Search

Although specific microRNA (miRNA) signatures in classical Hodgkin lymphoma (cHL) have been proposed, their relationship with clinical outcome remains unclear. Despite treatment advances, a substantial subset of patients with advanced cHL are refractory to standard therapies based on adriamycin and its variants. Global miRNA expression data of 29 advanced cHL patients and five cHL-derived cell lines were used to identify profiles from Hodgkin-Reed-Sternberg (HRS) cells and their non-tumoural microenvironment. A cHL-miRNA signature was identified with 234 miRNAs differentially expressed. A subset of these miRNAs was associated with outcome and selected for study in an independent set of 168 cHL samples using quantitative reverse transcription polymerase chain reaction. Multivariate Cox regression analyses including cross-validation with failure-free survival (FFS) as clinical endpoint revealed a miRNA signature with MIR21, MIR30E, MIR30D and MIR92B*that identified two risk-groups with significant differences in 5-year FFS (81% vs. 35·7%; P < 0·001). Additionally, functional silencing of MIR21 and MIR30D in L428 cells showed increased sensitivity to doxorubicin-induced apoptosis, pointing towards abnormalities of mitochondrial intrinsic and TP53-CDKN1A pathways as related to miRNA deregulation in cHL. These results suggest that clinical outcome in cHL is associated with a specific miRNA signature. Moreover, functional analyses suggest a role for MIR21 and MIR30D in cHL pathogenesis and therapeutic resistance. © 2013 John Wiley & Sons Ltd.

The aim of the present study was to analyze in a series of 24 HIV-positive Hodgkin's disease (HD) patients the morphological and immunological features, the presence of rearrangements in the immunoglobulin heavy chain (IgH) gene, expression of the Epstein-Barr virus (EBV) latent membrane protein-1 (LMP-1), and the existence of deletions in the intracytoplasmic domain of the LMP-1 gene. The results obtained were compared with those from a parallel series of 56 patients with ordinary HD. Briefly, comparison of the two series showed a predominance of unfavorable histological subtypes in HIV-positive HD patients. The mixed cellularity subtype was more frequent in HIV-positive than in HIV-negative HD patients: the difference in percentage was statistically significant (p = 0.04). Neoplastic cell-rich cases were significantly more frequent (p = 0.40) in HIV patients (59%) than in ordinary HD patients (34%). In 25% of HIV-infected and in 14% of ordinary HD patients, the neoplastic cells were CD20+, a difference that was not statistically representative. Clonal IgH rearrangements were detected in 33% of HIV-infected patients and in 23% of ordinary HD patients, a nonsignificant difference. LMP-1 expression was detected in 100% of HIV-positive patients and in 57% of ordinary HD patients (p = 0.004). A 30-base-pair deletion in the carboxy-terminal domain of the LMP-1 gene was found in 16 of 18 HIV-infected patients (89%), whereas it was identified in only 8 of 25 ordinary HD patients (32%) (p = 0.008). In conclusion, HD in HIV-infected patients as compared with HD in HIV-negative individuals is associated with morphological features of aggressivity, with a higher frequency of neoplastic cells, and with constant LMP-1 expression. The fact that LMP-1 is expressed in all HIV-infected patients suggests that EBV plays an etiological role in the pathogenesis of HIV-associated HD. Furthermore, the presence of EBV strains carrying deletions near the 3' end of the LMP-1 gene in the majority of cases may be related with the morphological and clinical aggressivity of HD in immunocompromised patients.

This international retrospective study of 593 Splenic Marginal Zone Lymphoma (SMZL) patients aimed to identify factors that determine treatment initiation and influence lymphoma-specific survival (LSS). Logistic regression was used to identify the factors associated with treatment. A Cox regression was used to analyse LSS in a derivation cohort of 366 patients. This produced a prognostic index (PI) and enabled the identification of three risk groups. The resulting stratification was validated in another cohort of 227 patients and compared with the Interguppo Italiano Linfomi (IIL) score in the group of 450 patients for whom all the required data were available using an extension of the net reclassification improvement. Haemoglobin concentration (Hb), extrahilar lymphadenopathy and hepatitis C virus status were associated with the initiation of treatment. Hb, platelet count, high lactate dehydrogenase level and extrahilar lymphadenopathy were independently associated with LSS. Three risk groups with significantly different five-year LSS (94%, 78% and 69%, respectively) were identified. This stratification (named HPLL on the basis of determinant factors) had a better discriminative power than the IIL score. This system is useful for stratifying SMZL patients into risk groups and may help in the selection of risk-tailored treatment approaches.

Purpose The pathogenic association between Chlamydophila psittaci (Cp) and ocular adnexal marginal zone lymphoma (OAMZL) and the efficacy of doxycycline monotherapy have been investigated in retrospective series with variations in stage, management, and follow-up duration. To our knowledge, this is the first international phase II trial aimed at clarifying Cp prevalence and activity of first-line doxycycline in a homogeneous series of consecutive patients with newly diagnosed stage I OAMZL. Patients and Methods Forty-seven patients were registered. Tumor tissue, conjunctival swabs, and peripheral blood from 44 patients were assessed for seven Chlamydiaceae infections by three polymerase chain reaction protocols. Thirty-four patients with measurable or parametrable disease were treated with doxycycline and assessed for chlamydial eradication and lymphoma response (primary end point). Results Cp DNA was detected in biopsies of 39 patients (89%); no other Chlamydiaceae were detected. Twenty-nine patients had Cp DNA in baseline swabs and/or blood samples and were evaluable for chlamydial eradication, which was achieved in 14 patients (48%). Lymphoma regression was complete in six patients and partial in 16 (overall response rate, 65%; 95% CI, 49% to 81%); 11 had stable disease, and one had progressive disease. At a median follow-up of 37 months (range, 15 to 62 months), 20 patients remained relapse free (5-year progression-free survival [PFS] ± standard deviation, 55% ± 9%). Cp eradication was associated with improved response rate (86% v 47%; P = .02) and 5-year PFS (68% v 47%; P = .11). Conclusion Upfront doxycycline is a rational and active treatment for patients with stage I Cp-positive OAMZL. Lymphoma regression is consequent to Cp eradication, which can easily be monitored on conjunctival and blood samples. Prospective trials aimed at identifying more effective administration schedules for doxycycline are warranted.

We assessed the efficacy of fludarabine, cyclophosphamide, and rituximab in combination (FCR) as frontline treatment in patients with follicular lymphoma (FL) followed by rituximab maintenance. Seventy-five untreated patients with FL received FCR followed by maintenance with rituximab 375 mg/m(2) weekly during 4 weeks and every 6 months for 2 years. The overall response rate was 100%, with 89% complete remission (CR) and 11% partial remission (PR). Molecular remission was observed in all but one patient. Only eight patients completed all therapy planned. With a median follow-up of 47 months, the 5-year overall survival (OS), progression-free survival (PFS), and event-free survival (EFS) were 77%, 93%, and 72%, respectively. Age below 60 and low Follicular Lymphoma International Prognostic Index (FLIPI) correlated with a better EFS. Ten patients died due to toxic complications. The FCR regimen is highly effective in untreated patients with FL, with 89% CR, including molecular responses, and a low progression rate. However, the high incidence of treatment-related mortality makes this regimen unsafe and it cannot be recommended as an upfront therapy in FL.

RESUMEN Durante años, han sido y siguen haciéndose investigaciones y trabajos sobre los estilos de aprendizaje, sobre cómo se enseña, sobre cómo se debería hacer para aprender mejor, para que el día de mañana nuestros hombres y mujeres sean más competentes en cualesquiera de las situaciones que la vida les plantee, aunque en muchas ocasiones se piense que sólo es en el ámbito profesional. Las representaciones gráficas también forman parte de la manera en cómo se pretende hacer entender lo que se pretende explicar, y ahí surgen las expresiones simbólicas, una cebolla, una cruz, una rosa de los vientos, … Pero no sólo han sido los estudiosos de los EA, cualquier persona utiliza en sus expresiones y en sus forma de comunicación no verbal, gestos y formas con las que transmitir lo que piensan, sienten, hacen, desean,… y al utilizar un útil de escritura y dejar sus marcas sobre el papel, van a proyectarlos y es ahí donde entra la Grafología (aunque no solo) al intentar explicar cómo somos y cómo nos proyectamos. La propuesta de este trabajo es la de “re-orientar” los esquemas de los modelos empleados en los EA, para que si bien no hay cambios, si se propone una reubicación en base a la psicología y nuestra propia forma de hablar, de pensar, de hacer y de expresarnos. LEARNING STYLES: SPATIAL SYMBOLISM ABSTRACT For years, research and studies have been and continue to be done on learning styles, teaching methods, and how to learn more effectively, so that in the future our men and women will be more competent in any of the situations that life presents them with, although in many cases it is thought that these competencies only apply to the professional environment. Visual representations are also part of how one attempts to make clear that which is being explained, and it is here that symbolic expressions arise: an onion, a cross, a wind rose. But this not only applies to the scholars of EA: everyone uses gestures and mannerisms in their form of expression and nonverbal communication to convey what they think, feel, do, and desire. And when they use a writing instrument and leave their marks on paper, all of this will be projected. This is where graphology (but not only graphology) comes in: when trying to explain who we are and how we project ourselves. The purpose of this study is to "redirect" the schemes of the models used in the EA, so that even if in the end no explicit changes are made, a schematic repositioning of these models – one based on psychology and our own way of speaking, thinking, acting and expressing ourselves will have been proposed and considered.

Diffuse large B-cell lymphoma (DLBCL) prognostication requires additional biologic markers. miRNAs may constitute markers for cancer diagnosis, outcome, or therapy response. In the present study, we analyzed the miRNA expression profile in a retrospective multicenter series of 258 DLBCL patients uniformly treated with chemoimmunotherapy. Findings were correlated with overall survival (OS) and progression-free survival (PFS). miRNA and gene-expression profiles were studied using microarrays in an initial set of 36 cases. A selection of miRNAs associated with either DLBCL molecular subtypes (GCB/ABC) or clinical outcome were studied by multiplex RT-PCR in a test group of 240 cases with available formalin-fixed, paraffin-embedded (FFPE) diagnostic samples. The samples were divided into a training set (123 patients) and used to derive miRNA-based and combined (with IPI score) Cox regression models in an independent validation series (117 patients). Our model based on miRNA expression predicts OS and PFS and improves upon the predictions based on clinical variables. Combined models with IPI score identified a high-risk group of patients with a 2-year OS and a PFS probability of < 50%. In summary, a precise miRNA signature is associated with poor clinical outcome in chemoimmunotherapy-treated DLBCL patients. This information improves upon IPI-based predictions and identifies a subgroup of candidate patients for alternative therapeutic regimens.

