time, evaluated as the increasing number of MRD clustering events, which may predict an impending relapse.

Introduction

Introduction:In elderly acute myeloid leukemia (AML) patients (pts) the debate about the use of intensive chemotherapy (iC) as opposed to non-intensive therapy (niT) or best supportive care (BSC) is a hot topic, particularly after the introduction of venetoclax (VEN) use. Age, comorbidities, functional impairment, therapy benefits and risks, pts preferences, and AML features influence this choice. The SIE/SIES/GITMO (“fitness”) criteria (Ferrara, 2013) are a valuable and comprehensive tool, but a revalidation is needed in the light of the new treatment options.

Introduction.The outcome of adult patients with acute lymphoblastic leukemia (ALL) has markedly improved following the introduction of a pediatric inspired chemotherapy backbone coupled with minimal residual disease (MRD) monitoring at well-defined timepoints (TP), translating into a rational patients' stratification for allogeneic transplantation (Tx). Immunotherapy, in particular blinatumomab, represents a further advancement in the management of ALL. We designed a phase II trial (GIMEMA LAL2317) for adult Ph- CD19+ B-lineage ALL (Ph- B-ALL) consisting of a pediatric chemotherapy backbone - with dose adjustment in patients >55 years - to which 2 cycles of blinatumomab were added, the first after early consolidation cycle 3 (high-dose methotrexate and Ara-C) and the second after late consolidation cycle 6. Tx allocation was based on MRD assessment, carried out in most cases by RQ-PCR and by flow cytometry when a sensitive molecular marker was not identified. The primary objective of the trial was to assess the impact of blinatumomab in increasing the rate of early MRD negativity at end of week 14 (TP3).

Background:CPX-351, has been approved for the treatment of patients diagnosed with Acute Myeloid Leukemia (AML) arising from a previous myelodysplastic syndrome (s-AML) or secondary to chemotherapy (t-AML) as per former WHO 2016 classification, following results from the phase III trial (Lancet et al, JCO2018). Long term results from the trial confirmed that the benefit from CPX-351 over conventional 3+7 induction was maintained both in patients proceeding or not to allogeneic stem cell transplantation consolidation (HSCT). However, the information on the optimal duration of treatment with CPX-351 or the best timing for HSCT consolidation are still incomplete. Furthermore, there is also scarce data on the efficacy of CPX-351 among NPM1or FLT3-ITDmutated AML or in patient with low risk AML according to European Leukemia Net (ELN) classification, as those subgroups are rare among t-AML and s-AML.

Background:Unanchored MAIC (Matching-Adjusted Indirect Comparison) is an ITC (Indirect Treatment Comparison) method adjusting for cross-trial heterogeneity in patient demographic or disease that are believed to be either prognostic or treatment effect modifiers. In this analysis, two trials for adults with secondary acute myeloid leukemia (AML) were compared by an unanchored MAIC.

BackgroundThe Italian national program of pediatric-inspired chemotherapy GIMEMA LAL1913 trial for adult Ph- acute lymphoblastic leukemia (Ph- ALL) has reported favorable results particularly in the younger subgroup of patients (pts) aged 18-40 years (Bassan et al, Blood Adv 2023). After the closure of the trial, this treatment scheme was adopted in the clinical practice by many Italian hematology centers for the treatment of newly diagnosed adult Ph- ALL. The safety of this intensive treatment in terms of infectious complications deserves to be investigated in the real life.

We have shown that human B-cell non-Hodgkin lymphomas (B-NHLs) express heat shock protein (HSP)H1/105 in function of their aggressiveness. Here, we now clarify its role as a functional B-NHL target by testing the hypothesis that it promotes the stabilization of key lymphoma oncoproteins. HSPH1 silencing in 4 models of aggressive B-NHLs was paralleled by Bcl-6 and c-Myc downregulation. In vitro and in vivo analysis of HSPH1-silenced Namalwa cells showed that this effect was associated with a significant growth delay and the loss of tumorigenicity when 104cells were injected into mice. Interestingly, we found that HSPH1 physically interacts with c-Myc and Bcl-6 in both Namalwa cells and primary aggressive B-NHLs. Accordingly, expression of HSPH1 and either c-Myc or Bcl-6 positively correlated in these diseases. Our study indicates that HSPH1 concurrently favors the expression of 2 key lymphoma oncoproteins, thus confirming its candidacy as a valuable therapeutic target of aggressive B-NHLs.

