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Abstract 1459 Background. Chronic lymphocytic leukemia (CLL) is a clinically heterogeneous disease. Adverse prognostic parameters include stage, CD38 and/or ZAP70 expression, the unmutated configuration of the variable region of the Ig heavy chain gene (IGHV) and the presence of specific chromosome aberrations. Using fluorescence in situ hybridization (FISH) with probes detecting trisomy 12 and deletions at 13q14, 11q22–23/ATM and 17p13/p53, approximately 60–80% of the cases carry an abnormality. Patients without FISH aberrations (“normal” FISH) have a relatively favourable outcome. Improved mitotic stimulation using oligonucleotide (odn) and interleukin-2 (IL-2) can detect karyotype aberrations in chromosome regions not covered by the classical 4-probe panel. This study was designed to assess whether the presence of karyotypic aberrations in CLL patients with “normal” FISH may have a correlation with established clinical and prognostic parameters. Methods. Eighty-four patients with “normal” FISH results referred to our laboratory between 2007 and June 2011 were included in the present report. These patients represent consecutive CLL cases diagnosed and treated, according to the NCI criteria, at 4 GIMEMA CLL group centres between 2006 and 2011. Indications for treatment included advanced stage (Binet C) or disease progression. The Matutes immunophenotypic score was calculated giving 1 point to CD5+, CD23+, CD22weak+, sIg weak+ and FMC7- and only patients with a score ≥3 (i.e. typical CLL) were included. The coexpression of the CD38 and CD19 antigens and ZAP-70 was tested on fresh PB cells with a 20% cut-off for positivity. IGVH genes were amplified from genomic DNA and sequenced according to standard methods and the cut-off of 98% homology to the germline sequence was chosen to discriminate between mutated ( Results. An abnormal karyotype was found in 30/84 cases (35,7%) with “normal” FISH. The chromosome aberrations affected regions not covered by the 4-probe panel used by FISH. Recurring aberrations were: interstitial deletions of 14q and of 7q in 5 and 3 cases, respectively; 14q32 translocations in 2 cases, balanced and unbalanced structural changes in 1 case each. A complex karyotype with 3 or more aberrations was found in 12 patients. The correlations between karyotype and clinicobiological parameters are shown in tables 1 and 2.Table 1:Correlation between karyotype and salient clinicobiologic parametersParameterNormal karyotype (54 cases)Abnormal karyotype (30 cases)p (Fischer's exact test)Binet Stage A/B/C45/9/020/7/30.04Matutes score3/4/54/24/257/6/120.035CD38pos/neg11/4112/180.079ZAP-70 pos/neg16/3115/110.083IGHV Unmutated/ Mutated4/208/80.037Table 2:Factors affectingTTFT in univariate snalysisNumber of casesMedian TTFT months (se)pKaryotype Normal Abnormal50 34Not reached at 54 months 18 months (6.7) At multivariate analysis, the following factors were independently predictive of shorter TTFT: advanced disease Binet stage (p=0.049, Hazard Ratio 2.39 [se: 1.06]), and abnormal karyotype (p Conclusions. Conventional karyotyping using odn + IL-2 as mitogens is an effective method for the detection of chromosome aberrations in approximately 1/3 of patients with “normal” FISH on a conventional 4-probe panel. Recurrent aberrations include interstitial deletions at 14q and 7q. The current data show that, in CLL patients with “normal” FISH, conventional cytogenetic analysis using odn + IL-2 identifies a subset of cases with adverse clinical and prognostic features. Disclosures: Rizzotto: CELGENE CORPORATION: Research Funding. Cuneo:Roche: Consultancy, Speakers Bureau.

Objective: Artificial prosthesis of the superior vena cava (SVC) may occlude with time. For this reason, we proposed in 2003 the use of a biological material (bovine pericardium) and devised an original technique to construct the prosthetic conduit. We hereby report the long-term results in 15 patients. Methods: The SVC prosthetic conduit is realized by wrapping a bovine pericardial leaflet around a 5 or 10 cm 3 syringe and stapling it on the side by a 60—80 linear stapler. This procedure is carried out intra-operatively after the size of the patient’s SVC has been ascertained; the conduit is then cut to the appropriate length. We have employed this technique in 15 patients with lung (eight) or mediastinal (seven) tumors; after a minimum follow-up of 1 year, all patients underwent computed tomographic-volume rendering (CT-VR) studies of the SVC. Results: Technically, the stapled pericardial conduit has several advantages: (1) it is simple and expeditious; (2) it allows an even and regular suture line, which cannot be achieved by hand suturing; (3)‘one size fits all’: with one single pericardial leaflet, conduits of all sizes can be realized; this is important for an operation which is performed only few times per year; (4) patency is granted by the intrinsic rigidity of the pericardium and staple line, without the need for any reinforcement; (5) different calibers at the two extremities can be obtained by simply placing the stapler obliquely; and (6) the staple line is excellent for the orientation of the conduit while suturing. In our patients, SVC clamping time ranged between 18 and 50 min (mean 29 min); one patient needed cardiopulmonary bypass. Intra-operative anticoagulation (1.500—2.500 units of heparin) was continued postoperatively subcutaneously for 7 days and then shifted to oral anticoagulation for 6 months. One patient died postoperatively of heart failure (mortality 6%). One to 5 years after surgery, CT-VR showed full patency of the pericardial conduit, no clots or thrombus formation, and absence of collateral venous circulation in all 14 patients. One- and 5-year survival was 93% and 73%, respectively (Kaplan—Meier). Conclusions: The stapled bovine pericardial conduit is a simple, expeditious, and economic solution to SVC replacement, and offers reliable long-term patency without permanent anticoagulation. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Background Fludarabine, is one of the most active single agents in the treatment of chronic lymphocytic leukemia (CLL). Over time, however, virtually all CLL patients become fludarabine-refractory. To elucidate whether microRNAs are involved in the development of fludarabine resistance, we analyzed the expression of 723 human miRNAs before and 5-days after fludarabine mono-therapy in 17 CLL patients which were classified as responder or refractory to fludarabine treatment based on NCI criteria. Results By comparing the expression profiles of these two groups of patients, we identified a microRNA signature able to distinguish refractory from sensitive CLLs. The expression of some microRNAs was also able to predict fludarabine resistance of 12 independent CLL patients. Among the identified microRNAs, miR-148a, miR-222 and miR-21 exhibited a significantly higher expression in non-responder patients either before and after fludarabine treatment. After performing messenger RNA expression profile of the same patients, the activation of p53-responsive genes was detected in fludarabine responsive cases only, therefore suggesting a possible mechanism linked to microRNA deregulation in non-responder patients. Importantly, inhibition of miR-21 and miR-222 by anti-miRNA oligonucleotides induced a significant increase in caspase activity in fludarabine-treated p53-mutant MEG-01 cells, suggesting that miR-21 and miR-222 up-regulation may be involved in the establishment of fludarabine resistance. Conclusions This is the first report that reveals the existence of a microRNA profile that differentiate refractory and sensitive CLLs, either before and after fludarabine mono-therapy. A p53 dysfunctional pathway emerged in refractory CLLs and could contribute in explaining the observed miRNA profile. Moreover, this work indicates that specific microRNAs can be used to predict fludarabine resistance and may potentially be used as therapeutic targets, therefore establishing an important starting point for future studies.

