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In this study we want to evaluate the efficacy of yoga practice on dysfunctional stress, inflammation and QOL in breast cancer patients undergoing adjuvant radiotherapy.Patients with stage 0 to III breast cancer were recruited before starting radiotherapy (XRT) and were randomly assigned to yoga group (YG) two times a week during XRT or control group (CG). Self-report measures of QOL, fatigue and sleep quality, and blood samples were collected at day 1 of treatment, day 15, end of treatment and 1, 3 and 6 months later. Cortisol blood level, IL6, IL10, IL1RA, TNFα and lymphocyte-to-monocyte ratio were analyzed as measures of dysfunctional stress and inflammation.Patients started XRT and yoga classes in October 2019. Due to COVID-19 pandemic we closed the enrollment in March 2020. We analysed 24 patients, 12 YG and 12 CG. The analysis of blood cortisol levels revealed an interaction (p = 0.04) between yoga practice and time, in particular YG had lower cortisol levels at the end of XRT respect to CG (pTo our knowledge, this is the first study to evaluate the effects of yoga in a cancer population studying inflammation markers, cortisol trend and QOL during and until 6 months after XRT. This study suggests that yoga practice is able to reduce stress and inflammation levels over time. Besides including a larger number of patients to increase the power, future studies should consider other inflammatory or pro inflammatory factors and long-term yoga program to gain more evidence on yoga practice benefits.

The fms-like tyrosine kinase 3 (FLT3) inhibitor gilteritinib improved the survival of patients with relapsed or refractory (R/R) FLT3-mutated acute myelogenous leukemia (AML) in the phase 3 ADMIRAL trial. In this study, we assessed survival and relapse rates of patients in the ADMIRAL trial who underwent hematopoietic stem cell transplantation (HSCT), as well as safety outcomes in patients who received post-transplantation gilteritinib maintenance therapy. ADMIRAL was a global phase 3 randomized controlled trial that enrolled adult patients with FLT3-mutated R/R AML. Patients with R/R AML who harbored FLT3 internal tandem duplication mutations in the juxtamembrane domain or D835/I836 point mutations in the tyrosine kinase domain were randomized (2:1) to gilteritinib (120 mg/day) or to preselected high- or low-intensity salvage chemotherapy (1 or 2 cycles). Patients in the gilteritinib arm who proceeded to HSCT could receive post-transplantation gilteritinib maintenance therapy if they were within 30 to 90 days post-transplantation and had achieved composite complete remission (CRc) with successful engraftment and no post-transplantation complications. Adverse events (AEs) during HSCT were recorded in the gilteritinib arm only. Survival outcomes and the cumulative incidence of relapse were assessed in patients who underwent HSCT during the trial. Treatment-emergent AEs were evaluated in patients who restarted gilteritinib as post-transplantation maintenance therapy. Patients in the gilteritinib arm underwent HSCT more frequently than those in the chemotherapy arm (26% [n = 64] versus 15% [n = 19]). For all transplantation recipients, 12- and 24-month overall survival (OS) rates were 68% and 47%, respectively. Despite a trend toward longer OS after pretransplantation CRc, post-transplantation survival was comparable in the 2 arms. Patients who resumed gilteritinib after HSCT had a low relapse rate after pretransplantation CRc (20%) or CR (0%). The most common AEs observed with post-transplantation gilteritinib therapy were increased alanine aminotransferase level (40%), pyrexia (43%), and diarrhea (40%); grade ≥3 AEs were related primarily to myelosuppression. The incidences of grade ≥III acute graft-versus-host disease and related mortality were low. Post-transplantation survival was similar across the 2 study arms in the ADMIRAL trial, but higher remission rates with gilteritinib facilitated receipt of HSCT. Gilteritinib as post-transplantation maintenance therapy had a stable safety and tolerability profile and was associated with low relapse rates. Taken together, these data support a preference for bridging therapy with gilteritinib over chemotherapy in transplantation-eligible patients.

Objectives Treatment options for malignant pleural mesothelioma (MPM) are limited but some studies on immune checkpoint inhibitors (ICIs) in MPM have reported antitumor activity. Very little is known about immune-related predictive factors. Materials and methods Here we report the case of a 45-year-old woman presenting with dyspnea and evidence of pleural effusion. She was diagnosed with malignant epithelioid pleural mesothelioma with brain metastasis and peritoneal carcinosis, refractory to initial standard chemotherapy treatment. Because of high PDL1 expression (100 %), she was treated with the anti-PD1 agent, pembrolizumab. Results Chemotherapy with cisplatin and pemetrexed was started, imaging studies showing stable disease after 3 treatment cycles. The patient underwent pleural decortication but rapidly progressed and thus started chemotherapy with carboplatin and gemcitabine. After 2 cycles she experienced seizures caused by a brain metastasis. This secondary lesion was surgically removed and confirmed as a metastasis from mesothelioma. Samples from both the primary tumor and the metastasis were molecularly characterized, the pleural sample proving ALK-positive and the brain sample, ALK-negative. PD-L1 was positive in 10 % of tumor cells in the pleural biopsy and 100 % in the brain lesion. Next generation sequencing analysis was negative for both samples. It was decided to start alectinib. Disease progression (peritoneal carcinosis and liver metastases) was documented after one month followed by complete bowel obstruction and recurrence in the site of the brain surgery. Alectinib was stopped and supportive care begun with parenteral nutrition via nasogastric tube. Pembrolizumab was started and after 15 days the patient’s condition had significantly improved, enabling recanalization and restoration of enteral nutrition. Imaging displayed complete response of the brain metastasis, peritoneal carcinosis, bone lesions and mediastinal nodal metastases. A partial response was documented in the pleural and pulmonary nodules, with stable liver metastases. The patient is still undergoing immunotherapy and has no cancer-related symptoms. Conclusions Our findings indicate that the use of immunotherapy in MPM warrants further investigation. Furthermore, the impressive clinical response obtained by our patient suggests that immune checkpoint inhibitors could help in the management of the disease after the failure of other treatments.

