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Background: The phase 3 GIMEMA-MMY-3006 trial, which compared bortezomib, thalidomide, and dexamethasone (VTD) combination therapy with thalidomide and dexamethasone (TD) as induction therapy before and consolidation therapy after double autologous haematopoietic stem-cell transplantation (HSCT) for newly diagnosed multiple myeloma, showed the superiority of the triplet regimen over the doublet in terms of increased complete response rate and improved progression-free survival. We report the results from the final analysis of the study. Methods: In this randomised, open-label, phase 3 study, patients aged 18–65 years with previously untreated symptomatic multiple myeloma and a Karnofsky Performance Status of 60% or higher were enrolled at 73 centres in Italy. Patients were randomised (1:1) by a web-based system to receive three 21-day cycles of thalidomide (100 mg daily orally for the first 14 days and 200 mg daily thereafter) plus dexamethasone (total 320 mg per cycle; 40 mg on days 1–2, 4–5, 8–9, and 11–12 in the VTD regimen, and 40 mg on days 1–4 and 9–12 in the TD regimen), either alone (TD group) or with bortezomib (1·3 mg/m2 intravenously on days 1, 4, 8, and 11; VTD group). After double autologous HSCT, patients received two 35-day cycles of either the VTD or TD regimen, according to random assignment, as consolidation therapy. The primary outcome was the rate of complete response and near complete response after induction (already reported). In this updated analysis we assessed long-term progression-free survival and overall survival (secondary endpoints of the study) with an extended 10-year median follow-up, and analysed the variables influencing survival. Analysis was by intention to treat. The study is registered with ClinicalTrials.gov, NCT01134484. Findings: Between May 10, 2006, and April 30, 2008, 480 patients were enrolled and randomly assigned to receive VTD (241 patients) or TD (239 patients). Six patients withdrew consent before start of treatment. 236 (99 [42%] women) in the VTD group and 238 (102 [43%] women) in the TD group were included in the intention-to-treat analysis. The data cutoff date for this analysis was May 31, 2018. Median follow-up for surviving patients was 124·1 months (IQR 117·2–131·7). The 10-year progression-free survival estimate for patients in the VTD group was 34% (95% CI 28–41) compared with 17% (13–23) for the TD group (hazard ratio [HR] 0·62 [95% CI 0·50–0·77]; p

Purpose The initial results of the APL0406 trial showed that the combination of all- trans-retinoic acid (ATRA) and arsenic trioxide (ATO) is at least not inferior to standard ATRA and chemotherapy (CHT) in first-line therapy of low- or intermediate-risk acute promyelocytic leukemia (APL). We herein report the final analysis on the complete series of patients enrolled onto this trial. Patients and Methods The APL0406 study was a prospective, randomized, multicenter, open-label, phase III noninferiority trial. Eligible patients were adults between 18 and 71 years of age with newly diagnosed, low- or intermediate-risk APL (WBC at diagnosis ≤ 10 × 109/L). Overall, 276 patients were randomly assigned to receive ATRA-ATO or ATRA-CHT between October 2007 and January 2013. Results Of 263 patients evaluable for response to induction, 127 (100%) of 127 patients and 132 (97%) of 136 patients achieved complete remission (CR) in the ATRA-ATO and ATRA-CHT arms, respectively ( P = .12). After a median follow-up of 40.6 months, the event-free survival, cumulative incidence of relapse, and overall survival at 50 months for patients in the ATRA-ATO versus ATRA-CHT arms were 97.3% v 80%, 1.9% v 13.9%, and 99.2% v 92.6%, respectively ( P < .001, P = .0013, and P = .0073, respectively). Postinduction events included two relapses and one death in CR in the ATRA-ATO arm and two instances of molecular resistance after third consolidation, 15 relapses, and five deaths in CR in the ATRA-CHT arm. Two patients in the ATRA-CHT arm developed a therapy-related myeloid neoplasm. Conclusion These results show that the advantages of ATRA-ATO over ATRA-CHT increase over time and that there is significantly greater and more sustained antileukemic efficacy of ATO-ATRA compared with ATRA-CHT in low- and intermediate-risk APL.

