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The primary mechanism for bone marrow failure in aplastic anaemia (AA) is autoimmune haematopoietic stem cell destruction. AA can be cured with antithymocyte globulin (ATG) treatment, and some smaller studies have indicated that the number of regulatory T cells (Tregs) may be predictive of response. Additionally, AA patients appear to have elevated numbers of Th17 cells and bone marrow macrophages, but outcome data are missing.We performed immunohistochemistry on bone marrow biopsies from 121 ATG-treated AA patients and 14 healthy controls, using antibodies against FOXP3 (for Tregs), IL-17 (for Th17), CD68 (for pan-macrophages), and CD163 (for M2 type macrophages) to study their possible relation to ATG response and AA prognosis.AA patients had significantly fewer Tregs and Th17 cells but significantly more macrophages compared with controls. Treg, Th17, and pan-macrophage cell numbers were not associated with ATG response or differences in survival. Patients with higher levels of M2 macrophages had improved 5-year overall survival: 79.6% vs. 57.4% (p=0.017), and this benefit was primarily seen in AA patients with non-severe disease.We found that Treg and Th17 cell numbers did not predict ATG response or survival, whereas M2 macrophages may be associated with improved survival.

The complexity of the activated B-cell like (ABC) diffuse large B-cell lymphoma (DLBCL) subtype is probably not only explained by genetic alterations and methods to measure global protein expression could bring new knowledge regarding the pathophysiology. We used quantitative proteomics to analyze the global protein expression of formalin-fixed paraffin-embedded (FFPE) tumor tissues from 202 DLBCL patients. We identified 6430 proteins and 498 were significantly regulated between the germinal center B-cell like (GCB) and non-GCB groups. A number of proteins previously not described to be upregulated in non-GCB or ABC DLBCL was found, e.g. CD64, CD85A, guanylate-binding protein 1 (GBP1), interferon-induced proteins with tetratricopeptide repeat (IFIT)2, and mixed lineage kinase domain-like protein (MLKL) and immunohistochemical staining showed higher expression of GBP1 and MLKL. A cluster analysis revealed that the most prominent cluster contained proteins involved in the tumor microenvironment and regulation of the immune system. Our data suggest that the therapeutic focus should be expanded toward the tumor microenvironment in non-GCB/ABC subtype patients.

In follicular lymphoma (FL), progression of disease

We performed a national population-based study of all patients diagnosed with diffuse large B-cell lymphoma (DLBCL) in Sweden in 2007–2014 to assess treatment intent and risk of relapsed/refractory disease, including central nervous system (CNS) relapse, in the presence of competing risks. Overall, 84% of patients started treatment with curative intent (anthracycline-based) (n = 3550, median age 69 years), whereas 14% did not (n = 594, median age 84 years) (for 2% the intent was uncertain). Patients treated with curative intent had a 5-year OS of 65.3% (95% CI: 63.7–66.9). The median OS among non-curatively treated patients was 2.9 months. The 5-year cumulative incidence of relapsed/refractory disease in curative patients was 23.1% (95% CI: 21.7–24.6, n = 847). The 2-year cumulative incidence of CNS relapse was 3.0% (95% CI: 2.5–3.6, n = 118) overall, and 8.0% (95% CI: 6.0–10.6, n = 48) among patients with high CNS-IPI (4–6), when considering other relapse locations and death as competing events. The incidence of relapsed/refractory DLBCL overall and in the CNS was lower than in previous reports, still one in seven patients was not considered fit enough to start standard immunochemotherapy at diagnosis. These results are important for quantification of groups of DLBCL patients with poor prognosis requiring completely different types of interventions.

Routine follow-up for diffuse large B-cell lymphoma have been shortened to 2 years when event-free survival at 24 months (EFS24) emerged as a new milestone. In the present study, we aimed to determine whether the achievement of this milestone affected overall survival (OS). We compared OS to that of an age- and sex-matched population, analysed other factors governing OS, and reviewed the causes of death. Data were collected from the Swedish Cancer Registry and from individual patient's records. We included 1169 adult patients from five counties between the years 2001 and 2014. The median (range) age was 64·6 (18-91) years, 56·6% were men and the median follow-up was 82·3 months. For early stages, the achievement of EFS12 did not improve OS. More than two-thirds of the patients (n = 837, 71·6%) achieved EFS24, of which 190 (22·7%) died during follow-up. Lymphoma (20%), cardiovascular disease (22·4%) and malignancies (16%) contributed to causes of death. Patients aged 60 years significantly affected OS after EFS24 compared with the standard population. We concluded that follow-up beyond EFS24 should be considered for patients aged >60 years. Amal Abu Sabaa and Charlott Mörth share first authorship

Introduction: Infant iron status assessments may be difficult to interpret due to infections. The soluble transferrin receptor (sTfR) has been suggested as a biomarker mainly unaffected by the acute phase response. Reference intervals reflecting dynamics of infant growth first year in life are not well established. Methods: The sTfR and CRP concentrations were measured in samples from 451 term infants with the Roche Cobas platform in umbilical cord, at 48-96 hours, 4 and 12 months. Reference values were constructed as the 2.5th and 97.5th percentiles. The relationship between CRP concentrations >1 mg/L and sTfR was tested by Kendall correlation. Results: Reference intervals for girls and boys were 2.4-9.5 mg/L at birth, 2.9-8.4 mg/L at 48-96 hours, 2.6-5.7 mg/L at 4 months and 3.0-6.3 mg/L at 12 months. No differences between sexes were observed except for at 4 months. sTfR did not covariate with CRP concentrations >1 mg/L except in 48-96 hours samples. Conclusion: This study reports reference intervals for sTfR from birth to 12 months of age in a large group of infants in a low-risk area for iron deficiency. sTfR might add value to infant iron status diagnostics since no covariation with CRP was found at birth, at 4 months or at 12 months.

Recent studies have identified prognostic mutational clusters for diffuse large B-cell lymphoma (DLBCL) patients, both within and outside the original cell-of-origin (COO) classification. For many of these mutations, there is limited information regarding the corresponding protein expression. With the aim to determine the relationship of protein expression and intensity to COO and prognosis, we used digital image analysis to quantitate immunohistochemical staining of CREBBP, IRF8, EZH2, and TBLR1 in 209 DLBCL patients. We found that patients with strong nuclear expression of TBLR1 had inferior progression-free survival (PFS) and overall survival (OS) in univariable analysis and inferior PFS in multivariable analysis. Patients with higher proportion of intermediate to strong nuclear CREBBP expression had a worse PFS and OS in univariable analysis. CREBBP was expressed with stronger intensity in non-GCB patients and the prognostic impact was restricted to this subgroup. These findings suggest that high nuclear protein expression of TBLR1 and CREBBP is negatively associated with prognosis in DLBCL.

Patients with diffuse large B-cell lymphoma (DLBCL) who fail to complete planned treatment with R-CHOP due to toxicity are sparsely described. We investigated the extent of failure to complete treatment (six cycles or more, or three cycles + RT for patients with stage I disease) with R-CHOP for reasons unrelated to non-response, the determinants of such failure and the outcome among these patients. Three thousand one hundred and forty nine adult DLBCL patients who started primary treatment with R-CHOP were identified through the Swedish lymphoma register 2007-2014. Of these, 147 (5%) stopped prematurely after 1-3 cycles of R-CHOP for reasons unrelated to non-response, 168 (5%) after 4-5 cycles and 2639 patients (84%) completed planned treatment. Additionally, 195 (6%) patients did not complete treatment due to non-response or death before treatment end. In a multivariable logistic regression model, age > 75 years, poor performance status, extranodal disease and Charlson Comorbidity Index >= 1 were significantly associated with failure to complete planned R-CHOP treatment for other reasons than non-response. Non-completion of treatment strongly correlated with survival. Five-year overall survival for patients who received 1-3 cycles was 26% (95% CI: 19%-33%), 49% (95% CI: 41%-57%) for 4-5 cycles and 76% (74%-77%) for patients who completed treatment. Failure to complete planned R-CHOP treatment is an important clinical issue associated with inferior survival. Old age and poor performance status most strongly predict such failure. These results indicate a need for improved treatment tailoring for patients with certain baseline demographics to improve tolerability and chance for treatment completion.

The tumor cells in diffuse large B‐cell lymphomas (DLBCL) are considered to originate from germinal center derived B‐cells (GCB) or activated B‐cells (ABC). Gene expression profiling (GEP) is preferably used to determine the cell of origin (COO). However, GEP is not widely applied in clinical practice and consequently, several algorithms based on immunohistochemistry (IHC) have been developed. Our aim was to evaluate the concordance of COO assignment between the Lymph2Cx GEP assay and the IHC‐based Hans algorithm, to decide which model is the best survival predictor. Both GEP and IHC were performed in 359 homogenously treated Swedish and Danish DLBCL patients, in a retrospective multicenter cohort. The overall concordance between GEP and IHC algorithm was 72%; GEP classified 85% of cases assigned as GCB by IHC, as GCB, while 58% classified as non‐GCB by IHC, were categorized as ABC by GEP. There were significant survival differences (overall survival and progression‐free survival) if cases were classified by GEP, whereas if cases were categorized by IHC only progression‐free survival differed significantly. Importantly, patients assigned as non‐GCB/ABC both by IHC and GEP had the worst prognosis, which was also significant in multivariate analyses. Double expression of MYC and BCL2 was more common in ABC cases and was associated with a dismal outcome. In conclusion, to determine COO both by IHC and GEP is the strongest outcome predictor to identify DLBCL patients with the worst outcome.