Background. We present our technique of omental flap transposition performed through a thoracotomy for bronchial stump protection, and employed over 11 years. Methods. Between February 1997 and January 2008, the transdiaphragmatic harvesting of the omentum was performed, using an original technique through a thoracotomy approach, in 45 patients. Forty-three patients (29 male, 14 female), considered at high risk for bronchial dehiscence, simultaneously underwent pneumonectomy and 2 patients (1 male, 1 female) were treated for an early postpneumonectomy bronchopleural fistula by the standard thoracotomy route. The omental flap was mobilized through a radial incision in the diaphragm avoiding an additional laparotomy. The only contraindication for this technique was a previous abdominal intervention. Duration of follow-up ranged between 6 and 102 months (median, 46). Results. There were no complications related to the omentoplasty. Major complications related to pneumonectomy occurred in 4 patients (9%). Perioperative mortality rate was 2.1% (1 of 45). The non-life threatening complication rate was 11.1% (5 of 45). Postoperative hospital stay ranged between 5 and 21 days (median, 8.3) in the 43 patients undergoing prophylactic omentoplasty and was 11 and 14 days, respectively, in the 2 patients receiving omentoplasty after bronchial dehiscence. No neoplastic recurrence on the bronchial stump or late fistula occurred during follow-up. Conclusions. This technique of omental flap transposition for bronchial stump coverage through a thoracotomy is an effective method for the prevention and treatment of postpneumonectomy bronchopleural fistula. The amount of omentum obtained by this technique is appropriate for bronchial reinforcement but not for filling the pleural cavity. This procedure can be performed safely through thoracotomy access avoiding an additional laparotomy.

Objective: A prospective, randomized study to evaluate the effectiveness and safety of a polymeric sealant (Coseal W , Baxter Healthcare, Deerfield,IL) to reduce air leaks and to improve postoperative outcome in patients undergoing lung resection.Methods:BetweenNovember 2005 and February 2008, 203 (128 M, 75 F) patients showing moderate/severe intraoperativeair leaks after pulmonary lobectomy/bilobectomy/sleeve lobectomy (110) or minor resection (segmentectomy/wedge) (93) have been prospectively enrolled and randomly assigned to receive one of the two following management strategies: suture/stapling (101 patients — standard care group (SCG)) or suture/stapling plus Coseal sealant (102 patients — Coseal group (CG)). To assess the effectiveness of the sealant the following data were registered and compared in the two groups: number of patients with air leak cessation intraoperatively, number of patients without air leaks at 24 h and 48 h, duration of air leaks, length of hospital stay. Results: No adverse event related to the sealant application occurred. Intraoperative air leak cessation rate was higher in the CG with a statistically significant difference (85.3% vs 59.4%; p < 0.001). Air leaks rate at 24 h and 48 h was significantly lower in the Coseal group (19.6% vs 40.6%; p = 0.001 at 24 h and 23.5% vs 41.6%; p = 0.006 at 48 h). Duration of air leaks was significantly shorter in the Coseal group (p = 0.01). The hospital stay was shorter in the Coseal group (mean: 5.7 2.3 days vs 6.2 2.5 days) but this difference did not reach statistical significance owing to the many known clinical interfering factors. Conclusions: The application of Coseal sealant proved safe and effective in reducing air leaks occurring after lung resection and in shortening the duration of postoperative air leak with a trend towards a shorter postoperative hospital stay. # 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Study objectives The reported 5-year survival rate after pulmonary metastasectomy from colorectal carcinoma, usually accomplished through thoracotomy or median sternotomy, ranges from 9 to 47%. Video-assisted thoracoscopy (VAT) is employed routinely for many thoracic surgical procedures, but the main concern about this approach for resection of lung metastases is that VAT does not allow complete lung palpation to identify and remove metastases not detected by preoperative radiologic examinations. Design In this study, we reviewed our experience with thoracoscopic resection of single peripheral lung metastases from colorectal carcinoma with potentially curative intent. Patients and interventions From July 1992 to September 1998, 24 patients (15 male, 9 female) with a mean age of 56 years, who previously had undergone resection for colorectal carcinoma and had a single limited and peripheral lung lesion identified by high-resolution CT, underwent thoracoscopic wedge resection of the lesions. Results No intraoperative complications developed. Three patients had minor postoperative complications successfully treated. In one case, we found a benign lesion, and this patient was excluded from the analysis. In the remaining cases, metastases from colorectal cancer were confirmed. The median follow-up was 29 months, ranging from 3 to 67 months. Thirteen patients (56.5%) developed recurrence of the disease, and 5 of them (21.7%) had local recurrence. Cumulative 5-year survival estimated by Kaplan-Meier method was 49.5%, not really different from the data reported in the literature. Conclusions Thoracoscopic resection of single peripheral lung metastases from colorectal cancer with potentially curative intent seems effective and justified since the ultimate outcome of this highly selected group of patients seems to be not different from that obtained after a more invasive approach.

This article supplies a comprehensive account of the anatomy and physiology of the intercostal space, the knowledge of which is important for thoracic surgeons. A wide variety of clinical applications involve the intercostal space, ranging from simple inspection of a widened space in the emphysematous patient, to thoracentesis, to the surgical preparation of an intercostal musculopleural flap. Each of these procedures, from the simplest to the most complex, can be easier and safer if the intercostal anatomy is thoroughly understood. Because postthoracotomy pain control is one of the major issues in modern thoracic surgery, the precise knowledge of the relationships between the neuromuscular and osseous components within the intercostal space may help reduce pain and improve chest wall motility.

Circulating endothelial cells (CECs) are associated with neoangiogenesis in various malignant disorders. Using flow cytometry, we studied CECs in 128 patients with myelodysplastic syndrome (MDS). MDS patients had higher CEC levels than controls (P

Thrombosis of the cerebral veins or sinuses is a rare cerebrovascular disorder, which seldom represents a complication of acute promyelocytic leukemia. To the best of our knowledge, it never occurred during treatment with all-trans retinoic acid. We report a case of a 35-year-old woman affected by acute promyelocytic leukemia, who developed massive thrombosis of the cerebral sinuses and veins when she was in complete morphological and molecular remission after all-trans retinoic acid and idarubicin treatment. Anticoagulant therapy contributed to progressive dissolution of the thrombosis as documented by magnetic resonance imaging with complete disappearance of neurological signs without sequelae.

Sleeve resection of the pulmonary artery (PA) is rapidly gaining acceptance as an alterative to pneumonectomy in selected patients with locally advanced lung cancer. Contrary to bronchial sleeve resection, for which bronchoscopy is an important preoperative investigation tool, the evaluation of the PA is still uncertain. There is general agreement that computed tomography (CT) with the injection of contrast material is the most accurate technique, but it is often difficult, if not impossible, to discriminate between simple adhesion and infiltration of the vascular wall.

In recent years, endothelial progenitor cells (EPCs), gave rise to increasing interest because of their possible use as a therapeutic tool in the treatment of vascular lesions in ischemic tissues or as a target for anti neoplastic therapy. It has been shown that several drugs can increase the number of EPCs into the peripheral blood (PB). However, there is insufficient data concerning the mobilization and collection of EPCs during CD34+ cell mobilization. In this study, we have evaluated EPC mobilization and collection in a series of 47 patients affected by lymphoid neoplasms [31 non Hodgkin lymphoma and 16 multiple myeloma] undergoing CD34+ cell mobilization with cyclophosphamide (4000 mg/m2) and Filgrastim (5 microg/kg). PB EPCs identified by flow cytometry as CD34+/VEGFR2+/CD133+ cells showed a peak on day +10. This peak paralleled that of PB CD34+/CD45+ cells. A direct correlation was observed between CD34+ and CD34+/VEGFR2+/CD133+ cells (r = 0.99 P < 0.0001). An average of 23.7 x 10e6 CD34+/VEGFR2+ CD133+ cells have been collected (range 12.1-41.76 x 10e6). These findings showed that in hematological diseases, cyclophosphamide in combination with filgrastim allows the mobilization and collection of large numbers of EPCs which may be used for reparative medicine studies in these patients.