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

Background: Uncertainty exists about the optimal schedule of adjuvant treatment of breast cancer with aromatase inhibitors and, to our knowledge, no trial has directly compared the three aromatase inhibitors anastrozole, exemestane, and letrozole. We investigated the schedule and type of aromatase inhibitors to be used as adjuvant treatment for hormone receptor-positive early breast cancer. Methods: FATA-GIM3 is a multicentre, open-label, randomised, phase 3 trial of six different treatments in postmenopausal women with hormone receptor-positive early breast cancer. Eligible patients had histologically confirmed invasive hormone receptor-positive breast cancer that had been completely removed by surgery, any pathological tumour size, and axillary nodal status. Key exclusion criteria were hormone replacement therapy, recurrent or metastatic disease, previous treatment with tamoxifen, and another malignancy in the previous 10 years. Patients were randomly assigned in an equal ratio to one of six treatment groups: oral anastrozole (1 mg per day), exemestane (25 mg per day), or letrozole (2·5 mg per day) tablets upfront for 5 years (upfront strategy) or oral tamoxifen (20 mg per day) for 2 years followed by oral administration of one of the three aromatase inhibitors for 3 years (switch strategy). Randomisation was done by a computerised minimisation procedure stratified for oestrogen receptor, progesterone receptor, and HER2 status; previous chemotherapy; and pathological nodal status. Neither the patients nor the physicians were masked to treatment allocation. The primary endpoint was disease-free survival. The minimum cutoff to declare superiority of the upfront strategy over the switch strategy was assumed to be a 2% difference in disease-free survival at 5 years. Primary efficacy analyses were done by intention to treat; safety analyses included all patients for whom at least one safety case report form had been completed. Follow-up is ongoing. This trial is registered with the European Clinical Trials Database, number 2006-004018-42, and ClinicalTrials.gov, number NCT00541086. Findings: Between March 9, 2007, and July 31, 2012, 3697 patients were enrolled into the study. After a median follow-up of 60 months (IQR 46–72), 401 disease-free survival events were reported, including 211 (11%) of 1850 patients allocated to the switch strategy and 190 (10%) of 1847 patients allocated to upfront treatment. 5-year disease-free survival was 88·5% (95% CI 86·7–90·0) with the switch strategy and 89·8% (88·2–91·2) with upfront treatment (hazard ratio 0·89, 95% CI 0·73–1·08; p=0·23). 5-year disease-free survival was 90·0% (95% CI 87·9–91·7) with anastrozole (124 events), 88·0% (85·8–89·9) with exemestane (148 events), and 89·4% (87·3 to 91·1) with letrozole (129 events; p=0·24). No unexpected serious adverse reactions or treatment-related deaths occurred. Musculoskeletal side-effects were the most frequent grade 3–4 events, reported in 130 (7%) of 1761 patients who received the switch strategy and 128 (7%) of 1766 patients who received upfront treatment. Grade 1 musculoskeletal events were more frequent with the upfront schedule than with the switch schedule (924 [52%] of 1766 patients vs 745 [42%] of 1761 patients). All other grade 3–4 adverse events occurred in less than 2% of patients in either group. Interpretation: 5 years of treatment with aromatase inhibitors was not superior to 2 years of tamoxifen followed by 3 years of aromatase inhibitors. None of the three aromatase inhibitors was superior to the others in terms of efficacy. Therefore, patient preference, tolerability, and financial constraints should be considered when deciding the optimal treatment approach in this setting. Funding: Italian Drug Agency.

Summary Background The prognosis of young patients with diffuse large B-cell lymphoma at high risk (age-adjusted International Prognostic Index [aa-IPI] score 2 or 3) treated with R-CHOP (rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisone) is poor. The aim of this study was to investigate the possible benefit of intensification with high-dose chemotherapy and autologous stem-cell transplantation as part of first-line treatment in these patients. Methods We did a multicentre, open-label, randomised, controlled, phase 3 trial with a 2 × 2 factorial design to compare, at two different R-CHOP dose levels, a full course of rituximab-dose-dense chemotherapy (no transplantation group) versus an abbreviated course of rituximab-dose-dense chemotherapy followed by consolidation with R-MAD (rituximab plus high-dose cytarabine plus mitoxantrone plus dexamethasone) and high-dose BEAM chemotherapy (carmustine, etoposide, cytarabine, and melphalan) plus autologous stem-cell transplantation (transplantation group) in young patients (18–65 years) with untreated high-risk diffuse large B-cell lymphoma (aa-IPI score 2–3). At enrolment, patients were stratified according to aa-IPI score and randomly assigned (1:1:1:1) to receive R-CHOP (intravenous rituximab 375 mg/m 2 , cyclophosphamide 750 mg/m 2 , doxorubicin 50 mg/m 2 , and vincristine 1·4 mg/m 2 on day 1, plus oral prednisone 100 mg on days 1–5) delivered in a 14-day cycle (R-CHOP-14) for eight cycles; high-dose R-CHOP-14 (R-MegaCHOP-14; R-CHOP-14 except for cyclophosphamide 1200 mg/m 2 and doxorubicin 70 mg/m 2 ) for six cycles; R-CHOP-14 for four cycles followed by R-MAD (intravenous rituximab 375 mg/m 2 on day 1 or 4 plus intravenous cytarabine 2000 mg/m 2 and dexamethasone 4 mg/m 2 every 12 h on days 1–3 plus intravenous mitoxantrone 8 mg/m 2 on days 1–3) plus BEAM (intravenous carmustine 300 mg/m 2 on day −7, intravenous cytarabine 200 mg/m 2 twice a day on days −6 to −3, intravenous etoposide 100 mg/m 2 twice a day on days −6 to −3, plus intravenous melphalan 140 mg/m 2 on day −2) and autologous stem-cell transplantation (day 0); or R-MegaCHOP-14 for four cycles followed by R-MAD plus BEAM and autologous stem-cell transplantation. The primary endpoint was failure-free survival at 2 years in the intention-to-treat population. This study is registered with EudraCT (2005-002181-14; 2007-000275-42) and with ClinicalTrials.gov, number NCT00499018. Findings Between Jan 10, 2006, and Sept 8, 2010, 399 patients were randomly assigned to receive transplantation (n=199) or no transplantation (n=200); 203 patients were assigned to receive R-CHOP-14 and 196 were assigned to receive R-MegaCHOP-14. With a median follow-up of 72 months (IQR 57–88), 2-year failure-free survival was 71% (95% CI 64–77) in the transplantation group versus 62% (95% CI 55–68) in the no transplantation group (hazard ratio [HR] 0·65 [95% CI 0·47–0·91]; stratified log-rank test p=0·012). No difference in 5-year overall survival was observed between these groups (78% [95% CI 71–83] versus 77% [71–83]; HR 0·98 [0·65–1·48]; stratified log-rank test p=0·91). Grade 3 or worse haematological adverse events were reported in 183 (92%) of 199 patients in the transplantation group versus 135 (68%) of 200 patients in the no transplantation group. Grade 3 or worse non-haematological adverse events were reported in 90 (45%) versus 31 (16%); the most common grade 3 or worse non-haematological adverse event was gastrointestinal (49 [25%] vs 19 [10%]). Treatment-related deaths occurred in 13 (3%) patients; eight in the transplantation group and five in the no transplantation group. Interpretation Abbreviated rituximab-dose-dense chemotherapy plus R-MAD plus BEAM and autologous stem-cell transplantation reduced the risk of treatment failure compared with full course rituximab-dose-dense chemotherapy in young patients with diffuse large B-cell lymphoma at high risk. However, these results might not be clinically meaningful, since this improvement did not reflect an improvement in overall survival. These results do not support further consideration of the use of intensification of R-CHOP as an upfront strategy in patients with diffuse large B-cell lymphoma with poor prognosis. Funding Fondazione Italiana Linfomi.