Todisco: Jannsen, Abbvie, Jazz:Membership on an entity's Board of Directors or advisory committees.Fracchiolla:Amgen:Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, accommodations, expenses, Speakers Bureau;ABBVIE:Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, accommodations, expenses;Gilead:Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, accommodations, expenses, Speakers Bureau;Pfizer:Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, accommodations, expenses, Speakers Bureau.Papayannidis:Abbvie, Janssen, Novartis, Amgen, Pfizer:Membership on an entity's Board of Directors or advisory committees, Patents & Royalties.Martelli:Pfizer:Membership on an entity's Board of Directors or advisory committees;Novartis:Membership on an entity's Board of Directors or advisory committees;Celgene:Membership on an entity's Board of Directors or advisory committees;Janssen:Membership on an entity's Board of Directors or advisory committees;AbbVie:Membership on an entity's Board of Directors or advisory committees;Amgen:Membership on an entity's Board of Directors or advisory committees;Jazz Pharmaceuticals:Membership on an entity's Board of Directors or advisory committees.Di Renzo:BerGenBio ASA:Research Funding.Tarella:ADC Therapeutics:Membership on an entity's Board of Directors or advisory committees, Research Funding;ImmunoGen:Research Funding;TG-therapeutics:Research Funding.Rossi:Jazz:Membership on an entity's Board of Directors or advisory committees;Abbvie:Membership on an entity's Board of Directors or advisory committees;Astellas:Membership on an entity's Board of Directors or advisory committees;Novartis:Other: Advisory board;Amgen:Honoraria;Pfizer:Membership on an entity's Board of Directors or advisory committees;Janssen:Membership on an entity's Board of Directors or advisory committees;Daiichi Sankyo:Consultancy, Honoraria;Takeda:Honoraria, Membership on an entity's Board of Directors or advisory committees;Alexion:Membership on an entity's Board of Directors or advisory committees;Celgene:Membership on an entity's Board of Directors or advisory committees;Sanofi:Honoraria.

Krampera: Janssen: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees. Todisco:Jannsen, Abbvie, Jazz: Membership on an entity's Board of Directors or advisory committees. Veronese:Novartis: Other: Travel Expenses; Bayer: Honoraria; AstraZeneca: Other: Travel Expenses; Janssen Cilag: Honoraria.Midostaurin for treatment of Core Binding Factor Leukemia. The drug has been used as KIT inhibitor.

We reported that the clinical efficacy of dendritic cell–based vaccination is strongly associated with immunologic responses in relapsed B-cell non-Hodgkin lymphoma (B-NHL) patients. We have now investigated whether postvaccination antibodies from responders recognize novel shared NHL-restricted antigens. Immunohistochemistry and flow cytometry showed that they cross-react with allogeneic B-NHLs at significantly higher levels than their matched prevaccination samples or nonresponders' antibodies. Western blot analysis of DOHH-2 lymphoma proteome revealed a sharp band migrating at approximately 100 to 110 kDa only with postvaccine repertoires from responders. Mass spectrometry identified heat shock protein-105 (HSP105) in that molecular weight interval. Flow cytometry and immunohistochemistry disclosed HSP105 on the cell membrane and in the cytoplasm of B-NHL cell lines and 97 diagnostic specimens. A direct correlation between HSP105 expression and lymphoma aggressiveness was also apparent. Treatment of aggressive human B-NHL cell lines with an anti-HSP105 antibody had no direct effects on cell cycle or apoptosis but significantly reduced the tumor burden in xenotransplanted immunodeficient mice. In vivo antilymphoma activity of HSP105 engagement was associated with a significant local increase of Granzyme B+ killer cells that very likely contributed to the tumor-restricted necrosis. Our study adds HSP105 to the list of nononcogenes that can be exploited as antilymphoma targets.

Eighteen relapsed patients with measurable indolent non-Hodgkin lymphoma (NHL) were vaccinated with dendritic cells (DCs) loaded with killed autologous tumor cells. Six patients had objective clinical responses including 3 continuous complete responses (CRs) and 3 partial responses (PRs), with a median follow up of 50.5 months. Eight patients had stable disease, whereas 4 had progressive disease. Clinical responses were significantly associated with a reduction in CD4+CD25+FOXP3+ regulatory T cells, an increase in CD3−CD56dimCD16+ natural killer (NK) cells, and maturation of lymphocytes to the effector memory stage in either postvaccination peripheral blood or tumor specimen samples. In partial responding patients, vaccination significantly boosted the IFN-γ–producing T-cell response to autologous tumor challenge. In one HLA-A*0201+ patient who achieved CR, IL-4 release by circulating T cells in response to tumor-specific IgH-encoded peptides was also documented. Immunohistochemical analysis of tumor biopsies using biotin-conjugated autologous serum samples revealed a tumor-restricted humoral response only in the postvaccination serum from responding patients. Collectively these results demonstrate that vaccination with tumor-loaded DCs may induce both T- and B-cell responses and produces clinical benefits in indolent NHL patients with measurable disease. This study is registered with the Istituto Superiore di Sanità: http://www.iss.it with protocol number 7578-PRE 21-801.