Objectives: Antithymocyte globulin (ATG)-based immunosuppression remains a cornerstone in aplastic anaemia (AA) treatment. However, most ATG studies are not population-based and knowledge about real-world results concerning response and outcome could offer important information for treating physicians. Methods: We have recently performed a nationwide retrospective cohort study on all AA patients diagnosed in Sweden in 2000-2011 and now present treatment and outcome data on patients receiving first-line ATG. In total, 158 patients showed a 47.0% response rate which was similar in all age groups (range 41.5%-51.7%) with no difference regarding ATG formulation. The response was significantly associated with severity grade-especially at time of treatment initiation: very severe (VSAA) 22.7%; severe (SAA) 54.5% (P < .001); and non-severe 88.5% (P < .001). A logistic regression-based predictive model indicated that VSAA patients with an absolute reticulocyte count

Long-term real-world results of ibrutinib therapy in patients with relapsed or refractory chronic lymphocytic leukemia : 30-month follow up of the Swedish compassionate use cohort

Purpose: Follicular lymphoma (FL) is generally regarded as an indolent malignancy, yet the clinical outcome is highly variable. In recent years, POD24 (progression of disease within 24 months) has emerged as a potential prognostic marker for overall survival (OS) in FL and other non-Hodgkin lymphomas. The association with survival, however, has mostly been studied in selected clinical trial cohorts and among patients treated with R-CHOP. We aimed to investigate OS by timing of progression and type of primary treatment in a population-based setting in Sweden. Methods: We identified all patients diagnosed with FL in stages II-IV and grade 1-3a between 2007 and 2014, using the population-based Swedish lymphoma register. Data were complemented with information on progression, transformation and second-line treatment through medical charts review up to December 31st, 2017. The analysis covered 4 out of 6 health care regions (75% of all patients diagnosed nationally). The patients were categorized according to type of first-line treatment: R-chemo of any type, R-Benda, R-CHOP (including R-CHOEP), or other (including immunotherapy only). Among patients where it was decided to start first-line treatment within 6 months of diagnosis (and where treatment was started within nine months), POD was defined as either lack of response to first-line therapy (stable [SD] or progressive disease [PD]), or initial response and subsequent relapse/progression/transformation as indication for second-line therapy. To quantify the impact of timing of POD on survival, the five-year OS conditional on either being progression-free (PF) or having experienced POD at different time points during follow-up, was estimated using a flexible parametric illness-death model. Results: Among a total of 970 FL patients, median age at diagnosis was 66 years and patients were followed for a median of 6.4 years (range 0-12 years). The 5-year OS was 75% and progression-free survival was 59%. Six hundred (62%) patients had a first-line treatment within nine months of diagnosis and were hence analyzed further, whereas the remaining 370 (38%) patients were classified as wait-and-watch and were not analyzed further. Among the 600 treated patients, 337 (56%) had R-chemo (R-CHOP or alike (n=210), R-Benda (n=97), other (n=30)), and 263 (44%) received non-R-chemo treatment (mainly R-monotherapy, radiotherapy only, or R-lenalidomide). Patients who received R-Benda were on average older than the other groups. Among patients treated with R-chemo, those who stayed progression-free had a 5-year conditional OS above 75% regardless of PF time point. For patients who progressed, the 5-year conditional OS improved as time point of POD was prolonged (Fig 1a, left panel). Early POD (within 12-24 months) was associated with a particularly poor prognosis (5-year conditional OS below 55%). The OS improvement over time of POD was especially pronounced among R-Benda treated patients (Fig 1b, right panel). Among patients receiving non-R-chemo treatments, early POD was associated with a slightly worse 5-year OS but differences between POD and PF patients were less marked (Fig 1a, right panel). Conclusion: This population-based study of Swedish stage II-IV FL patients shows that among immunochemotherapy-treated patients, progression of disease was always associated with worse survival in comparison to progression-free patients regardless of timing of progression. This reduction in survival was more pronounced the earlier the progression (as described by others). Interestingly, among patients selected for milder non-immunochemotherapy-based treatments, progression of disease did not have a strong effect on survival. Disclosures Weibull: Janssen Cilag: Research Funding. Wahlin:Gilead Sciences: Research Funding; Roche: Consultancy, Research Funding. Smedby:Takeda: Research Funding; Janssen: Research Funding; Celgene: Consultancy.

Background Today, even though most patients with diffuse large B-cell lymphoma (DLBCL) can be cured with standard immunochemotherapy, 20-30% are refractory to primary therapy or relapse during follow-up with a drastic worsening of the prognosis. In recent years, new promising treatment options including CAR-T cell therapy are becoming available for relapsed/refractory (R/R) DLBCL patients although so far with logistic challenges including disease control and toxicities, and a considerable cost. In view of these challenges, we aimed to estimate the proportion of patients with R/R DLBCL that are likely to be eligible for CAR-T cell therapy in clinical routine, and their expected outcome in the pre-CAR-T era. Methods All patients with DLBCL starting primary therapy with curative intent were identified in the Swedish Lymphoma Register for the period 2007-2014 (N=3550). Primary CNS and primary mediastinal B-cell lymphomas were excluded. Data regarding primary treatment response and relapse was validated through medical chart review in the entire cohort during follow-up until Dec 31st 2017, and information about additional treatment lines including disease characteristics, blood test results, and relapse treatment response was collected. Eligibility for CAR-T cell therapy was estimated retrospectively based on eligibility criteria specified in clinical trials, both at first relapse by applying similar criteria as in the ongoing TRANSFORM, ZUMA-7 or PILOT studies (hereafter termed "CAR-T-2ndline"), and at second relapse applying criteria similar to those specified in the JULIET trial (hereafter termed "CAR-T-3rdline"). Administration of second- and third-line therapies and corresponding response rates were considered as proxies for eligibility and response to bridging therapies. Criteria applied for "CAR-T-2ndline" included R/R DLBCL within 12 months of evaluation date of primary treatment, age 18-75 years, ECOG 0-1, and additional criteria as specified in the TRANSFORM trial (see figure footnote). Criteria applied for "CAR-T-3rdline" included relapse following second-line therapy, age 18-76 years, ECOG 0-1, and additional criteria as in the JULIET trial (see figure footnote). Individuals with missing data on performance status were assumed ineligible. We lacked information about other malignancies in the disease history. Overall survival probabilities were estimated with the Kaplan-Meier method among all R/R DLBCL patients in the trial-specified age intervals and separately among those fulfilling all trial criteria. Results In the cohort of 3550 curatively treated DLBCL patients, 847 (cumulative incidence 23%) experienced R/R disease during a median follow-up of 4.3 years. Median age at first relapse was 71 years (range 18-95 years). Overall, 308 patients ≤75 years experienced progression/relapse within 12 months and were able to start second-line therapy. Of these, 148 patients (17% of all R/R DLBCL patients) fulfilled trial eligibility criteria for "CAR-T-2ndline", of whom 60 responded with at least partial remission (overall response rate, ORR, 41%). At second relapse, 370 patients 76 years or younger received third-line therapy, of whom 55 (6.5% of all R/R DLBCL patients) were deemed eligible for "Car-T-3rdline", and 13 responded (ORR 24%, another 5 patients had SD). Two-year overall survival (OS) among all R/R DLBCL patients ≤75 years receiving second-line therapy was 20% (95% confidence interval, CI, 16-25%) (Fig 1). Among those eligible for "CAR-T-2ndline", 2-year OS was 24% (95% CI 17-31%). Among patients ≤76 years at second relapse, 2-year OS was 18% (95% CI 13-24%), and among those eligible for "CAR-T-3rdline", 21% (95% CI 11-32%). Conclusion In the population-based setting, one in six patients (17%) with R/R DLBCL fitted trial eligibility criteria for CAR-T-cell therapy at first relapse and only one in fifteen patients (6.5%) fitted trial criteria at second relapse at retrospective evaluation. Figures were reduced when adding requirement of response to relapse/bridging therapy. These estimates illustrate to what extent current CAR-T cell therapies may be applied in a routine setting when based on trial criteria, and the need for development of modified and additional therapies in this group. Outcome estimation confirmed a poor outcome in these groups and did not indicate that fulfillment of trial criteria led to selection bias in terms of survival. Disclosures Ekstroem Smedby: Janssen Cilag: Research Funding; Celgene: Other: Advisory Board; Takeda: Research Funding. Harrysson:Janssen Cilag: Research Funding. Jerkeman:Janssen: Research Funding; Roche: Research Funding; Celgene: Research Funding; Abbvie: Research Funding; Gilead: Research Funding. Eloranta:Janssen Cilag: Research Funding.

The metabolome, which is the final down-stream global product of metabolic processes in organisms, is not sufficiently described in multiple myeloma (MM) patients. The aim of this study was, therefore, to study the serum metabolomic profile using proton nuclear magnetic resonance (1H-NMR) spectroscopy, and its relationship to clinical characteristics and patient outcome. Serum samples, which were taken at diagnosis, from 201 MM patients who underwent high-dose melphalan followed by autologous stem cell transplantation as the first-line therapy, were analyzed. We found that the metabolomic profile differed between patients with different MM International Staging System (ISS) stages. The profile revealed increased levels of cholesterol, phospholipids, high-density lipoprotein, low-density lipoprotein, apolipoproteins A1 and A2, valine, and leucine in ISS I patients compared with ISS III patients. The metabolomic profile also differed between patients with IgA and IgG paraproteins, predominantly because of higher levels of high- and low-density lipoprotein subfractions in IgA patients. The exact pathway of metabolism leading to accumulation of these metabolites is still elusive, but this study indicates an area of interest for further investigation in the search for new therapy targets and prognostic markers for this disease.

Allogeneic stem cell transplantation (SCT) as primary treatment for aplastic anemia (AA) is being increasingly used. Yet, age, stem cell source, and donor type are important outcome factors. We have recently performed a nationwide cohort study of all patients with AA in Sweden diagnosed from 2000 to 2011 and now present outcome data on SCT patients. In total, 68 patients underwent SCT, and 63% of them had failed immunosuppressive therapy. We found that, with a median follow-up of 109 months (range, 35 to 192 months), 5-year overall survival (OS) for all patients was 86.8%, whereas graft-versus-host disease-free, relapse/rejection-free survival (GRFS) at 5 years was 69.1%. There was no survival impact regarding the donor type or stem cell source. Patients aged ≥40 years had a higher transplant-related mortality (29.4% versus 7.8%; P = .023), which translated into a lower 5-year OS: 70.6% versus 92.2% (P = .022) and a trend of lower GRFS (52.9% versus 74.5%; P = .069). In conclusion, we found in this real-world setting that both OS and GRFS were high, but SCT for patients with AA aged ≥40 years is problematic, and clinical trials addressing this issue are warranted.