Histone deacetylase 2 (HDAC2) is overexpressed or mutated in several disorders such as hematological cancers, and plays a critical role in transcriptional regulation, cell cycle progression and developmental processes. Here, we performed comparative transcriptome analyses in acute myeloid leukemia to investigate the biological implications of HDAC2 silencing versus its enzymatic inhibition using epigenetic-based drug(s). By gene expression analysis of HDAC2-silenced vs wild-type cells, we found that HDAC2 has a specific role in leukemogenesis. Gene expression profiling of U937 cell line with or without treatment of the well-known HDAC inhibitor vorinostat (SAHA) identifies and characterizes several gene clusters where inhibition of HDAC2 ‘mimics’ its silencing, as well as those where HDAC2 is selectively and exclusively regulated by HDAC2 protein expression levels. These findings may represent an important tool for better understanding the mechanisms underpinning immune regulation, particularly in the study of major histocompatibility complex class II genes.

To retrospectively assess the efficacy of bendamustine alone and with rituximab (R-B), 109 patients with relapsed chronic lymphocytic leukaemia (CLL) were enrolled in 24 Italian centres. The median age was 66 years (range 39-85). Forty-three percent of patients had relapsed and 57% were resistant (median previous therapies = 3; range 1-8). Twenty-two patients received bendamustine alone and 87 patients received R-B (median B dosage: 100 mg/m(2) per day, range 90-130 mg/m(2) per day). The overall response rate was 69·6% (complete response 28·6%; partial response 41%), and was significantly higher in patients treated with R-B (P = 0·014) and in those responsive to the previous treatment (P=0·04). After a median follow-up of 7·9 months (range 1-148), the median progression-free survival was 16 months and the median duration of response was 13 months. Median overall survival (OS) was 16·8 months for the whole cohort; patients not responding to the treatment had a significantly worse outcome than those who attained a response (P = 0·0001). In multivariate analysis, only resistant disease status at start of bendamustine treatment (HR 3·2, 95% CI 1·4-7·3, P = 0·006) had an independent prognostic value for OS. Toxicity was manageable and mostly haematological. In conclusion, in our experience R-B was an effective and well-tolerated treatment for relapsed/refractory CLL patients, producing a remarkable high CR rate and mild toxicity.