Long non-coding RNAs (lncRNAs) form the largest part of the mammalian non-coding transcriptome and control gene expression at various levels including chromatin modification, transcriptional and post-transcriptional processing. LncRNAs are implicated in initiation and progression of several cancers.Cancer-associated genomic regions are regions showing high frequency of cancer related abnormalities, such as loss of heterozygosity or amplifications. One such widely studied CAGR is the 8q24.21 genomic region. One SNP of particular importance present at this locus is rs6983267, with the G allele of the SNP conferring increased risk of colorectal, prostate, breast and bladder cancers. CCAT2 is a lncRNA that spans this highly conserved region. CCAT2 has been shown to play an important role in inducing chromosomal instability and supporting cell proliferation and cell cycle arrest. Despite advances in diagnosis of MDS patients, the underlying mechanisms that lead to spontaneous induction of MDS remains poorly understood. Here we attempted to elucidate the role of CCAT2 and its specific alleles (G/T) in regulation of cellular processes that drive spontaneous tumorigenesis using a genetically engineered mouse model. We generated transgenic mice for each CCAT2 allele using random integration approach in C57Bl6/N background, expressing CCAT2 in all tissues of mice. In this study, we identified that CCAT2 plays an important role in regulation of normal hematopoiesis. Constitutive in vivo overexpression of each CCAT2 transcript in the mice resulted in spontaneous induction of widespread pancytopenias. CCAT2(G/T) BM biopsies displayed severe myeloid or erythroid hyperplasia, and dysplastic megakaryocytic proliferation, along with enhanced proliferation and excessive apoptosis. Interestingly, we identified two distinct phenotypes in CCAT2(G/T) mice with equal prevalence of MDS or mixed MDS/MPN. This suggests that CCAT2 overexpression might affect regulation of hematopoietic stem cells, disturbing their self-renewal or maturation capacity, and subsequently resulting in BM failure. Percentage of HSPCs was significantly reduced in BM of MDS mice, with increased presence of immature erythroid blasts and granulocyte-macrophage progenitors suggesting a block in differentiation. HSPCs of CCAT2(G/T) mice also showed increased frequency of cytogenetic aberrations, including breaks and chromosomal fusions. However, these mice don't develop sAML, suggesting CCAT2 is critical in initiation of MDS. We further identified significantly higher CCAT2 expression in the MDS patients as compared to healthy volunteers. Patients with sAML had significantly lower expression of CCAT2 as compared to patients with only MDS. To determine the mechanism by which CCAT2 induces genomic instability and myelodysplasia, we screened for several genes that have been previously reported to induce myelodysplasia as potential targets of CCAT2. Interestingly, EZH2 was downregulated in the BMCs of CCAT2(G/T) mice compared to WT littermates. EZH2 downregulation was observed in both MDS only and MDS/MPD mice. In CCAT2(G/T) mice, EZH2 and H3K27Me3 reduction was observed in hematopoietic stem and progenitor cells (HSPCs) as well as lineage positive bulk cells,suggesting that CCAT2 might induce alteration in EZH2 levels in the HSC compartment. Interestingly, we identified miR-26a and miR-26b, that were already reported to target EZH2, were significantly overexpressed only in BM of CCAT2-G mice. These data suggests that CCAT2-G regulates EZH2 expression primarily through regulation of target miRNAs. On the other hand, we identified EZH2 to interact preferentially to CCAT2-T compared to WT or CCAT2-G transcript. These data confirmed that EZH2 preferentially binds to the CCAT2 in an allele-specific manner. In conclusion, deciphering the role of CCAT2 in spontaneously induced myelodysplasia and cytopenias will help us further characterize the poorly understood MDS/MPN phenotype. CCAT2 mice can serve as a robust model for studying initiation of de novo MDS/MPN that does not progress to secondary AML, and as a pre-clinical model for evaluation of new therapies for MDS. It has high translational potential as CCAT2 can be developed into a diagnostic and prognostic marker, as well as a novel intervention target for MDS therapy. Disclosures No relevant conflicts of interest to declare.

S26 had an alternative diagnosis for their neurologic symptoms identified after tissue biopsy and/or other work-up. On LP, lower glucose levels (median 54 mg/dL, p1⁄40.02), elevated total nucleated cells (TNC)(median 14/mL, p1⁄40.004), absolute lymphocyte count (ALC) (median 12/mL, p1⁄40.02), CLL cells percentage (median 5%, p1⁄40.05) and count (median 1.5/mL, p1⁄40.02) significantly associated with a final diagnosis of CNS involvement CLL/RS. Despite this association, none reliably discriminated as to whether the etiologies of patients’ neurologic symptoms were due to clinically significant CNS involvement by CLL/RS or another etiology. Conclusions: Neurological symptoms requiring an LP are rare in patients with CLL/SLL (4% of cases). CNS CLL/RS is a rare condition, and neurologic symptoms in patients with CLL are attributable to other etiologies in w80% of cases. Analysis of the CSF has high sensitivity but limited specificity to distinguish CNS CLL from other etiologies and additional parameters are needed. 306 Front-line Treatment with Ofatumumab in Elderly Unfit Patients with CLL Candida Vitale, Maria Ciccone, Christina Hinojosa, Michael J. Keating, Naveen Pemmaraju, Susan O’Brien, William G. Wierda, Deborah Thomas, Gautam Borthakur, Maro Ohanian, Jan A. Burger, Alessandra Ferrajoli Department of Leukemia, The University of Texas MD Anderson

Acquired von Willebrand Syndrome (AVWS) is a bleeding disorder characterized by a non-inherited low activity of von Willebrand factor (VWF), occurring in patients with no prior medical or family hi...

CASTLE seem to have a better prognosis. However, CASTLE has a potentially invasive behavior, and invasion of neighboring cervical structures is possible. In particular, tracheal or laryngotracheal resections have been necessary to excise the lesion. The extent of this invasion may sometimes prevent a complete resection or require surgically challenging procedures, as in our experience. The parietal invasion can involve the muscles, connective tissue, and skin. Nodal involvement is probably a negative prognostic factor, because it has been associated with the occurrence of locoregional or systemic spread. Adjuvant radiotherapy is generally advocated in case of nodal metastasis. On the other hand, local recurrence is possible in the absence of nodal disease, thus suggesting a role for systematic adjuvant radiotherapy because of the radiosensitivity of this tumor. References 1. Luo CM, Hsueh C, Chen TM. Extrathyroid carcinoma showing thymuslike differentiation (CASTLE) tumor: a new case report and review of literature. Head Neck. 2005;27:927-33. 2. Miyauchi A, Kuma K, Matsuzuka F, Matsubayashi S, Kobayashi A, Tamai H, et al. Intrathyroidal epithelial thymoma: an entity distinct from squamous cells carcinoma of the thyroid. World J Surg. 1985;9: 128-35. 3. Mizukami Y, Kurumaya H, Yamada T, Minato H, Nonomura A, Noguchi M, et al. Thymic carcinoma involving the thyroid gland: report of two cases. Hum Pathol. 1995;26:576-9. 4. Bayer-Garner IB, Kozovska ME, Schwartz MR, Reed JA. Carcinoma with thymus-like differentiation arising in the dermis of the head and neck. J Cutan Pathol. 2004;31:625-9. 5. Ahuja AT, Chan ESY, Allen PW, Lau KY, King W, Metreweli C. Carcinoma showing thymic-like differentiation (CASTLE tumor). AJNR Am J Neuroradiol. 1998;19:1225-8.

In multiple myeloma (MM), circulating endothelial cells (CECs) represent a vascular marker of angiogenesis and may reflect tumor mass. In this report, we showed that, in 5 MM patients with 13q14 deletion, CECs carried the same chromosome aberration as the neoplastic plasma cells (11%-32% of CECs with 13q14 deletion). Most of the CECs displayed immunophenotypic features of endothelial progenitor cells as they expressed CD133, a marker gradually lost during endothelial differentiation and absent on mature endothelial cells. To the contrary, in 3 patients with monoclonal gammopathy of undetermined significance and 13q14 deletion, CECs were cytogenetically normal and had a mature immunophenotype. In MM CECs, immunoglobulin genes were clonally rearranged. These findings suggest a possible origin of CECs from a common hemangioblast precursor that can give rise to both plasma cells and endothelial cells and point to a direct contribution of MM-derived CECs to tumor vasculogenesis and possibly to the spreading and progression of the disease. (Blood. 2006;107:2531-2535)

Surgery is the cornerstone of therapy for recurrent thymic tumors. The pattern of recurrence is, however, less defined. Between 1966 and 1988, we operated on 83 patients with thymoma, 11 of whom underwent surgery for recurrence (group I). In 1989, we initiated a prospective multimodality protocol and have enrolled 128 patients with 9 (7%) recurrences since (group II). In group I, 1 patient was originally at stage I, 2 were at stage II, 5 at stage III, and 3 at stage IV. The patients underwent 1 (#10) or 2 (#1) reoperations and 5 showed histological progression of malignancy. One patient died postoperatively, 6 died of disease, and 3 are alive and disease free 18 to 22 years after the first operation. In group 2, no patient was originally at stage I, 1 was at stage II, 4 were at stage III, and 4 at stage IV. Reoperation (5 patients) was followed by chemotherapy and 2 showed histological progression of disease. One patient died after 2 years, and 4 patients are alive after 6 to 11 years. All recurrent tumors were thymomas with cortical differentiation. Early onset of recurrence was a negative prognostic factor. Thymomas can recur also at early stages. A multimodality approach is indicated also for early stage lesions based on histology.