Despite improvement in the treatment of advanced classical Hodgkin lymphoma, approximately 30% of patients relapse or die as result of the disease. Current predictive systems, determined by clinical and analytical parameters, fail to identify these high-risk patients accurately. We took a multistep approach to design a quantitative reverse-transcription polymerase chain reaction assay to be applied to routine formalin-fixed paraffin-embedded samples, integrating genes expressed by the tumor cells and their microenvironment. The significance of 30 genes chosen on the basis of previously published data was evaluated in 282 samples (divided into estimation and validation sets) to build a molecular risk score to predict failure. Adequate reverse-transcription polymerase chain reaction profiles were obtained from 262 of 282 cases (92.9%). Best predictor genes were integrated into an 11-gene model, including 4 functional pathways (cell cycle, apoptosis, macrophage activation, and interferon regulatory factor 4) able to identify low- and high-risk patients with different rates of 5-year failure-free survival: 74% versus 44.1% in the estimation set (P < .001) and 67.5% versus 45.0% in the validation set (P = .022). This model can be combined with stage IV into a final predictive model able to identify a group of patients with very bad outcome (5-year failure-free survival probability, 25.2%).

Background Splenic diffuse red pulp small B-cell lymphoma is an uncommon B-cell lymphoma, now recognized as a provisional entity in the 2008 update of the WHO Classification. Additional work is required to review this entity and establish its diagnostic features.Design and Methods We have retrospectively analyzed the disease features in a highly selected series of 17 patients diagnosed as splenic diffuse red pulp small B-cell lymphoma.Results The median age was 65.5 years (range 40–79 years) and there was a predominance of males (male/female ratio: 2.4). Clinical manifestations were mainly derived from splenomegaly. Splenectomy was the front-line treatment in 11 symptomatic patients; the remaining 6 received chemotherapy initially followed by splenectomy. After a mean follow-up of 72 months, the five-year overall survival was 93%. All cases showed a purely diffuse pattern of splenic infiltration by monomorphous small cells with small round nuclei and pale cytoplasm. All bone marrow biopsies showed tumoral infiltration, with intrasinusoidal infiltration. Peripheral blood cells were small to medium-sized, with clumped chromatin and round nuclear outline and villous cytoplasm. Neoplastic cells had a CD20+, CD23−, bcl6−, Annexin A1- phenotype, with frequent expression of DBA44+ (15/17) and IgG (10/15). FCM data had a B-cell phenotype (CD19+, CD20+, CD22+) with FMC7 (10/11) and CD11c (5/8) expression. Clonal IgH rearrangement studies in 4 cases showed IgVH mutations in all cases, without VH1.2 usage.Conclusions Our data suggest that splenic diffuse red pulp small B-cell lymphoma is a distinct entity with morphological and immunophenotypical features that differ from those of other splenic lymphomas.

Clinico-pathological features of 56 patients with primary gastric lymphoma were evaluated retrospectively. All cases were regraded according to a classification of Isaacson et al into high grade and low grade B-cell mucosa associated lymphoid tissue lymphoma. A third group of mixed grade was recognised in 11 patients with low grade who also had occasional areas of high grade. Low grade and mixed grade patients had a 100% actuarial survival at 156 months, which was significantly better (p < 0.01) than that of 52% for patients with high grade disease. Different treatment methods--surgery, chemotherapy, or a combination of both--did not significantly affect survival. Low grade tumours occurred mainly in men with a history of several years, and who presented with non-specific gastric symptoms without remarkable exploratory or laboratory findings: most patients were in stage IE-IIE and achieved remission and cure. High grade can have a shorter history, systemic symptoms, abnormal exploratory and laboratory findings, gastric tumour masses, stage IV disease, and a worse outcome. The only significant prognostic factors for survival were the type of lymphoma and stage IV disease. These findings support the Isaacson classification system which separates two extreme groups of gastric lymphomas with different morphology, behaviour, and outcome. The presence of limited areas of high grade in a specimen showing low grade does not change the outcome but suggests that primary gastric lymphoma forms a continuum between these extreme types.

BACKGROUND: Currently, there are no consensus guidelines regarding the best therapeutic option for patients with extranodal marginal zone lymphomas of the mucosa-associated lymphoid tissue (MALT) type. METHODS: Patients with systemically untreated or de novo extranodal MALT lymphoma received rituximab 375 mg/m2 intravenously on Day 1 and fludarabine 25 mg/m2 intravenously on Days 1 through 5 (Days 1-3 in patients aged >70 years) every 4 weeks, for 4 to 6 cycles. After the first cycle, oral fludarabine could be given orally at 40 mg/m2 on the same schedule. After 3 cycles, a workup was done. Patients who achieved a complete remission (CR) received an additional cycle, and patients who achieved a partial remission (PR) received a total of 6 cycles. RESULTS: Twenty-two patients were studied, including 12 patients with gastric lymphoma and 10 patients with extragastric MALT lymphoma. Six patients (27%) had stage IV disease. In total, 101 cycles were administered (median, 4 cycles per patients). After the third cycle, 13 patients (62%) achieved a CR, and 8 patients (38%) achieved a PR. Primary extragastric disease was an adverse factor to achieve CR after 3 cycles of chemotherapy (hazard ratio, 23.3; 95% confidence interval, 2.0-273.3). At the end of treatment, the overall response rate was 100%, and 90% of patients achieved a CR. The progression-free survival rate at 2 years in patients with gastric and extragastric MALT lymphoma was 100% and 89%, respectively. Toxicities were mild and mainly were hematologic. CONCLUSIONS: Combination therapy with rituximab and fludarabine is a very active treatment with favorable safety profile as first-line systemic treatment for patients with extranodal MALT lymphoma. Cancer 2009. © 2009 American Cancer Society.

Multiple lymphomatous polyposis is a rare type of non Hodgkin lymphoma that has aggressive biological behavior, early systemic dissemination and poor prognosis. In most cases it is considered to be a gastrointestinal manifestation of mantle cell nodal lymphoma. We describe a case of a 55 year old man, with favorable outcome after chemotherapy.

The purpose of this work was to study retrospectively the molecular response and outcome of 19 gastric mucosa associated lymphoid tissue (MALT) lymphoma patients achieving histological remission after chemotherapy or surgery. Immunoglobulin heavy chain variable (IgV(H)) gene rearrangements were studied by PCR in biopsies obtained at diagnosis and follow-up. Presence of t(11;18)(q21;q21) was studied by FISH or RT-PCR. Sequencing analysis of three t(11;18)(q21;q21) positive and two negative lymphomas with persistent monoclonal IgV(H) rearrangements was also performed. Long-term IgV(H) monoclonality was demonstrated in 11/19 patients (58%); in five of them monoclonal rearrangements were present in all samples throughout the follow-up. Persistent IgV(H) monoclonality was detected a median of 49 months after the achievement of histological response and did not condition histological relapse in most cases. All three t(11;18)(q21;q21) positive patients had maintained IgV(H) monoclonality and sequencing analyses revealed the same mutated IgV(H) alleles in the diagnostic and the follow-up samples. Over half of the patients with gastric MALT lymphoma with histological response after chemotherapy and/or surgery have long-term persistent monoclonality. The presence of t(11;18)(q21;q21) seems to condition long-term persistence of the initial lymphoma clone.trade mark.

Some case reports and a Japanese series suggest benefit from the use of rituximab in patients with intravascular large B-cell lymphoma (IVL). Rituximab efficacy was evaluated in Western patients with IVL, comparing outcome of 10 patients treated with rituximab + chemotherapy (R-CT) and of 20 patients treated with chemotherapy alone (CT). There were no significant differences in patients' characteristics between the two subgroups. The addition of rituximab was associated with improved complete remission rate (90% vs. 50%; P = 0.04), event-free survival (3-year: 89% vs. 35%; P = 0.003) and overall survival (3-year: 89% vs. 38%; P = 0.01). In conclusion, rituximab may substantially change the dismal prognosis of IVL.

Summary We describe 40 HIV-seropositive patients who developed visceral leishmaniasis. All the patients lived in areas endemic for visceral leishmaniasis and belonged to groups at risk for AIDS. Twenty-three patients (57·2 %) had definitive AIDS before or after diagnosis of leishmaniasis and 77·5 % were classified as belonging to CDC group IV. Fever was present in 95 % patients and enlargement of the liver and/or spleen in 92·5%. Lymphopenia was found in 78·3 %, depression of the absolute number of CD4 lymphocytes in 90 % and depression of the CD4 to CD8 ratio in all evaluated cases but leishmania antibodies were found in only 35·2 %. Parasites were demonstrated in the bone marrow or liver in every case. Thirty patients (75%) showed an initial good response to antimonial drugs, although the leishmaniasis followed a chronic or relapsing course in 17 (42·5%). HIV-related mortality was 40%. A significant correlation was found only between the relapsing course of the disease and mortality. In a multivariate linear regression model, the relapsing course was the only variable that influenced mortality. Visceral leishmaniasis is an opportunistic disease that should be suspected in HIV-infected patients. We suggest that it should be included in the CDC group IV C-1 and considered as a disease indicative of AIDS.

Background and Objectives Single-nucleotide polymorphisms (SNP) in interleukin-10 (IL-10) genes can influence immune responses, which may affect the outcome of patients with lymphoid neoplasms. The aim of this study was to explore the association between polymorphisms of IL-10-1082A>G and IL-10-3575T>A with the overall survival in patients with lymphoid neoplasms.Design and Methods We analyzed two IL-10 SNP (−1082 and −3575) in 472 consecutive cases with lymphoid neoplasms. Genotypes were tested for association with overall survival and classical prognostic factors by multivariate analysis. Haplotype analysis was carried out using the haplostats package implemented in R software. The implications for survival of patients with lymphoma were evaluated using multivariate analysis.Results Lymphoma patients with the IL-10-3575T>A genotype had a better overall survival (p= 0.002), as did the subgroup with non-Hodgkin’s lymphoma (NHL) (p=0.05). Patients with the IL10-1082GG genotype had a better median overall survival (p=0.05). When both genotypes were included in a multivariate analysis, IL-10-3575AA genotype was the only independent prognostic factor for survival (HR=0.20, 95%CI 0.05–0.92). Patients with the IL-10-1082 and -3575 G-A/G-A diplotype had a longer overall survival (p=0.003) and this combination appeared to be an independent prognostic factor for survival (HR:0.26; 95%CI 0.08–0.83).Interpretation and Conclusions The IL-10-3575A/A genotype was identified as a marker of favorable survival. Because the IL-10-1082 and -3575 G-A/G-A diplotype was also identified as an indicator of longer survival, we cannot exclude the potential additive role of the IL-10-1082GG genotype. These results need to be replicated in larger series and examined in different NHL subtypes.