Background Our knowledge of the outcome of patients with relapsed/refractory diffuse large B-cell lymphoma (R/R DLBCL) in the rituximab era is mostly derived from randomised controlled trials or specialized center cohorts presenting selected patient materials. With new targeted therapies being evaluated in the relapsed/refractory setting such as CART therapy, there is a need for a better understanding of the expected survival in real-world cohorts of R/R DLBCL and the likelihood of patients being selected for established intensive treatment schedules and consolidation with autologous stem cell transplantation (ASCT). Here we investigated timing of relapse, treatment intensity and outcome among patients with R/R DLBCL in a nationwide population-based cohort. Methods Patients with R/R DLBCL (N=713) were identified among all patients with a first incident DLBCL diagnosed 2007-2014 recorded in the Swedish Lymphoma Register and treated with primary anthracycline-based immunochemotherapy (N=3528), with follow-up until December 31st 2018. The register holds information about clinical characteristics at diagnosis, primary treatment, treatment response and relapse. Data regarding treatment response and relapse was validated through medical chart review in the entire cohort and information about second-line treatment and ASCT was collected. Timing of progression/relapse was categorized by time interval in months from diagnosis (0-12, 12-24, 24+). Treatment intensity was categorized in four groups: intensive chemotherapy (e.g., DHAP, ICE, GDP) with intent of ASCT, remission-inducing chemotherapy (e.g., GemOx, IME, Benda), palliative therapy (oral chemotherapy, radiotherapy) and no active antitumoral treatment (e.g., steroids, best supportive care). Second-line treatments could have been given with or without immunotherapy. Overall survival probabilities were estimated in the entire cohort and by age >/≤ 70 years using the Kaplan-Meier method. Results In the study population of 713 patients (59% men), median age at relapse was 71 years (range 18 to 95) and 61% had stage IV disease. Most patients relapsed within 12 months (N=428, 60%) whereas 135 patients (19%) relapsed 12-24 months from diagnosis and 148 patients (21%) after 24 months. In patients ≤70 years of age, intensive chemotherapy with intent of ASCT was started in 206 out of 354 patients (58%) and 124 (35%) subsequently received a consolidative ASCT. Remission-inducing chemotherapy was given to 95 patients (27%), 22 (6%) received palliative treatment directly and 31 (9%) were deemed unfit for any active treatment. Among patients >70 years at relapse, 63 patients started intensive chemotherapy (18%) and 4 (1%) were eventually transplanted, whereas another 127 (35%) received remission-inducing chemotherapy, 92 (26%) palliative therapy directly and 77 (21%) no active therapy. Overall survival in the entire cohort was 26% at 2 years (Figure 1A). Timing of relapse strongly correlated with survival, primarily among patients 50% in relapse 12 months or after). Among patients >70 years, outcomes were strikingly poor in all treatment intensity groups (2-year OS 23% or lower). Conclusion In the population-based setting, less than 60% of patients with R/R DLBCL ≤70 years at relapse could go on to receive curative intent second-line treatment and only about one third were consolidated with ASCT (even fewer among those with early relapse). Among patients >70 years, outcomes were very poor and second-line treatment intensity seemed to have little impact on outcome, although there were a few longer-term survivors in all treatment groups. More efficient and less toxic therapies are urgently needed for R/R DLBCL at all ages. Figure 1 A-C Overall survival of patients with relapsed/refractory diffuse large B-cell lymphoma in Sweden 2007-2014 (N=713) in the entire cohort (1A), by age >/≤ 70 years and timing of relapse (0-/≤ 70 years and treatment intensity categorized in 4 groups (1C). Disclosures Ekstroem Smedby: Janssen Cilag: Honoraria, Other: Grant funding, Research Funding; Celgene: Honoraria, Other: Grant funding, Research Funding; Takeda: Honoraria, Other: Grant funding, Research Funding. Ekberg:Swedish Cancer Society: Other: This project was partly funded by the Swedish Cancer Society; Janssen Pharmaceuticals: Other: This project was partly funded through a private-public collaboration between KI and Janssen pharmaceuticals.. Eloranta:Karolinska Institutet: Other: coordinator for a public-private real world evidence; Janssen Pharmaceuticals.: Other: project coordinator for a public-private real world evidence. Enblad:Kite/Gilead: Membership on an entity's Board of Directors or advisory committees. Jerkeman:Janssen: Honoraria, Research Funding; Gilead: Honoraria, Research Funding; Acerta: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Roche: Honoraria, Research Funding. Andersson:Gilead: Research Funding; Gilead, Janssen and Roche: Consultancy; Abbvie and Janssen: Membership on an entity's Board of Directors or advisory committees. Harrysson:Swedish Cancer Society: Other: This project was partly funded by the Swedish Cancer Society.; Janssen pharmaceuticals: Other: This project was partly funded through a private-public collaboration between KI and Janssen pharmaceuticals..

Background: The cell-of-origin (COO) concept, based on gene expression profiling (GEP), dividing diffuse large B-cell lymphoma (DLBCL) patients into germinal center B cell (GCB) or activated B cell (ABC) subtypes, is a well-established subclassification where ABC patients have an inferior survival. The hallmark the ABC-type is constitutive activation of nuclear factor kappa B (NF-κB), often due to mutations in the B-cell receptor (BCR) signaling pathway. This has been the underlying rationale for adding newer drugs, such as bortezomib, ibrutinib or lenalidomide, to R-CHOP for ABC patients. However, none of these combinations studied in phase III trials have shown any clinical benefit. So, the complexity of ABC DLBCL is probably not only explained by genetic alterations and transcriptional changes as gene expression not necessarily correlate with protein expression, and protein action and dynamics are not caught by genomics-based techniques. Instead, using methods to measure global protein expression and interactions could offer new insights into the ABC subtype and possibly aid in the identification of novel drug targets. Aim: To study possible differences in global protein expression between ABC and GCB DLBCL subtypes using quantitative proteomics. Patients: A total of 213 adult DLBCL patients in western Sweden diagnosed between 1/1 2004 and 31/12 2016, were included. All patients received immunochemotherapy (R-CHOP). Primary mediastinal large B-cell lymphoma, primary CNS lymphoma, HIV-related lymphoma and transformed lymphoma were excluded. From archived formalin-fixed, paraffin-embedded (FFPE) tissue sections, from the time of diagnosis, a core biopsy (1 mm diameter) were obtained from each patient sample. Methods: COO was determined using the Hans immunohistochemistry algorithm. For 92 of the 213 patients, COO was also determined using the gene expression Lymph2cx chip: 14% changed subtype group from either non-GCB to GCB (n=8), GCB to ABC (n=4) or GCB to unclassified (n=1). From the FFPE samples a proteomic analysis was performed. In short, peptides were labelled using tandem mass tag (TMT) according to the manufacturer instructions and samples were analysed on an Orbitrap Fusion Tribrid mass spectrometer. The data files were merged for identification and relative quantification using Proteome Discoverer version 1.4.The search used the Human Swissprot Database version August 2016 using Mascot 2.3 as a search engine. The differentially expressed proteins were analysed using STRING version 10.0, for pathway analysis we used the Reactome database resource, and for potentially druggable proteins we used the Human Protein Atlas website which holds protein information of the current FDA approved drugs directed to 672 separate human proteins. Results: In all, 3078 proteins could be identified in all patients and 793 proteins were differentially expressed (p Conclusions: In this large proteomic study we found a number of overexpressed proteins in the ABC subtype, previously not described in DLBCL. Even though functional studies aimed at individual proteins and protein interactions to evaluate potential clinical effect are needed, our findings reveal novel proteins that could be potential druggable targets in ABC DLBCL patients. Figure 1 Disclosures Enblad: Kite/Gilead: Membership on an entity's Board of Directors or advisory committees. Mellqvist:Amgen, Janssen, Oncopeptides, Sanofi, Sandoz, Takeda: Honoraria. Andersson:Abbvie and Janssen: Membership on an entity's Board of Directors or advisory committees; Gilead, Janssen and Roche: Consultancy; Gilead: Research Funding.

Background Diffuse large B cell lymphoma (DLBCL) is an aggressive but often curable disease. However a proportion of the patients are primary refractory or relapse (R/R DLBCL) following standard immuno-chemotherapy, which is associated with a much worse prognosis especially if the CNS is involved. Current knowledge around the incidence of R/R DLBCL is mostly derived from randomized controlled trials or specialized center cohorts presenting selected patient materials. With new available treatment options for these patients it is of great importance to accurately estimate the incidence in absolute terms. Here we investigated the incidence of R/R DLBCL overall and in the CNS in a nationwide population-based cohort accounting for the presence of competing risks. Methods Patients with a primary diagnosis of DLBCL in 2007-2014 were identified using the Swedish Lymphoma Register and followed until October 31st 2017. Primary CNS lymphomas, primary mediastinal B-cell lymphomas and transformed lymphomas were excluded. The register contains information about clinical characteristics, primary treatment, treatment response and relapse. Information regarding treatment response and progression/relapse as well as site of relapse was validated through medical chart review in all patients. Primary treatment with curative intent was defined as having started treatment with anthracycline-based chemotherapy (mostly R-CHOP). Overall (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method in the full cohort. Cumulative incidence of R/R DLBCL was estimated in the subset of patients who were treated with curative intent accounting for the competing risk of death. The net probability of CNS progression/relapse by CNS IPI was estimated in curatively treated patients who did not have CNS involvement at diagnosis. The cumulative incidence of CNS relapse was estimated non-parametrically with death and non-CNS progression/relapse as competing risks among all curatively treated patients and restricted to patients with high CNS IPI (4-6) separately. Results In the study population of 4205 patients, median age at diagnosis was 71 years (range 18 to 105). Sixteen percent of patients (n=677, median age 83 years) were not able to start treatment with curative intent, with the median OS in this group of only 2.7 months. Two-year OS for patients treated with curative intent was 88% (95% CI: 87-89) and 2-year progression free survival (PFS) was 70% (95% CI: 69-72) (fig 1a). The 5-year cumulative incidence of relapsed/refractory disease in patients treated with curative intent was 23% (95% CI: 22-24, total N=713) (fig 1b) and the majority relapsed within two years (n=646, 77%). Five percent of the patients starting primary treatment with curative intent, only received 1 or 2 treatment cycles and were not evaluated for response. The 2-year cumulative incidence of CNS relapse in curatively treated patients was 2.8% (95% CI: 2.7-3.4, total N=126) (fig 1b). For patients with high CNS IPI (4-6) the 2-year rate of CNS relapse was 12% (95% CI: 8-16) when estimated using the Kaplan-Meier method (fig 1c), but only 8% (95% CI: 6-11) in the cumulative incidence model (fig 1d) accounting for other relapses and death as competing events. Conclusion The 5-year cumulative incidence of relapsed/refractory disease in patients with DLBCL treated with curative intent is 23% in this population-based study, which is lower than in previously published reports. Overall, 16% of patients were not able to start primary curative intent treatment, representing an older group of patients with a dismal OS. An additional 5% of patients were not able to tolerate more than 1-2 cycles, defining another group of patients with unmet medical needs. The 2-year cumulative incidence of CNS relapse is Figure 1 A): Overall survival (OS) and progression-free survival (PFS) among 4205 patients with diffuse large B-cell lymphoma (DLBCL) diagnosed in Sweden 2007-2014 treated with curative (n=3528 ) or palliative intent (n=677). B): Cumulative incidence of CNS relapse in the presence of competing risks of death and non-CNS relapse. C): Net probability of CNS relapse by CNS IPI (N=3499). D): Cumulative incidence of CNS relapse restricted to 414 patients with high CNS IPI (4-6). Disclosures Harrysson: Janssen pharmaceuticals: Other: This project was partly funded through a private-public collaboration between KI and Janssen pharmaceuticals.; Swedish Cancer Society: Other: This project was partly funded by the Swedish Cancer Society.. Eloranta:Karolinska Institutet: Other: coordinator for a public-private real world evidence; Janssen Pharmaceuticals.: Other: project coordinator for a public-private real world evidence. Ekberg:Janssen Pharmaceuticals: Other: This project was partly funded through a private-public collaboration between KI and Janssen pharmaceuticals.; Swedish Cancer Society: Other: This project was partly funded by the Swedish Cancer Society. Enblad:Kite/Gilead: Membership on an entity's Board of Directors or advisory committees. Jerkeman:Janssen: Honoraria, Research Funding; Gilead: Honoraria, Research Funding; Acerta: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Roche: Honoraria, Research Funding. Wahlin:Roche and Gilead: Consultancy. Andersson:Gilead, Janssen and Roche: Consultancy; Gilead: Research Funding; Abbvie and Janssen: Membership on an entity's Board of Directors or advisory committees. Smedby:Janssen Pharmaceuticals: Other: This project was partly funded through a private-public collaboration between KI and Janssen pharmaceuticals.; Takeda: Research Funding; Celgene: Honoraria.