Blinatumomab (Blina) and inotuzumab (InO) have improved the outcome of relapsed/refractory B-lymphoblastic leukemia (R/R B-ALL). However, many patients (pts) relapse after these treatments and little is known on their outcomes after recurrence and re-treatment with subsequent immunotherapy. We hereby describe the clinical characteristics and outcome of 71 pts with R/R B-ALL treated with both Blina and InO in any sequence - Blina/InO or InO/Blina - at different disease recurrences. At diagnosis, the median age was 34 years (15-64) and the male/female ratio was 1.6. Sixteen pts (22%) were Ph+ ALL, 3 (4%) were t(4;11)+ and 9 (13%) carried a complex karyotypes. ECOG PS was 0-1 in 66 pts (93%).

Background: Inotuzumab-ozogamicin (IO) is one of the drugs of choice for relapse/refractory (R/R) acute lymphoblastic leukemia (ALL). Patients who received IO in a clinical trial had a CR rate of approximately 81% and a median overall survival of approximately 8 months, superior to best available therapy and numerically comparable with blinatumomab. Toxicities were generally manageable, veno-occlusive disease/ sinusoidal obstruction syndrome (VOD/SOS) was reported as a rare adverse event possibly linked to the drug that require attention, especially during hematopoietic stem cell transplant after IO. Data on IO effectiveness in the real-life setting are generally lacking, for the low incidence of the disease and the high number of possible therapies that are emerging.

Introduction:

Microbial diversity is associated with improved outcome in patients receiving allogeneic hematopoietic cell transplantation (allo-HCT), however, the mechanism underlying this observation is unclear. Unconventional T cells recognize specific metabolites of bacterial biosynthesis and their role in the post-HCT immunity has not yet been fully clarified. Here we have performed an observational study (n = 174 patients) using 16S rRNA sequencing of early post-HCT patient stool samples (day 7-21 after HCT) paired with multiparameter flow cytometry (performed at day 30 and day 100 after HCT) to explore the relationship between the intestinal microbiome early after HCT and the unconventional T cell populations in circulation. Our data extend findings of other groups suggesting that mucosal-associated invariant T (MAIT) cells are dependent on a diverse microbiome and are also associated with favorable allo-HCT outcome. In addition, we report for the first time that the Vδ2 subset of γδ T cells is positively correlated with MAIT cells as well as independent predictors of favorable transplant outcome.

Rossi: Sandoz: Honoraria; Daiichi-Sankyo: Consultancy; Roche: Membership on an entity's Board of Directors or advisory committees; Janssen: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees; Gilead: Membership on an entity's Board of Directors or advisory committees; Sanofi: Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; Jazz: Membership on an entity's Board of Directors or advisory committees; Astellas: Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria; Mundipharma: Honoraria; BMS: Honoraria.

Rossi: Daiichi-Sankyo: Consultancy; Celgene: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees; Gilead: Membership on an entity's Board of Directors or advisory committees; Sanofi: Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; Jazz: Membership on an entity's Board of Directors or advisory committees; Astellas: Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria; Mundipharma: Honoraria; BMS: Honoraria; Janssen: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees; Sandoz: Honoraria.

Del Principe: Gilead: Membership on an entity's Board of Directors or advisory committees. Fracchiolla:Gilead: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Pfizer Pharmaceuticals: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Merck: Honoraria, Speakers Bureau; Amgen: Membership on an entity's Board of Directors or advisory committees. Foà:NOVARTIS: Speakers Bureau; CELGENE: Other: ADVISORY BOARD, Speakers Bureau; AMGEN: Other: ADVISORY BOARD; JANSSEN: Other: ADVISORY BOARD, Speakers Bureau; CELTRION: Other: ADVISORY BOARD; GILEAD: Speakers Bureau; ABBVIE: Other: ADVISORY BOARD, Speakers Bureau; INCYTE: Other: ADVISORY BOARD; ROCHE: Other: ADVISORY BOARD, Speakers Bureau.

BackgroundClassic Ph-negative myeloproliferative neoplasms (MPN) include essential thrombocythemia (ET), polycythemia vera (PV) and primary myelofibrosis (PMF). Clonal evolution can lead MPN patients in chronic phase (CP) to developacute myeloid leukemia (AML), called blast phase (BP), a rare and late event in the natural history of MPN.