Using quantitative fluorescence in situ hybridisation and flow cytometry (flow-FISH), we investigated the biological and clinical relevance of telomere length in 55 patients affected by myelodysplastic syndromes (MDS) compared with 55 sex- and age-matched controls. We found that telomere fluorescence in MDS granulocytes, and CD34+ cells did not decline with age as in normal controls and that MDS granulocytes and CD34+ cells had significantly shorter telomeres than healthy controls. A significant higher incidence of cases with intermediate-unfavourable cytogenetics and International Prognostic Scoring System (IPSS) int-2/high-risk group was observed among patients with lower telomere fluorescence. We also found that apoptosis in CD34+ cells was significantly higher in IPSS int-1 low-risk patients when compared with IPSS int-2 high-risk cases and healthy controls and that CD34+ cell telomere fluorescence directly correlated with CD34+ cell apoptosis. Reduced telomere fluorescence was associated with a history of occupational exposure to toxic agents and with worse survival in univariate and multivariate analyses. Our results suggest that flow-cytometry assessment of telomere dynamics may represent a valuable tool in the biological and clinical-prognostic characterisation of MDS disorders.

The in vivo effect of recombinant human erythropoietin (rHuEpo) and granulocyte colony-stimulating factor (G-CSF) combined treatment on CD34(+) cells was evaluated by fluorescence in situ hybridization (FISH) in 13 myelodysplastic syndrome (MDS) patients with known cytogenetic abnormalities. After treatment, responsive patients presented a significantly lower proportion of FISH abnormal CD34(+) cells than before treatment (P = 0.003), and in comparison with unresponsive cases (P = 0.007). Response to treatment was associated with a reduced degree of apoptosis in CD34(+) cells (P = 0.021): however, no difference in telomere length was observed in responsive patients after growth factor administration. Although the number of patients analysed was relatively small, the present data suggest that, in MDS patients, response to rHuEpo and G-CSF may be related to the proliferation of karyotypically normal but potentially defective CD34(+) progenitor cells.

We have analyzed the kinetics of reconstitution of circulating dendritic cell (DC) subsets (myeloid-DC1 and lymphoid-DC2) in 19 patients affected by acute leukemia undergoing allogeneic hematopoietic stem-cell transplantation (HSCT). We have found that pretransplant DC1 and DC2 were lower in leukemic patients than in healthy subjects (P = 0.003 and P = 0.004, respectively) and that the number of DC2 (but not DC1) infused with the graft was higher in patients receiving peripheral blood stem cells (PBSC) (P = 0.03). Patients recovered to the pretransplant DC1 and DC2 levels within day +60; however, a normal DC1 number was reached on day +365, while DC2 remained lower than in controls up to 1 yr after transplant. DC1 reconstitution did not differ significantly between patients receiving bone marrow stem cells (BMSC) or PBSC, while patients receiving PBSC presented increased levels of DC2 on day +30 (P = 0.008) and +100 (P = 0.047) and a higher number of T lymphocytes and natural killer cells until day +365. The occurrence of graft vs. host disease (GVHD) was not influenced in our cases by DC1/DC2 graft composition, but patients with acute GVHD when compared with patients without acute GVHD presented a significantly less rapid DC recovery (DC1 P = 0.03, DC2 P = 0.009 on day +30, and DC1 P = 0.012, DC2 P = 0.006 on day +100). At the moment of relapse, a decrease of DC1/DC2 numbers was observed in four patients and the presence of two different DC populations one with a normal karyotype, and the other with the same cytogenetic abnormality as the malignant clone was detected by fluorescence in situ hybridization analysis. In conclusion, these observations suggest that in allogeneic HSCT recipients, DC recovery is a slow process possibly contributing to the high risk of infections in the post-transplant period and is possibly influenced by the source of HSC, the occurrence of GVHD and relapse. Further studies are warranted to investigate the significance of DC reconstitution in the transplant setting.

Objective: Surgery is the first line of treatment for laryngotracheal stenosis; Montgomery tube or permanent tracheostomy have been so far the only alternatives. Nd-YAG laser resection and indwelling endotracheal stents have rarely been used in subglottic stenosis for anatomic and technical reasons. We have used the latter approach to optimize the timing of surgery or to achieve palliation without tracheostomy. Methods: Between 1991 and 2001 we have treated 18 patients with subglottic stenosis (10 males, 8 females; age range 14‐78, mean 34). The upper margin of the stricture was 2 mm to 1 cm below the vocal cords; the stenotic segment extended from 1.5 to 5 cm. Three patients had tracheostomy done elsewhere. Four patients (Group I) had laser and stenting by a Dumon prosthesis as the only treatment; six had laser and stenting (#4) followed after 1‐6 months by laryngotracheal resection (Group II); eight had surgery alone (Group III). Results: In Group I, one patient required repositioning of the stent and in two the stent was removed; two patients died of their underlying disease; at a follow-up of 2‐9 years all living patients did well but required permanent aerosolized therapy and periodical bronchoscopy. In Group II, we had two wound infections due to airway colonization by staphylococcus aureus. In Group III, two patients developed anastomotic postoperative stenosis, treated by laser (#2) and stenting (#1), and one patient with previous tracheostomy had a wound infection. Overall, in the 14 surgical patients (Groups II and III) stenosis occurred in 14.2% and infection in 21.3%. After a follow up of 15 months to 12 years, all surgical patients breathe and speak well. Conclusions: Laser resection and endoluminal stenting can be a viable alternative to surgery or optimize the timing of operation in patients with subglottic stenosis. q 2004 Elsevier B.V. All rights reserved.

Objective: Numerous reports have confirmed the early benefits of lung volume reduction surgery for selected patients with emphysema. This report documents the long-term survival and functional results after lung volume reduction surgery. Methods: Between January 1993 and June 2000, a total of 250 consecutive patients underwent bilateral lung volume reduction surgery through median sternotomy at our institution. All patients had disabling dyspnea, thoracic hyperinflation, and a heterogeneous pattern of emphysema with suitable target areas for resection. Preoperative pulmonary rehabilitation was required and post-rehabilitation data were used as the baseline for data analysis. Follow-up ranged from 1.8 to 9.1 years (median 4.4 years). Results: Prolonged air leaks (>7 days) were the most common complication (45.2%, n=113). Reexploration rates for air leak and bleeding were 3.2% (n = 8) and 1.2% (n = 3), respectively. Eighteen patients (7.2%) required reintubation and mechanical ventilation. The in-hospital mortality in this series was 4.8% (n = 12). The median length of hospitalization was 9 days (range 4-168 days). Kaplan-Meier survivals after lung volume reduction surgery were 93.6%, 84.4%, and 67.7% at 1, 3, and 5 years, respectively. Eighteen patients (7.2%) have subsequently undergone lung transplantation after a median interval of 4.3 years (range 2.1-6.4 years). Spirometric values, lung volumes, and gas exchange parameters improved after surgery. The forced expiratory volume in 1 second and the residual volume showed statistically significant improvements between preoperative values and each time point of follow-up. Health-related quality of life showed significant postoperative improvement and with time correlated well with the improvement in forced expiratory volume in 1 second. Conclusions: Lung volume reduction surgery produces significant functional improvement for selected patients with emphysema. For most of these patients, benefits appear to last at least 5 years. J Thorac Cardiovasc Surg 2003;125:513-25