Background. The prognosis in multiple myeloma (MM) has improved significantly in the last two decades. However, the outcome after initial high dose melphalan followed by autologous stem cell infusion (ASCT) is very diverse and prognostic markers, based on techniques such as FISH and next generation sequencing have been proposed. Metabolomics, where low molecular weight molecules are detected in body fluids or tissues, is an emerging technique used for diagnostics and prognosis in different cancers. Indeed, as the metabolome is the final down-stream product of the metabolic processes in the organism, it could be highly representative of a disease phenotype. In this study we wanted to examine the metabolomic profile in MM patients treated with ASCT, using nuclear magnetic resonance (NMR) spectroscopy, with the primary aim to determine if possible differences could be correlated to clinical outcome. Patients. MM patients from two Swedish regions, Skåne and Västra Götaland, diagnosed from Jan 2006 to Dec 2016 were identified using the Swedish National Myeloma Registry and ASCT lists from the Sahlgrenska and Lund University Hospitals. Patients with stored serum in the Swedish National Myeloma Biobank, from the time of diagnosis (and pre-treatment), who underwent ASCT as part of the first line therapy were included. A total of 201 patients were included. Clinical data, such as ISS, paraprotein type, high risk cytogenetics, induction therapy, response, progression-free survival (PFS) and overall survival (OS) were obtained from the Swedish National Myeloma Registry or from medical records. Last follow-up was Feb 2019. Methods. Serum samples were analyzed using a 600 MHz 1H NMR spectrometer equipped with a 5 mm BBI room temperature probe. After the 1H NMR data acquisition, peak picking, alignment and integration of the 1D CPMG data was performed in R with an in-house developed script using the speaq-package. The integrated peak data was analyzed using multivariate statistics in SIMCA 14. Principal component analysis was used to check for outliers, followed by discriminant analysis using orthogonal projections to latent structures - discriminant analysis (OPLS-DA) to discriminate between patients with differences in ISS stage and paraprotein type. The validity of the models was judged from R2 and Q2 values compared to permutation tests. Results. As expected, PFS after ASCT differed significantly between the ISS groups. We found that patients with ISS stage III had a significantly different metabolomic profile than stage I patients (Fig 1). Among the most discriminating metabolites were e.g. the amino acids valine, alanine, glutamine and leucine which were higher in the ISS I group. Interestingly, stage I patients had a totally different lipid profile: they had significantly higher levels of apolipoproteins A1 and A2, the total cholesterol level and in most HDL and LDL main fractions compared to stage III patients. Furthermore, IgA patients had a different metabolomic profile compared with IgG patients (Fig 2), where e.g. the level of N-acetylated amino acids were higher in IgA patients. We found no metabolomic correlation with gender, response or high risk cytogenetics. Discussion. We found in this study that the serum metabolomic profile at diagnosis differed in ASCT-treated MM patients with low and high ISS stage. We also found different patterns in patients with IgA vs IgG myeloma. A certain metabolomic pattern could reflect a more aggressive disease and also give potential information on different host factors important for the course of the disease. Together, these findings could form a base for future metabolomic studies of the biology of MM. Figure 1 Disclosures Mellqvist: Amgen, Janssen, Oncopeptides, Sanofi, Sandoz, Takeda: Honoraria.

The aim of this study was to investigate long-term outcome following first-line therapy in consecutive chronic lymphocytic leukemia (CLL) patients in a well-defined geographic area: Sweden. All patients diagnosed with CLL (2007-2013) (n=3672) were identified from national registries, screening of patient files identified all (100%) treated first line (n=1053) and for those, an in-depth analysis was performed. End points were overall response rate, progression-free survival (PFS), overall survival (OS), and safety. Median age was 71 years; 53% had Rai stage III-IV and 97% had performance status grade 0-2. Fluorescence in situ hybridization (FISH) was performed in 57% of patients: 15% had del(17p). Chlorambucil + prednisone was used in 39% (5% also received rituximab). Fludarabine+cyclophosphamide+rituximab or fludarabine+cyclophosphamide was used in 43% and bendamustine + rituximab in 6%. Overall response rate was 64%; chlorambucil 43%, fludarabine+cyclophosphamide+rituximab 84%, fludarabine+cyclophosphamide 75% and bendamustine + rituximab 75%. Median PFS and OS was 24 and 58 months, respectively, both were significantly associated (multivariate analysis) with type of treatment, del(17p), performance status, gender, age and geographical region (OS only). Chlorambucil-treated patients had a median PFS and OS of only 9 and 33 months, respectively. Chlorambucil usage declined gradually throughout the study period, but one-third of patients still received chlorambucil + rituximab in 2013. Infections amp;gt;= grade III were significantly associated with treatment; chlorambucil 19% versus fludarabine+cyclophosphamide+rituximab 30%. Richter transformation occurred in 5.5% of the patients, equally distributed across therapies. This is the largest retrospective, real-world cohort of consecutive first-line treated CLL patients with a complete follow up. In elderly patients, an unmet need for more effective, well-tolerated therapies was identified. Funding Agencies|AFA Insurance [130054]; SLL/ALF [20150070]; Blodcancerfonden 2016; Dr Ake Olsson Foundation [2-791/2016]; SLL/KI Hogre klinisk forskare 2018/2019 [K2894-2016]; Svenska Lakaresallskapet [SLS-406961]; Gilead Sciences Nordic Fellowship Programme 2015; Swedish Cancer Society [150930, 160534]

Survival has improved among patients with diffuse large B-cell lymphoma (DLBCL) with the addition of anti-CD20 antibody therapy. We aimed to quantify trends and remaining loss in expectation of life (LEL) due to DLBCL at a national population-based level. Patients diagnosed with DLBCL 2000-2013 (N = 7114) were identified through the Swedish Lymphoma Registry and classified according to the age-adjusted International Prognostic Index (aaIPI). The novel measure LEL is the difference between remaining life years among patients and the general population and was predicted using flexible parametric models from diagnosis and among 2-year survivors, by age and sex. Median age at DLBCL-diagnosis was 70 (18-105) years and 54.8% presented with stage III-IV disease. On average, LEL due to DLBCL decreased from 8.0 (95% CI: 7.7-8.3) to 4.6 (95% CI: 4.5-4.6) years over the study period. By risk group, LEL was most reduced among patients with aaIPI ≥2 aged 50-60 years. However, these patients were still estimated to lose >8 years in 2013 (eg, LELmales50years 8.6 years (95% CI: 5.0-12.3)). Among 2-year survivors, LEL was reduced from 6.1 years (95% CI: 5.6-6.5) (aaIPI ≥ 2) and 3.8 years (95% CI: 3.6-4.1) (aaIPI < 2) to 1.1 (95% CI: 1.1-1.2) and 1.0 year (95% CI: 0.8-1.1), respectively. The reduction was observed across all ages. Results for females were similar. By using LEL we illustrate the improvement of DLBCL survival over time. Despite adequate immunochemotherapy, substantial LEL among patients with IPI ≥ 2 points to remaining unmet medical needs. We speculate that observed reduced losses among 2-year survivors indicate a reduction of late relapses.

Diffuse large B cell lymphoma (DLBCL) patients with early relapse or refractory disease have a very poor outcome. Immunochemotherapy resistance will probably, also in the era of targeted drugs, remain the major cause of treatment failure. We used proteomic mass spectrometry to analyse the global protein expression of micro-dissected formalin-fixed paraffin-embedded tumour tissues from 97 DLBCL patients: 44 with primary refractory disease or relapse within 1 year from diagnosis (REF/REL), and 53 who were progression-free more than 5 years after diagnosis (CURED). We identified 2127 proteins: 442 were found in all patients and 102 were differentially expressed. Sixty-five proteins were overexpressed in REF/REL patients, of which 46 were ribosomal proteins (RPs) compared with 2 of the 37 overexpressed proteins in CURED patients (P = 7·6 × 10-10 ). Twenty of 37 overexpressed proteins in CURED patients were associated with actin regulation, compared with 1 of 65 in REF/REL patients (P = 1·4 × 10-9 ). Immunohistochemical staining showed higher expression of RPS5 and RPL17 in REF/REL patients while MARCKS-like protein, belonging to the actin network, was more highly expressed in CURED patients. Even though functional studies aimed at individual proteins and protein interactions to evaluate potential clinical effect are needed, our findings suggest new mechanisms behind immunochemotherapy resistance in DLBCL.

There have been concerns about serious infusion-related adverse drug reactions (ADR) with rituximab in chronic lymphocytic leukemia (CLL). We therefore conducted an observational trial in which CLL patients planned for rituximab-containing therapy were eligible. Ninety-six patients from 19 centers were enrolled. The most common regimen was rituximab, fludarabine and cyclophosphamide. Fifty-six patients experienced ADR during rituximab infusion. Reactions ≥ grade 3 occurred in five patients and no cases of tumor lysis syndrome were recorded. Despite a high number of circulating tumor cells few severe ADR were noted. Thus, rituximab-containing regimens can be considered safe for CLL patients in general practice.