Background and aims: Serum galactomannan (GM) is used as a screening test for the early diagnosis of Aspergillus infection in high risk patients for fungal invasive infection. Serial GM levels analysis have proven to be useful in the high risk clinical setting patients, specially when neutropenic and not receiving anti-mold agents prophylaxis. There is a lack of information regarding the benefit of GM in patients undergoing allogeneic hematopoietic cell transplant (HCT). The aim of this work is to measure the real clinical benefit of the serial periodic determination of GM in the post allo-HCT period. Material and methods: 139 consecutive patients who receivedan allo-HCT (59% related family member donorsand 41% unrelated donors) in our centre for five years (since January 2010 to February 2015) were included in the study. Median age was 46 years. Baseline characteristics of these patients are shown in figure 1. Patients were monitored with GM weekly and received primary prophylaxis with fluconazole since the admission until the immunosuppression was tapered. In order to find a population that could benefit the most for AGA monitoring, we classified our population in low risk patients for invasive fungal infection (IFI) versus high risk patients (those with previous proven or probable IFI or those suffering from GVHD; high risk patients received anti-mold prophyllaxis, mainly with voriconazole or posaconazole). Patients considered as low risk who suffered from Graft versus Host Disease (GVHD) in the ulterior outcome, were censored for low risk and considered as high risk since the development of GVHD, and therefore anti-mold agent prophylaxis was started. GM positivity was determined according standard criteria. When GM positivity was detected, radiological and clinical studies (chest/sinus CT scans, cultures, etc.) to discard Aspegillosis were done as soon as possible. Every patient was followed up prospectively until the last medical consultation or decease. Results: Global overall survival (OS) for the entire cohort was 55.39% and cumulative incidence for severe GVHD grade III/IV was 49.5%. During the follow up, GM became positive in 31/139 (22%) cases. With this approach, the global false positive and false negative rate was 31% and 6% respectively.110/139 (79.14%) patients were identificated as low risk cases. We observed GM positivization in 1.81% (2/110) and 37.18% (29/78) for low and high group respectively. All 2 positive GM in the low risk group were false positives. Regarding the high risk group, 34.48% (10/29) were false positives while in the rest 19 patients (65.52%), subsequent radiological and clinical findings allowed us to diagnose Aspergillus infection (besides they received anti-mold agent prophylaxis). Conclusions: In our experience there is not enough evidence for supporting making serial monitoring with GM in low risk patients for IFI in the post allo-HCT period. However it may be an useful tool in high risk patients. Table 1. N (%) Age (years) Mean 46.18 Median 48.01 Sex (man vs woman) 91 vs 48 (65 vs 35%) Hematology disease Acute Mieloid Leukemia Acute Limphoblastic Leukemia Multiple Myeloma Chronic Mieloid Leukemia Non Hodgkin Lymphoma Hodgkin Lymphoma Others diseases 79 (56.8%) 18 (12.9%) 9 (6.5%) 3 (2.2%) 13 (9.4%) 9 (6.5%) 8 (5.6%) Pre allo-HSCT IFI 17 (12.2%) Aconditioning Myeloablative Reduced Intensity 95 (68.3%) 44 (31.7%) Source of progenitors Peripherical blood Bone marrow 132 (95.0%) 7 (5.0%) Type of donor Related Non-related 82 (59.0%) 57 (41.0%) Graft time (days) Neutrophils (>500 in two consecutive determinations) Platelets (>30.000 in two consecutive determinations) 15.52 17.75 Post-transplant CMV viremia (number of patients with >600 copies in the post-HSCT period) 48 (34.5%) Disclosures No relevant conflicts of interest to declare.

INTRODUCTION Follicular lymphoma (FL) may, over time, transform into an aggressive lymphoma, usually diffuse large B-cell lymphoma (DLBCL). Transformed follicular lymphomas (tFL) have a worse prognosis due to poorer response to treatment than primary DLBCL. The incidence of transformation is estimated in ~3% per year, although it varies largely between different studies (24%-70% overall). These differences are mainly due to different criteria to define tFL, to lack of evidence of tFL by biopsy, absence of clonality studies discarding secondary de novo NHL, studies performed in the pre-Rituximab era, or different follow-up times among studies. With all this pitfalls, the actual incidence of transformation remains an open question. The aim of the present study is to analyse the incidence and prognostic impact of transformation in patients with FL in a large retrospective series of the Spanish group of Lymphomas (GELTAMO). PATIENTS&METHODS A total of 1763 patients from 19 Spanish centres diagnosed of FL between 2000 and 2011 were recruited in the study. Data were obtained from the database of centres willing to participate in this study. True tFL (FL to DLBCL) were recorded. From the original cohort, FL IIIb, composite FL+DLBCL, discordant FL (FL in bone marrow and DLBCL in adenopathy or viceversa), and downgrading tFL (DLBCL at diagnosis and relapse of FL) were excluded. Patients with inadequate follow-up were not considered. Therefore, 1611 patients (grade I, II, and IIIa) were finally included. This study was approved by the Salamanca University Hospital Ethic Committee. RESULTS One hundred and ten patients (median follow up of 6 years) were transformed to DLBCL. Cumulative incidence of transformation at 5, 10, and 15 years was of 5%, 9%, and 14%, respectively. With a median follow up of 75.9 months (2 to 179), median time to transformation was 66 months, ranged 1-179. Considering survival from diagnosis of FL, tFL patients had a shorter OS than non-transformed (19% vs. 69%, p2 (p=0.002, HR: 2,1 95% CI: 1.3-3.4). In the multivariate analysis, factors predicting decreased OS after transformation included non-achievement of CR after first line therapy (p We analyzed separately the role of autologous stem cell transplantation (ASCT) in transformed FL patients. Patients that received ASCT were significantly younger ( CONCLUSIONS In this series, one of the largest reported in the rituximab era, high risk FLIPI (>=2) and non-response to FL first line therapy were associated with a higher risk of transformation.Only non-response to transformed FL treatment therapy and a high LDH at transformation were associated with a worse OS after transformation in the multivariate analysis. Autologous transplantation in transformed patients could have a benefit in terms of OS after transformation, but after the introduction of immunochemotherapy strategies, perhaps patients responding to treatment after transformation do not beneficiate from this strategy. *Equal contribution; ‡Equal senior contribution Disclosures Sancho: CELLTRION, Inc.: Research Funding.

Classical Hodgkin´s lymphoma (cHL) is a clonal proliferation of the characteristic Hodgkin and Reed Sternberg cells (HRS), diluted in a reactive inflammatory background, and characterized by a defective B cell immunophenotype. Few studies have been aimed to the identification of the driver mutations in this disease, and only occasional gene mutations in members of the NF-kappaB and JAK/STAT pathways, and, more recently B2M, have been previously described. We analyzed 57 cHL tumor samples (FFPE) using massive parallel sequencing (Ion Torrent™ semiconductor technology). To increase coverage a previous tumor cell enrichment process by punch tissue cores from selected tumor-rich areas was implemented. In addition, we sequenced 7 cHL cell lines using the same technical approach. Bioinformatics analysis, including alignment with germline sequences and SNPs filtering, were done using the Torrent Suite Software and Variant Caller. Pathogenic prediction of single nucleotide variants (SNVs) and mutation interpretation were performed using the Alamut and Provean softwares. All experiments were done in duplicate to minimize false positive rates. Overall, the results show very high genomic heterogeneity with a range of 10-400 SNVs per sample, most of them (~60%) missense type. We found a relatively large number of genes recurrently mutated at low frequency and only a few genes mutated in up to 15-20% of the patients, reflecting a high level of genomic instability in the neoplasm. Specific mutations in genes previously described in cHL (NFKBIA, TNFRSF14) and in diffuse large B-cell lymphomas (CARD11, STAT6, CREBBP, CMYB) were consistently found, as well as new SNVs in genes not previously described (BTK, NFKB2). Mutations affecting selected genes (B2M, CARD11, NFKBIA, CSF2RB, and STAT3) in cell lines were additionally validated by Sanger sequencing. Of note, we found high prevalence of mutations affecting BTK and the BCR pathway, suggesting some dependencies of active BCR signaling albeit the absence of BCR expression by HRS cells. Consistent with this interpretation, incubationof a panel of cHL cellular models with either Ibrutininb or AVL-292, selective-BTK inhibitors, in vitro constrains cell proliferation and causes cell death. Interestingly, the concentration to induce cell apoptosis in cHL was comparable to other cell models of diffuse large B-cell and mantle cell lymphoma sustaining the requirement of an active BCR signaling for cHL cell viability. In conclusion, cHL is characterized by high genomic instability, including numerous mutations in genes related with B-cell function and specific signaling pathways. Pathogenic predictions of the different SNVs identify potential driver mutations that can be associated with the pathogenesis of the disease and might represent new therapeutic targets. Disclosures No relevant conflicts of interest to declare.

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is the paradigm of lymphomas developing in extranodal areas after antigen stimulation. In the stomach, Helicobacter pylori colonization induces the appearance of MALT and, eventually, MALT-derived lymphoma. This type of lymphoma is initially a localized form of disease, but may disseminate and transform into high-grade lymphoma, making full staging (as for nodal lymphomas) and endoscopic ultrasonography to evaluate the penetration of the lymphoma through the gastric wall mandatory. In localized gastric MALT lymphoma, the first step in treatment is eradication of H. pylori, which results in 60-90% regression. This response is maintained for years in most patients, with only 10-15% relapse, frequently precipitated by H. pylori reinfection. A component of high-grade lymphoma, penetration to gastric serosa or beyond and translocation t(11;18) are the main factors that make lymphoma resistant to eradication. Surgery or radiotherapy can cure localized lymphomas in 75-90% of patients. Chemotherapy with alkylating agents, combination chemotherapy and purine analogs, and anti-CD20 antibodies can also induce remission of localized lymphomas refractory to eradication, as well as locally advanced and disseminated lymphomas. The optimum chemotherapy treatment for advanced disease has not yet been established; however, combination therapy, including purine analogs with or without anti-CD20, may be a promising option. Despite histological responses and prolonged remissions, residual molecular disease can be demonstrated in most cases treated with H. pylori eradication, radiotherapy or alkylating agents, and even after more intense chemotherapy, although this does not seem to lead to late relapses. High-grade gastric MALT lymphoma should be treated with chemotherapy, with cyclophosphamide, doxorubicin, oncovin and prednisone being the best first-line option. All gastric MALT lymphomas associated with H. pylori should receive eradication treatment in addition to other required treatment.