Purpose Treatment of secondary CNS dissemination in patients with aggressive lymphomas remains an important, unmet clinical need. Herein, we report the final results of a multicenter phase II trial addressing a new treatment for secondary CNS lymphoma based on encouraging experiences with high doses of antimetabolites in primary CNS lymphoma and with rituximab plus high-dose sequential chemoimmunotherapy (R-HDS) in relapsed aggressive lymphoma. Patients and Methods HIV-negative patients with aggressive B-cell lymphoma and secondary CNS involvement at diagnosis or relapse, age 18 to 70 years, and Eastern Cooperative Oncology Group performance status ≤ 3 were enrolled and treated with high-doses of methotrexate and cytarabine, followed by R-HDS (cyclophosphamide, cytarabine, and etoposide) supported by autologous stem-cell transplantation (ASCT). Treatment included eight doses of rituximab and four doses of intrathecal liposomal cytarabine. The primary end point was 2-year event-free survival; the planned accrual was 38 patients. Results Thirty-eight patients were enrolled; CNS disease was detected at presentation in 16 patients. Toxicity was usually hematologic and manageable, with grade 4 febrile neutropenia in 3% of delivered courses and grade 4 nonhematologic toxicity in 2% of delivered courses. Four patients died because of toxicity. Autologous stem cells were successfully collected in 24 (89%) of 27 patients (median, 10 × 106/kg); 20 patients underwent ASCT. Complete response was achieved in 24 patients (complete response rate, 63%; 95% CI, 48% to 78%). At a median follow-up of 48 months, 17 patients remained relapse free, with a 2-year event-free survival rate of 50% ± 8%. At 5 years, 16 patients were alive, with a 5-year overall survival rate of 41% ± 8% for the whole series and 68% ± 11% for patients who received transplantation. Systemic (extra-CNS) and/or meningeal disease did not affect outcome. Conclusion The combination of high doses of antimetabolites, R-HDS, and ASCT is feasible and effective in patients age 18 to 70 years old with secondary CNS lymphoma, and we propose it as a new standard therapeutic option.

A specific prognostication score for hepatitis C virus-positive diffuse large B-cell lymphomas is not available. For this purpose, the Fondazione Italiana Linfomi (FIL, Italian Lymphoma Foundation) carried out a multicenter retrospective study on a large consecutive series of patients with hepatitis C virus-associated diffuse large B-cell lymphoma to evaluate the prognostic impact of clinical and virological features and to develop a specific prognostic score for this subset of patients. All prognostic evaluations were performed on 535 patients treated with an anthracycline-based induction regimen (with rituximab in 255 cases). Severe hepatotoxicity was observed in 14% of patients. The use of rituximab was not associated with increased rate of severe hepatotoxicity. Three-year overall survival and progression-free survival were 71% and 55%, respectively. At multivariate analysis, ECOG performance status of 2 or over, serum albumin below 3.5 g/dL and HCV-RNA viral load over 1000 KIU/mL retained prognostic significance. We combined these 3 factors in a new "HCV Prognostic Score" able to discriminate 3 risk categories with different overall and progression-free survival (low=0; intermediate=1; high-risk ≥2 factors; P

Background: We recently showed that the combination of ATRA and arsenic trioxide (ATO) is at least not inferior and possibly superior to standard ATRA and chemotherapy (CHT) in the front-line management of low/intermediate risk APL (Italian-German APL 0406 trial; Lo-Coco et al., NEJM 2013). We report herein on the extended and final series of 276 patients (162 were in the previous report) with the last case being enrolled into the study in January 2013. Methods: The APL0406 study was a prospective, open-label, randomized intergroup trial conducted by the Italian GIMEMA and the German SAL and AMLSG study groups. Eligible patients were adults aged 18- Results: A total of 254 patients were evaluable for response to induction. CR was achieved in 122/122 (100%) in the ATRA-ATO versus 128/132 (97%) in the ATRA-CHT arm (P=0.12). Four patients died during induction in the ATRA-CHT arm. After a median follow-up of 36 months (range 1-75 months), the 2-year EFS was 98% and 84.9% in the ATRA-ATO and ATRA-CHT groups respectively (P= 0.0002), The 2-year cumulative incidence of relapse (CIR) rate was 1.1% and 9.4%, respectively (P=0.005) and, finally, the 2-year overall survival (OS) rate was 99.1% vs. 94.4% (P=0.01) for ATRA-ATO vs ATRA-CHT, respectively. Conclusions: The data on this extended cohort demonstrate a significantly augmented survival benefit coupled to a higher antileukemic efficacy provided by ATRA-ATO as compared to ATRA-CHT, in low/intermediate risk APL. These results further support ATRA-ATO as the new standard of care in this clinical setting. Figure 1 Figure 1. Disclosures Platzbecker: Teva: Honoraria. Off Label Use: Presentation includes off-label use of arsenic trioxide (ATO) in front-line management of APL. ATO is currently approved in treatment of relapsed APL in the US and Europe. Breccia:Bristol Myers Squibb: Consultancy; Novartis: Consultancy. Fiedler:TEVA: Travel reimbursement for meeting attendance Other. Lübbert:Cephalon / TEVA: Travel support Other. Link:TEVA: Consultancy, Speakers Bureau. Radsak:Celgene: Research Funding. Döhner:TEVA: Research Funding. Schlenk:TEVA: Research Funding, Speakers Bureau. Lo-Coco:TEVA: Honoraria; Lundbeck: Honoraria.