A plastic anemia is a rare life-threatening disease. However, since the introduction of immunosuppressive therapy and allogeneic stem cell transplantation, the outcome has improved considerably, and the 5-year survival is reported to be 70-80% in selected patient cohorts. Yet, contemporary population-based data on incidence and survival are lacking. We performed a national retrospective study to determine the incidence, treatment, and survival of patients with aplastic anemia diagnosed in Sweden from 2000-2011. Patients were included via the National Patient Registry, and diagnosed according to the Camitta criteria. In total, 257 confirmed cases were identified, with an overall incidence of 2.35 (95% CI: 2.06-2.64) cases per million inhabitants per year. Median age was 60 years (range: 2-92), and median follow up was 76 (0-193) months. Primary treatments included immunosuppressive therapy (63%), allogenic stem cell transplantation (10%), or single-agent cyclosporine/no specific therapy (27%). The 5-year survival was 90.7% in patients aged 0-18 years, 90.5% in patients aged 19-39 years, 70.7% in patients aged 40-59 years, and 38.1% in patients aged amp;gt;= 60 years. Multivariate analysis showed that age (both 40-59 and amp;gt;= 60 age groups), very severe aplastic anemia and single-agent cyclosporine/no specific therapy were independent risk factors for inferior survival. In conclusion, younger aplastic anemia patients experience a very good long-term survival, while that of patients amp;gt;= 60 years in particular remains poor. Apparently, the challenge today is to improve the management of older aplastic anemia patients, and prospective studies to address this medical need are warranted. Funding Agencies|ALF Vastra Gotaland; Gothenburg Medical Society; Alexion Sweden

Background Our knowledge around the incidence of relapse and primary refractory disease in patients with diffuse large B-cell lymphoma (DLBCL) in the rituximab era is mostly derived from randomized controlled trials or specialized center cohorts presenting selected patient materials. With new therapies being evaluated and launched at diagnosis as well as in the relapsed/refractory setting there is a need for a better understanding of the response and outcome with current treatment strategies. Here we investigated the incidence of primary refractory DLBCL and first relapse as well as survival among patients with relapsed/refractory DLBCL in a population-based cohort. Methods Patients with a primary diagnosis of DLBCL in 2007-2014 were identified using the Swedish Lymphoma Register in 5 of 6 health care regions, and followed until October 31st 2017. Primary CNS lymphomas and primary mediastinal B-cell lymphomas were excluded. The register contains information about clinical characteristics, primary treatment, treatment response and relapse. Information regarding treatment response and progression/relapse was validated through medical chart review in all patients. Primary treatment with curative intent was defined as having started treatment with anthracycline-based chemotherapy (mostly R-CHOP). Early relapse was defined as having primary refractory disease (stable or progressive disease (SD/PD) at response evaluation) or relapse within a year from diagnosis. Overall and progression-free survival probabilities were estimated with the Kaplan-Meier method in the entire cohort and among relapsed/refractory patients by early/late relapse and by age +/- 70 years. Additionally, cumulative incidence of relapsed/refractory disease by follow-up time was shown graphically accounting for the presence of competing risks. Results In the study population of 3165 patients, median age at diagnosis was 71 years (range 18 to 97). In this unselected cohort, 80% of the patients started treatment with curative intent. Five-year overall survival (OS) for patients treated with curative intent was 78% (95% CI: 76-80) and 5-year progression free survival (PFS) was 60% (95% CI: 58-62). Patients who received non-curative intent or palliative therapy (20%) had a median OS of 4.7 months (95% CI: 3.4-5.7). The 10-year cumulative incidence of relapsed/refractory disease in patients treated with curative intent was 22% (95% CI: 20-24) and the majority relapsed within two years (n=315, 60%). Five percent of the patients starting primary treatment with curative intent, only received 1 or 2 treatment cycles and were not evaluated for response. Patients with relapsed/refractory disease had a poor prognosis. For patients with early relapse, median survival from the date of relapse was 4.6 months (95% CI: 4.1-5.7) and 5-year OS was 11% (95% CI; 8-15) whereas patients with late relapse had a median survival of 18.0 months (95% CI: 13.0-24.5) and a 5-year OS of 26% (95% CI: 20-33). Survival in younger patients (≤70 years) by early and late relapse was higher although still low; 5-year OS in early relapse was 17% (95% CI: 12-23) and in late relapse 37% (95% CI: 27-48). Among older patients (>70 years) with early relapse, 5-year OS was only 4% (95% CI: 2-9) and in patients with late relapse it was 16% (95% CI: 9-24). More information regarding treatment intensity among relapsed/refractory patients will be presented. Conclusion The 10-year cumulative incidence of relapsed/refractory disease in patients with DLBCL treated with curative intent is 22% in this population-based study, which is lower compared to previous reports. Outcome for patients with relapsed/refractory disease continues to be poor especially for patients with early progression/relapse, even among younger patients going on to intensive second-line chemotherapy aiming for autologous stem cell transplantation. These results underscore both the urgency of new therapies for relapsed/refractory DLBCL as well as the need for identification of high-risk patients already at diagnosis. Figure 1. Overall survival (OS) and progression-free survival (PFS) among 3165 patients with diffuse large B-cell lymphoma (DLBCL) diagnosed in Sweden 2007-2014 treated with curative or palliative intent, and cumulative incidence of relapsed/refractory disease and survival among 529 relapsed/refractory patients by timing of relapse (early/late) and age (+/-70 years). Figure. Figure. Disclosures Harrysson: Janssen Pharmaceuticals: Other: The Department have recieved partial funding from Janssen Pharmaceuticals. Eloranta:Janssen Pharmaceuticals: Other: S Eloranta is currently employed as a project coordinator and her salary is funded via a public-private real world evidence collaboration between Karolinska Institutet and Janssen Pharmaceuticals. Ekberg:Janssen Pharmaceuticals: Other: The department has received partial funding from Janssen Pharmaceuticals. Wahlin:Gilead: Consultancy, Honoraria, Research Funding; Roche: Research Funding. Smedby:Janssen Pharmaceuticals: Other: The Department have recieved partial funding from Janssen Pharmaceuticals.

Purpose: A few patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) who start on standard primary treatment with R-CHOP do not complete the recommended 6-8 cycles for reasons related to toxicity, however, this group has seldom been formally studied. We set out to describe the outcome of DLBCL patients failing to complete at least 6 R-CHOP cycles for reasons other than non-response, and to investigate determinants of such failure. Methods: We identified patients diagnosed with DLBCL in Sweden 2007-2014 who started primary treatment with R-CHOP (i.e., received at least one cycle) with the aim to receive 6 or 8 cycles, in the national Swedish Lymphoma Register (N=2,155). The analysis covered 5 out of 6 health care regions (70% of all patients diagnosed nationally). Overall survival by number of cycles was estimated using Kaplan-Meier curves (with censoring at stable disease or progression at first interim evaluation to avoid inclusion of patients who switched therapy due to non-response). Univariable and multivariable logistic regression was used to estimate odds ratios (OR) with 95% confidence intervals (CI) for the association between baseline clinical and demographic characteristics and failure to complete full R-CHOP treatment (i.e., receipt of less than 6 cycles compared with 6 cycles or more). Baseline characteristics included age, sex, calendar period of diagnosis, performance status, Ann Arbor stage, serum-lactate dehydrogenase, hemoglobin level, number of extranodal disease locations, and international prognostic index (IPI) score. In the logistic regression analysis, patients with early tumor progression (stable or progressive disease at interim or final evaluation) were excluded. Results: Among the 2,155 patients who started on R-CHOP, 399 (18.5%) failed to complete 6 cycles. Of these, 137 patients (6.4%) received only 1 or 2 cycles, and 262 (12.2%) received between 3 and 5 cycles. Only 42 patients stopped prematurely due to evidence of non-response whereas the majority (357 out of 399 patients, 89%) did so for other reasons related to toxicity and early death. Patients who failed to complete 6 cycles were older than other patients (median age 77 versus 68 years), more often had a WHO performance status of 2 or more (33% versus 12%) and more often were diagnosed with stage IV disease (40% versus 33%). Number of received R-CHOP cycles strongly correlated with survival (Figure 1). Among patients 65 years of age or younger, 5-year OS varied from 18% (95% CI 4-42%) following 1 extranodal disease location and high IPI were statistically significantly associated with failure to complete at least 6 R-CHOP in univariable analysis. In a multivariable model, old age, poor performance status and >1 extranodal location remained significantly associated with failure to complete 6 cycles of R-CHOP for reasons other than non-response. Conclusion: A surprisingly large proportion of patients diagnosed with DLBCL intended for treatment with 6-8 R-CHOP cycles fail to complete the treatment at the population-based level for reasons unrelated to non-response. Failure to complete at least 6 R-CHOP cycles was associated with poor survival, especially for patients receiving 1-2 cycles only, but also for those receiving 3-5 cycles. Old age and poor performance status most strongly predicted such failure. Figure 1: Kaplan-Meier curve of overall survival of patients with DLBCL diagnosed in Sweden 2007-2014 by number of administered R-CHOP cycles overall (top panel) and by age at diagnosis above or below 65 years (bottom panels). Disclosures Ekstrom Smedby: Janssen Pharmaceuticals: Other: The Department have recieved partial funding from Janssen Pharmaceuticals. Harrysson:Janssen Pharmaceuticals: Other: The Department have recieved partial funding from Janssen Pharmaceuticals. Ekberg:Janssen Pharmaceuticals: Other: The department has received partial funding from Janssen Pharmaceuticals. Eloranta:Janssen Pharmaceuticals: Other: S Eloranta is currently employed as a project coordinator and her salary is funded via a public-private real world evidence collaboration between Karolinska Institutet and Janssen Pharmaceuticals.

The prognosis of diffuse large B-cell lymphoma (DLBCL) has improved significantly since the introduction of immunochemotherapy (rituximab [R] with cyclophosphamide, doxorubicin, vincristine, prednisone [CHOP]). However, few outcome data are available for very elderly patients (≥ 80 years). Therefore, we compared all patients with DLBCL aged ≥ 80 years diagnosed in the Gothenburg area during two time periods (2006-2009, "post-R" and 1997-2000, "pre-R"). Forty and 30 patients were identified, corresponding to 23.5% and 20.5%, respectively, of the entire population with DLBCL. Estimated 3-year progression-free (PFS) and overall (OS) survival was better post-R than pre-R: 41% vs. 17% (p = 0.015) and 41% vs. 17% (p = 0.01), respectively. Fifty-three percent of post-R patients were treated with curative intent with a moderately reduced R-CHOP regimen (median relative dose intensity: 0.86). At a median follow-up of 29 months, the 3-year PFS and OS were 70% (p = 0.018) and 76% (p = 0.0089), respectively. In conclusion, moderately reduced R-CHOP is tolerable and effective for a considerable number of very elderly patients with DLBCL and high age by itself should not be a reason for excluding a patient with DLBCL from such treatment.

Introduction: Today, a number of therapeutic options are available as the patient with myeloma relapses from initial treatment with high-dose melphalan and autologous stem cell transplantation (ASCT). For patients who experience a durable response to primary ASCT, retreatment with high-dose melphalan is recommended by many current guidelines. Yet, toxicity is an important aspect in the choice of relapse treatment, and a second ASCT in this setting could be associated with enhanced toxicity. As the goal for the treatment for relapsed myeloma should be disease control while maintaining quality of life, lower doses of melphalan might be preferable. Methods and Objectives: In this retrospective study, we account for the outcome of 66 patients with myeloma in first systemic relapse after ASCT, who were treated with intermediate-dose melphalan, 100 mg/m2, and stem cell support (MEL 100). The aim was to evaluate this treatment in relation to prior response duration after initial ASCT and with respect to response rate, toxicity and survival. Results: The overall response rate was 62%. There was limited, mostly haematological, toxicity, and no treatment–related mortality was observed. The median progression-free survival (PFS) was 8.5 months, and the median overall survival was 24 months. Patients with time to progression of 34 months or more (n = 17; ≥75th percentile) after initial ASCT had a median PFS of 12.5 months after MEL 100. Conclusion: For patients with a long-lasting response after ASCT, MEL 100 could be a therapeutic option with low toxicity and with efficacy comparable to newer immunomodulatory drugs.