Introduction:The European Leukemia Net (ELN) stratification classifies as favorable prognosis four different subgroups of acute myeloid leukemia (AML) with specific cytogenetic/molecular abnormalities. These forms are potentially curable with standard chemotherapy, even though about 30% of patients (pts) still relapse. Overall survival (OS) of 60% at 5 years is reported but it is not clear if all different subgroups show an homogeneous outcome. The purpose of this study was to assess, in a real life setting, the response rate and the outcome of newly diagnosed AML patients with favorable prognosis based on ELN classification. Data were collected from six hematological centers of the regional network REL (Rete Ematologica Lombarda).

Castagnola: Gilead Sciences: Research Funding.

No relevant conflicts of interest to declare.

Gianni: Hoffmann-La Roche: Consultancy, Honoraria.

No relevant conflicts of interest to declare.

A monosomal karytype (MK) is defined by the presence of at least two or more distinct autosomal monosomies or an autosomal monosomy along with a structural defect. In AML this cytogenetic pattern has a very well-known poor prognostic significance independently of the specific chromosome involved. Currently, in MDS this negative prognostic influence is also emerging as recent data suggest that any monosomy in a complex karyotype (≥3 abnormalities) may have the same poor prognostic impact as monosomy 5 and 7 (−5,−7).Thus, the principal goal of the present study was to test whether a MK further worsen the already poor prognostic influence of a complex karyotype and to establish whether autosomal monosomies have the same unfavourable prognostic impact on OS and progression free interval (PFI) as −5/−7.The eighty-five consecutive MDS patients with a complex karyotype analysed by the present study were included in a series of 631 patients who came at our observation in the period January 2000-December 2010. They were thirty-two females and fifty-three males with a median age of 65 years (range 25–85). Fifty-five patients were diagnosed as MDS and were subdivided in 3 RARS, 6 RA, 6 RCMD, 2 RCMDS, one MDS-u, 13 RAEB-1 and 24 RAEB-2. The IPSS score was intermediate-1 in 5, intermediate-2 in 23 and high in 27. During the follow-up 31 MDS patients died and 41 experienced disease progression (3 RARS, 5 RA, 4 RCMD, one MDS-u, 9 RAEB-1 and 19 RAEB-2). Thirty patients were diagnosed as AML evolved from MDS. Fifteen of them received supportive treatment only, the remaining single agent chemotherapy to control leukocytosis. Nineteen of these thirty patients died of disease related complications.On conventional cytogenetics 37 patients (4 RA, 5 RCMD, one MDS-u, 8 RAEB-1, 12 RAEB-2 and 7 AML) presented a complex karyotype without monosomies and 48 (3 RARS, 2 RA, 2 RCMDS, one RCMD, 5 RAEB-1, 12 RAEB-2, 24 AML) a complex karyotype with monosomies. These two patients subgroups were comparable in terms of age, sex distribution, haemoglobin level, leukocyte or platelet counts, bone marrow blast cell percentage and IPSS score. However, median survival was 8 months (range 1–131) for patients with a complex karyotype without monosomies and 5 months (range 1–81) for those with a complex karyotype with monosomies (p=0.001). Twenty patients (54.0%) without monosomies died after a median time of 6 months (range 2–35), whereas 30 patients (62.5%) with monosomies died after a median time of 5 months (range 1–24). Disease progression was observed in 22 (59.4%) and 19 (39.5%) patients respectively (p=0.001). The 48 patients with a MK were further subdivided in those with −5/−7 versus those with other autosomal monosomies. The 23 patients with −5/−7 presented a median survival of 4 months (range 1–15) and the 25 with other monosomies presented a median survival of 5 months (range 1–81) (p=Not Significant). Fourteen −5/−7 patients died after a median time of 4 months (range 1–15) and 13 patients with autosomal monosomies died after a median time of 6 months (range 1–24). Disease progression occurred in 12 (52.1%) and 7 (28%) respectively.i) a MK further refines the prognostic stratification of MDS with a complex karyotype as it identifies a subgroup of patients with an extremely poor clinical outcome; ii) autosomal monosomies have an impact on disease outcome as detrimental as −5/−7.No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