Context: Genetic/genomic instability is a hallmark of CML. SETD2, a histone methyltransferase that trimethylates histone H3 on K36 (H3K36me3), has recently demonstrated a crucial role in preserving genomic integrity by modulating DNA Mismatch Repair (MMR) and Homologous Recombination (HR) repair. By Western blotting (WB), we previously observed SETD2 and H3K36me3 loss (resulting from aberrant SETD2 turnover) in 85% of blast crisis (BC) CML patients but not in newly diagnosed chronic phase (CP) patients who will achieve optimal responses. Objectives: 1. To investigate whether SETD2 is involved in the maintenance of genetic/genomic stability in CML. 2. To assess whether SETD2 loss precedes or follows progression from CP to blast crisis BC. Materials: SETD2-proficient (LAMA84) and -deficient (KCL22) CML cell lines and primary patient samples (n=86) were studied. Results: To investigate whether SETD2/H3K36me3 loss impinges on the activation and proficiency of HR, we used UV rays to induce DNA damage in SETD2 siRNA-depleted LAMA 84 (SETD2-proficient) cells. Compared to control cells, cells silenced for SETD2 displayed a marked increase in γH2AX (a marker of DNA damage) and fewer RAD51 foci (markers of ongoing HR). Assessment of MMR proficiency is ongoing. To further confirm the role of SETD2 as a tumor suppressor implicated in maintaining genomic stability in CML, we transfected KCL22 (SETD2-deficient) cells with an ectopic SETD2 plasmid. Preliminary results showed that SETD2 re-expression induced a reduction in cell doubling time, an accumulation of cells at G1/S checkpoint and a significant reduction in clonogenic potential. Studies are ongoing to assess the effects on DNA damage repair pathways. We next wondered when during disease history SETD2/H3K36me3 loss occurs. WB analysis ofpaired (diagnosis/progression) samples from four CML patients suggested that patients who will progress still have intact and functional SETD2 at diagnosis. Additional analyses are ongoing to assess whether SETD2/H3K36me3 loss precedes, hence allows to predict, progression to BC. Conclusion: Loss of SETD2/H3K36me3 is a novel, BCR-ABL1-independent mechanism of genetic instability in CML. Further investigations are needed to establish to what extent SETD2/H3K36me3 loss contributes to (and may be predictive of) disease progression. Supported by AIRC project 23001.