Chemotherapy and rituximab (R) is current standard therapy in diffuse large B-cell lymphoma (DLBCL), but a substantial proportion of patients still fail to reach sustained remission. In vitro studies have indicated that rituximab resistance could be accompanied by dysregulated apoptotic pathways, such as the phosphatidylinositol 3-kinase (PI3K)/AKT signaling pathway, which can be constitutively activated in DLBCL. In this retrospective, immunohistochemical study on 106 patients treated with R-CHO(E)P (cyclophosphamide, doxorubicin, vincristine, prednisone, rituximab [+etoposide]), we investigated the prognostic role of proteins involved in different apoptotic pathways; phosphorylated AKT (p-AKT), bcl-2, MCL1, bcl-xL, Bax and Bak. High p-AKT expression (>108 cells/mm2, highest quartile, n=27) predicted worse progression-free (PFS) (P=0.02) and overall (OS) (P=0.01) survival, independent of International Prognostic Index and sex. Also bcl-2+ (cut-off 50%) predicted worse PFS (P=0.005) and OS (P=0.05) but after adjustment for clinical factors only the influence on PFS (P=0.03) remained significant. The prognostic impact of p-AKT overexpression was independent of bcl-2 status. MCL1, bcl-xL, Bax and Bak expression did not add any prognostic information. Our results suggest that high p-AKT expression predicts worse outcome, possibly indicating that inhibition of the activated PI3K/AKT pathway could be of clinical interest in DLBCL patients. In addition, bcl-2 status could have prognostic importance also in the era of immunochemotherapy.

The prognostic significance of tumour-infiltrating lymphocytes (TILs) in patients with diffuse large B-cell lymphoma (DLBCL) remains controversial. Furthermore, the possible impact of regulatory T cells (T(regs)) on survival in DLBCL is still unknown. We performed a retrospective study on the immunohistochemical expression of cytotoxic cells and T(regs), and their correlation with survival in 195 DLBCL patients. Patients with a small number of cytotoxic T-cell intracytoplasmic antigen-1 (TIA-1)+ T cells (or =260 cells/mm(2) tumour area; n = 52) had significantly better outcome than patients with a large number (260 cells/mm(2); n = 143); progression-free survival (PFS) at 5 years was 67% vs. 50% (P = 0.03) and overall survival (OS) was 73% vs. 57% (P = 0.03). In multivariate analysis, the low TIA-1+ group still had a better PFS (relative risk 0.75, 95% confidence interval 0.31-0.99; P = 0.05). The number of forkhead box protein 3 (FOXP3)+ T(regs) had no influence on PFS (P = 0.89) or OS (P = 0.75). These results suggest that immunohistochemical analysis of cytotoxic T cells at time of diagnosis could provide additional prognostic information. The lack of correlation between the number of FOXP3+ cells and survival could possibly indicate that tumour-infiltrating T(regs) are of less clinical importance in DLBCL. However, these findings need to be explored in functional studies.

The Rai and Binet staging systems are currently being challenged by the development of new biological methods to characterize the prognosis and management of chronic lymphocytic leukemia (CLL). To evaluate these two systems in recently diagnosed CLL patients, we performed a retrospective population-based study including 344 patients in western Sweden diagnosed between 1995 and 2000. Binet stage A patients had longer median overall survival (OS) (100 months) than stage B (55 months; P < 0.001) and C patients (45 months; P < 0.0005). Median OS for stage B and C could not be separated (P = 0.94). When transferring Rai stages into three groups, a similar pattern was found. Overall response differed only between Binet A and C patients and there was no difference regarding time to next treatment between any of the Binet stages. Finally, in both systems, low stage patients had inferior survival compared to age- and sex-matched controls. Our data emphasize the need for a new risk stratification system for CLL pat...

Chronic idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder in which activated T-helper (Th) cells and different Th-cell cytokines might play an important role. We have recently reported that chronic ITP patients in remission had elevated plasma levels of the Th3 cytokine transforming growth factor-beta1 (TGF-beta1), possibly as a part of a bystander immune suppression. In the present study we found that, in ITP patients with active disease [platelet count (plc) 150 x 10(9)/l (1894 +/- 244 pg/ml; n =12; P

Background Candidatus Neoehrlichia mikurensis is a newly discovered noncultivatable bacterium spread among ticks and rodents in Europe and Asia that can infect humans, particularly immunocompromised patients. Methods We compiled clinical and laboratory data from 11 patients with hematological malignances or autoimmune diseases who were diagnosed with Candidatus N. mikurensis infection in Europe 2010-2013. Both published (6) and unpublished cases (5) were included. Results The patients had a median age of 67, were mostly male (8/11), and resided in Sweden, Switzerland, Germany, and the Czech Republic. All but one had ongoing or recent immune suppressive treatment and a majority were splenectomized (8/11). Less than half of them recalled tick exposure. The most frequent symptoms were fever (11/11), localized pain afflicting muscles and/or joints (8/11), vascular and thromboembolic events (6/11), that is, deep vein thrombosis (4), transitory ischemic attacks (2), pulmonary embolism (1), and arterial aneurysm (1). Typical laboratory findings were elevated C-reactive protein, leukocytosis with neutrophilia, and anemia. Median time from onset of symptoms to correct diagnosis was 2 months. In at least 4 cases, the condition was interpreted to be due to the underlying disease, and immunosuppressive therapy was scheduled. All patients recovered completely when doxycycline was administered. Conclusions Candidatus N. mikurensis is an emerging tick-borne pathogen that may give rise to a systemic inflammatory syndrome in persons with hematologic or autoimmune diseases that could be mistaken for recurrence of the underlying disease and/or unrelated arteriosclerotic vascular events. Awareness of this new pathogen is warranted among rheumatologists, hematologists, oncologists, and infectious disease specialists.

Introduction: Diffuse Large B-cell Lymphoma (DLBCL) patients with early relapse or refractory disease have a very poor outcome. The major prognostic tool used today is still the clinically based International Prognostic Index (IPI). Yet, IPI seems to be less useful in the identification of individual patients with high risk of failing immunochemotherapy. Despite the higher risk of treatment failure in patients with biological subtypes such as ABC-DLBCL and double-hit DLBCL, about 30-40 % are long term progression-free with current therapy. So, novel biomarkers that more accurately can identify the high-risk patients are warranted, and there is a need to further explore underlying tumor biology features causing treatment resistance. Aims: We compared the proteome in tumor tissue from two groups of DLBCL patients treated with modern immunochemotherapy, i) early relapse/refractory patients and ii) long-term progression-free patients, with the aim to determine if differences in clinical outcome could be correlated to diverse proteomic profiles. Patients and Methods: Formalin-fixed paraffin-embedded tumor tissue, collected at diagnosis, from 93 DLBCL patients, divided into two groups: A) early relapse, i.e. within 12 months, or primary refractory patients, n=44 (REF/REL), and B) cured patients, i.e. with a follow-up of at least 5 years without relapse, n=49 (CURED). Micro-dissected tissue was analyzed using TMT-based mass spectrometry (MS): equal amounts of protein solutions from each patient sample and a reference pool were trypsin-digested into peptides using the FASP-method. NanoLC-MS/MS analysis was performed using a QExactive-Easy-nLC 1,000 instrument combination. Raw data were merged during the database search for protein identification and relative quantification using Proteome Discoverer. Results: In total, we identified 1996 proteins of which 443 were found in all patient samples. Of the 443 proteins, 86 were differentially expressed between the two patient groups. Fifty-seven proteins were overexpressed in the REF/REL group, among which 36 were ribosomal proteins (RP), e.g. RPS2, S3, S5, S6, S7, S13, S15a, S23, L3, L5, L6, L7a, L10, L13a, L18, L31 and L32. In contrast, only 1 RP was overexpressed in the CURED group (RPS10) (p Discussion: We found that a number of RP was overexpressed in DLBCL patients with early relapse or refractory disease. RP play a fundamental role not only in ribosome biogenesis and protein translation but there is also accumulating evidence that dysregulated RP could contribute to tumorigenesis, tumor progression and metastasis. Furthermore, multidrug resistance in some other cancer forms has been associated with overexpression of RP. In DLBCL, apart from overexpression of RPS6 (also found in this study), there is no previous available data on RP dysregulation. Conclusion: Overexpression of multiple ribosomal proteins appears to be associated with failure to immunochemotherapy in DLBCL, and further understanding of their role could potentially lead to new therapeutic strategies in this disease. Disclosures Andersson: Roche: Speakers Bureau.

Introduction: Aplastic anemia (AA) is a rare life-threatening disease but since the introduction of immunosuppressive therapy (IST) and allogeneic stem cell transplantation (alloHCT), the outcome in selected patient cohorts has improved considerably with a 5-year overall survival of 70-80 %. However, there is a lack of contemporary population-based data on the incidence and survival of AA. Aims: To determine incidence, treatment and survival in AA patients (pts) diagnosed in Sweden during 2000-2011. Patients and Methods: In a retrospective study, the Swedish National Patient Registry was utilized to identify pts diagnosed with AA. After careful revision of each patient's chart, 257 cases proved to fulfill the diagnostic Camitta criteria. Incidence and confidence intervals were calculated according to Rothmann, rates and proportions with Pearson's chi-square test, survival statistics using the Kaplan-Meier and log-rank method and the relative survival analysis used the Ederer II method. Results: The overall incidence of AA was 2.35 (95% CI 2.06-2.64) cases per million inhabitants per year. A biphasic age distribution was seen; one peak in pts aged 15-20 (CI 2.87; 1.72-4.03), and one in pts >60 years (4.36; CI 3.55-5.18). Median age at diagnosis was 60 (2-92) years (yrs), and median follow-up 76 (range 0-193) months. The disease severity grades were non-severe AA 38%, severe AA 38%, and very severe AA 24%, with no age-related differences. The primary treatment was IST (63%), alloHCT (10%), or palliation (27%). Distribution of initial treatment in different age groups are given in Table 1. Five-year survival of AA patients was 61%, and median survival 150 months. The 5-year survival, irrespective of treatment modality, varied in different age groups and was significantly lower in pts aged 40-59 and >60 yrs compared to young pts (p 60 yrs. The age-related survival difference was visible early after diagnosis: pts >60 yrs had a 3-month survival of 84% compared to 98% for pts 0-18, 98% 19-39 and 93% for 40-59 yrs (p=0.021, 0.023 and 0.151, respectively). For all pts, type of primary treatment was significantly associated with survival; alloHCT pts had a 5-year survival rate of 96%, the IST group 69%, and palliative pts 30% (p=0.009 and p In patients treated with primary IST (n=161) there was no difference in 5-year survival between the age groups 0-18, 19-39 and 40-59 yrs, whereas patients above 60 yrs did significantly worse than all other age groups; 86%, 90%, 70% and 52%, respectively (p60 yrs underwent HCT compared to 14 pts (48%), 17 pts (57%) and 10 pts (30%) in the other age groups. The relative 5-year survival (i.e. the excess mortality) for all patients was 66% (95% CI 59-72). When dividing patients by the median age at diagnosis, relative 5-year survival was 85% (CI 77-90) in patients 60 did significantly worse, 47.0% (CI 37-57). When splitting pts into two time-periods (2000-2005 or 2006-2011), we found no difference in 5-year survival, neither for all patients nor for the different age groups. Conclusions: Younger AA patients, regardless of initial therapy, experience a very good long-term survival. Also middle-aged patients do reasonably well but for patients above the median age at diagnosis (>60 yrs), the excess mortality is still substantial. Apparently, the challenge today is how to improve the management of elderly AA patients and prospective studies to address this medical need are warranted. Disclosures Brune: Meda Pharma: Consultancy.