This study aimed at evaluating the impact of three different pre-transplant therapies on the outcome of patients (pts) eligible for high-dose therapy.two-hundred sixty eight newly diagnosed MM pts aged £65 years, Durie-Salmon stage III, II, or I in progression, were consecutively enrolled from 2000 to 2007 in three different protocols, with three different pre-transplant therapy: Group 1: (145 pts) 3 pulse-VAD cycles; Group 2: (67 pts) 3 pulse-VAD cycles plus 3 Thal-Dex cycles (thalidomide at the dose of 100 mg/day orally at bedtime, continuously for 3 months, oral dexamethasone at the dose of 20 mg on days 1-4 and 14-17 every 28 days); Group 3: (57pts) 4 Vel-Dex courses (Bortezomib 1.3 mg/m2 i.v. on days 1, 4, 8, 11; oral Dexamethasone 40 mg on days 1-4 and 8-11 every 3 weeks). After induction all pts received two DCEP-short cycles as mobilization (oral Dexamethasone 40 mg/day on days 1-4 + Cyclophosphamide 700 mg/m2/day i.v., Etoposide 100 mg/ m2/day i.v., cisPlatin 25 mg/m2/day for 2 days) with peripheral blood stem-cell (PBSC) collection prompted by G-CSF followed by one or two transplants (Tx) with melphalan 200 mg/m2 as conditioning regimen. Response was defined according to IMWG uniform criteria. Pts were considered responsive when obtaining at least a PR.pts in the three group were similar for age, gender, Ig type, ISS stage. A significant higher percentage of Durie and Salmon stages III was found in group 3 (83% vs 68% in group 1 and 67% in group 2, p=0.0002). The median follow-up was 46 (1-150) months for group 1, 43 (1-68) months for group 2, and 29.7 (1-79) months for group 3. At the time of this analysis in the three groups 51%, 65%, 90% of transplanted pts respectively were still alive, and progression after transplant was registered in 84%, 80%, 50% respectively. Patient flow before Tx was similar (p=0.45): 19% in group 1, 27% in group 2, 23% in group 3. In group 1, 2% of pts went off-study after VAD, and 17% after mobilization phase. In group 2, patient flow was equally distributed: 7% after pulse VAD, 10% after thal-dex, 9% after DCEP. In group 3, 12% of the pts went off-study after Vel-Dex, 11% after DCEP. Table 1 summarized responses. In group 3 (Vel-Dex) response was better along all protocol phases with respect to group 1 or 2 (p<0.00001). The number of responsive pts progressively increased from 87% after Vel-Dex (CR 31%), to 96% after transplant (CR 38%). Response rates of group 1 and 2 patients were not significantly different either after induction (p=0.6), after DCEP (p=0.5), and after Tx (p=0.65). On intention to treat basis, vel-dex induction produced a better, although not significant, PFS (34.6 months vs 29 in group 1 and 26.8 in group 2, p=0.56). OS were not statistically different among the three groups, event though the different follow-up could affect the analysis (median OS 110 in group 1, 66 months in group 2, and not reached in group 3, p=0.37). In multivariate analysis PFS was improved only by the achievement of CR (p=0.001). No significant difference was observed between VGPR or PR (p=0.43).In this study, only CR not VGPR impacts on the outcome. Vel-Dex producing a significant high CR rate after TX (38%), seems to improve survival of MM patients candidate to high-dose therapy with respect to conventional pre-transplant strategies.Morra: Roche:.

No relevant conflicts of interest to declare.

Background and Objectives: The significant toxicities associated with current treatments of Burkitt’s lymphoma (BL) have fostered the identification of novel targets for effective but less toxic therapies. c-myc overexpression is the hallmark of BL; however it is per se insufficient to cause lymphoma development. Recent studies indicating aberrant expression of microRNAs (miRNAs) in BL have raised the possibility of a c-myc - miRNA interaction within the genesis and the maintenance of the lymphoma phenotype. Myc oncoproteins indeed have been found to inhibit the transcription of tumor suppressor genes. This occurs for instance by recruiting histone deacetylase (HDAC) 1 proteins to target genes, including tissue transglutaminase 2 (TG2), a multifunctional protein that promotes apoptosis and differentiation in normal tissues. Since inhibitors of the epigenetic regulator HDACs are revealing very effective as anticancer agents, we evaluated ITF2357, a new hydroxamate inhibitor of HDAC, with respect to its ability to induce proliferative arrest and apoptosis in BL cell lines by modulating c-myc mRNA, miRNAs and TG2 expression. Methods and Results: Cell growth inhibition by ITF2357 was determined using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay in the BL cell lines Namalwa and Raji. ITF2357 IC50 was 200nM after 48h exposure. Most treated Namalwa and Raji cells became respectively late and early apoptotic as assessed by annexin V and propidium iodide staining. Accordingly, ITF235 induced SUBG1 peak formation in Namalwa cells and G1 arrest in Raji cells. Repeated addition of ITF2357 at 24h-intervals enhanced these effects. Array analyses and quantitative real-time PCR of miRNAs indicated a significant decrease in the expression of miR-155 and miR-98, which exert oncogenic activity in MYC-associated tumors, at 24–72 h after treatment. Conversely, the Let-7a miRNA, which targets the c-MYC mRNA stabilizer IMP-1 among its tumor suppressive functions, was up regulated peaking at 24h after drug administration. Finally, immunohistochemical analysis of TG2 expression in ITF2357-treated Raji cells revealed a diffuse cytoplasmic staining, whereas in their untreated counterparts TG2 was sporadically and faintly detectable. Despite ITF2357 restored the expression of different targets of myc, quantitative real-time PCR revealed no parallel decrease in c-myc mRNA suggesting that the epigenetic modulation provided by ITF2357 on BL cell lines did not directly affect myc expression level. Conclusion: Our data indicate potent cytotoxic and growth inhibitory activities of ITF2357 on BL cell lines. These effects might be related to the modulation of both oncogenic and tumor-suppressing miRNAs and to the restoration of the tumor suppressor TG2. Further evidences for the potential candidacy of ITF2357 as a therapeutic agent for BL awaits ongoing analyses in BL primary tumors and in animal models.