Background: Helicobacter pylori infection is associated with low-grade gastric MALT lymphoma, and available data support that the eradication of the H. pylori can cause histological regression of the lymphoma. Patients and methods. Nine patients with low-grade gastric MALT lymphoma were treated with amoxicillin, metronidazole, and omeprazole for 14 days in a prospective study. Patients were followed up with sequential endoscopy, mapping gastric biopsies, and molecular studies with PCR amplification of the IgH gene in order to assess the response to H pylori eradication and the evolution of the histological and molecular responses. Results: H. pylori was eradicated in all patients and reinfections were not demonstrated. After H. pylori eradication treatment, the lymphoma regressed both endoscopically and histologically in eight of the nine patients (88.8%). In four of the eight histologically cured patients, no clonal band was detected by PCR; in the remaining four patients: PCR identified a clonal band, which disappeared in all patients after a mean of 12 ± 4 months. No clonal band was detected by the PCR analysis in any of the eight patients with histological regression after a median of 7 ± 6 months (range 1-20). The seven followed-up patients have a persistent clinical and histological remission after a median of 14 ± 5 months. Conclusions: (1) Low-grade gastric MALT lymphoma can be histologically cured with eradication therapy for H pylori. (2) After histological regression, PCR amplification of the IgH gene can identify an eventually persisting clonal population. (3) Sequential histological and molecular studies are essential for the assessment of the evolution of the lymphoma. (4) The clonal population tends to disappear, but its disappearance may be delayed for months. (5) Patients with histological regression but with a persistent clonal band should not be treated unless the lymphoma can be histologically demonstrated. All these observations suggest that gastric lymphoma can be effectively cured, but the ultimate fate of these patients is unknown until long-term follow-up studies are available.

Purpose: Recent studies of Hodgkin's lymphoma (HL) have suggested that the presence of regulatory T cells in the reactive background may explain the inhibition of the antitumoral host immune response observed in these patients. This study aimed to assess the relevance of regulatory T cells and CTLs present in the background of HL samples in the prognosis of a series of classic HL (cHL) patients.Experimental Design: Expression of granzyme B and TIA-1 (markers for CTL) and FOXP3 (a marker for regulatory T cells) were evaluated independently by immunohistochemistry in tissue microarrays of 257 cHL patients and correlated with patient outcome.Results: The combined influence of the presence of FOXP3+ and TIA-1+ cells distinguished three risk groups of patients with 5-year overall survival of 100%, 88%, and 73%. The presence of a small number of FOXP3+ cells and a high proportion of TIA-1+ cells in the infiltrate represent an independent prognostic factor that negatively influenced event-free survival and disease-free survival in cHL. Compared with the features at diagnosis, relapsed samples tended to have more TIA-1+ cells and a lower proportion of FOXP3+ cells in the reactive background.Conclusions: These data suggest that low infiltration of FOXP3+ cells in conjunction with high infiltration of TIA-1+ cells in cHL may represent biological markers predicting an unfavorable outcome. Moreover, the variation of these markers over the course of the disease implies a possible role for them in the progression of HL cases.

Hodgkin's lymphoma can be considered in most cases a B-cell lymphoma due to the presence of potentially functional immunoglobulin (Ig) gene rearrangements in the neoplastic cells. In contrast to lymphocyte-predominant Hodgkin's lymphoma, Hodgkin/Reed-Sternberg (HRS) cells from classical Hodgkin's lymphoma have low frequency of B-cell marker expression and lack Ig light and Ig heavy messenger RNA. Recent studies have shown transcription machinery deficiency in Hodgkin's lymphoma caused by an absence of the transcription factors OCT.1, OCT.2 and/or BOB.1. By using the tissue microarray technique, we have performed an immunohistochemical study of OCT.1, OCT.2 and BOB.1 in 325 classical Hodgkin's lymphoma cases. The results have been correlated with the expression of the B-cell markers CD20, CD79a, B-cell-specific activator protein (BSAP) and MUM.1, the presence of Epstein-Barr virus and the histological subtype. The percentage of CD20 and CD79a positivity was low (18 and 18%, respectively), whereas MUM.1 and BSAP were positive in the majority of cases. Considering the positive cases with independence of the intensity of staining, 62% of them expressed OCT.2, 59% OCT.1 and 37% BOB.1. Nevertheless, when we considered only the strongly positive cases, the results were similar to those previously described by others. No statistical association was found between the transcription factor expression, histological subtype and Epstein-Barr virus presence. To our knowledge, this is the largest series of classical Hodgkin's lymphoma cases in which the expression of transcription factors has been studied. We have found a notorious percentage of cases displaying weak positivity for OCT.2 and BOB.1 factors in HRS cells. We propose that other mechanisms different from the absence of transcription factors OCT.2 and BOB.1 might be involved in the control of Ig transcription and B lineage in classical Hodgkin's lymphoma.

Purpose Current therapies fail to cure a significant proportion of patients with Hodgkin's lymphoma (HL). Predictive systems for stratification of the disease and selection of treatment based on sets of clinical variables, such as the international prognostic score (IPS), are of relatively small practical value. The predictive use of biologic parameters has so far provided limited and inconsistent results. Here we explore the influence of a set of molecular markers on the outcome of HL. Patients and Methods Forty molecular markers involved in B-cell differentiation and activation, signal transduction, cell cycle, and apoptosis control were analyzed in 259 classic HL patient cases by using tissue microarrays. Univariate analysis was performed to evaluate the influence of markers on favorable outcome (complete remission of > 12 months). Significant variables were included in a multivariate logistic regression analysis, and the probability of favorable outcome was estimated. Results Univariate analysis revealed four molecular markers that predicted outcome, and the multivariate analysis showed p53, Bcl-XL, and terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate-biotin nick-end labeling (TUNEL) to have independent significance. The combination of these factors determined two groups of patients (group I, zero to one factor; group II, two to three factors) with a probability of a favorable outcome of .948 and .687, respectively. A multivariate Cox's model shows that these biologic risk groups have special predictive power in low-IPS patients. Conclusion The data from this exploratory study suggest that the accumulation of molecular events seems to influence the outcome of HL, particularly in the low-IPS group.

A 75-year-old patient presented with a superior vena cava syndrome (SVCS) lasting 3 years. A prostatic carcinoma was found and a supraclavicular lymph node biopsy specimen disclosed metastasis of the prostatic carcinoma. Antiandrogen and luteinizing hormone-releasing hormone analogue therapy produced a marked improvement. Prostatic carcinoma, although a very rare cause, must be considered in the diagnosis of cases of SVCS with a protracted course, since it is a treatable disease.

Patients with Hodgkin's disease and nodal non-Hodgkin's lymphomas seem to have an excess risk for other cancers. A high incidence of other cancers has also been found in some series of patients with gastric MALT lymphomas. In a series of 136 patients with gastric MALT lymphomas the occurrence and features of other cancers have been described. In order to evaluate their occurrence statistically (excluding skin cancers) standard incidence ratios (SRI) have been calculated, using the incidence rates of a Cancer Registry in Spain as a reference. A Cox's multivariate proportional hazard model was fitted in order to evaluate the influence of age, sex, histological grade and treatment with chemotherapy or chemotherapy plus radiotherapy in the development of other non-skin cancers occurring after the diagnosis of MALT lymphoma. Other cancers were detected in 16 of the 136 patients (11.7%); the other cancer was detected prior to MALT gastric lymphoma in 6 patients (4.41%), concomitantly in 4 (2.9%) and after diagnosis of the lymphoma in 6 (4.41%). Other cancers occurred in 14.4% of the male and in 8.3% of the female patients; in 12% of the patients with low grade and in 11% of the patients with high grade lymphomas. Of the 6 cancers that occurred after diagnosis of the gastric lymphoma, 3 did in the 80 patients (3.7%) that had been treated with chemotherapy, 1 in the 3 cases (33%) treated with chemotherapy and radiotherapy and 2 in the 53 patients (3.7%) who had not received chemotherapy or radiotherapy. The most frequent other cancers were lymphoid neoplasms and gastric carcinoma. There was not an excess of other cancers in the whole cohort or in the sex or histological grade strata. There was an excess close to significance (SIR =2.59; 95% CI:0.98-6.88) in the patients under 50 years of age. In the Cox's analysis, age, sex, histological grade and treatment did not influence the occurrence of other cancers after the diagnosis of lymphoma. In conclusion, in patients with gastric MALT lymphoma other cancers also occur. An excess incidence was not demonstrated, although it may exist in patients under 50 years. Of special importance is the occurrence of gastric cancer that appears concomitantly or after gastric lymphoma.

sHLA are soluble forms of class I histocompatibility antigens detected in human serum and cerebrospinal fluid. These molecules are secreted by B and T lymphocytes and the secretion increases dramatically upon mitogenic activation of these cells. sHLA was quantified by an ELISA sandwich method in sera from healthy blood donors, and from patients with Non Hodgkin's Lymphoma (NHL) and Hodgkin's Disease (HD) both at diagnosis and at remission. Pretreatment sHLA serum levels in NHL and in HD were compared with the values found in controls. sHLA levels are increased in patients with NHL (low grade: 6.68 +/- 1.80; high grade: 2.65 +/- 0.53 microg/ml X +/- S.E.) and HD (6.44 +/- 0.98) at diagnosis and in relapses when compared with controls (0.89 +/- 0.08). This increment is statistically significant (low grade NHL: p = 0.0038; high grade NHL: p = 0.0049 and HD: p = 0.0005 versus control group). No statistical differences between titers of sHLA after complete remission and sHLA in the control group were found. The high levels of sHLA detected in patients with lymphoma are mainly due to low molecular weight HLA molecules (55 KD) (60-75% of the HLA present in serum in the control group and 75-100% in serum of patients with lymphoma).