Introduction FLT3 receptor gene has been reported to be mutated in about 30% of AML, with two different kinds of mutations identified: in-frame duplications within the juxtamembrane region (FLT3-ITD) and point mutations in the tyrosine kinase domain (FLT3-TKD). In term of prognosis, the proper role of these mutations is still debated. Moreover, FLT3 mutations are often subjected to clonal evolution, thus how to properly monitor FLT3 mutated clones, evaluate minimal residual disease, manage FLT3 inhibitors (FLT3i) are only some of the open issues. FLAM is an observational study involving FLT3 positive AMLs to gain clinical and molecular data useful to ameliorate real-life physicians' management of this disease. Here we report the results of a preliminary analysis of the retrospective phase of the study. Methods The retrospective phase of FLAM multi-center observational study enrolled each AML patient treated in 33 participating Italian centers detected to carry a FLT3 mutation since 2012. Clinical and molecular data were collected in accordance with GCP and Helsinki declaration in electronic case report forms. Results At data cut-off , 1st of July 2020, 289 patients with FLT3 mutation at diagnosis were enrolled in the retrospective phase of FLAM study, being evaluable in this analysis, with a median age at diagnosis of 62 years (min-max: 18-94) and a M:F ratio of 141/148 (Patients' characteristics are summarized in table 1). 29 out 289 (10 %) patients had a low risk AML, 190/289 (65,7 %) had an intermediate risk AML and 27/289 (9,3 %) patients had a high risk AML, according to ELN 2017 risk stratification or ELN 2010 in case of allelic ratio unavailability (43 patients had no available ELN risk at baseline). A more frequent association between FLT3-ITD and normal karyotype and between FLT3-TKD mutation and other cytogenetic alterations not conferring a favorable/adverse risk has been observed (p = 0.045). Among the study population, 255/289 (88 %) patients carried a FLT3-ITD, 32/289 (11 %) a FLT3-TKD point mutation and 2/289 (1 %) patients both mutations. Capillary electrophoresis has been the technical method used to investigate FLT3-ITD in 163 of 226 (72 %) patients with information on the method used, while Sanger Sequencing in 47 out of 226 (21 %) patients and Next generation sequencing (NGS) in 16 out of 226 (7 %) patients. Overall, NGS has been adopted to investigate FLT3 gene status in 18 out of 259 patients (7 %). FLT3-ITD allelic ratio was available in 62 of 257 (24 %) ITD patients and was greater than or equal to 0.5 in 35/62 (56 %) patients. During patients' follow-up, 19/289 (7 %) patients affected by a FLT3 positive AML at diagnosis underwent a disease clonal evolution with a FLT3 negative AML progression or relapse. Regarding treatment options in FLT3-AML, in our cohort FLT3i were administered as first-line of therapy in only 36/289 (13 %) patients, always in a combination, of which in 26/36 (72.2 %) with intensive chemotherapy. As expected, intensive chemotherapy represented the induction regimen in the majority of the patients (211/289, 73 %). On the other hand, FLT3i were administered as rescue therapy in 62/171 (36 %) cases (47/62 single-agent and in 15/62 in combination) and as re-induction therapy in 22/80 (28 %) cases (10/22 single-agent and 12/22 in combination). Overall, a FLT3i has been administered as single-agent 81 times, of which Gilteritinib was the most frequently used (56/81, 69,1 %), followed by quizartinib (18/81, 22,2 %). Among the 52 documented combinations of a FLT3i with other drugs, particularly noteworthy is the administration of Sorafenib, in 20/52 (39 %) cases in this real-life study. Lastly, nine out of 289 (3 %) patients received a FLT3i as maintenance therapy after HSCT. Data regarding the correlation among the different regimens, with a special focus on FLT3i, other molecular features and response/survival are currently under analysis. Conclusions These data coming from a preliminary analysis portray the state of a large multi-center retrospective cohort of FLT3-positive AML patients treated in Italy between 2012 and 2020, including interesting insights regarding technical methods used to characterize the disease and the therapeutic scenario in which FLT3 inhibitors have been developed. Further safety and effectiveness data may reveal beneficial to ameliorate physicians' real-life clinical practice. Acknowledgements: work supported by Daiichi-Sankyo. Download : Download high-res image (459KB) Download : Download full-size image Disclosures Martelli: Amgen: 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; Janssen: Membership on an entity’s Board of Directors or advisory committees; Celgene: Membership on an entity’s Board of Directors or advisory committees; Jazz Pharmaceuticals: Membership on an entity’s Board of Directors or advisory committees; Novartis: Membership on an entity’s Board of Directors or advisory committees. Rigolin: Abbvie: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Speakers Bureau; Janssen: Membership on an entity’s Board of Directors or advisory committees, Speakers Bureau; Gilead: Membership on an entity’s Board of Directors or advisory committees, Research Funding, Speakers Bureau. Fracchiolla: Amgen: 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; 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. Bocchia: Incyte: Honoraria; CELGENE: Honoraria. Todisco: Jannsen, Abbvie, Jazz: Membership on an entity’s Board of Directors or advisory committees. Papayannidis: Abbvie, Janssen, Novartis, Amgen, Pfizer: Membership on an entity’s Board of Directors or advisory committees, Patents & Royalties. OffLabel Disclosure: Sorafenib is a registered drug for the treatment of hepatocellular carcinoma. Due to its multi-targeted tirosine kinase inhibitor effect it demonstrated efficacy in FLT3-AML when administered as an off-label prescription.

Transport networks consist of multiple layers, technologies, and areas of deployment. For example, they combine electronic packet and wavelength circuit switching in a single turnkey solution. Conventional solutions have for the longest time segregated the network management and control schemes of these layers, creating silos of operations. This legacy limits flexibility and programmability of extant solutions. In this paper, we describe PROnet, its SDN orchestrator, and a demonstration of its reliability while supporting an advanced manufacturing application running in decentralized mode. PROnet is a two-layer Research and Education Network (REN) under deployed at and around the UT Dallas campus. Resources in the PROnet Ethernet-over-Wavelength Division Multiplexing (WDM) two-layer architecture are managed by a hierarchical SDN orchestrator, which provides two critical functions: 1) on-demand multi-layer path provisioning and 2) coordinated fault handling at both layers. With the first function, the orchestrator automatically provisions optical circuits to efficiently meet the Ethernet flow fault-tolerant requirement as dictated by the application. With the second function, the orchestrator coordinates response procedures at both layers to overcome a first network outage and prepare the network to handle a potential second outage. We refer to this latter function as Multi-layer Protection (implemented at the Ethernet layer) and Restoration (implemented at the WDM layer) mechanism.