The urokinase-type plasminogen activator (uPA) system, which consists of a proteinase (uPA), a receptor (uPAR or CD87) and inhibitors, is involved in proteolysis, cell migration, tissue remodelling, angiogenesis and cell adhesion. Recent findings suggest that malignant plasma cells express uPA and uPAR. The expression of these factors could represent a process by which myeloma plasma cells interact with the bone marrow (BM) environment and influence important biological events such as bone matrix degradation, plasma cell invasion and homing and, possibly, clinical evolution. We evaluated uPAR (CD87) and its soluble form (suPAR) in 49 multiple myeloma (MM) patients and correlated their expression and levels with clinico-biological characteristics of the disease. Flow cytometric analysis demonstrated that CD87 was expressed in all MM patients. High CD87 expression was associated with higher intensity of expression of CD56 (P = 0.038), CD38 (P = 0.058) and CD138 (P = 0.054) and CD45bright positivity (P = 0.014). suPAR levels correlated positively with soluble serum CD138 (P = 0.001), creatinine (P = 0.001), beta2-microglobulin (P0.001), disease stage (P = 0.017) and extra-BM involvement (P = 0.002). In the 46 evaluable patients, multivariate analysis showed that high levels of suPAR (P = 0.0214) and disease stage (P = 0.0064) were predictive of extra-BM involvement. In multivariate Cox analysis, 13q deletion (P = 0.0278), high soluble serum CD138 (P = 0.0201) and high suPAR (P = 0.0229) were the only parameters that independently affected survival. We conclude that CD87 is expressed on myeloma plasma cells and that suPAR, which predicts extra-BM involvement and poor prognosis, possibly represents a molecule with a relevant role in the biology of MM.

The isolated retroperitoneal malignant schwannoma unassociated with Von Recklinghausen's disease is an unusual neoplasm, representing 0.01% of all retroperitoneal malignant neoplasms, with a poor prognosis, and an average survival at 5 years of 50% in patients treated by radical exeresis. At present, it is impossible, without histologic and immunohistochemical examinations, to differentiate it from other isolated retroperitoneal sarcomatous neoplasms. The authors report a case of retroperitoneal malignant schwannoma 20 cm in diameter in a 62-year-old woman surgically treated by radical exeresis. Postoperative complications were absent, and the patient, discharged from the hospital on the 12th postoperative day, died 8 months later of diffuse metastases, withouth local relapse. Despite the patient's short survival, the authors believe radical surgery to be the best therapeutic choice. Only surgery can establish a final diagnosis and can offer the best chance of survival and a significant and sometimes prolonged relief of symptomatology.

The issue of whether, in patients affected by myelodysplastic syndromes (MDS), haematological response to cytokines, particularly to recombinant human erythropoietin (rHuEpo), is a phenomenon related to the stimulation of normal haemopoietic cells or to the differentiation of cells belonging to the abnormal clone remains an open question. To assess the pattern of response to rHuEpo treatment of bone marrow (BM) cells, we evaluated in 13 low-risk MDS patients with known cytogenetic abnormalities the number of cytogenetically normal and abnormal cells by conventional cytogenetic analysis (CCA) and by a fluorescence in situ hybridization (FISH) technique, enabling the simultaneous visualization of FISH chromosomal abnormalities in morphologically and immunophenotypically identifiable BM elements. Patients responding to rHuEpo presented a lower number of abnormal metaphases at diagnosis in comparison with patients who did not respond (22.74% vs 76.23%, P =0.001). This was confirmed by the combined morphological FISH analysis, showing that, before treatment, BM samples from patients responding to rHuEpo had a lower proportion of both FISH abnormal erythroid (36.48% vs 66.93%, P = 0.002) and myeloid (40.76% vs 67.70%, P = 0.014) elements than unresponsive patients. After rHuEpo treatment, responding patients presented a significantly lower proportion of FISH abnormal erythroid precursors than observed before treatment (16.93%vs 36.48%, P = 0.017). Likewise, in responding patients, a significantly lower proportion of FISH abnormal erythroid elements (16.93% vs 66.30%, P0.001) was detected in comparison with unresponsive patients. These findings provide evidence that, in low-risk MDS patients with known cytogenetic abnormalities, response to rHuEpo may be due to the proliferation of karyotypically normal erythroid precursors, possibly representing residual normal erythroid elements.

Background: Accumulating evidence suggests that the donor's cause of death may influence posttransplantation allograft function. We conducted a retrospective analysis of our adult lung transplant experience to investigate the influence of donor traumatic brain injury versus nontraumatic brain injury on posttransplantation outcome. Methods: We retrospectively reviewed donor records and recipient medical charts for 500 consecutive lung transplants performed between July 1988 and December 1999. Recipient follow-up was complete, with a minimum follow-up of 1 year of survival. Results: There were 295 and 205 donors in the traumatic and nontraumatic brain injury groups, respectively. Young male donors predominated in the traumatic brain injury group. Recipients receiving donor lungs from the traumatic and nontraumatic brain injury groups did not differ by age, sex, diagnosis, type of transplant (single-lung versus double-lung) or requirement for pretransplantation mechanical ventilatory assistance. Recipients did not differ in immediate or 24-hour PaO 2 /inspired oxygen ratio, ventilation time, hospital stay, hospital mortality, or overall survival. Recipients of organs from donors who died of traumatic brain injury showed a higher severity and frequency of rejection episodes during the first year after transplantation. Freedoms from bronchiolitis obliterans syndrome at 5 years were 34.5% and 50.8% for recipients of organs from donors who died of traumatic and nontraumatic brain injury, respectively ( P =.002). Conclusions: The cause of donor brain death does not appear to influence early results of lung transplantation. Traumatic brain injury, or some phenomenon associated with it, may predispose a transplanted lung and its recipient toward more severe early rejection episodes and subsequent development of bronchiolitis obliterans syndrome. J Thorac Cardiovasc Surg 2002;123:429-36

Treatment of most primary mediastinal tumors is based on positive histological diagnosis; we describe a variation of anterior mediastinoscopy under local anesthesia. After infiltration with local anesthetic, a transverse skin incision is made in the second, third, or fourth interspace. The endothoracic fascia is incised vertically adjacent to the periosteum and a mediastinoscope is inserted in the mediastinum. Between 1995 and 2001, we have employed this technique in 46 patients with anterior mediastinal tumors. Histological diagnosis was obtained in all patients. Pneumothorax (2 patients) was drained by a tube removed at the end of the procedures. No other complications occurred and all patients were discharged from hospital within 24 hours. Mediastinoscopy under local anesthesia proved safe and effective for diagnosing anterior mediastinal tumors.

Background . Lobectomy associated with reconstruction of the pulmonary artery (PA) is a technically feasible alternative to pneumonectomy in patients with lung cancer. However, concern about postoperative complications and long-term survival limited its acceptance so far. Methods . Between 1989 and 1996, we performed a PA reconstruction in 52 patients (41 men, 11 women; age range 35 to 75 years, mean 60 years) with lung cancer. Eleven patients had induction chemotherapy. We performed 15 PA sleeve resections, 34 PA reconstructions by a pericardial patch, and three PA reconstructions by a pericardial conduit, associated with a bronchial sleeve lobectomy or bilobectomy (33), or with standard lobectomy (19). Immediate and long-term postoperative evaluation included spirometry, echocardiography, perfusion lung scans, computed tomography, and PA angiography. The follow-up ranged between 27 and 96 months and is complete for all patients. Results . We had one specific postoperative complication (PA thrombosis) and no mortality. Perfusion scans and PA angiography were normal in all but the 1 patient having thrombosis. Mean forced expiratory volume (FEV) in 1 s and forced vital capacity (FVC) were, respectively, 72% and 80% preoperatively, 65% and 76% 1 month after surgery, and then they plateaued at 70% and 78% after 6 months. Echocardiography showed patterns in the normal range and normal estimates of PA pressures in all but 2 patients. Five-year survival was 38.3% for the entire group, 18.6% for stages IIIA and B, and 64.4% for stages I and II. Conclusions . Morbidity, mortality, and functional data do not differ from what is currently reported for standard lobectomy. Long-term survival is in line with that reported for standard resection. These data support PA reconstruction as a viable option in the treatment of lung cancer.