Introduction The simultaneous detection of autoantibodies and alloantibodies to red blood cells (RBC) following allogeneic transfusion is poorly understood. The incidence of autoimmune hemolysis in these patients is not well established (Young et al., Transfusion 2004; 44: 67-72). Methods Patients with a positive antibody screen, an identified alloantibody and a positive direct antiglobulin test (DAT) were selected from our hospital Blood Bank database from January 2002 to June 2013. Sex, age, main clinical diagnosis, transfusion history, alloantibody and autoantibody specificity and hemolysis parameters were analysed retrospectively in those patients with simultaneous first detection of auto and alloantibodies. In our Blood Bank, all patients to be transfused underwent a three-cell antibody screen by gel technology (Ortho Clinical Diagnosis). If the screen was positive, two microcolumn panels with eleven cells (DianaGel) and an autocontrol were performed in Liss-Coombs and with papain-treated erythrocytes for antibody identification. Test-tube testing at different temperatures with Reagent RBC (Makropanel) and a polyethyleneglycol (PEG) antiglobulin technique were carried out to confirm antibody specificity when deemed appropriate. Polyspecific and monospecific (anti-IgG and C3d) DAT (Menarini reagents) and a 6% albumin negative control were performed in all patients presenting a positive autocontrol. Acid glycine elution (Gamma ELU-KIT II) was the method of choice to prepare the eluates. Adsorption techniques were used in some cases to remove autoantibodies. Results A total of 2915 patients formed alloantibodies; 4.5% (n=132) presented both auto- and alloantibodies. The temporal relationship between the antibodies detected had the following distribution: 96.2% (n=127) simultaneous auto- and alloantibody, 2.3% alloantibody identification and on subsequent studies autoantibody and 1.5% had autoantibody previous to alloimmunization. The following results will refer to the group with simultaneous detection of auto and alloantibodies. In the selected group, 55% had a complete register of previous RBC transfusion with a median of 8.5 transfusions lifelong (range: 2 to 81) and a median of 38.5 days (range: 4 to 270 days) between last negative and first positive antibody screen. The ratio male to female was 1:1 and the median age was 67 years-old (range: 20 to 91 years-old). The most common diagnosis in these patients were: solid neoplasia (21.3%), oncohematologic disease (13.4%; mielodysplastic syndromes were included in this subgroup), chronic hepatopathy (15%; of which 58% are HVC-related), cardiovascular disease (9.5%), traumatism (7%), pregnancy (3.2%) and autoimmune disease (3.1%). The most frequent alloantibodies identified were: anti-E (39.3%) > anti-C (28.3%) > anti-K (24.5%). Most autoantibodies had no apparent specificity (67%), those that did have a specific pattern were related to Rh antigens (anti-e 7%; anti-c 1.5%; anti-D 1.5%), and the remainder 23% were crioagglutinins. A total of 16 patients (12.5%) had concomitant hemolysis at the time of antibody detection of which 43.7% (n=7) had an active cancer (57% due to oncohematologic disease), 25% (n=4) HCV hepatopathy and 12.5% autoimmune hepatitis (n=2). Conclusion Patients with de novo alloimmunization showed concomitant antierythrocytic autoantibodies in 4.5% of our population. Most cases appear to be related to previous RBC transfusion and medical conditions affecting normal immunological functioning. However, hemolysis was only found in 12.5% of these patients at the time of antibody detection and all of them had diseases with a known associated risk of developing autoimmune anemia. Disclosures: No relevant conflicts of interest to declare.

Patients with FL can have long time of survival, but disease progression typically occurs 3-5 years after initial treatment. Consolidation with Z after initial therapy has shown to improve progression-free survival (PFS) mainly in the pre-R era, whereas maintenance with R also has demonstrated a substantial benefit in terms of PFS in patients treated with immunochemotherapy. In this setting, the Spanish intergroup PETHEMA/GELTAMO/GELCAB started a randomized phase 2 trial in order to compare the use of consolidation with Z vs. R maintenance in patients with FL responding to R-CHOP. From June 2008 to July 2010, 146 patients (66M/80F; median age, 55 years) were enrolled from 25 Spanish institutions in the randomized phase 2 trial ZAR2007 (ClinicalTrials.gov, number NCT00662948). Main inclusion criteria were: FL grade 1, 2 or 3a, age 18-75 years, stages II-IV and need of treatment according to modified GELF criteria. Patients with FL grade 3b or transformed to DLBCL were excluded. In addition, patients with platelet count 25% before randomization were also excluded. Main end-point of the trial was PFS from randomization. The distribution according to the FLIPI score was as follows: low-risk 14%, intermediate 47%, and high 39%. After R-CHOP, 124 patients in CR (n=56), CR[u] (13) or PR (55) were randomized 1:1 (stratified by response) to arm A (90Y ibritumomab tiuxetan 0.4 mCi/kg IV; total dose of 90Y was capped at 32 mCi) vs. arm B (1 infusion of R 375 mg/m2 every 8 weeks for 2 years). Sixty three (51%) patients were assigned to arm A (Z) and 61 (49%) to arm B (R). Twenty two patients were not randomized due to response Disclosures: Lopez-Guillermo: Roche: Membership on an entity’s Board of Directors or advisory committees. Briones:F. Hoffmann-La Roche: Honoraria.

Abstract 1639 Objectives To evaluate the efficacy and safety of rituximab-bendamustine-mitoxantrone-dexamethasone (R-BMD) in patients with relapsed or refractory follicular lymphoma, (R/R FL) to first-line therapy with R-chemotherapy (R-ChemoT), followed by maintenance with R. Methods Phase II trial including 61 patients with R/R LF, after a 1st R-ChemoT line. Induction treatment: Rituximab 375 mg/m2 iv, day 1; bendamustine 90 mg/m2 iv, days 1 and 2; mitoxantrone 6 mg/m2/day iv, day 1; oral dexamethasone 20 mg / day, days 1 to 5. Cycles of 28 days. Evaluation of response after 3rd cycle. If stable disease or progression: withdrawal from the study. If complete response (CR) or complete response unconfirmed (CRu): administration of a 4th cycle. If partial response (PR): administration up to 6 cycles. If CR, CRu or PR at the end of induction: patients receive maintenance with R 375 mg/m2/day every 12 weeks for 2 years. Primary objective: Complete responses (CR + CRu). Results are presented as valid % and median [range]. Results Results from 46 patients who completed induction period. 52.2% women, age 63 [32–76] years. Ann Arbor stage III / IV 75.6% (31/41) and III / IV-B 22.6% (7/31). FLIPI: intermediate risk 28.9% (11/38); high-risk 23.7% (9/38). Number of administered cycles: 4 [1–6]. Overall response 93.5% (43/46); CR: see Table 1. Progression Free Survival –median (CI95%)-: 14.5 (11.6-NA) months. The most relevant grade 3/4 toxicity: neutropenia 52% (n = 24; 17 patients received G-CSF) and thrombocytopenia 4.3% (n = 2). Infections grade 3/4: 6.5% (n = 3). One patient died due to CMV reactivation. No skin reactions were reported. There are maintenance available data from 15 patients: 3 patients sustained CR at the end of this period, and 2 patients progressed. Conclusions R-BMD is a treatment schedule effective and a safe alternative for patients with R/R FL, after a 1st line with R-ChemoT. No skin reactions were reported, possibly due to the inclusion of dexamethasone in the treatment scheme. Additional follow up is required to achieve more conclusive findings. Disclosures: No relevant conflicts of interest to declare.

Abstract 1596 Background: The IPI, which takes into consideration both host and tumor factors, is the standard method used to stratify aNHL into different risk categories. The IPI was derived in the pre-rituximab era and confirmed as valid in the Rituximab (R) era. The major mechanism of action of R appears to be through the host's immune system. Host factors related to the immune status have been recently recognized as significant in predicting outcome. The ALC, AMC, and ALC/AMC ratio were identified by Wilcox et al. as having an impact on both progression free survival (PFS) and overall survival (OS) (Leukemia 2011;25:1502-09). In order to confirm these findings in a different population of aNHLs we have studied 402 patients with aNHL treated in the R era at 5 centers: 1 in Puerto Rico, 4 in Spain (1 Barcelona, 2 Madrid, 1 Valencia). Methods: 402 patients diagnosed between December 2000 and April 2011 with aNHL were included. ALC and AMC were obtained from pretreatment CBC. All patients received anthracycline and R based chemotherapy. ALC was divided in quartiles (Q): 1st Q ALC ranged between 277 and 950, 2nd Q ALC 951–1352, 3rd Q ALC 1353–1870, and the 4th Q ALC 1871– 5400. The lower Q ALC of 950 and the median of 1353, as well as the lower Q AMC of 366 and the median AMC of 504 were assessed as cutoffs to divide patients into groups with low or high ALC and AMC. Results: Median age was 64 (17–92) and 55% were females. Median follow up was 50 months. FFS and OS at 4 years were 73% and 79% respectively. FFS was superior for patients with an ALC >950 vs =366 vs =504 and 2) whose 4 yr FFS and OS were 53% and 65% respectively (p950 vs Conclusions: We have confirmed that the ALC is an independent prognostic factor for FFS in aNHL. It can identify patients with an inferior outcome despite having a favorable IPI and its effect seems to be more striking in males than in females. In contrast to Wilcox's findings, the AMC and ALC/AMC ratio was not an important predictor of FFS and OS in our cohort. Improved FFS in patients with higher ALC suggests that the immune system plays an important role inthe outcome of patients treated with R-chemo. Disclosures: No relevant conflicts of interest to declare.

Abstract 5049 Background. Treatment of frail or elderly patients with relapsing symptomatic/active Multiple Myeloma (MM) is very difficult due to concomitant diseases, impaired bone marrow reserve, systemic toxicity, relatively decreased renal function and general problems of old age. Dexamethasone and new agents (thalidomide, lenalidomide, bortezomib and bendamustine) have been used in this setting, in most cases with doses adapted to the clinical situation. Aims. To retrospectively analyze the management of frail and/or very elderly MM patients with relapsed and active disease treated with reduced doses of the aforementioned agents in five hospitals in Madrid, Spain. Methods. The files of this group of MM patients were studied. The most common treatment has been the combination of low doses of lenalidomide (len) and of dexamethasone (dex), whereas treatment with reduced doses of other agents has been anecdotal; therefore we analyzed the results of len/dex combinations. Len and dex have been used in lower than standard doses, adapted to the individual initial situation of the patients and tailored according to effect and toxicity throughout treatment. There was no specific protocol and the management of the patients has depended exclusively on the practice and criteria of the treating physicians. Patient risk was stratified following the Salmon and Durie (S&D) score and the International Staging System (ISS). Response was assessed with the IMWG criteria. The study has been approved by the Ethics Committee of Hospital Ramon y Cajal, as coordinating center. Results. 38 patients were included in the study. Mean age was 79 years (range 68–90). 30 pts (79%) were older than 75 years and 10 pts had over 85 years. More than half of the patients (21) had two or more comorbidities. Patients had previously received 1 to 5 (m=1. 8) different treatment modalities, including steroids, melphalan (25), bortezomib (20), thalidomide (6) (or their combinations), and others or even APBSCT (3). 23 pts (60%) had IgG (m=4087 mg/dl, range 868–13000); 13 (34%) IgA (m=2115, range 355–4930) and 2 (5%) only light chains. 22 had κ and 15 λ light chains. 19 (50%) had BJ proteinuria. Mean Hemoglobin level was 10. 7 gr/dl (7. 5–14. 1) and mean creatinine level 1. 3 mg/dl (0. 4–12. 9); 28 (74%) had bone disease. 3 pts had S&D stage I, 22 stage II, and another 13 stage III. 13 pts had ISS stage I, 17 had stage II and 7 stage III. Patients received between 1 and 30 cycles of len/dex (m= 8). Median initial Len dose was 10 mg, the majority between 5 and 15mg, although 4 received 25 mg that were rapidly reduced. Mean initial dex dose was 20mg/day for 4 days. 4 pts (10. 5%) achieved Complete Remission (CR) (3 with negative IF), 27 (71%) Partial Remission (PR) (5 with VGPR) and 2 (5%) a significant, but lesser than 50%, reduction of the M-component (Stable Disease, Std). Altogether, overall response (CR+PR+Std) occurred in 33 pts (86%). The best response occurred after 2 to 9 cycles (m=4) of len/dex. Treatment was stopped in 15 patients due to neurological (4) or hematological (1) toxicity, pulmonary embolism (1), unrelated causes (4) and after achieving a plateau response (5). Time to next treatment was 1–30 months, (m=8 mo). 7 pts relapsed after 3–21 months (m=7). 10 patients died, 5 of related (disease progression, cardiac amyloidosis, renal progression to ESRF) and 5 of unrelated (cancer, sepsis, myocardial infarction, congestive heart failure) causes. Grade III-IV bone marrow toxicity occurred in 9 pts and neurological toxicity (PNP) in 5 (all of them had previously been treated with bortezomib or thalidomide). Conclusions. Personalized low doses of len/dex have been the most common treatment for frail/very elderly patients with relapsed MM in our centers and it is an active and tolerable option in this setting. The haematological toxicity was expectable and manageable, but prior treatments with bortezomib or thalidomide were associated with limiting neurotoxicity. Disclosures: No relevant conflicts of interest to declare.