Context: Ponatinib (PON) is active against native BCR-ABL1 and all identified single-resistance mutations, including T315I. In the PACE study, heavily pretreated patients with Ph+ ALL treated with PON had nondurable responses because of new compound mutations (Cortes 2013, 2018). Sequential use of tyrosine kinase inhibitors (TKIs) can select for T315I and compound BCR-ABL1 mutants. Use of first-line PON in Ph+ ALL may decrease likelihood of these mutations. A Phase 2 study of PON with chemotherapy in newly diagnosed Ph+ ALL reported improved long-term outcomes (5-year event-free survival, 67%; overall survival, 71%) versus a second-generation TKI (Sasaki 2016). Objective: Compare efficacy and safety of first-line PON versus imatinib with reduced-intensity chemotherapy in patients with newly diagnosed Ph+ or BCR-ABL1–positive ALL (p190/p210 transcript type). Methods: PhALLCON (NCT03589326) is a Phase 3, open-label, parallel-assignment, randomized study. Patients remain on treatment until they complete study, relapse from complete remission (CR), have progressive disease, have unacceptable toxicity, withdraw consent, proceed to hematopoietic stem cell transplant (HSCT), or sponsor terminates study. The study started August 2018 and will be conducted in up to 35 countries. Currently, 115 sites are active globally. Accrual is ongoing, with 134 patients enrolled. The trial will enroll ≈230–320 patients (≥18 years) with ECOG performance status ≤2. Patients will be randomized 2:1 to PON 30 mg/d or imatinib 600 mg/d orally, with reduced-intensity chemotherapy in induction (Cycles 1–3), consolidation (Cycles 4–9), and maintenance (Cycles 10–20). Primary endpoint is measurable residual disease (MRD)-negative (BCR-ABL1/ABL1 ≤0.01%) CR at end of induction (≈3 months). The key secondary endpoint is event-free survival, defined as dates of randomization until death (any cause), failure to achieve MRD-negative CR by end of induction, or relapse from CR. Other secondary endpoints include CR/incomplete blood count recovery rates, molecular response rates, MRD-negative CR duration, primary induction failure, overall response rate, CR duration, time to treatment failure, MR4.5 duration after induction, overall survival, and safety, including arterial occlusive/venous thromboembolic events. Other analyses include a subgroup analysis of patients with/without HSCT and an exploratory analysis by mutation status. PhALLCON is sponsored by Takeda Development Center Americas, Inc.

Objective The objective of this study was to compare the efficacy and safety of pegfilgrastim in heavily pretreated MM treated with pomalidomide-dexamethasone in order to determine whether a single subcutaneous injection of pegfilgrastim is as effective as daily injections of standard filgrastim. Design 57 patients (31 M/26 F), median age at diagnosis 69 years (range: 52–84), and median age at the start of treatment 76 years (range: 56–90), who were treated with several lines of treatments (median 7, range: 2–12) and were refractory to all drugs previously received, received pomalidomide-dexamethasone (P: 4 mg for 21 days, D: 40 mg days 1, 8, 15, and 22, pegfilgrastim day +8) every 28 days, until progression. Starting with the first course, patients performed blood counts once weekly and received, from day +8 to day +19, prophylactic oral chinolonic antibiotics and anti-fungal drugs. Main Outcome Measures During neutropenia after the first cycle, filgrastim (5 µg/kg/day for 3 days) was given if the neutrophil count was Results During pegfilgrastim, neutropenia never lasted longer than 8 days, with a consequent reduction of neutropenia-related infections. Median nadir neutrophil count, evaluated for every patient for at least three courses of therapy (range: 3–6) and registered at day +11, was 1.28 (range: 0.9–2.2). Only 4 patients needed a supplement of 3 administrations of filgrastim. Pegfilgrastim was well tolerated in all patients; the main side effects in our patients were mild fever and bone pain (21.2%). Conclusions In patients affected by heavily pretreated MM treated with pomalidomide-dexamethasone, pegfilgrastim seems to reduce the incidence of severe neutropenia and infections and may increase the possibility to maintain the scheduled time of treatment.

Earthquake precursors are elusive, and this elusiveness has hampered earthquake prediction. In this paper, the available catalogues of historical and contemporary geochemical and fluid-related precursors of earthquakes are considered. The locations of recording sites are mapped and compared with data concerning volcanic locations, heat flows, crustal velocities and the depth of seismic events. Possible relations among the considered geophysical parameters and the occurrence of fluid-related earthquake precursors are discussed. Only some geological and geophysical conditions may allow for the occurrence of fluid-related earthquake precursory phenomena. As a consequence, the geophysical models utilized to explain the occurrence of earthquake precursors should be updated. Furthermore, only some areas of the world are deemed suitable for earthquake fluid-related precursor monitoring.