Objective: We used induction chemotherapy in a prospective, single-institution clinical trial intended to achieve resectability in patients with centrally located, unresectable T4 non–small cell lung cancer. Other types of IIIB disease were excluded. Methods: Between January 1990 and April 1996, we enrolled 57 patients with histologically confirmed non–small cell lung cancer. Eligibility criteria for T4 were clinical (superior vena cava syndrome, 9 patients), vocal cord paralysis (6 patients), dysphagia from esophageal involvement (1 patient), radiologic (computed tomography and magnetic resonance evidence of infiltration, 10 patients), bronchoscopic (tracheal infiltration, 11 patients), and thoracoscopic (histologically proven mediastinal infiltration, 20 patients). After 3 cycles of cisplatin (120 mg/m 2 ), vinblastine (4 mg/m 2 ), and mitomycin (2 mg/m 2 ), patients were reevaluated. Results: Forty-two patients (73%; 36 men, 6 women; age range, 42-75 years; mean, 58 years) responded to therapy and underwent thoracotomy; 11 patients did not respond, and 4 patients had major toxicity. Thirty-six patients (63% of the entire group) had complete resection. We performed 4 exploratory thoracotomies, 6 pneumonectomies, 32 lobectomies (20 procedures were associated with reconstruction of hilar-mediastinal structures). Overall, 4 patients had no histologic evidence of disease. We had 2 bronchopleural fistulas with 1 death and 5 other major complications. Overall survival at 1 and 4 years is 61.4% and 19.5%, respectively. Forty-two patients (73%) underwent exploratory operation, with a 4-year survival of 25.9%; 36 patients (63%) had complete resection, with a 4-year survival of 30.5%. Conclusions: Induction chemotherapy is effective for downstaging and surgical reconversion of centrally located T4 non–small cell lung cancer. Survival is promising, especially in patients whose disease becomes resectable. (J Thorac Cardiovasc Surg 1999;117:225-33)

Objective: Retrograde pneumoplegia seems to improve early graft function in experimental and clinical lung transplantation. We evaluated the role of retrograde flushing in addition to antegrade pneumoplegia in clinical lung transplantation. Methods: Fourteen patients undergoing lung transplantation were randomized into 2 groups: in group I we performed antegrade pulmonary artery flushing with alprostadil (prostaglandin E 1 ) and modified Euro-Collins solution at the time of retrieval. In group II additional retrograde flushing through the pulmonary veins was performed at the back table, before reimplantation. Hemodynamic variables, mean airway pressure, and blood gas analysis were monitored at different time points. Postoperative volumetric monitoring was performed to assess extravascular lung water. The reimplantation response was assessed by a radiographic score; extubation time and intensive care unit stay were recorded. Results: During retrograde flushing, blood and clots coming out from the pulmonary artery were observed; 2 lungs harvested from a donor with multiple bone fractures had fat emboli in the retrograde perfusate. Hemodynamic monitoring did not demonstrate any difference between the 2 groups. The ratio of arterial oxygen tension to inspired oxygen fraction, extravascular lung water, duration of intubation, and length of stay in the intensive care unit were improved in group II, but the differences did not reach statistical significance. Intrapulmonary shunt fraction was significantly improved in group II at each time point ( P = .02), as well as indexed alveolar-arterial oxygen tension gradient ( P = .04), mean airway pressure ( P = .04), and chest x-ray score ( P = .03). Conclusions: Preimplantation retrograde flushing is not detrimental and helps to improve early graft function. (J Thorac Cardiovasc Surg 1999;118:107-14)

Objective: Surgical treatment of bullous emphysema has received renewed attention because of recent advances in minimally invasive techniques. We describe our experience in the thoracoscopic management of patients with bullous emphysema over the last 5 years. Methods: Twenty-five patients (24 male, one female) with a mean age of 57 years with giant bullae associated with various degree of underlying emphysema, were operated on thoracoscopically at our Institution. The severity of the emphysema was classified according to the criteria of the American Thoracic Society: five patients were in stage I (FEV1 . 50%), eight patients were in stage II (FEV1 35 to 49%) and 12 patients were in stage III (FEV1 , 35%). Nine patients underwent operation to treat complications related to bullae, 12 presented dyspnoea and four were asymptomatic. We performed 23 unilateral and two bilateral staged thoracoscopic procedures. Results: No intraoperative complications developed. Mean operative time was 107 ^ 25 min. No patient dead. Mean post-operative chest tube duration was 8 ^ 4:13 days and mean post-operative hospital stay was 11 ^ 5:76 days. The most frequent post-operative complication was air-leakage that in 12 patients lasted more than 7 days. Pulmonary function tests were obtained 3‐6 months after the operation and statistical comparison between pre-operative and post-operative data was performed using Student’s paired t-test. We observed best results in I and II stage patients, but also stage III patients experienced clinical improvement and better quality of life. Conclusions: Our experience supports the safety and effectiveness of video-assisted thoracoscopy for the treatment of giant bullae. Minimally invasive approach is fully justified especially in the group of patients with severe impairment of lung function. q 1999 Elsevier Science B.V. All rights reserved.

Objective: Patients undergoing pulmonary resections often present postoperative air leaks of varying magnitude and duration; this complication is more frequent with incomplete or absent interlobar fissures. Small leaks close spontaneously within 5-7 days; larger leaks may persist longer and could be associated with increased morbidity and prolonged hospitalization. We evaluated the role of different techniques to complete interlobar fissures before pulmonary lobectomy to prevent postoperative air leaks and reduce hospital stay and costs. Methods: A total of 30 patients undergoing pulmonary lobectomy for lung cancer and presenting incomplete interlobar fissures that needed to be opened both anteriorly and posteriorly were randomized into three groups. In Group I, fissures were created with a GIA stapler and buttressed with bovine pericardial sleeves. In Group II, we used TA 55 staplers alone; in Group III we used the 'old fashion' cautery, clamps and silk ties. The three groups were homogeneous for age, type of pulmonary resection and stage of the tumor. The duration of postoperative air leaks and hospital stay were compared with the one-way variance analysis. Results: Postoperative air leaks for Groups I, II and III persisted for 2 ± 0.94, 5.3 ± 2 and 5.3 ± 1.7 days, respectively. Mean hospital stay was 4.4 ± 0.96, 7.8 ± 2.14 and 7.2 ± 1.5, respectively. The difference between groups in terms of duration of postoperative air leaks and hospital stay was statistically significant (P = 0.0001). Conclusions: The use of GIA staplers and pericardial sleeves to complete interlobar fissures for pulmonary lobectomy significantly reduces the duration of postoperative air leaks and hospital stay; no complications were associated with this technique.

Between November 1996 and November 1997 we have transplanted 13 patients with Cystic Fibrosis (CF). Bilateral Sequential Lung Transplantation (BSLT) was successfully performed in all patients; one patient died from pneumonia and sepsis in the postoperative period and 12 are alive and well after a follow-up ranging between 1 and 13 months. Blood gas analysis improved from mean values of PaO2: 56 mm/Hg (with oxygen) and PaCO2: 43 mm/Hg to mean values of PaO2: 85 mm/Hg and PaCO2: 37 mm/Hg. Pulmonary function tests also improved dramatically: FEV1 improved from 20% predicted to 98% predicted. FVC also improved from 39% to 100%. The quality of life markedly improved: the ideal body weight moved from about 84% to normal values within nine months, and the 6-minute walk-test improved after transplantation from a preoperative distance of 325 meters, to 600 meters after 6 months. In conclusion, our favorable experience with BSLT in CF patients emphasizes the importance of lung transplantation in these patients. Carefully selected and properly managed patients may benefit from transplantation in terms of quality and duration of life.