Abstract 267 BACKGROUND: Chlamydophila psittaci (Cp) infection carries a potential pathogenic role in OAMZL and has been detected in tumor tissue of a high proportion of patients (pts), with geographic differences in its prevalence rates. The use of immunohistochemistry, immunofluorescence and electronic microscopy techniques has identified monocyte/macrophage as carriers of Cp in OAMZL, and bacteria eradication with doxycycline (DOXY) has been associated with lymphoma regression in half of pts. Notwithstanding these achievements, clinical and therapeutic knowledge on this association mainly result from retrospective studies or trials including also patients with relapsed disease after wide-ranging follow-up. Prospective studies focusing exclusively on pts with newly diagnosed OAMZL do not exist. Herein, we report the final results of the first international prospective phase II trial aimed to investigate Cp prevalence and DOXY efficacy as first-line therapy in pts with newly diagnosed OAMZL (ClinicalTrial.gov NCT01010295). AIMS: To elucidate prevalence of Chlamydiae infections, and to evaluate the efficacy of DOXY both in terms of bacterial eradication and as upfront anti-lymphoma therapy in pts with newly diagnosed OAMZL. METHODS: This trial included two different parts, named A and B. The part A included pts with newly diagnosed stage-IEA OAMZL and measurable/parametrable disease; these pts were assessed for chlamydial infection and were treated with DOXY 100 mg orally twice daily for 21 days. The part B included pts with lymphoma categories other than MZL, non neoplastic lesions of the ocular adnexae or OAMZL not eligible for part A; these pts were treated following local guidelines. Chlamydial infections were assessed on diagnostic tumor samples, conjunctival swabs and peripheral blood mononuclear cells (PBMC) from A and B pts by three different PCR protocols targeting 16rRNS and intergenic spacer 16S–23S, ompA and hsp60, respectively. Bacterial eradication was tested on conjunctival swabs and PBMC collected at basal time, at 3 and 12 months after DOXY (only part A pts). Clinical and ophthalmologic examination and MRI imaging were performed at the same timepoints, and every six months during follow-up. RESULTS: From August 2006 to November 2010, 54 pts from 6 centers were enrolled; 34 pts with OAMZL entered the part A, while 13 pts with non-parametrable OAMZL and 7 pts with other lymphoproliferative disorders entered the part B. Diagnostic material was available for molecular analysis in 44 cases; Cp was detected in biopsies of 32/37 OAMZL (86%) and in 4/7 non-MZL. All cases were negative for C. pneumoniae and C. trachomatis. Among 36 Cp+ pts, infection was detected in 100% of swabs and in 75% of PBMC; swabs or PBMCs from pts with Cp-negative OAMZL were invariably negative. All pts completed the planned DOXY treatment; no relevant toxicity was reported. Among 34 pts entering the part A, 28 were evaluable for bacteria eradication (Cp detected in swabs in 8 pts, in PBMC in one, in both samples in 19). At 3 months from DOXY, Cp was not detected in swabs and PBMC of 14 evaluable pts, with an eradication rate of 50%; at one year of follow-up, Cp was still detected in three of these apparently eradicated pts. Lymphoma regression after DOXY treatment (part A) was complete in six pts (18%; 95%CI: 5–31%), and partial in 16 (ORR= 65%, 95%CI: 49–81%); 11 had SD and one PD. At a median follow-up of 27 months (range 3–51), 13 pts experienced relapse, with a 2-year PFS of 55±9%. A trend to a higher response rate (82% vs. 53%; p=0.12) and 3-yr PFS (72% vs. 52%; p=0.14) was observed in eradicated pts. No significant association between site of presentation (conjunctiva vs. orbit) and clinical outcome was detected. There was no association between animal exposure and bacteria eradication or lymphoma response. All patients but two (stroke and myocardial infarction) are alive, with a 3-yr OS of 92%. CONCLUSIONS: Cp infection is frequent in newly diagnosed OAMZL, and could be also present in other lymphoproliferative disorders of the ocular adnexae. First-line DOXY is an active, safe and rational strategy in pts with limited-stage OAMZL, with lymphoma regression in 65% of cases. However, DOXY failed to eradicate Cp infection in half of pts, with a negative impact on outcome. Further investigations aimed to identify additional potential infective agents associated with OAMZL and more active antibiotic regimens are warranted. Disclosures: Montalban: Red Temática de Investigación Cooperativa en Cancer (RETICC): Research Funding; Asociación Española contra el Cancer: Research Funding.

Abstract 3780 Background: Imatinib has shown an outstanding improvement in the prognosis of chronic myeloid leukemia (CML) patients. Nevertheless, some of them have proven to be resistant or intolerant to imatinib. For these patients, second-generation tyrosine kinase inhibitors (TKIs) are available. These drugs may be indicated in different circumstances as primary or second resistance, suboptimal responses or intolerance.The real benefits of second-generation TKIs as salvage treatment are surely in dependence with the indication in each case and are, therefore, difficult to evaluate. Second-generation TKIs are being evaluated as first line treatment compared to imatinib with quite favourable outcomes so long, but have not yet been compared with a strategy combining imatinib followed by second-generation TKIs for patients with previous unfavourable responses. Aims: Evaluate the real benefit of second-generation TKIs in second line treatment for CML patients regardless of the indication for its use. Study groups and methods: We have studied 98 patients treated with imatinib as first tyrosin kinase inhibitor (TKI) in our centre. These patients have been classified according whether second-generation TKIs were available or not. Group 1 includes 60 patients treated since 2001 to 2005, when the only salvage treatment was an increased imatinib dose, chemotherapy or allogenic stem cell transplantation. Group 2 includes 38 patients treated since 2005 until today. In the second group second-generation TKIs (dasatinib or nilotinib) were used according to the indications mentioned above. Follow up period was 39 months and 32 months for group 1 and 2 respectively. Sokal risk index was high in 14% and 16%; intermediate 42 % and 40%; and low in 44% and 44 % for group 1 and 2 respectively. Results: The use of second-generation TKIs as second line resulted in significant benefit to patients in terms of responses. Complete cytogenetic responses (CCR) at any time were achieved in 73% and 86% for patients in group 1 and 2 (p=.09). Probability of the achievement of mayor molecular responses (MMR) was 42% vs 71% for group 1 and 2 respectively [p=.009; ratio=0.3 (0.1–0.7)]. Response rates at the last follow up for group 1 and 2 were: MMR: 33% vs 62%; CCR: 68% vs 94% and failure 32% vs 6% (p=.008). Progression free survival (including all the patients who started treatment) was 88% vs 94% for group 1 and 2 respectively. We found no correlation among responses and some prognostic factors (Sokal index, mutations at the TK domain or imatinib plasma levels). Imatinib doses were increased in 21 patients (35%) in group 1 (reasons for increasing doses were failure in 14 patients and suboptimal responses in 7 patients). 10 patients (26%) in group 2 received second-line TKIs as second line treatment (4 because imatinib failure, 3 by suboptimal responses and 3 due to intolerance). Conclussions: The use of second-generation TKIs as salvage has improved the responses of CML patients treated with TKIs. Once the second-generation TKIs has shown benefit compared to imatinib in first line treatment, this therapeutic strategy should be compared vs the use of imatinib followed of second-line TKIs for patients without optimal responses to imatinib. Disclosures: Montalban: Red Temática de Investigación Cooperativa en Cancer (RETICC): Research Funding; Asociación Española contra el Cancer: Research Funding.

Abstract 1583 Splenic Marginal Zone Lymphoma (SMZL) is a distinct lymphoma included in the WHO 2008 classification. Ann Arbor staging system is not adequate to stratify SMZL patients into risk groups, as blood and bone marrow are usually involved. Further, there are neither established criteria for starting treatment nor gold standard treatment. Herein we report an international retrospective study on 593 SMZL patients aimed to identify which factors could influence starting treatment and which could allow stratify risk categories. Logistic regression was used to identify the factors that have conditioned treatment in the whole series and Cox regression for factors influencing Lymphoma Specific Survival (LSS) in a training set of 336 patients. The variables used were age, hemoglobin level and platelet count (as continuous variables) and sex, low albumin serum level ( Hemoglobin (p=0.000), extrahilar lymphadenopathy (p=0.000), and HCV positivity (p=0.001), were the factors independently conditioning treatment. Untreated patients had a significant longer LSS than treated patients (p=0.000). In the treated group there were no differences in LSS according to the type of therapy (splenectomy, chemotherapy, rituximab or their combinations) (Figure A). The low number of rituximab treated patients (n=39) precluded statistically reliable conclusions. In the training set, haemoglobin (p=0.003), platelet count (p=0.043), high LDH (p=0.011) and extrahilar lymphadenopathy (p=0.020) were the factors independently influencing LSS. The resulting PI was: 0.6 × platelet count (in hundreds of thousands/mm3) + 0.2 × hemoglobin (g/dl) − 1 × high LDH (1 when LDH above normal, 0 when normal) – 0.75 × extrahilar lymphadenopathy (1 when present, 0 when absent). Applying the cut points a low, intermediate and high risk groups with significantly different 5 year LSS of 0.94, 0.78 and 0.67, respectively, were identified (Figure B). In the validation set the system also separated 3 groups with significant different 5 year LSS of 0.96, 0.88 and 0.44, respectively. This stratification was named HPLL after the determinant factors (H emoglobin, P latelet count, high L DH, L ymphadenopathy) and the resulting risk groups HPLLA, HPLLB and HPLLC. In the comparison HPLL/ABC system separated 3 groups with significantly different LSS, whereas in the IIL score there was no significant difference between the low and intermediate risk groups (p=0,102). Using as reclassification calibration statistics the Hosmer-Lemeshow test, HPLL/ABC (χ2 =1.48; p=0.475) showed a better fit than the IIL score (χ2= 3.339; p=0.118) indicating that HPLL/ABC discriminated better the risk groups. In this large SMZL series, haemoglobin, extrahilar lymphadenopathy and HCV positivity were the factors independently conditioning treatment. The combination of hemoglobin, platelet count, high LDH and extrahilar lymphadenopathy stratify the patients in three groups with significantly different outcome. This system may be helpful to select risk-tailored treatment approaches. Disclosures: Montalban: Red Temática de Investigación Cooperativa en Cancer (RETICC): Research Funding; Asociación Española contra el Cancer: Research Funding. Mollejo:Red Temática de Investigación Cooperativa en Cancer (RETICC): Research Funding; Asociación Española contra el Cancer: Research Funding. Piris:Red Temática de Investigación Cooperativa en Cancer (RETICC): Research Funding; Asociación Española contra el Cancer: Research Funding.