Summary Background Internal tandem duplication mutations in FLT3 are common in acute myeloid leukaemia and are associated with rapid relapse and short overall survival. The clinical benefit of FLT3 inhibitors in patients with acute myeloid leukaemia has been limited by rapid generation of resistance mutations, particularly in codon Asp835 (D835). We aimed to assess the highly selective oral FLT3 inhibitor gilteritinib in patients with relapsed or refractory acute myeloid leukaemia. Methods In this phase 1–2 trial, we enrolled patients aged 18 years or older with acute myeloid leukaemia who either were refractory to induction therapy or had relapsed after achieving remission with previous treatment. Patients were enrolled into one of seven dose-escalation or dose-expansion cohorts assigned to receive once-daily doses of oral gilteritinib (20 mg, 40 mg, 80 mg, 120 mg, 200 mg, 300 mg, or 450 mg). Cohort expansion was based on safety and tolerability, FLT3 inhibition in correlative assays, and antileukaemic activity. Although the presence of an FLT3 mutation was not an inclusion criterion, we required ten or more patients with locally confirmed FLT3 mutations ( FLT3 mut+ ) to be enrolled in expansion cohorts at each dose level. On the basis of emerging findings, we further expanded the 120 mg and 200 mg dose cohorts to include FLT3 mut+ patients only. The primary endpoints were the safety, tolerability, and pharmacokinetics of gilteritinib. Safety and tolerability were assessed in the safety analysis set (all patients who received at least one dose of gilteritinib). Responses were assessed in the full analysis set (all patients who received at least one dose of study drug and who had at least one datapoint post-treatment). Pharmacokinetics were assessed in a subset of the safety analysis set for which sufficient data for concentrations of gilteritinib in plasma were available to enable derivation of one or more pharmacokinetic variables. This study is registered with ClinicalTrials.gov, number NCT02014558, and is ongoing. Findings Between Oct 15, 2013, and Aug 27, 2015, 252 adults with relapsed or refractory acute myeloid leukaemia received oral gilteritinib once daily in one of seven dose-escalation (n=23) or dose-expansion (n=229) cohorts. Gilteritinib was well tolerated; the maximum tolerated dose was established as 300 mg/day when two of three patients enrolled in the 450 mg dose-escalation cohort had two dose-limiting toxicities (grade 3 diarrhoea and grade 3 elevated aspartate aminotransferase). The most common grade 3–4 adverse events irrespective of relation to treatment were febrile neutropenia (97 [39%] of 252), anaemia (61 [24%]), thrombocytopenia (33 [13%]), sepsis (28 [11%]), and pneumonia (27 [11%]). Commonly reported treatment-related adverse events were diarrhoea (41 [16%] of 252]), fatigue (37 [15%]), elevated aspartate aminotransferase (33 [13%]), and elevated alanine aminotransferase (24 [10%]). Serious adverse events occurring in 5% or more of patients were febrile neutropenia (78 [31%] of 252; five related to treatment), progressive disease (43 [17%]), sepsis (36 [14%]; two related to treatment), pneumonia (27 [11%]), acute renal failure (25 [10%]; five related to treatment), pyrexia (21 [8%]; three related to treatment), bacteraemia (14 [6%]; one related to treatment), and respiratory failure (14 [6%]). 95 people died in the safety analysis set, of which seven deaths were judged possibly or probably related to treatment (pulmonary embolism [200 mg/day], respiratory failure [120 mg/day], haemoptysis [80 mg/day], intracranial haemorrhage [20 mg/day], ventricular fibrillation [120 mg/day], septic shock [80 mg/day], and neutropenia [120 mg/day]). An exposure-related increase in inhibition of FLT3 phosphorylation was noted with increasing concentrations in plasma of gilteritinib. In-vivo inhibition of FLT3 phosphorylation occurred at all dose levels. At least 90% of FLT3 phosphorylation inhibition was seen by day 8 in most patients receiving a daily dose of 80 mg or higher. 100 (40%) of 249 patients in the full analysis set achieved a response, with 19 (8%) achieving complete remission, ten (4%) complete remission with incomplete platelet recovery, 46 (18%) complete remission with incomplete haematological recovery, and 25 (10%) partial remission. Interpretation Gilteritinib had a favourable safety profile and showed consistent FLT3 inhibition in patients with relapsed or refractory acute myeloid leukaemia. These findings confirm that FLT3 is a high-value target for treatment of relapsed or refractory acute myeloid leukaemia; based on activity data, gilteritinib at 120 mg/day is being tested in phase 3 trials. Funding Astellas Pharma, National Cancer Institute (Leukemia Specialized Program of Research Excellence grant), Associazione Italiana Ricerca sul Cancro.

Context SETD2 is a tumor suppressor encoding a histone methyltransferase that trimethylates histone H3 at lysine 36 (H3K36Me3) and is involved in various cellular processes, including transcriptional regulation and repair of DNA damage. SETD2 loss of function due to mutations or deletions has been observed in some solid tumors and acute leukemias. Objective We aimed to investigate the frequency and underlying mechanisms of SETD2 loss of function in advanced phase of Chronic Myeloid Leukemia (CML). Patients A large cohort of 90 CML patients with advanced phase CML was screened for SETD2 and H3K36Me3 status. Results Reduced or null SETD2 and H3K36Me3 were detected by western blotting in 88% of advanced-phase CML patients, as compared to a pool of healthy donors and to CP patients at diagnosis. No genetic abnormalities or transcript downregulation were observed and enhanced SETD2 proteasome-mediated degradation was rather found to occur. After proteasome inhibition, accumulation of hyper-ubiquitinated SETD2 bound to MDM2 was observed. Both MDM2 pharmacological inhibition by SP-141 and siRNA-mediated silencing suggested that MDM2 is implicated in SETD2 loss. Aurora Kinase A, that is overexpressed in CML, was also found to co-immunoprecipitate with SETD2. Both pharmacological inhibition and knock-down of Aurora A rescued SETD2 and H3K36Me3. SETD2/H3K36Me3 loss was found to impair the proficiency of homologous recombination (HR) repair as demonstrated by comparison of phosphorylated histone 2A.X and Rad51 foci in steady-state conditions and after sub-lethal DNA damage by UV exposure in SETD2-deficient CML cells as well as in SETD2-proficient CML cells subjected to SETD2 silencing. Reduction of clonogenic growth after treatment with proteasome, MDM2, and Aurora kinase A inhibitors at nanomolar or subnanomolar concentrations was observed both in cell lines and in primary cells from SETD2-deficient advanced-phase CML patients. Conclusions In advanced-phase CML, phosphorylation by Aurora kinase A and hyper-ubiquitination by MDM2 are responsible for SETD2 non-genomic loss of function. Loss of SETD2/H3K36Me3 was associated with increased DNA damage and impaired HR repair. Restoring physiological H3K36Me3 levels should further be explored as a therapeutic strategy to help improve the outcome of this critical subset of patients.