Bronchial dilation is usually required to treat a number of disorders; the most frequent are complications after airway surgery, including lung transplantation, stenosis after radiotherapy, and compression by an extraluminal mass. The procedure is performed by forcing the tip of a rigid bronchoscope through the stenosis using barrels of increasing size; however, when there is a clear discrepancy between the caliber of the rigid instrument and the stenosis, the first step may be difficult. In such cases, we have successfully employed two types of old-fashioned esophageal dilators rescued from the armamentarium of our endoscopy unit.

Objectives: The ‘clamshell incision’ is considered the standard approach for bilateral sequential lung transplantation (BSLT); however, a considerable morbidity may be related to this incision. The bilateral anterolateral thoracotomy without sternal division is an alternative approach that may contribute to avoid chest wall complications. Methods: We have employed this approach in a prospective series of 34 patients undergoing bilateral transplantation (Group I). The results were retrospectively compared with an historical control group of 37 patients (Group II) undergoing transplantation through the clamshell incision. Results: The operative time in Groups I and II were 228 ^ 32 and 293 ^ 37 min, respectively; the difference between the ischemic time of the first and second lungs were 68 ^ 20 and 73 ^ 15 min. Intensive care unit stay was 5 ^ 6 vs. 13 ^ 10 days and length of hospitalization was 25 ^ 16 vs. 32 ^ 10 days. Vital capacity measured 3 weeks after the transplant was significantly higher in Group I (65 ^ 13 vs. 45 ^ 8% predicted) as well as FEV1 (71 ^ 8 vs. 58 ^ 7% predicted). No wound related complication was observed in Group I; in Group II, there were 17 chest wall complications: sternal osteomyelitis in three patients (surgical debridement and closure with a muscle flap), migration of the Kirshner wire in three (removal of the wire), sternal override in three (surgical correction) and prolonged pain in eight. Conclusions: The bilateral anterolateral thoracotomy without sternal splitting is a safe and effective approach for BSLT; it allows to avoid sternal complications and contributes to improve respiratory function in the early postoperative period. q 2003 Elsevier Science B.V. All rights reserved.

Abstract 2429 Up to 80% of Chronic Lymphocytic Leukemia (CLL) harbour clonal chromosome aberrations having important clinical implications (i.e. 13q deletion, +12, 11q/ATM and 17p/TP53 deletions). 14q32/IGH rearrangements were recently found in 6–19% of CLL patients and were associated with therapy-demanding disease and inferior outcome. Whereas evidence was provided that some of the classical aberrations, such as 11q-, 17p-, may appear late in CLL clinical history, no information is presently available concerning 14q32/IGH translocations. The aim of this study was i) to analyze the incidence of 14q32/IGH translocations occurring at clonal evolution in CLL, ii) to analyze the clinicobiologic significance of late-appearing 14q32/IGH translocations. One hundred-five CLL cases seen at our institution in a 10-year period were submitted to FISH analysis at diagnosis or before 1st line treatment as part of routine diagnostic workup. In 47 patients with indolent disease (untreated or treated with 1 line without relapse, group 1) FISH analysis was repeated after 48–96 months (median 72). In 58 relapsed patients who started 2nd line treatment (group 2), FISH was performed sequentially before administration of the 2nd line and before each subsequent line of therapy. These 105 patients fulfilled the following criteria: a) diagnosis of bona fide CLL based on morphology and immunophenotyping (CD5/CD19+, CD23+ as minimal requirement), b) clinical records available for review, c) successful FISH analysis at diagnosis and during follow-up. Those cases with t (11;14)(q13;q32)/CCND1-IGH or other 14q32/IGH translocations present at diagnosis were excluded from this study. Sequential FISH studies were performed in all patients on peripheral blood (PB) samples using commercially available probes for the identification of deletions at 13q14, 11q22/ATM, 17p13/TP53, of trisomy 12 and of 14q32/IGH translocations. In 10 patients bone marrow (BM) aspiration and/or lymph node (LN) biopsy were studied by FISH as well. The patients were treated at disease progression as defined by NCI criteria. Refractory disease was defined by stable disease or progressive disease during treatment or disease progression within 6 months of from antileukemic treatment using fludarabine alone or in combination with other agents. Time to chemorefractoriness was measured from date of first line treatment to date of refractoriness to fludarabine containing regimen or date of last follow-up. Overall survival was measured from diagnosis to date of last follow-up or death and from initiation of first line treatment to the date of death or last follow-up. At diagnosis 39% of the cases had 13q-, 14% had +12, 7% had 11q- and 3% had 17p-. A late-appearing 14q32/IGH rearrangement was not detected among 47 patients in group 1, whereas 7/58 cases (12,1%) in group 2 showed a 14q32/IGH break in 16–25% of the cells. These 7 patients had the following aberrations at diagnosis: 13q- and 11q- in 1 case, 13q- in 2 cases; 11q- in 1 case, +12 in 2 cases, no aberrations 1 case. The 14q32 translocation appeared after a median time of 64 months (range 51–91). It was associated with the appearance of 17p- in 3/7 cases with one of these presenting also biallelic del13q. In two cases paired BM or LN sample and PB samples were available for FISH studies and the appearance of IgH translocation in the BM or in the LN sample preceded its appearance in PB by 13–58 months. All 7 cases with late appearing 14q32/IGH translocation developed chemorefractoriness to fludarabine regimen with a median TTC of 27 months (range 12–40 months), as compared with a TTC of 67 months (range 1–143 months) in 51 treated patients who did not develop the 14q32 translocation (p=0.0002). Overall survival did not differ significantly either when measured from diagnosis or from 1st line treatment in 7 patients with 14q32 translocation as compared with the appropriate control. We arrived at the following conclusions: i) a late-appearing 14q32/IGH translocation occurred at a relatively high incidence (12,1%) in patients with relapsing disease and not in patients with stable disease, ii) this aberration involved a minority of cells and, in approximately half of the cases, it was associated with other aberrations, reflecting complex clonal evolution, iii) in 2 assessable cases it first appeared first in the BM or LN; iv) the appearance of 14q32/IGH translocation was associated with shorter TTC. Disclosures: No relevant conflicts of interest to declare.

Objective Reconstruction of the pulmonary artery in association with lung resection is technically feasible with low morbidity and mortality. To assess long-term outcome, we report our 20-year experience. Methods Between 1989 and 2008, we performed pulmonary artery reconstruction in 105 patients with non–small cell lung cancer (tangential resections not included). Twenty-seven patients received induction therapy. We performed 47 pulmonary artery sleeve resections, 55 reconstructions by pericardial patch (with 3 left pneumonectomies under cardiopulmonary bypass), and 3 by pericardial conduit. In 65 patients, a bronchial sleeve resection was associated; in 6 cases superior vena caval reconstruction was also required. Fifteen patients had stage IB disease, 37 stage II, 31 IIIA, and 22 IIIB. Sixty-one patients had epidermoid carcinoma, and 38 adenocarcinoma. Mean follow-up was 46 ± 40 months. Results The procedure–related complications were 1 pulmonary artery thrombosis requiring completion pneumonectomy and 1 massive hemoptysis leading to death (operative mortality, 0.95%); 28 patients had other complications, with the most frequent prolonged air leakage. Overall 5-year survival was 44%. Five- and 10-year survivals for stages I and II versus stage III were, respectively, 60% versus 28% and 25% versus 12%. Five-year survivals were 52.6% for N0 and N1 nodal involvement versus 20% for N2; 10-year survivals were 28% versus 3%. Multivariate analysis yielded induction therapy, N2 status, adenocarcinoma, and isolated pulmonary artery reconstruction as negative prognostic factors. Conclusions Pulmonary artery reconstruction is safe, with excellent long-term survival. Our results support this technique as an effective option for patients with lung cancer.