Abstract 2664 Diffuse large B cell lymphoma (DLBCL) is a heterogeneous group of aggressive lymphomas. Despite improvements in diagnostic and therapeutic procedures, DLBCL still represents a significant cause of morbidity and mortality. Two molecularly defined types of DLBCL have been recently described: the germinal center B-cell (GCB) and the activated B-cell (ABC) subtype. GCB type DLBCL has been shown to have a better OS and PFS than ABC-type in multiple series of DLBCL patients treated with chemoimmunotherapy. The processes involved in lymphomagenesis in both subtypes are not fully understood, but deregulated expression of various proto-oncogenes is observed, often as the result of chromosomal translocations leading to constitutive gene expression. The specific role of the cMYC gene abnormalities in the pathogenesis of these lymphomas is still a matter of debate. To address this question, the status of the cMYC gene was analyzed by interphase fluorescence in situ hybridization (FISH) using a break apart probe, in TMA arranged tissue samples from 241 patients with de novo DLBCL treated with chemoimmunotherapy (R-CHOP and R-CHOP-like regimens). cMYC was rearranged in 15 cases out of 166 evaluable (9.26%). We did not find differences in the incidence of cMYC rearrangements between GCB and ABC-DLBCL subtypes (9/74 GCB and 6/82 ABC type) as classified according to extended immunohistochemical algorithms (Choi et al in Cancer Res. 2009). In our series, patients with DLBCL and cMYC rearrangements presented more frequently extranodal disease (p=0.007), higher IPI (p=0.037) and tended to have less than 60 years (p=0.053). cMYC gains were observed in 33 cases (21.85%). In the univariate analysis, cMYC abnormalities (gains and rearrangements) had no impact on the clinical outcome in the ABC subtype. However, whilst the cMYC gains did not identify a risk group in terms of OS or PFS the presence of cMYC rearrangements showed a significantly inferior progression-free survival (PFS) in the GCB-type group (p Disclosures: Montalban: Red Temática de Investigación Cooperativa en Cancer (RETICC): Research Funding; Asociación Española contra el Cancer: Research Funding. Mollejo:Red Temática de Investigación Cooperativa en Cancer (RETICC): Research Funding; Asociación Española contra el Cancer: Research Funding.

A total of 41 non-cutaneous peripheral T-cell lymphomas were classified following the updated Kiel classification. Of these, 20 cases belonged to the low-grade group (T-cell chronic lymphocytic leukaemia, 3; lymphoepithelioid, 5; angioimmunoblastic, 4; pleomorphic small cell, 8) and 21 to the high grade group (pleomorphic medium and large cell, 11; immunoblastic, 3; large-cell anaplastic Ki-1 positive, 7). Seventy per cent showed a CD4+/CD8-phenotype, 39% a defective phenotype and 88% an activation phenotype. Eighty per cent had B-symptoms, 63% hepatomegaly, 48% splenomegaly and 26% had involvement of more than three lymphoid areas. Bone marrow was infiltrated in 34% central nervous system in 4%, lung in 12% and skin in 14.6%. Seventeen per cent presented with extranodal disease and 82.8% had stage III/IV disease. Hypergammaglobulinaemia was found in 29%, hypercalcaemia in 7%, raised LDH serum levels in 58% and HTLV-I antibodies in only one case. Of the 37 treated patients 18 (48%) achieved a complete remission, but 33% relapsed. Mortality was 59% and actuarial overall survival at 38 months was 0.32. In the comparison of the clinical, analytical and immunophenotypic variables and outcome between low and high grade groups, only the average of bone marrow infiltration in the low grade and stage I–II, presence of defective phenotypes and higher Ki-67 positivity in the high grade group were significantly different. In the statistical studies, extranodal prentation and the failure to achieve a complete remission were the only variables that influenced mortality; there weere no significant differences in the general features of the low and high grade groups and only minor differences were found in the immunoblastic and angioimmunoblastic subgroups. There were no differences in the actuarial survival between the low and high grade groups, among the subgroups of the Kiel classification, among stages I to IV, between patients with or without B-symptoms, with or without defective phenotypes, Ki-67 positivity over or under 60%, or among different CD4/CD8 phenotypes. The updated Kiel classification did not separate groups with a prognostic significance.

Abstract 4950 Background & Aims The management of elderly patients with Multiple Myeloma (MM) previously treated requiring further therapy (although in most cases palliative) is very difficult due to the presence of concomitant diseases, decreased bone marrow reserve, systemic toxicity, relatively decreased renal function and general problems of old age. As in this setting the tolerability of standard doses of conventional chemotherapy, high doses of dexamethasone or IMiDs is a concern, we report the preliminary results of the combination of tailored low doses of lenalidomide (len) and low doses of dexamethasone (dex). Methods We retrospective analyze the results of the combination of low dose lenalidomide and low dose of dexamethasone (len/dex) in 14 patients aged over 70 years with pretreated MM and progressive disease. Low doses of len (5-10 mg daily for 21days) were initially given and flexibly modified in subsequent cycles according to response and toxicity, along with low doses of dex (20-40 mg/day for 4 days) in most (12) patients. G-CSF and red cell transfusions were used when needed. Patient risk was stratified following the Salmon and Durie (S&D) score and the International Staging System (ISS). Response was assessed with the IMWG criteria. Results Median age was 80 years (70-90). All patients had received between 2-5 different previous modality treatments (m=2), including bortezomib (7), thalidomide (4) or PBSCT (2). 11 pts had IgG, m=3397mg/dl (868-4990), 2 IgA m=1460 (1050-1870) and another one BJ. 9 pts had κ and 4 » light chains. Median Hemoglobin level was 10 gr/dl (7.2-11.4) and median creatinine level 1.19 mg/dl (0.75-1.63). 11 (78%) had bone disease. 9 pts had S&D stage II, 4 stage III and another one stage I. 7 pts had ISS stage II, 4 had stage I and 2 stage III. Patients received between 2 and 13 cycles of len/dex (m=6.8). 11 pts (78%) achieved Partial Remission (PR) and 2 (14%) achieved significant, but lesser that 50%, reduction of the M-component (Stable Disease: Std). Overall response (PR+Std) occurred in 13/14 patients (92.8%). The best response occurred between 2-12 cycles of len/dex. Grade III-IV bone marrow toxicity occurred in 5 pts (35 %) and neurological toxicity (PNP) in 5 pts (35%) (all of them had received previous bortezomib or thalidomide). Treatment was stopped in 6 pts: for unrelated causes (1), due to neurological (3) or haematological (1) toxicity and in 2 pts after achieving Std and both relapsed after 3 months. Conclusions Treatment with tailored low doses of lenalidomide and low doses of dexamethasone (len/dex) is an active and tolerable option for previously treated elderly patients with symptomatic MM. Low lenalidomide doses can be flexibly modified according to the quality of the response and the hematological toxicity that is expectable and manageable. Previous treatments with bortezomib or thalidomide is associated with neurotoxicity. Disclosures No relevant conflicts of interest to declare.

Backgroud: Synergistic antitumor effect with combination of fludarabine and rituximab has been demostrated on MALT cells. Addition of rituximab to other drugs has improved outcomes in several types of NHL without a significant addition of toxicity. Our aim was to evaluate the safety and efficacy of rituximab combined with fludarabine (RF) in first-line therapy for extranodal MALT lymphoma. Patients and methods: Adult patients with untreated extranodal MALT lymphoma who were included and received rituximab 375 mg/m intravenously (IV) on day 1 and fludarabine 25 mg/m (IV) given on days 1–5 (days 1–3 in > 60 years), every 4 weeks; after the first cycle, oral fludarabine was permitted. After 3 cycles, a work-up was done. Patients in complete remission (CR) received an additional cycle and, if partial remission (PR), a total of 6 cycles. Results: 22 patients were included. Characteristics: median age: 60 years (32–83); 45% male; PS 0–1 (100%); site of lymphoma origin: gastric (61%) and extragastric (39%); stage: I (45%), II1 (23%), II2 (5%) and IV (27%). A total of 101 cycles of RF were administered and 21 pts were evaluable for response. After the third cycle, 13 pts (62%) achieved CR and 8 pts (38%) PR. At the end of therapy, 19 pts (90%) achieved CR and 2 pts (10%) PR. Univariate analysis identified primary extragastric disease as an adverse factor to reach CR after 3 cycles of RF (HR 23.3 (95% CI, 2.0–273.3)). The median follow-up time was 23 months (95% CI, 18–27 months). Progression free survival (PFS) at 24 months was 88 % (95% CI, 80–100%). PFS at 24 months in gastric and extragastric MALT lymphoma were 100% and 79%, respectively. Tolerance to oral fludarabine was excellent. Mild neutropenia was the most common toxicity, usually presenting after the third cycle and 2 pts had prolonged mild thrombocytopenia. No grade 3–4 infections were observed. Conclusions: Immunochemotherapy with RF, either with intravenous or oral fludarabine, achieves a high CR rate in both gastric and extragastric MALT lymphoma, although the firsts responded faster. With only four cycles of RF, two thirds of patients achieves CR. RF is associated with a good safety profile being mild granulocytopenia and thrombocytopenia the main adverse events. The long-term benefit of this therapy will require prolonged follow-up.

8608 Background: The addition of rituximab to other drugs has improved outcomes in several types of NHL without a significant addition of toxicity. Our aim was to evaluate the safety and efficacy o...