Context: Pegfilgrastim is a pegylated long-acting recombinant form of G-CSF that extends its half-life and allows for once-per-cycle dosing, requiring less frequent dosing than non-pegylated G-CSF. Objective: The objective of this study was to compare the efficacy and safety of pegfilgrastim in heavily pre-treated MM treated with pomalidomide-dexamethasone. Design: Real-world analysis. Setting: Supportive care in rrMM. Patients: We enrolled 57 patients (31 M and 26 F) with a median age at diagnosis of 69 years (r. 52–84) and a median age at start of treatment of 76 years (r.56–90) who were treated with several lines of treatments (median 7, r. 2–12), were refractory to all drugs previously received, and had received Pomalidomide-Dexamethasone (P 4 mg for 21 days, D 40 mg on days 1, 8, 15, 22, pegfilgrastim day +8) every 28 days until progression. Interventions: Pegfilgrastim in rrMM. Main outcome measures: Results were evaluated according to IMWG criteria. Results: Since first course, which was received in domestic setting, patients had blood counts performed once weekly and received, from day +8 to day +19, prophylactic oral chinolonic antibiotics and anti-fungal drugs. During neutropenia after the first cycle, filgrastim (5 μg/kg/day for 3 days) was given if the neutrophil count was Conclusions: In patients affected by heavily pre-treated MM treated with pomalidomide-dexamethasone, pegfilgrastim seems to reduce the incidence of severe neutropenia and infections and may increase the possibility of maintaining the scheduled time of treatment.

Context: Fedratinib is approved in the US for patients with Intermediate-2/High-risk myelofibrosis. Myelofibrosis can evolve from prior PV or essential thrombocythemia (ET). The ARD12042 study assessed fedratinib in patients with PV/ET. There was no response among 36 ET patients who received fedratinib 100-600 mg/day. Objective: Determine fedratinib clinical activity in patients with PV in ARD12042. Methods: Phase II, open-label, dose-ranging and -expansion study. Patients were aged ≥18 years with WHO-defined PV, ECOG-PS score ≤ 2, and were resistant/intolerant to hydroxyurea. Patients received once-daily fedratinib 100 mg, 200 mg, or 400 mg doses during the dose-ranging phase, and 400 mg during dose-expansion, in continuous 28-day cycles. All endpoints were prospectively defined. Response rate (RR) was the proportion of patients with hematocrit Results: 45 PV patients received fedratinib. Median age was 63 years (36-86) and 98% had ECOG-PS 0-1. The mITT population included 15 patients (13 dose-ranging, 2 dose-expansion): fedratinib 100 mg, n=2; 200 mg, n=5; 400 mg, n=8. RRs during dose-ranging were 0%, 40%, and 67% in the fedratinib 100 mg, 200 mg, and 400 mg groups. Both expansion phase patients responded. Clinicohematologic RRs were 20% and 63% with fedratinib 200 mg and 400 mg. Median SVRs from baseline at EOC8 were -16% and -39% in the 200-mg and 400-mg groups, respectively; 3 fedratinib 400 mg patients (38%) had ≥35% SVR. Among all patients, most common AEs were diarrhea (56%), nausea (53%), and vomiting (31%). Grade 3-4 AEs occurred in 21 patients (47%), most commonly lipase increases (11%) and abdominal pain (9%). Most frequent reason for treatment discontinuation was study termination (56%). AEs led to discontinuation for 7 patients (16%). Conclusion: Fedratinib 400 mg/day was manageable and induced hematocrit

Context: Erythropoiesis-stimulating agents (ESAs) are the frontline treatment in low-risk anemic MDS patients, and employment of this therapy in the earlier stage of the disease can delay the need for RBC transfusion, hypothetically by slowing the disease course. It is a matter of debate whether the clinical response is a result of proliferation and maturation of the dysplastic clone or stimulation of residual normal erythropoiesis by ESAs. Objective: Macrocytosis is one of the cytological hallmarks of dyserithropoiesis in MDS. An analysis of the erythropoietic response to ESA therapy in a cohort of anemic, non-transfusion-dependent MDS patient, enrolled in a retrospective registry, RECAMDS, a subgroup of Italian register, was performed. Design: Real-world analysis. Setting: Low-risk MDS. Patients: One hundred eighty-three patients treated with standard-dose ESAs have been retrospectively analyzed. Data analysis was performed according to IWG 2006 criteria at baseline and after 3 and 6 months of continuous treatment, with a sub-analysis of the patients according to WHO and R-IPSS risk stratification. ESAs were started at mean Hb concentration of 9.31 g/dl and mean serum EPO concentration of 51 mU/L after a mean time from diagnosis of 6 months (r.1–118). Interventions: ESAs to manage low-risk MDS. Main outcome measures: Results were evaluated according to IMWG 2006 criteria. Results: ORR was 83.6% (153/183); no difference among WHO and IPSS subgroups was found: 132/183 (72.1%) achieved response after 3 months of treatment, while the other 21/183 (11.2%) achieved response after 6 months. Nineteen patients with stable disease (non-responders, according to IWG criteria), in whom treatment was continued, achieved response after 9 months. In the macrocytic-responders group, 83.2% exhibited repeat macrocytosis after 3 months, while 16.8% became normocytic. In the normocytic-responders group, 89.8% exhibited repeat normocytosis, while 10.2% become macrocytic: in these patients, after 3 months, there was a contemporary worsening in neutropenia and thrombocytopenia with transfusion-dependence, which was regarded as first signs of progression of disease. Non-responders were 30/183 (16.3%): in the macrocytic non-responders group, 89% exhibit macrocytosis again after 3 months, while 11% became normocytic; in the normocytic group, 76% exhibited macrocytosis again, while 24% became normocytic. Conclusions: These preliminary data can suggest that, in the majority of MDS patients responsive to ESAs, the increase of Hb concentration occurs, mainly stimulation of erythroid production in MDS clones. In the minority of patients, it likely happens due to recruiting residual polyclonal erythropoiesis. It is interesting to note that stimulating effects of ESAs last, even when the expression of dysplasia progresses.