Bystander immune suppression has been demonstrated in experimental models of oral immune tolerance induction. This phenomenon is associated with expression of transforming growth factor (TGF)-beta1 and T-helper cell (Th) 2 cytokines. We have studied serum levels of Th cytokines and B- and T-lymphocyte subsets in chronic idiopathic thrombocytopenic purpura (ITP), a disorder in which the production of platelet autoantibodies might be caused by a cytokine network dysregulation. Forty-six patients with ITP were separated into three groups depending on the platelet count (pltc): (1)50 x 10(9)/l, (2) 50-150 x 10(9)/l and (3)150 x 10(9)/l. We found significantly elevated plasma levels of the Th3 cytokine TGF-beta1 in patients with pltc150x10(9)/l (23.5+/-2.8ng/ml), compared with patients with pltc50x10(9)/l (2.3+/-0.6 ng/ml; P0.0001), patients with pltc 50-150x 10(9)/l (7.2+/-1.7 ng/ml; P0.0001) and healthy volunteers (9.8+/-1.3 ng/ml; P0.01). The serum levels of the Thl cytokines interleukin (IL)-2 and interferon (IFN)-y were below the detection limits of the assays. Likewise, the Th2 cytokine IL-4 was not detectable or was very low both in patients and controls. The serum levels of IL-10, a Th2 cytokine, were within the assay range and patients with pltc50 x 10(9)/l had significantly lower levels (0.6+/-0.1 pg/ml) than both patients with pltc 50-150 x 10(9)/l (1.8 +/- 0.1 pg/ml; P0.005) and healthy volunteers (1.4+/-0.1 pg/ml; P0.005). Furthermore, patients with pltc50 x 10(9)/l and splenectomised patients had significantly higher levels of CD4 + CD25 + activated T cells [26.2 +/- 14.8% (P0.05) and 26.7+/-11.9% (P0.005), respectively] than healthy controls (16.5+/-4.0%). Also, the number of natural killer (NK) cells among patients with pltc150 x 10(9)/l were significantly elevated (26.6+/-16.0%; P0.05) compared with controls (17.4+/-7.6%). In conclusion, our data corroborate previous findings of elevated numbers of activated T cells in chronic ITP patients with active disease, but neither a clear-cut Th1 nor a Th2 serum cytokine profile could be established. However, ITP in remission was associated with elevated TGF-beta1, which might be a part of a bystander immune suppression. We propose that the effect of possible expression of TGF-beta1 by oral immune tolerance induction deserves to be explored in ITP patients with an active disease.

The value of menorrhagia as a predictor for mild bleeding disorders has been very little studied and the results are divergent. In the present study on 30 women with objectively verified menorrhagia, we found a significantly increased prevalence of von Willebrand's disease (20%). By keeping a strict sampling and laboratory routine, and by restricting sampling to cycle days 5-7, we also obtained a very low interindividual variation of von Willebrand factor and coagulation factor VIII. We conclude that menorrhagia is a valuable predictor for coagulation and platelet disorders, and that time of sampling is of importance. This should be considered in the investigation of menorrhagia, and can be a guideline in looking for mild bleeding disorders.

Purpose APR-246 (PRIMA-1MET) is a novel drug that restores transcriptional activity of unfolded wild-type or mutant p53. The main aims of this first-in-human trial were to determine maximum-tolerated dose (MTD), safety, dose-limiting toxicities (DLTs), and pharmacokinetics (PK) of APR-246. Patients and Methods APR-246 was administered as a 2-hour intravenous infusion once per day for 4 consecutive days in 22 patients with hematologic malignancies and prostate cancer. Acute myeloid leukemia (AML; n = 7) and prostate cancer (n = 7) were the most frequent diagnoses. Starting dose was 2 mg/kg with dose escalations up to 90 mg/kg. Results MTD was defined as 60 mg/kg. The drug was well tolerated, and the most common adverse effects were fatigue, dizziness, headache, and confusion. DLTs were increased ALT/AST (n = 1), dizziness, confusion, and sensory disturbances (n = 2). PK showed little interindividual variation and were neither dose nor time dependent; terminal half-life was 4 to 5 hours. Tumor cells showed cell cycle arrest, increased apoptosis, and upregulation of p53 target genes in several patients. Global gene expression analysis revealed changes in genes regulating proliferation and cell death. One patient with AML who had a p53 core domain mutation showed a reduction of blast percentage from 46% to 26% in the bone marrow, and one patient with non-Hodgkin's lymphoma with a p53 splice site mutation showed a minor response. Conclusion We conclude that APR-246 is safe at predicted therapeutic plasma levels, shows a favorable pharmacokinetic profile, and can induce p53-dependent biologic effects in tumor cells in vivo.

By providing some examples of variations in the levels of von Willebrand factor antigen (vWF : Ag), ristocetin cofactor, and Factor VIII during one month, the authors wish to emphasize the difficulty of diagnosing mild forms of von Willebrand's disease (vWD), especially type I. In three of 15 normal female volunteers the vWF : Ag levels, on some sampling occasions, were so low (0.25–0.30 IU/mL, normal > 0.50 IU/mL) that the diagnosis of vWD type I might be made while on other occasions normal levels were obtained. The coefficients of variation (CV) for vWF : Ag in these three women were 12%, 25%, and 43%. However, CVs of similar magnitude were also observed for “non-diseased” males and females. The ratio F VIII/vWF : Ag also varied greatly. In the three women with suspected vWD it was 36%, 15%, and 34%. A representative level for the entire cycle of vWF : Ag and ristocetin cofactor seems to have been obtained in the follicular phase and therefore it is suggested that in order to make the diagnosis of vWD type I, at least in females, blood samples should be taken in this phase. © 1992 Wiley-Liss, Inc.

The prognostic role of overexpression of Ki-67 protein in diffuse large B-cell lymphoma (DLBCL) is still unclear. Furthermore, immunohistochemical studies have suggested a correlation between markers of proliferation, B-cell differentiation and apoptosis, but the prognostic relevance of these findings has not been clarified. To investigate the prognostic impact of Ki-67, in the context of this correlation, a retrospective immunohistochemical study was performed on 199 DLBCL patients treated with curative intent. Patients with low Ki-67 expression (

Most studies concerning therapy and prognosis in diffuse large B-cell lymphoma (DLBCL) are based on highly selected patient material. To evaluate treatment, clinical prognostic factors, and outcome in a population-based cohort, we performed a retrospective study comprising 535 de novo DLBCL patients in western Sweden, diagnosed between 1995 and 2000. The median age was 73 years. Treatment with a curative intent was administered to 376 (70%) patients. The International Prognostic Index (IPI) strongly predicted overall (OS) and progression-free (PFS) survival, but high age (68 vsor = 68 years) had no significant influence on response rate (p = 0.86) or PFS (p = 0.14). Male sex had a negative impact on both OS (p0.001) and PFS (p0.001), independent of IPI. In conclusion, a considerable proportion of the patients did not receive curative treatment, but among those treated, the response and PFS were not influenced by age. As men had lower PFS and OS than women, it seems important that gender perspective be taken into account in future studies.

Immune surveillance of tumours is mediated by cytotoxic T cells (CTL) that recognise tumour antigen. Reduced reactivity of CTL towards tumour cells could thus lead to disease progression and loss of tumour control. In B-cell chronic lymphocytic leukaemia (B-CLL), the function of tumour-reactive CTL seems to correlate inversely to disease stage. Inhibitory NK cell receptors are known to suppress the CTL response upon interaction with major histocompatibility complex (MHC) class I and increased expression of such receptors on CTL may inhibit the anti-tumour response. So, the aim of this study was to investigate the expression of NK cell inhibitory receptors on CTL in B-CLL patients and if such expression correlated to disease stage. CD8+ T cells from B-CLL patients in Binet stage A (n = 26) and stage C (n = 14) and healthy controls (n = 14) were analysed for the expression of killer immunoglobulin-like receptors (KIR) CD158a (KIR2DL1), CD158b (KIR2DL2), CD158e (KIR3DL1) and the C-type lectin receptor CD94, by flow cytometry analysis. Patients with advanced disease (Binet stage C) had a significantly greater percentage of CTL expressing CD158b, CD158e and CD94 than patients with non-progressive disease (Binet stage A) and healthy controls. Stage C patients also had a significantly higher percentage of CTL expressing CD158a than stage A patients. No statistically significant differences were found between Binet A patients and healthy controls. Our results suggest that increased expression of KIR and CD94 on CTL in advanced stage B-CLL may potentially contribute to the impaired anti-tumour immune response in these patients.

Introduction: The addition of the anti-CD20 antibodies rituximab or ofatumumab to chemotherapy has improved the outcome for patients with chronic lymphocytic leukemia (CLL), but the efficacy of anti-CD20 monoclonal antibodies (mAbs) as single agents is limited. Immunosuppressive reactive oxygen species (ROS), produced by myeloid cells, including monocytes, may be a limiting factor for the efficacy of ADCC-dependent therapy. With the aim of reducing a potentially inhibitory role of ROS on mAb-dependent NK cell cytotoxicity against CLL cells, we performed in vitro cytotoxicity experiments in the presence of monocytes and the ROS formation inhibitor histamine dihydrochloride (HDC). Methods: After informed consent, blood samples were collected from Binet stage A CLL patients seen at Sahlgrenska University Hospital, Gothenburg, Sweden. NK cells, monocytes and CLL cells were isolated from PBMCs by immunomagnetic negative selection or flow cytometry. ROS production by monocytes was assessed by isoluminol-enhanced chemiluminescense upon stimulation with the chemotactic peptide fMLF in the presence or absence of CLL cells, rituximab (Roche), ofatumumab (GSK), HDC or the NADPH oxidase inhibitor DPI. NK cell death was assessed by flow cytometry after over-night culture of monocytes and lymphocytes. Autologous ADCC assays were performed with NK cells, monocytes and CFSE-labeled CLL cells in the presence or absence of rituximab, ofatumumab, HDC, catalase and interleukin-2 (IL-2). CLL cell death was determined by flow cytometry after live/dead staining. The study was approved by the local ethical review board of Gothenburg, and conducted in accordance with the declaration of Helsinki. Results: Rituximab and ofatumumab both triggered extracellular ROS production by monocytes. ROS production was blocked by the NADPH oxidase inhibitor DPI. Furthermore, monocytes induced ROS-dependent apoptosis in adjacent NK cells. In the cytotoxicity experiments, rituximab-mediated NK cell dependent cytotoxicity against CLL cells was significantly inhibited by the presence of autologous monocytes. This suppression, as well as the induction of NK cell apoptosis, were dependent on ROS, since both HDC and catalase significantly increased cytotoxicity and rescued NK cells from monocyte-induced apoptosis. Expectedly, IL-2 augmented NK cell-mediated ADCC. Conclusion: The results imply that CLL patients harbor immunosuppressive myeloid cells that reduce CD20-antibody dependent NK cell-mediated cytotoxicity against leukemic cells by producing ROS. We propose that treatment with HDC, preferably in conjunction with NK cell stimulatory cytokines, may improve anti-CD20-based immunotherapy in CLL. Disclosures No relevant conflicts of interest to declare.