Extramedullary myeloma (EMM) at diagnosis or during the course of the disease is rare and often anecdotal. We reviewed the records of 965 consecutive MM pts diagnosed and followed from 1969 to July 2007 in order to evaluate: the overall incidence of EMMs and the changes over time clinical presentation, response to treatment and outcome of EMM pts divided into two subgroups according to the time of appearance, at diagnosis or during the course of the disease. We considered three periods: 1969–1989 (conventional chemotherapy, CCT); 1990–1999 (introduction of high-dose therapy, HDT); 2000–2007, (era of novel agents). The overall incidence of EMM was of 13% (129/965 pts), 87/42 M/F, median age 58 (31–80) years. A prior MGUS was present in 24 pts and a solitary plasmacytoma in 10 (8%). Characteristics at the time of EMM were: 77 pts IgG (60%), 23 IgA (18%), 2 IgM (2%), 16 light chain (12%), 11 not secretory (8%); 29 pts were in stage I, 14 in stage II, 86 in stage III; 30/129 pts (23%) were asymptomatic. More frequently involved sites were: paravertebral (40%), rib cage (32%), pelvis (10%). Multiple localizations were present in 27 pts (21%). A plasmacytic leukemia was observed during the follow-up in 9 pts (7%). The overall median follow-up was 24.4 (2.5–148) months. Seventy-three pts presented EMM at the time of diagnosis with different incidences in the 3 periods: 1969–1989 4.5%, 1990–99 4.3%, 2000–07 12.7%. These pts were treated with HDT in 43 cases (59%) and CCT in 30 (41%). Radiotherapy (RT) was associated in 38 pts (52%). A partial response (PR) was achieved in 49 pts (67%). Progression or relapse were observed in 46 pts (63%) and the median time to progression (TTP) and overall survival (OS) in this subgroup of pts were 17.3 and 21.5 months respectively. The other 56 pts showed an EMM during the course of the disease after a median time of 20 (2–144) months from diagnosis. EMM incidence varied as follows: 1969–1989 2.7%, 1990–99 7.2%, 2000–07 7.4%. Median number of previous lines of therapy was 1 (range: 1–7), including HDT in 22 pts (39%), thalidomide or lenalidomide in 18 (32%), bortezomib in 5 (9%). The median time from HDT to EMM was 17 (2–125) months. Treatment of these pts consisted of CCT in 36 cases (64%), thalidomide in 3 (5%) and bortezomib in 8 (14%). RT was given in 29 cases (52%). Response rate in this subgroup was low, only 30% of pts obtained a PR. The median TTP and OS from the time of appearance of EMM were 4.7 and 6.5 months respectively and the overall survival from the diagnosis was 29.9 months. The two groups of EMM pts were also compared for all the clinical characteristics, response to therapy and outcome. EMM pts at diagnosis showed higher levels of monoclonal component and haemoglobin, and lower bone marrow plasmacytosis with respect to the others. OS from diagnosis was similar in the two groups. In conclusion, our study shows an increased incidence of EMM over time. The more recent increase of EMM at diagnosis might be due to the wider use of more sensitive imaging techniques as CT scan and magnetic resonance, while during the course of the disease after 1990 could be related to the longer survival of pts thanks to the new therapeutic approaches. Anyway, the presence of EMM whether at diagnosis or at progression seems to negatively affect the outcome of pts since the OS is shorter than MM pts without EMM.