The management of patients with Hodgkin lymphoma (HL) recurring after stem cell transplantation (SCT) and multiply relapsed disease remains challenging. We report on 41 such patients who received bendamustine hydrochloride, a bifunctional mechlorethamine derivative mechanistically unrelated to traditional alkylators, after a median of four prior chemotherapy lines, including SCT in 85% of cases. Bendamustine was given at doses of 90-120 mg/m(2) every 21 or 28 d. At first assessment (2-4 cycles), the overall response rate (ORR) was 78% with 12 (29%) complete (CR) and 20 (49%) partial responses (PR). Upon treatment prolongation to 6-8 courses, 40% of PRs progressed, yielding a final ORR of 58% with 31% of CRs. Eight patients (two CRs, six PRs) were subsequently allotransplanted. Median progression-free and overall survival exceeded 11 and 21 months respectively; complete responders displayed a median disease-free survival above 9 months with a relapse rate of only 30%. Outcomes were independent of disease chemosensitivity, previous transplant and bendamustine dose-intensity. No life-threatening or unexpected adverse events occurred. Within the limits of a retrospective analysis and schedule heterogeneity, these results appear very encouraging and prompt prospective trials to confirm bendamustine as a valuable option in the palliative setting and in cytoreductive strategies before allotransplantation.

Abstract 2898 Background: Notwithstanding the improved results with first-line therapy, CLL remains incurable, and patients are destined to relapse after primary treatment. The management of relapsed CLL pts is then dependent on several factors, including age, performance status, previous therapy, response and duration of response to therapy, and time from last therapy. Currently, the optimal treatment for pts with relapsed disease is not known. Bendamustine (BEN) demonstrated clinical activity in pre-treated hematological malignancies due to its unique mechanism of action distinct from standard alkylating agents. Alemtuzumab (CAM) is active in previously treated pts with CLL refractory to alkylating agents and purine nucleoside analogs. We designed a multicentric, single arm, dose escalation study to determine maximum tolerated dose (MTD) and to evaluate the efficacy and safety of Ben Cam combination in refractory/relapsed CLL pts. Methods: Previously treated CLL pts requiring therapy were enrolled. In the first part of the study, the tolerability of a stepwise dose-escalation schedule of BEN along with an increasing dose of CAM has been determined. BEN was given at a starting dose of 50 mg/sqm for 2 consecutive days along with CAM 20 mg sc on days 1 to 3; if MTD was not reached within the 1st cohort, the 2nd cohort received an increased dose of CAM 30 mg with a subsequent further increase of BEN 70 mg/sqm if MTD was not reached. Treatment was repeated every 28 d up to 4 course. If one of 3 pts at each dose level experienced DLT three additional pts were added (max 6). If 5 of the 6 subjects were able to complete the first 2 courses without experiencing DLT, this level was considered tolerable and dose-escalation continued initiating the following cohort. Results: Between July 2008 and March 2012, 50 pts with previously treated CLL requiring therapy according to IWCLL criteria were enrolled in 9 Italian centres. The median age of our population was 67 years (range 46–82), 64% were male and all pts presented with Binet stage B or C. Pts' population was characterized by high risk biological and clinical disease profile: 44% were in Binet stage C, bulky lymph nodes were present in 24% of pts, refractory pts represented 26% of our population. According to hierarchical model, del17p was present in 28% and del11q in 24%; 66% were IGVH unmutated, 40% ZAP70+ and 36% CD38+. Median number of prior regimens was 2 (range, 1–4): 84% had previously received fludarabine-based treatment and 70% monoclonal antibodies in monotherapy or in combination. Twelve pts have been enrolled in the Phase I of this trial: 3 pts in each of the first 2 cohorts, 6 in the third cohort. BEN 70 mg/sqm and CAM 30 mg sc resulted as the MTD. Median number of courses administered was 4 (range, 1–4), 72% of pts completed treatment program being progression the major cause of discontinuation. At the time of writing 43 pts (86%) are evaluable for response, evaluation is pending in 7 pts who completed in all cases treatment program. Overall response rate resulted of 70% including 26% of CRs and 44% of PRs; 18% of pts maintained a stable disease; 12% showed a progression. Significant difference in response rate (P=0.009) was observed among pts with relapsed versus refractory disease. Previous treatment and unfavourable biological features did not affect response achievement. None of the variables considered showed to be significant in reaching a CR. In the whole series of treated pts grade III-IV hematological toxicity was: neutropenia in the 33% of courses, thrombocytopenia and anemia in 7 and 4% respectively. Febrile neutropenia developed in the 15% of courses. CMV reactivation occurred in 10% of courses without any organ involvement. We recorded 8 major infections: 3 sepsis, 4 pneumonias and 1 enteritis. Extra-hematological toxicity was mild. Median time to progression in responders was reached after a median follow-up of 15,5 months. Conclusions: Analysis of results data collected on 43/50 pts treated with 4-weekly dosing BENCAM regimen suggests that this combination is effective in relapsed and refractory CLL pts, most of them carrying adverse prognostic factors. Hematologic toxicity was the only serious adverse event observed with a manageable myelosuppression. Major infections recorded were not superior in quantity and quality to those observed using other immuno-chemotherapeutic regimens in the same setting. No toxic deaths were recorded while on treatment. Disclosures: No relevant conflicts of interest to declare.