Background and objective Fludarabine in combination with cyclophosphamide (FC) plus rituximab (R) is an effective treatment for newly diagnosed as well as relapsed follicular lymphoma (Tam 2004; Keating 2005; Sacchi 2007). Maintenance treatment with R, after different induction treatments, improves overall and progression-free survival (Forstpointner 2006; van Oers 2006). Therefore, we aimed to evaluate the efficacy and safety of the FC-R regime followed by maintenance doses of R. Patients and Methods We present an intermediate report of the one-arm study in which 75 previously untreated patients with a diagnosis of follicular non-Hodgkin’s lymphoma in Ann Arbor stage II–IV were included between October 2004–2006. Seventy four were assessed for safety after receiving at least one FC-R dose (F: 3x25 mg/m2 and C: 1 g/m2; R: 375mg/m2), and 72 for response to treatment. Patients aged 53.4 years in average, one in five showed bulky disease and 72.2% Ann Arbor IV staging. FLIPI index determined 23.9% patients with low (0–1) score, 38% with intermediate (2) and 38% with poor score (3). A total of 47 patients presented some molecular alteration in PB or BM. Results Induction therapy was delivered throughout 4–6 courses, resulting in 91% complete responses (CR) and 9% partial responses (PR) (Table 1). From the patients who presented monoclonal population at diagnosis, 40 were evaluated for molecular response after induction and only 1 remained MDR positive for bcl2/IgH. Overall survival (OS) at 24 months was 87.5%, and two patients presented progressive disease within this period. The median OS has not been reached at this evaluation. To the date, 262 adverse effects grade 3–4 (32.6%) have been documented (80.9% neutropenias) and 80 infectious complications were recorded (23.8% grade 3–4). Three patients died from respiratory diseases, two from acute leukemia, and six from other causes. Table 1 EVOLUTION OF RESPONSE Evaluated Response at End of Induction Therapy Evaluated Response Post-Course 3 Assesable End Ind. (n=67) Missing End Ind. (n=5) CR: complete response; uCR: unconfirmed CR; PR: partial response; NE: not evaluated; WD: withdrawn; EX: exitus. Assesable PC3 (n=70) CRITERIA CR PR NE WD EX 14 CR 12 - 1 1 - 32 uCR 31 - 1 - - 24 PR 16 6 - - 2 2 Missing PC3 (NE) 2 - - - - 72 Total 61 6 2 1 2 Conclusions The FC-R has proven a potent antitumoral activity in untreated follicular lymphoma patients, rendering very high clinical and molecular responses. However, as reported in similar studies (Hochster 2007 ASCO), the high incidence of prolonged neutropenias and lymphopenias developed as consequence of the chemotherapy regime, questions the safety of the induction treatment.

Background: Fludarabine as a single agent or in combination with chemotherapy has shown activity in MALT lymphoma. Our ex vivo preliminary results indicate a synergistic antitumor effect on MALT cells with combination of fludarabine and rituximab. The addition of rituximab to other drugs has improved outcomes in several types of NHL without a significant addition of toxicity. Methods: This study enrolled adult patients with untreated MALT lymphoma who were candidate to receive systemic treatment. Patients received rituximab 375 mg/m2 intravenously (IV) on day 1 and fludarabine 25 mg/m2 (IV) given on days 1–5 (days 1–3 in > 60 years), every 4 weeks; after the first cycle, oral fludarabine was allowed to be given orally at 40 mg/m2 with the same schedule. After three cycles, a work-up was done. Patients in CR received an additional cycle and, if PR, a total of 6 cycles was recommended. Use of G-CSF and prophylactic antibiotics was optional. Results: Characteristics of all 18 pts: median age: 59 years (range: 32–83); 7 male, 11 female; PS 0 (94%); site of lymphoma origin: stomach (61%), skin (16%), lung (11%), parotid gland (11%); stage: I (66%), II (16%) and IV (16%). A total of 82 cycles of R-F were administered; 2 pts received 2 cycles, 9 pts 4 cycles, 7 pts 6 cycles. 17 pts are evaluable for response. Overall response rate was 100% with 94% achieving CR. In the pt in PR, symptoms resolved and received no further treatment. One pt with parotid gland involvement at dx relapsed at 6 m from the end of treatment in two unaffected areas at dx (breast and bone marrow). Median follow-up from starting treatment is 15 m (range: 17–27). PFS rate is 93% (CI95%: 79–100%) at 12 m and OS rate is 100% at 12 m. Tolerance to oral fludarabine was excellent with many patients preferring this formulation. Mild neutropenia was the most common toxicity, usually presenting after the third cycle. 1 pt developed a prolonged grade 4 neutropenia after the 6th cycle. No blood transfusions were required. 3 pts developed grade 2 respiratory infection, but none pt had to be admitted. Conclusions: These preliminary data indicate that the RF regimen, either with intravenous or oral fludarabine, was well tolerated even in elderly patients. This combination is very active for the treatment of untreated MALT lymphoma, even with fewer cycles than initially planned. A phase II national multicenter study is being planned.

Background: The molecular response in patients with gastric MALT lymphoma achieving histological remission after chemotherapy with or without surgery is not well established. Patients and Methods: 19 patients with gastric MALT lymphoma achieving complete histological remission after treatment with chemotherapy and/or surgery was studied retrospectively. IgVH gene rearrangements were studied by PCR in gastric biopsies obtained at diagnosis and during follow-up. Presence of t(11;18)(q21;q21) was studied by FISH or PCR. Sequencing analysis of PCR products of patients with t(11;18)(q21;q21) was performed. Results: t(11;18)(q21;q21) was present in 3 patients (15.7%) at diagnosis. Median follow-up was 73 months (13–240). In patients with complete histological remission, monoclonality was demonstrated in 11 out of 19 (58%) and maintained monoclonality in 8 out of 10 (80%) who had sequential studies. All 3 t(11;18)(q21;q21) positive patients had maintained monoclonality and sequencing analyses revealed the presence of the same mutated IgVH alleles in diagnostic and in follow-up samples. In contrast, in 2 cases without t(11;18)(q21;q21) the monoclonal rearrangements corresponded to unrelated alleles. Persistent monoclonality was detected after a median of 49 months (6–134) and did not condition histological relapses, either in negative or positive t(11;18)(q21;q21) patients. Conclusions: More than half of patients with gastric MALT lymphoma achieving histological response after chemotherapy and/or surgery have long term persistent monoclonality. t(11;18)(q21;q21) determines long term persistence of the initial lymphoma population. However, the presence of maintained monoclonality did not determine relapse.

Despite the major advances in the treatment of classical Hodgkin Lymphoma (cHL) patients, around 30% to 40% of cases in advanced stages may relapse or die as result of the disease, and current markers to predict prognosis are rather unreliable. The identification of molecular events and biological processes associated with treatment failure are essential to develop new predictive tools. We used gene expression data from 29 samples of advanced cHL patients and HL-derived cell lines in order to identify transcriptional patterns from both tumoral cells and cell microenvironment. Student t-test was used to detect genes differentially overexpressed in cell lines and in tumor samples, thus creating two databases that report for genes expressed by the tumor HRS cells and genes expressed by the microenvironment. Using Gene Set Enrichment analysis (GSEA) we identified specific gene sets enriched in both databases in patients with favorable and unfavorable outcome, respectively. To validate these pathways we designed a novel Taqman low-density array (LDA) to examine the expression of the most relevant genes in 60 formalin-fixed, paraffin embedded (FFPE) tissue samples, and correlated the results with treatment outcome. Functional pathways related to unfavorable outcome significantly enriched in the HRS cells included the regulation of the G2/M checkpoint of the cell cycle, S phase and G1/S transition, chaperons, histone modification and other signaling pathways with an important representation of the MAPK pathway. On the other hand, genes reporting for specific T-cell populations (T-cytotoxic and T-regulatory cells) and macrophage activation were found to be overexpressed in the microenvironment. The final model presents a balanced representation of these genes, including also genes encoding factors implicated in drug resistance (RRM2, TYMS and TOP2A). RNA extracted from FFPE sections yielded analyzable data for 80% of samples. LDA analysis of the genes included in the model confirmed the feasibility of this approach, and the capacity for identifying cases with increased risk of failure.LDA provides an effective technique for analyzing gene expression in FFPE tissues, and it can be used for clinical prediction in diagnostic samples, using a selection of genes identified after GSEA analysis of the initial molecular signatures. This novel Taqman LDA will be used to develop a new molecular predictor of the outcome of patients with advanced cHL.

Objectives. To evaluate clinical efficacy, molecular response and safety following the use of a regimen of fludarabine (25 mg/m2 x 3 days) Cy (1g/m2 x 1 day) and Rituximab (375 mg/m2/ x 1 day) (FCR)x 6 cycles, followed by maintenance with rituximab (375 mg/m2/week/x 4 weeks every 6 months x 2 years). (LNHF-03 Study). Patients and methods. Seventy-five (75) patients with a diagnosis of follicular NHL were included in the study between October 2004 and January 2006. The median age was 54 years (30–75). Twenty-one per cent (21%) of the patients had bulky disease. According to the FLIPI index: (0–1): 22.6%; 2: 40,3%; 3: 37,1%. Minimal residual disease (MRD): A clonal population on diagnosis was identified by means of the bcl–2/IgH major and minor rearrangement study by means of quantitative PCR rearrangements of the Igs by means of fluorescent PCR. Subsequently, samples were studied following the induction treatment and during the maintenance treatment. The analysis is performed in the 70 patients that completed the six induction regimens and were evaluated. Results. 64/70 patients were given the six cycles planned (91%). The presence of persistent cytopenia limited the cycles given in the other 6 patients to 4 or 5. Three hundred and thirty-eight (338) adverse effects were documented in the 414 cycles given to the 70 patients evaluated, almost all of them being mild, and 26 severe (degree 3–4), and almost all the cases were neutropenias. Infectious complications were frequent and many were severe: herpes zoster (5), pneumonia (5), cerebral toxoplasmosis (1), aspergillosis (1), infection by CMV (2). One patient developed erythroleukaemia within the first year following completion of the treatment. Three patients died ( CMV + aspergillosis, pneumonia, erythroleukaemia). 86% of the patients reached CR following induction, 6% unconfirmed CR and 8% partial response. On diagnosis, a clonal population was identified in 63% (45/71) of the cases. Of these 45 patients, samples are available following induction treatment in 35 cases. The molecular disease was negativised in all the cases, except one case with persistence of positive bcl2/IgH (0.3% as opposed to diagnosis) and is in uncertain CR. Of the 34 cases with negative ER, 32 are in CR or uncertain CR and 2 PR. Conclusions. The FCR regimen has proven to have a potent antitumoral activity in recently diagnosed follicular lymphoma patients with very high clinical (86% CR) and molecular (95%) responses. The immunosuppression caused is profound, with the appearance of opportunistic infections, and in some cases prolonged lymphopenias and neutropenias that call for future assessment and follow-up.