Introduction: A phase II multi-center study was performed to investigate the efficacy of Bortezomib with high-dose dexamethasone (Vel-Dex) as induction therapy in multiple myeloma (MM) patients (pts) candidates to high-dose therapy. Methods: Patients were planned to receive 4 courses of Vel-Dex (Bortezomib 1.3 mg/m2 i.v. on days 1, 4, 8, 11; oral Dexamethasone 40 mg on days 1–4 and 8–11 every 3 weeks), followed by 2 courses of DCEP 4 weeks apart with stem cell collection, and a single autologous transplant with melphalan 200 mg/m2. Patients were untreated, aged ≤65 years, with Durie-Salmon stage III, II, or I in progression. Criteria of response were: CR: negative serum/urine immunofixation with <5% bone marrow plasmacytosis (BMPC); nCR: positive serum/urine immunofixation with <5% BMPC; VGPR/PR: reduction of at least 90%/50% of serum/urine monoclonal component (MC), and of BMPC. Adverse events (AE) were graded by the NCI-CTC version 3.0. Mann-Whitney U test was used to correlate response and main prognostic parameters. Results: From March 2006 to June 2007, 52 out of the 54 planned pts entered the protocol. Patient characteristics at enrolment were: male/female 33/19; median age 57 years (37–65); IgG/IgA/light-chain 33/9/10 pts; stage III/II/I in progression 44/5/3 pts; ISS I/II/III 21/14/17 pts; cytogenetic analysis showed del 13 in 54%, t (4;14) in 15%. Thirty-nine of 52 enrolled pts are evaluable for efficacy and toxicity after 4 Vel-Dex courses. Six pts were withdrawn (3 for progression, 2 for toxicity, 1 patient withdrew informed consent). Overall response rate (ORR) was 85%, with 67% major responses (CR 33%, nCR 26%, VGPR 8%), PR 18%, stable disease 7%, progression 8%. No statistically significant correlation was found between response and either age, stage, ISS, or unfavorable cytogenetics. Friedman ANOVA (p=0.00001) and Wilcoxon Matched Pairs (p<.05) tests showed a statistically significant progressive decrease of serum MC after each Vel-Dex cycle. Urine MC and serum free light chain ratio showed a strikingly rapid reduction after the first course with no further statistically significant decrease during the following courses. Regarding toxicity, NCI grade 1 or 2 AE were: infection (19), constipation (16), peripheral neuropathy (13), diarrhea (9), gastritis (6), nausea (5). NCI grade 3 AE were: infection (9) with 5 varicella-zoster, peripheral neuropathy (4), cardiac arrhythmia (2). A single grade 4 AE (fatal sepsis) occurred. At the time of this analysis, 25 pts completed the stem cell mobilization phase. All pts collected adequate number of stem cells (median CD34+ cells 6.2x106/kg, range 3.5–18.0x106/kg, median number of collection procedures 1). Discussion: This study shows that Vel-Dex as first line therapy produces high response rates in MM pts (ORR 85%, major response 67%). Toxicity was generally predictable and manageable. Stem cells were successful harvested in all patients. Vel-Dex appears an effective and safe pre-transplant treatment for younger MM patients.

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) <5%; very good partial remission (VGPR)/partial remission (PR)/minimal response (MR)/stable disease (SD), reduction of at least 90%/50%/25%/<25% of serum and urine MC, and of BMPC; progression, increase of serum and urine MC or BMPC. Toxicity was registered according to WHO classification. Results: Responses after VAD were evaluable in 60 pts: RC 7%, VGPR 38%, PR 27%, MR 10%, SD 10%, progression 8%. Four pts dropped out after pulse-VAD for progression and in 1 for toxicity. Responses after Thal-Dex in 52 evaluable pts were: RC 12%, VGPR 40%, PR 17%, MR 4%, SD 4%, Progression 23%. Three pts dropped-out during Thal-Dex, 1 for progression and 2 for toxicity. Of note, pts who obtained a scarce response to VAD, namely a MR or SD, showed a higher probability (85% of cases) to have a progression during or after the administration of Thal-Dex. Statistical analysis (Kendall Concordance Coefficient (p<0.0001); and non parametric Wilcoxon matched pairs test (p=0.12)) did not show any improvement of the response rate after Thal-Dex with respect to the evaluation after pulse-VAD cycles.The pulse-VAD related toxicity was as follows: 1 died for sepsis after the first pulse-VAD, 5 developed grade 2 WHO infections, 4 developed mild constipation. Side effects during Thal-Dex therapy were: grade 1–2 peripheral neuropathy in 7 pts, grade 1 constipation in 6 pts; 4 pts developed thrombotic events (TVP in 3, and a bowel infarction with subsequent colectomy in one). Conclusions: The combination thalidomide-dexamethasone after pulse-VAD is not effective in improving response rate, and shows an additional toxicity. Thus it does not seem useful for the intensification before transplant.