BACKGROUND: The efficacy of azacitidine for the treatment of high-risk myelodysplastic syndromes has prompted the issue of its potential role even in the treatment of acute myeloid leukemia (AML). METHODS: The authors analyzed 82 patients with AML who were diagnosed according to World Health Organization criteria. The median patient age was 72 years (range, 29-87 years), and 27 patients (33%) had secondary AML. Of 62 patients with evaluable cytogenetics, 18 patients (29%) had a poor-risk karyotype, and 44 patients (71%) had an intermediate karyotype. Thirty-five patients (43%) received azacitidine as front-line treatment, and 47 patients (57%) had previously received 1 or more line of chemotherapy. RESULTS: The overall response rate was 32% (26 of 82 patients) and included 12 (15%) complete remissions (CRs), 4 (5%) CRs with incomplete blood count recovery (CRi), and 10 (12%) partial responses (PRs). Responses were observed more frequently among untreated patients compared with pretreated patients; in fact, 17 of 35 untreated patients (48%) responded, including 11 responses (31%) classified as CR/CRi. Conversely, only 9 of 47 pretreated patients (19%) responded, including 5 responses (11%) that were classified as CR/Cri. The response rate was significantly higher for untreated patients (P = .006) and those who had white blood cell counts

Bendamustine is an alkylating agent with a nitrogen mustard group and a purine-like benzimidazole group. The aim of this study was to collect all the Italian experiences with this drug in order to evaluate the results in term of response to therapy and toxicities. We analyzed lymphoma patients treated in 24 Italian haematological centres with bendamustine alone or in combination with anti-CD20 antibody. One hundred seventy-five relapsed or refractory lymphoma patients were enrolled. The median age was 69 years (range 26-87). Seventy-nine patients were relapsed, 35 were refractory and 61 presented a progressive disease after partial response. The diagnoses were 60 indolent non-follicular lymphomas, 34 diffuse large B-cell lymphomas, 48 follicular lymphomas, 30 mantle cell lymphomas and three peripheral T-cell lymphomas. All patients were evaluable for response: 52 (29%) with complete remission, 72 (43%) with partial response with an overall response rate of 71%, and 51 non-responders. With a median observation period of 10 months (1-43), 70% of patients are alive. In summary, this retrospective study shows that treatment with bendamustine alone or in combination with rituximab is a safe and effective regimen in a subset of multi-resistant patients.