OFA was approved for the treatment of fludarabine and alemtuzumab refractory CLL on the basis of a single-arm study which also included pts with BFR CLL. This open label, randomized, Phase III study of OFA or PC treatment in pts with CLL refractory to fludarabine and with bulky lymphadenopathy (at least one lymph node > 5 cm) was conducted to confirm the results of OFA in BFR pts and also through a 2nd randomization to compare extended OFA (12 months) vs. approved regimen of OFA (6 months). PC was considered an appropriate comparator for these pts given the lack of a consensus around standard of care treatment for this difficult-to-treat population. Pts were randomized 2:1 to receive either the approved regimen of 8 weekly infusions of OFA followed by 4 monthly infusions (Dose 1, 300 mg; Doses 2–12, 2000 mg) or PC of non-OFA containing therapy, including treatments approved for CLL and well established standards of care for up to 6 months. Pts in the OFA arm who had an investigator-assessed CR, PR or SD underwent a 2nd 2:1 randomization to 6 additional OFA infusions 2000 mg every 4 weeks (OFA Ext), or observation (Obs). Pts in the PC arm who developed disease progression during the study could receive OFA salvage therapy for up to 12 months of treatment. Premedication for OFA infusions consisted of glucocorticoid, paracetamol, and antihistamine. The primary objective of this study was to evaluate progression-free survival (PFS) with OFA treatment versus PC as assessed by an Independent Review Committee (IRC). Response assessments were performed using the 2008 Update of the NCI-WG CLL Guidelines [Hallek, 2008]. Secondary endpoints included overall response rate (ORR), time to next therapy (TNT), overall survival (OS), and safety. 122 pts were randomized (79 OFA, 43 PC). Pts completed a median of 12 OFA infusions and 3 months PC therapy. The median PFS (mPFS) as measured by IRC was 5.4 months for OFA and 3.6 months for PC (hazard ratio [HR] 0.79, p=0.27, stratified log rank test; Fig 1). Median PFS as assessed by the investigator (INV) was 7.0 months for OFA and 4.5 months for PC (HR 0.56, p=0.003). The median time to start of next anti-CLL treatment was 11.5 months for OFA and 6.5 months for PC (p=0.0004, stratified log rank test). The ORR (95% CI) by IRC evaluation was 38% (27%, 50%) for OFA and 16% (7%, 31%) for PC (p=0.02). 37 pts underwent a 2nd randomization to either OFA Ext (n=24) or Obs (n=13). From 2nd randomization, mPFS (INV) was 5.6 months for OFA Ext and 3.5 months for Obs (HR: 0.49, p=0.026, stratified log rank test) (Fig 2). Grade ³3 infusion reactions occurred in 5% of pts in the OFA arm with no fatal reactions in either arm. Grade ≥3 cytopenias in the OFA arm included neutropenia (24%, no prolonged neutropenia and 1 patient with late onset neutropenia), thrombocytopenia (8%), anemia (8%). Of the 43 PC pts, 22 received OFA Salvage with an ORR of 50% and mPFS of 5.4 months. Table of Response and Time to event Endpoints OFA (N=79) PC (N=43) Characteristics Median (range) Age, years 61.5 (46 – 82) 63 (40 – 76) No. prior therapies 4 (2 – 16) 3 (2 – 11) No. of infusions 12 (1 – 18) 3 (1 – 6) IRC Investigator Efficacy endpoints OFA PC p-value OFA PC p-value Responders, % 38% 16% 0.019 49% 37% 0.415 mPFS, months 5.36 3.61 0.267 7 4.5 0.003 OFA PC TNT, months 11.5 6.5 p=0.0004 OS, months 19.2 14.5 p=0.13 Figure 1. Kaplan-Meier Estimates of PFS by IRC (OFA vs. PC) Figure 1. Kaplan-Meier Estimates of PFS by IRC (OFA vs. PC) Figure 2. Kaplan-Meier Estimates of PFS by INV (OFA Ext vs. Obs from 2nd randomization) Figure 2. Kaplan-Meier Estimates of PFS by INV (OFA Ext vs. Obs from 2nd randomization) Conclusions: Although the study did not meet its primary endpoint of demonstrating statistically significant superior PFS by IRC, the ORR, PFS by investigator, TNT, and OS favor OFA and were consistent with previously reported results in BFR pts. There was also a longer PFS in pts who underwent the 2nd randomization to receive OFA Ext vs. the approved OFA treatment regimen of 6 months treatment. Disclosures Österborg: GSK: Research Funding. Off Label Use: Discussion of extended ofatumumab dosing (12 months) in addition to the approved 6 month dosing of ofatumumab in refractory CLL. Zaritskey:Novartis: Consultancy, Honoraria. Kaplan:GSK: Honoraria. Steurer:GSK: Consultancy, Honoraria, Research Funding. Schuh:GSK: Honoraria; Roche: Honoraria; Gilead: Honoraria; Celgene: Honoraria; Napp: Honoraria. Montillo:GSK: Honoraria. Kulyaba:GSK: Honoraria. Gorczyca:GSK: Employment. Daly:GSK: Employment. Chai-Ni:GSK: Employment. Lisby:Genmab: Employment. Gupta:GSK: Employment.

SummaryIdiopathic thrombocytopenic purpura (ITP) is an organ specific autoimmune disorder in whichT-lymphocyte abnormalities have pathogenetic importance.In a DNA microarray screen of CD3+ T-lymphocytes from ITP patients and healthy controls we found an altered expression of genes associated with apoptosis, e.g. A20, caspase-8 and Bax.This together with our previous findings of increased gene expression of Fas,interferon-g and IL-2 receptor beta (IL2RB) indicated an altered activation induced cell death (AICD) of T-cells in ITP. Using a proliferation assay we found that CD3+ lymphocytes from ITP patients were significantly more resistant to dexamethasone induced suppression compared to normal lymphocytes.We also found that cultured CD3+ lymphocytes from ITP patients in remission were more susceptible to apoptosis both in the presence and absence of dexamethasone compared to cells from patient with active ITP and healthy controls, as indicated by increased staining of AnnexinV binding. Our findings suggest that apoptotic resistance of activated T-lymphocytes in patients with active ITP may lead to defective clearance of autoreactive T-lymphocytes through AICD, which might cause a continued immune destruction of platelets. Conversely, a loss of resistance to AICD in ITP patients in remission might be an important mechanism for the achievement of remission.

Chronic idiopathic thrombocytopenic purpura (ITP) is a bleeding disorder that is characterized by increased platelet destruction and is believed to be autoantibody mediated. In this study, CD3+ T cells from ITP patients had increased expression of genes involved in cell-mediated cytotoxicity. In addition, cytotoxic cell-mediated lysis of autologous platelets was shown in active ITP. Our data suggest that T-cell-mediated cytotoxicity is an alternative mechanism for platelet destruction in ITP.

Patients with relapsed aggressive lymphoma after high dose chemotherapy have a very poor prognosis and long-term survival is rare. Most patients are not eligible for allogeneic stem cell transplantation in this setting and treatment, therefore, becomes palliative. A few studies have shown that trofosfamide, an oral alkylating agent, may be effective as palliative treatment in non-Hodgkin's lymphoma. Trofosfamide therapy is considered rather non-toxic with an overall response rate from 50 to 80%. Most responses are, however, partial and their duration is short. We report a patient with a very aggressive ALK + anaplastic large cell lymphoma (ALCL), relapsing shortly after high dose chemotherapy. Unrelated allogeneic transplantation was hot possible. After several radio/chemotherapy regimens trofosfamide was started as palliative treatment. This therapy resulted in a complete remission, still ongoing, 27 months after termination of intravenous cytotoxic therapy and 16 months after withdrawal of trofosfamide. Thus, in this particular case, trofosfamide turned out to be an unexpectedly effective salvage therapy for an otherwise very aggressive relapsing ALCL.

We present a patient with a Philadelphia chromosome positive (Ph+) acute lymphocytic leukaemia (ALL) refractory to standard induction chemotherapy. Treatment with the ABL-specific tyrosine kinase inhibitor STI571 (Glivec, Gleevec, imatinib mesylate) resulted in a complete haematologic and cytogenetic remission. Allogeneic stem cell transplantation from an unrelated donor could be undertaken while the patient was in STI571-induced complete remission from the leukaemia. At present, the patient has a 15-month post-transplantation follow-up and is in stable molecular remission as evaluated by quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) for the BCR/ABL fusion gene transcript. Our case demonstrates that STI571 can act as a bridge to potentially curative allogeneic stem cell transplant in otherwise poor prognosis Ph+ ALL.

Between 1989 and 1998 93 patients with malignant lymphoma were treated, in our centre, with high-dose chemotherapy and autologous stem cell transplantation. Diagnosis according to the REAL-classification were: 38 patients with high-grade lymphoma (diffuse large B-cell lymphoma (DLCL) (n = 26), anaplastic T-cell (n = 5), lymfoblastic (n = 3) and others (n = 4)), 31 patients with low-grade lymphoma (follicular (n = 18), mantle cell (n = 4), B-CLL (n = 3) and others (n = 6)) and, finally, 24 patients with Hodgkin's disease. The source of stem cells was bone marrow (14 patients), peripheral blood stem cells (64 patients) or a combination of both sources (15 patients). There was no early ( < 100 days) transplant-related mortality. One patient died 11 months post-transplant in unexplained liver failure and all other causes of death were related to relapse of lymphoma. So far, no case of myelodysplastic syndromes or secondary acute leukacmia's has occurred. Overall survival (OS) and progression-free survival (PFS) are: (a) DLCL (26 patients, 4-year probability) OS 40%. PFS 33%; (b) follicular (18 patients, 3-year probability) OS 79%, PFS 52%; (c) Hodgkin's lymphoma (24 patients, 5-year probability) OS 65%, PFS 55%. Out of 52 evaluable patients, 34 (65%) have reached remission inversion. The most important findings are no early transplantation-related mortality, remission inversion in a majority of patients, and so far no cases of secondary myelodysplastic syndromes (MDS) acute myelogenous leukaemias (AML). Concerning OS and PFS, our results seem to be in accordance with other centres.