Objective: Lung transplantation is a viable option for patients with cystic fibrosis. The current strategy of selection, based on spirometry and deterioration of quality of life, results in a high mortality on the waiting list. We reviewed the case histories of patients with cystic fibrosis accepted for lung transplantation to ascertain whether pulmonary hemodynamics could contribute to predict life expectancy. Methods: Forty-five patients with cystic fibrosis were accepted: 11 died on the waiting list (group I), 24 underwent transplantation (group II), and 10 are still waiting (group III). During evaluation we recorded spirometry, oxygen requirement, ratio of arterial oxygen tension to inspired oxygen fraction (PaO 2 /FIO 2 ), arterial carbon dioxide tension (PaCO 2 ), 6-minute walk test results, right ventricular ejection fraction, echocardiography, and pulmonary hemodynamics. We compared data from group I, II, and III patients. A comparison was also made within group II between the data collected at the time of evaluation and at the time of transplantation to quantify the deterioration during the waiting time. Results: The waiting time, spirometry, 6-minute walk test results, and right ventricular ejection fraction did not differ among the three groups. A statistically significant difference was found for PaO 2 /FIO 2 , PaCO 2 , mean pulmonary artery pressure, cardiac index, pulmonary arterial wedge pressure, and intrapulmonary shunt between groups I and II. Groups I and III showed statistically significant differences for mean pulmonary artery pressure, PaO 2 /FIO 2 , and systemic vascular resistance indexed. No differences were observed between groups II and III. The comparison within group II showed a significant deterioration of pulmonary hemodynamics during the waiting time. Conclusions: Pulmonary hemodynamics are worst in patients dying on the waiting list and deteriorate significantly during the waiting time. They may thus contribute to establish priority for lung transplantation in patients with cystic fibrosis. (J Thorac Cardiovasc Surg 2000;119:682-9)

Introduction Hemophagocytic Lymphohistiocytosis (HLH) is a rare disorder characterized by an ineffective T-cell and NK response resulting in an exuberant cytokine production. Ibrutinib is an oral irreversible inhibitor of Bruton Tyrosine Kinase (Btk) significantly improving objective responses in patients with relapsed/refractory Chronic Lymphocytic Leukemia (CLL). We report the diagnostic work up and the clinical course of a case of HLH occurring in a patient with relapsed CLL during treatment with ibrutinib. Case report: the patient was a 77-years-old male diagnosed with CLL at the age of 70. At time diagnosis, the disease presented with unfavorable prognostic markers (CD38pos, ZAP70pos and unmutated IGVH). Two years later, the patient developed progressive lymphoadenopathy and a fludarabine-based regimen was administered. No objective response was observed and multiple lines of treatment attained only partial short lasting responses. In the presence of refractory disease with del17p Ibrutinib at a daily dose of 420 mg was started. On day 7 of treatment, febrile neutropenia occurred that did not benefit from antibiotics therapy. Due to persistent fever and deterioration of the clinical picture on day 16, Ibrutinib was hold and the patient hospitalized. Blood counts progressively dropped and disseminated intravascular coagulation complicated the clinical course. Additionaly, splenomegaly, hypertriglyceridemia and unexplainable severe hyperferritinemia (23,023 ng/mL) were encountered. The occurrence of 5 out of 8 diagnostic criteria allowed for a diagnosis of HLH to be made and treatment with dexamethasone, in combination with cyclosporin A and intravenous immunoglobulin, was started (Figure 1). We performed viral genome load and cytokine dosage tests on sera samples, showing high serum EBV genome title. In consideration of the activity of anticytokine treatment in the setting of HLH, the patient was treated by anti-interleukin(IL)-6 receptor Tocilizumab. Despite intensive supportive treatment, irreversible multiorgan failure developed with life-threatening bleeding and death. We retrospectively measured at two different time points the levels of interleukin (IL)1beta, IL2, IL6, IL10, IL12, IL18 and TNFalfa. In both samples, the IL1beta, IL6, IL10 and IL18 were significantly elevated compared with two healthy controls (Figure 2). Conclusion: HLH is a rare occurrence in CLL and the relationship with ibrutinib treatment is uncertain in this patient. However it is worth noting that off-target effects of ibrutinib may include downregulation of CD8/NK activity which may be involved in initiating HLH. The demonstration of IL6 elevated levels confirmed that Tocilizumb may be effective in the treatment of HLH. Figure 1. Clinical and laboratory parameters trend in a patient with CLL developing HLH. Serum ferritin and temperature were significantly elevated from hospital admission to death. Although frozen plasma, red packed cells and platelet transfusions, the fibrinogen, hemoglobin and platelet count progressively dropped. Ferritin, serum ferritin in ng/mL; plt, platelet count, x10e3/mm3; fibrinogen, plasma fibrinogen mg/dL; Hb, hemoglobin in g/dL; and T, temperature in Celsius grade (°C). Figure 1. Clinical and laboratory parameters trend in a patient with CLL developing HLH. Serum ferritin and temperature were significantly elevated from hospital admission to death. Although frozen plasma, red packed cells and platelet transfusions, the fibrinogen, hemoglobin and platelet count progressively dropped. Ferritin, serum ferritin in ng/mL; plt, platelet count, x10e3/mm3; fibrinogen, plasma fibrinogen mg/dL; Hb, hemoglobin in g/dL; and T, temperature in Celsius grade (°C). Figure 2. Cytokines levels before the administration of Tocilizumab. IL18, IL1beta, IL10, and IL6 serum levels were significantly elevated at two different time points (3512 and 3515) compared with the serum from two healthy donors (Control1, CTRL1; and control2, CTRL2). Figure 2. Cytokines levels before the administration of Tocilizumab. IL18, IL1beta, IL10, and IL6 serum levels were significantly elevated at two different time points (3512 and 3515) compared with the serum from two healthy donors (Control1, CTRL1; and control2, CTRL2). Disclosures Off Label Use: Tocilizumab for the treatment of HLH. Cuneo:Roche: Speakers Bureau; Gilead: Speakers Bureau; Jannsen: Speakers Bureau; Celgene: Speakers Bureau; Novartis: Speakers Bureau.

Bilateral lung transplantation is actually considered a valuable option for patients with endstage lung disease related to cystic fibrosis. Timing is crucial to transplant successfully as many patients as possible and it is mainly based on the progressive worsening of pulmonary function tests and quality of life. We reviewed the charts of all patients accepted for lung transplantation at our institution, in order to assess the role of several functional and demographic parameters; we compared the group of patients able to successfully wait for transplantation (Group A) with patients dying on the waiting list (Group B). Twenty-eight patients were accepted: 15 were successfully transplanted (2 at other institutions) (mean waiting time: 117 days), 7 died waiting (mean waiting time: 108 days) and 6 are still on the list. We recorded FEV-1, FVC, PaO2, PaCO2, supplemental O2 requirement, 6-minute walking test, right ventricular ejection fraction (RVEF) and cardio-pulmonary hemodynamics measured at right heart catheterization; we recorded also age at time of diagnosis and at time of evaluation, sex, weight and Schwachman score. These parameters were compared between Group A and B. Age at time of evaluation, sex, weight and Schwachman score did not present any difference between the two groups, as well as pulmonary function tests, PaO2, 6-minute walk test and RVEF. A statistically significant difference was found in terms of PaCO2 (43.9 +/- 9.3 in Group A vs 69.1 +/- 32.4 in Group B, heart rate at rest (102 +/- 21 vs 131 +/- 12) mean pulmonary artery pressure (20.6 +/- 2.9 vs 36 +/- 15.7), pulmonary vascular resistances (350 +/- 96 vs 460 +/- 119.4), cardiac index (3.2 +/- 0.6 vs 5.4 +/- 0.9). On the base of our initial experience we conclude that a careful evaluation of CF candidates for lung transplantation is recommended. A deterioration of pulmonary function tests and quality of life are useful parameters to accept patients in the waiting list; however priority should be attributed also on the base of cardio-pulmonary hemodynamics. A larger series of patients is required to draw definitive conclusions.

Chronic lymphocytic leukemia (CLL) is the most common leukemia among adults in western countries. This SnapShot depicts the origins and evolution of this B cell malignancy, describes prognostic factors and CLL animal models, and illustrates therapies in preclinical and clinical development against CLL.