Introduction: Management of Ph+ ALL has changed since the introduction of tyrosine kinase inhibitors (TKI). We previously reported the preliminary findings of the GIMEMA LAL 1509 total therapy protocol, based on dasatinib plus steroids administration as induction therapy (Chiaretti et al, ASH 2014). The updated results on overall survival (OS), disease-free survival (DFS) and the impact of a genetic-based prognostic stratification are hereby provided. Methods: Steroids were administered from day -6 to day 31. Dasatinib (140 mg/day) was given between days 1 and 84. Patients reaching a complete molecular response (CMR, i.e. BCR/ABL1 to ABL1 ratio=0) at the end of induction (day 85) continued Dasatinib. Patients in complete hematologic remission (CHR), but not in CMR, underwent chemotherapy (clofarabine-cyclophosphamide) and/or an allogeneic transplant (HSCT), according to eligibility and donor availability. Dasatinib was administered until disease progression. Molecular testing was used to identify the presence of the BCR/ABL1 transcript on bone marrow samples, to define the fusion protein and to quantify BCR/ABL1 levels at baseline and follow-up (FU). Mutational screening was performed in relapsed cases, based on material availability. SNP array analysis was carried out using the Cytoscan HD arrays (Affymetrix, Santa Clara, CA) to identify genomic aberrations. Results: 60/63 enrolled patients were eligible. Median age was 41.9 years (range 18.7-59.1), 34 were males and 26 females; median WBC count was 12.5 x 109/l (range 1.4-178.0); the p190 fusion product was detected in 33 patients, p210 in 18 and p190/p210 in 9. Median FU is 28.4 months (range 4.2-43.7). After the steroid pre-phase, 38 patients (63%) had a blast reduction ≥75%. At day 85, 58 patients were in CHR (97%), while 2, in CHR at day 57, lost it: both harbored the p210 fusion transcript. They both returned into CHR following chemotherapy. A sustained CMR was obtained in 11 patients (18.6%): 72% had a p190 fusion transcript. No deaths in induction occurred. Among the CMR patients, only 1 experienced a hematologic relapse, which carried a T315I mutation. Of the 46 non-CMR cases, 14 relapses occurred, 8 of which in p210+ patients. Overall, there have been 12 deaths in CHR. OS is 58.3% (95%CI: 44.4-76.3) at 36 months and DFS at 30 months is 48.9% (95%CI: 36.8.0-64.9). A better DFS was observed in patients who obtained a CMR compared to cases with minimal residual disease (MRD) at day 85 (75% vs 44%, p=0.06), and in p190+ vs p210+ patients (57.1% vs 39.6%, p=ns). Mutational screening, performed in 7/15 cases at hematologic relapse detected mutations in 5: 3 T315I and 2 V299L, of which 1 with a concomitant F317I and F317L. SNP array analysis, performed in 39 cases with available DNA, showed that the most frequent aberrations were deletions of IKZF1 (85%), PAX5 (38%), CDKN2A/B (33%), MLLT3 (33%), RB1 (28%) and JAK2 (28%). While IKZF1 deletions alone did not impact on CHR or CMRachievement and DFS, a significantly worse DFS (p=0.01) and increased cumulative incidence of relapse (CIR, p=0.024) were observed in cases harboring deletions of IKZF1 plus CDKN2A/B and PAX5 (DFS: 40% vs 65% at 18 months; CIR: 40% vs 14% at 18 months (Fig. 1A and B). The relevance of this finding was further refined by stratifying patients according to the fusion protein: the impact of IKZF1 plus CDKN2A/B and PAX5 deletions is prognostically relevant in p190+, but not in p210+ patients, possibly because of the worse outcome of the latter group (Fig. 2). Finally, this analysis identified a set of genes specifically deleted in CMR cases; investigations are ongoing on additional cases to validate their potential role in predicting response to TKI. Conclusions: In this updated analysis of the GIMEMA 1509 trial, we confirm the effectiveness of a chemo-free induction in inducing CHR in almost all adult Ph+ ALL patients (97%) and CMR in a subgroup of cases (18.6%). OS and DFS at 36 months and 30 months, approaching 60% and 50%, are encouraging. More importantly, CMR achievement at day 85 is associated with extremely promising results, being 75% at 30 months, underlying that CMR should be regarded as a primary endpoint in Ph+ ALL. We confirm that p210+ patients may require an intensified approach, given the lower rate of CMR achievement and the higher relapse rate. Finally, we provide evidence that a broader genetic characterization at diagnosis allows a more refined prognostic stratification of Ph+ ALL patients. Disclosures Martinelli: Pfizer: Consultancy; Ariad: Consultancy; AMGEN: Consultancy; BMS: Consultancy, Speakers Bureau; ROCHE: Consultancy; MSD: Consultancy; Novartis: Consultancy, Speakers Bureau. Foà:Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Background Improving strategies for patients (pts) with relapsed/refractory (R/R) Hodgkin lymphoma (HL) who fail stem cell transplantation (SCT) or are unsuitable for the procedure remains an essential need. Lenalidomide and bendamustine are active and well tolerated as single agents in recurrent HL, with overall response rates (ORR) of 30% to 53% [Fenhinger, 2012; Corazzelli, 2012; Moskowitz, 2012].These agents independently frame different targets on tumor and microenvironment cells and may cooperate to override disturbed immunologic pathways and circumvent drug resistance in HL. In a Bayesian, multi-center, open label phase 1/2 study, we investigated for safety and efficacy the combination of continuous lenalidomide with weekly bendamustine (ClinicalTrials.gov # NTC01412307). Methods The study aimed at defining the optimal daily dose of continuous lenalidomide (10, 15, 20 or 25 mg) as combined, in a 28-day cycle, to weekly fixed-dose bendamustine (60 mg/m2; d 1, 8, 15). The dose-finding algorithm proceeded in cohorts of 3 pts, based on anticipated efficacy and toxicity pairs of probability (Thall & Cook, Biometrics 2004). Trade-offs between response [Cheson 2007 criteria] and dose-limiting toxicity [CTCv3.0 grade (G) >3 lasting >2 weeks] were assessed after 2 cycles (day +56) and pts were planned to receive up to 6 total courses, unless progression or unacceptable toxicity occurred. ORR and progression-free survival (PFS) were additional endpoints. Results Thirty-six pts (69% male) with a median age of 31 yrs (r 19-75) were enrolled. The median number of prior therapies was 4 (r 1-9) and the median time from upfront treatment was 24 mo.s (r 7-118). Twenty-six pts (72%) had primary refractory disease after ABVD, 16 pts (44%) failed prior SCT [single (n=7) or tandem (n=3) ASCT, tandem ASCT/alloSCT (n=6)]. Fifteen pts (42%) had previously received a median of 5 cycles (r 2-8) of brentuximab vedotin (BV) and 3 pts were already given bendamustine (>3 courses). Overall, 23 pts (64%) were refractory to most recent therapy. Eff/Tox trade-offs at cycle 2 showed that 73% of pts had response w/o toxicity, 19% had no response w/o toxicity, 6% had response with toxicity and 2% had no response with toxicity. With such Eff/Tox profiles, the study algorithm did not prompt any dose escalation for lenalidomide after the first 18 pts and the initial dose level (10 mg) was adopted for the expansion phase. A total of 156 LeBen cycles were administered, and pts received a median of 4 courses (r 1-6). Overall, 16 cycles were delayed due to G3/G4 thrombocytopenia (n=6), G4 neutropenia (n=3), G3 pneumonia (n=3), G3 respiratory infection (n=2), G2 phlebitis (n=1), G2 supraventricular arrhythmia (n=1). Two patients discontinued treatment, while in PR and CR after 4 courses, due to protracted (>2 weeks) thrombocytopenia. No G4 extra-hematological toxicity was observed. The complete response (CR) rate was 44% (16/36) with an ORR of 75% (27/36; 95% CI, 59-86). Notably, substantial CR and PR rates were achieved after LeBen regardless of primary refractoriness, SCT and BV failure (Table). Most CRs (14/16) were obtained within the first 4 cycles; 6 responders (4 CRs and 2 PRs) underwent SCT. Median PFS was 3.2 mo.s (r 1.5-5.4) for pts with progressive (PD) or stable disease (SD) and 11.4 mo.s (r 4-31) for those achieving CR/PR. Median overall survival for the entire cohort was 24 mo.s. Overall, complete responders (including 6 pts consolidated with SCT) had a 2-year disease-free survival of 41% (median, 14.3 mo.s). Conclusions The innovative schedule of the Leben combination is safe, yields high response rates in heavily pretreated and primary refractory HL pts, including SCT and BV failures, and steps over the 'single agent' activity of its components. Due to its immunomodulatory potential the Leben platform is amenable to further upgrading through lenalidomide maintenance, combination with immune checkpoint inhibitors and BV. | Responses no. (%) | All pts | Refractory to upfront therapy | Refractory to most recent therapy | Failure after SCT | Failure after ASCT | Failure after AlloSCT | Failure after BV | Failure after SCT and BV | Failure after bendamustine | No BV | | ------------------------ | ------- | ----------------------------- | --------------------------------- | ----------------- | ------------------ | --------------------- | ---------------- | ------------------------ | -------------------------- | ------- | | (n=36) | (n=26) | (n=23) | (n=16) | (n=10) | (n= 6) | (n=15) | (n=8) | (n=3) | (n=21) | | CR | 16 (44) | 11 (42) | 8 (35) | 8 (50) | 6 (60) | 2 (33) | 5 (33) | 3 (37) | | 11 | | PR | 11 | 8 | 9 | 4 | 2 | 2 | 4 | 2 | | 7 | | SD | 2 | 2 | 2 | 1 | | 1 | 1 | 1 | 1 | 1 | | PD | 7 | 5 | 4 | 3 | 2 | 1 | 5 | 2 | 2 | 2 | | CR+PR | 27 (75) | 19 (73) | 17 (74) | 12 (75) | 8 (80) | 4 (66) | 9 (60) | 5 (62) | | 18 (86) | Table 1. Efficacy results Disclosures Pinto: Takeda, Celgene, Roche, TEVA: Honoraria; Takeda: Research Funding. Zinzani: Takeda: Membership on an entity's Board of Directors or advisory committees; JJ Gilead: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees.