The new Regulation (EU) No. 536/2014 for clinical trials of medicinal products for human is part of a European regulatory framework in which the European Commission has wished to give a strong impetus to scientific research and industrial progress. It is a new regulation that fills a series of regulatory gaps in the Clinical Trials through the creation of a uniform framework for the authorization of clinical trials by all interested Member States with a single assessment of the results. The Regulation thus facilitates cross-border cooperation to make the clinical tests wider and encourage the development of special treatments, for example for rare diseases, but above all streamlines the rules on clinical trials across European Union (EU), introducing simplified rules for experimentation so-called 'low level of intervention', on which much has been discussed and still arouses concern, providing for authorized medicines or used off-label in the presence of scientific evidence published on efficacy and safety and to benefit from they will be mainly the pediatric and oncological therapeutic areas. The applications and any communication will be submitted paperlessly via a new electronic EU portal. The complex processing procedures and shorter time limits are to be stressed in comparison to the previously valid regulations. This is a major challenge for all stakeholders, but on the other hand it should contribute to the future role of the EU in the development of innovative medicines. Keywords: Clinical trials, New regulation, Reporting member states, Interventional study

Autophagy protects chronic myeloid leukemia stem cells from tyrosine kinase inhibitors hence supporting the disease persistence under therapy. However, the signals involved in autophagy regulation relative to BCR–ABL1 are still elusive. The autophagic flux proceeding from the inhibition of BCR–ABL1 tyrosine kinase represents a regulatory mechanism of β-catenin stability through events encompassing the activation of calpain, which targets β-catenin for proteasome-independent degradation. Accordingly, its inactivation may contribute to induce autophagy and autophagy induction may, in turn, promote β-catenin autolysosomal degradation to originate a regulatory loop where β-catenin plays a central role in cell decision between life and death. Here we proved that the cytoplasmic accumulation of β-catenin driven by up-regulation of its antagonist Chibby1 is a component of autophagy induction in response to imatinib in BCR–ABL1 + cells opposing the apoptotic death. It is contingent upon ER stress and elevation of free Ca2 + cytosolic concentration and results in the calpain cleavage into a 28 kDa fragment implicated in β-catenin proteasome-independent degradation. More important for BCR–ABL1 + cell survival and proliferation following IM treatment, might be the calpain-mediated cleavage of β-catenin accumulated within the cytoplasmic compartment into a 75 kDa fragment, still owning TCF-dependent transcriptional activity. Such a β-catenin fragment might be crucial for BCR–ABL1 + cell survival following the fusion protein TK inhibition.