Background: Bisphosphonates (Bi) have been proven to be effective in preventing or delaying skeletal complications in multiple myeloma (MM) with a significant improvement of the quality of life. The 2002 ASCO guidelines indicate that once initiated intravenous Bi should be continued until an evident substantial decline of performance status. Recently, osteonecrosis of the jaw (ONJ) has been reported as complication of intravenous Bi treatment, with an incidence ranging between 6 and 13% and a greater occurrence in patients (pts) receiving zoledronic acid (Zol) than in those treated with pamidronate (Pam). Aim. In this retrospective study we evaluated the incidence of ONJ and of skeletal related events (SRE) in a cohort of MM pts divided in two groups according to the schedule of administration of Bi; group A: monthly administrations until tolerated (standard), group B: monthly administrations during the first year and then every 3 months (reduced). Methods: One hundred and six MM pts (M: 63, F: 43) were included in this study: 51 pts received a standard treatment (group A) and 55 a reduced schedule (group B). Pam 90 mg i.v. was administered as a three hour infusion and Zol 4 mg i.v. as a 15 minutes infusion. SRE was defined as: pathologic fracture, radiation to bone, spinal cord compression with vertebral fracture, hypercalcemia. Results: No difference was found between the two groups concerning pts characteristics at the onset: age, sex, extension of bone disease, status of the disease (progressive or responsive). Twenty pts received only Pam, 42 only Zol and 44 pts Pam followed by Zol. The distribution of the different type of Bi was not different in the two groups. ONJ occurred in 7 pts (6.6%) with a significant difference between the two groups: 6 pts in standard schedule (11.7%) and 1 in the reduced (1.8%), p=0.01, after a median time of 22.8 months in group A, and 37.8 months in the case of group B. Four of out 7 ONJ occurred during the second year of treatment (12–24 months): that period resulted significantly related (p=0.000) to the occurrence of ONJ with respect to the others (24–38 months, 40–100 months). All ONJ occurred in pts treated with Zol alone (5 pts) or with Zol after Pam (2 pts), whereas no cases were observed in Pam alone pts (p= 0.005). The median number of infusions was 20 with comparable results in the two groups (20 in group A, 19 in group B). SRE was observed in 38 pts (35.8%): 16 pts in group A and 22 pts in group B without statistical difference (p=0.6), after a median time of 9.8 months. Conclusions: These results suggest that the reduced schedule of Bi is associated with a significant lower incidence of ONJ and, although the sample size is limited, the appearance of ONJ seems delayed with respect to the standard treatment. Moreover, the incidence of SRE is similar in the two groups. In conclusion, the reduced schedule, could be applied in order to combine the antiresorptive efficacy of Bi with a higher safety and a better compliance.

The mechanisms underlying the mobilization of peripheral blood stem cells (PBSC) are still unknown, even though studies on healthy donors and on cancer patients have hypothesised a central role for CD34+ stem cells adhesion molecules and for chemokines serum levels. The type of mobilizing regimen and the pathologic condition can exert different effects on cytokine levels and adhesion molecules expression. To evaluate the modification of these parameters during mobilization we studied 10 MM patients treated with DCEP chemotherapy (Decadron, Cyclophosphamide, Etoposide, cis-Platin) followed by G-CSF (5 mg/kg/day starting 48 hours after chemotherapy until PBSC collection). The expression of four CD34+ cell adhesion molecules (Thy1, L-selectin, VLA4, CXCR4) was measured in the bone marrow before mobilization therapy and in the leukapheresis product. Serum levels of five cytokines (TGF-β, IL-8, HGF, VEGF-A, sVCAM-1) were assessed, through specific ELISA kits, before therapy, 5 days after the G-CSF stimulation and at stem cells collection. Each parameter was correlated with the number of CD34+ cells collected. Thy1 significantly decreased (p=0.007) and L-selectin significantly increased (p=0.038) in nearly all cases. By contrast, no statistically significant differences were observed for VLA4 and CXCR4 due to a consistent variability. Serum levels of IL-8 showed an increase at day 5, then a significant decrease at the time of the harvest (p=0.013); VEGF-A constantly increased (p<0.001) and TGF-β decreased (p=0.001). The modifications registered for sVCAM-1 and HGF did not reach statistical significance. The expression of CD34+ adhesion molecules did not correlate with the number of PBSC collected, while among cytokines, high baseline levels of TGF-β and VEGF-A significantly correlated with high number of CD34+ stem cells yielded (p=0.016, p=0.042 respectively). In conclusion, this study shows that during stem cells mobilization in MM Thy-1 expression significantly decreases while L-selectin increases; the behaviour of VLA-4 and CXCR4 is extremely variable. As regards cytokines, we found a statistically significant increase of VEGF-A level, while TGF-β, which induces the stem cell homing, decreases during the mobilization allowing stem cells to migrate in the peripheral blood. High baseline levels of TGF-β and VEGF-A predict a good stem cells harvest.