Background Carfilzomib is an epoxyketone proteasome inhibitor of second generation, proved to be effective and safe in relapsed and refractory Multiple Myeloma (rrMM), in combination with dexamethasone or lenalidomide and dexamethasone. Aims In this retrospective observational trial, it has been evaluated efficacy and safety of carfilzomib, in combination with lenalidomide-dexamethasone (KRD) as salvage regimen in patients with rrMM, refractory to lenalidomide, where lenalidomide-based regimens have no proven efficacy. Methods 41 patients (23 M/18 F), with rrMM, median age at diagnosis 63.7 years (r. 43-82), median age at start of treatment 67 years (r. 48-84) previously treated with several lines of treatments (median 3, r. 2-11), underwent to KRD regimen (ASPIRE trial schedule) for a median treatment cycles of 8 (r 2-18). ISS was equally distributed, and all patients had previously been treated with bortezomib and IMIDs, and were refractory to this agents. 61% (19/31) of them had undergone at least to a single ASCT. Results According to IMWG criteria, after a median follow-up of 9 months (r. 2-18), ORR was 68,2% (28/41: 9 CR, 12 VGPR, 7 PR) with 5 progressive diseases (PD) and 8 patients in stable disease (SD): this can be considered as an impressive result in this subset of rrMM patients, refractory to lenalidomide. In particular, for 11 patients, KRD was, after having achieved at least a PR, a bridge to second/third autologous SCT. Median time to response was 1.3 months (r.1-4), median OS from diagnosis was 62 months (r. 9-170), median OS from start of Carfilzomib was 11 months (r. 2-18). Carfilzomib was well tolerated, with grade 2 anemia in 39%(16/41) of patients, successfully managed by ESAs, without necessity of blood transfusions; 29% (12/41) grade 3-4 neutropenia (pegfilgrastim in primary prophylaxis was given, no ospedalization was required, no septic shocks were observed); 34% (14/41) grade 2, 21% (9/41) grade 3 and 12% (5/41) grade 4 thrombocytopenia, without hemorrhagic events and transfusion-dependency. Moreover, it was observed pneumonia in 39% (16/41) of patients, treated by common antibiotic drugs and always solved. A cardiac monitoring was performed for all patients: hypertension (grade 2-3) in 34% (14/41) of patients; fatigue in 39% (16/31) of patients. Conclusions Carfilzomib-Lenalidomide-Dexamethasone has shown significant efficacy in a particularly severe setting of patients, relapsed and refractory to all available therapeutic resources, also lenalidomide, and it could be considered as a bridge to a second autologous or allogenic SCT. Disclosures Lucchesi: Incyte: Honoraria; Novartis: Honoraria; Pfizer: Honoraria. Martinelli: Amgen: Consultancy; Celgene: Consultancy, Speakers Bureau; Jazz: Consultancy; Incyte: Consultancy; Pfizer: Consultancy, Research Funding, Speakers Bureau; Roche: Consultancy; Daichii Sankyo: Consultancy, Research Funding; AbbVie: Consultancy, Research Funding; Janssen: Consultancy.

Context Post-HSCT relapse of B-cell ALL is associated with a dismal outcome. IO allows, in the setting of R/R B-ALL patients, high response rates, but with limited duration. Objective To report the outcome of 8 B-ALL adult patients, relapsed after allogeneic HSCT, treated with IO and DLI. Design Retrospective analysis (first patient treated in April 2015, last patient in October 2019). Setting Multicenter (Italian centers). Patients or other participants Five Ph-negative and 3 Ph-positive B-ALL adult patients, with BM disease (6 morphological relapse and 2 MRD-positivity) were treated; 2 patients had additionally extramedullary (EM) disease. Three patients were in salvage 1, 5 patients in salvage ≥ 2; 50% of the patients had previously received Blinatumomab. Median time from transplant to relapse and from relapse to IO was 11 (range 2-21) and 2.5 (range 0-65) months, respectively. Interventions Patients received a median of 3 (range 2-6) IO courses. Four patients received IO and DLI in an alternate schedule and 4 patients sequentially after IO; a median of 3 (range 2-4) DLI at escalating dose was administered (1st dose ranging from 1 × 104/kg CD3+ to 5 × 106/kg CD3+; following doses from 1 × 105 to 5 × 107/kg CD3+). Main outcome measures CR and MRD rate, EM response, DFS, OS, toxicity. MRD was evaluated with BCR-ABL fusion transcript or V(D)J IgH/TCR disease-specific rearrangement on BM. DFS and OS were calculated from start of IO. Toxicity was graded according to CTCAE version. 4.03. Results All patients achieved CR after 1st IO cycle. Six of 8 patients obtained MRD negativity after 2nd IO cycle (4 of 6 patients after 1st cycle). Both PET+ patients achieved PET-negativity. With a median follow-up of 23.5 (range 3-58) months, 6 of 8 (75%) patients are alive. Four of 8 (50%) patients relapsed, of which 2 with CNS localization. Median DFS is 12 months (range 3-58) and median OS is 23.5 (3-58) months. Four out of 8 patients experienced G4 thrombocytopenia. Two patients experienced grade 1 GvHD and no VOD were reported. Conclusions IO and DLI are a safe combination in the post-HSCT setting that may ameliorate the dismal prognosis of this patient subset.

A total of 11 rock samples were systematically collected along the main flow of geofluids running on the slope of the Baiyanggou mud volcanic system and analyzed for their mineralogical and chemical compositions as well as for iron species using XRD, XRF and Mossbauer spectroscopy, respectively. The analytical results clearly indicated spatial variations for most geochemical parameters caused by redox fluctuation processes around the Baiyanggou mud volcanic system. Close to the mud volcanic craters, the bleached greyish rocks mainly contained ferrous iron in chlorite and muscovite (para-Fe2+) with some portion of ferric hydroxide and ferric iron in clay minerals (para-Fe3+), suggesting a strong reducing environment. Further away from the craters, the relative contents of reducing iron species (Fe2+) in the rocks gradually decreased. The reddish rocks did not appear to be greatly influenced by erupting geofluid and contained relatively high contents of para-Fe3+ and ferric iron in hematite (hem-Fe3+). A redox front occurred at a certain distance from the active mud volcanic craters, in which sharp changes of iron-bearing minerals could be tracked. The reducing and weakly alkaline medium contributed to the precipitation of secondary carbonate minerals such as calcite and siderite. Geofluids composed of brackish waters, gases and oils tended to migrate through sandy veins in a clay sequence, faults and fracture networks with relatively high porosity and permeability. Iron speciation of the solid rocks in the seepage areas could therefore be considered a potential indicator for the migration of reducing geofluids including hydrocarbons located underground.