5-azacytidine (AZA) significantly prolonged overall survival in higher-risk patients with myelodysplastic syndromes (MDS) in a large, international, randomized, phase III trial (AZA-001). However, data about efficacy and safety of AZA in lower risk MDS are less consistent and only few small studies have addressed this topic. Among a total of 246 MDS treated with AZA in 31 different Italian Institutions since 2005 within to a national patient named program, we evaluated 82 patients scored as low/int-1 IPSS risk MDS. Median age was 68 years (range 34–85), male/female ratio 50/32. According to WHO classification, there were 21 RA/RARS, 4 5q-syndromes, 20 RCMD, 24 RAEB-1, 5 RAEB-2, 4 CMMoL, and 4 MDS unclassified. Median time from diagnosis was 27 months (range 1–132). Sixty-eight patients (82.9%) were transfusion-dependent, sixty (74%) had received a prior treatment, mostly with erythropoiesis stimulating agents. AZA was administered as single drug in 61 patients (74.4%), while in the remaining subjects it was variously combined with growth factors, valproic acid or other agents. Forty-eight patients (58.5%) received a “standard” AZA dose of 75 mg/sqm/d s.c., thirty-four (41.5%) a fixed dose of 100 mg/d s.c. Single cycle treatment duration was 7 days in 45 patients (54.9%), < 7 days in 32 patients (39%), > 7 days in 3 patients (3.7%), unknown in 2 patients (2.4%). The median number of monthly cycles was 6 (range 1–21), and 63 patients (76.8%) completed at least 4 cycles. The most relevant toxicities observed (grade 3–4) were represented by myelosuppression (22%) and infections (6%). According to 2006-updated IWG criteria, overall response rate was 39% (47.5% in patients who had completed at least 4 cycles). In particular, complete response, partial response and hematological improvement occurred in 12.2%, 8.5% and 18.3% of patients (15.8%, 11.1% and 20.6% in those who were treated with at least 4 cycles), respectively. Stable or progressive disease was observed in 29.3%/25.6% and 30.2%/22.2% of patients receiving less than or at least 4 cycles, respectively. Response duration ranged from 1 to +21 months. There were no significant differences in response rate according to dose and schedule employed, although a slight trend in favour of 75 mg/sqm vs 100 mg fixed dose was seen (45.8% vs 29.4%, respectively). There was also no difference in the percentages of response according to age, previous treatment and transfusion dependence. Overall survival at 2 years was 62%. A survival benefit emerged for responding patients, compared to non responders (82% vs 57%) (p=0.015). A favourable trend was also observed for transfusion-independent patients, while age, pre-treatment and AZA dose did not influence survival. These data indicate that AZA may be safe and effective for a subset of patients with low/int-1 IPSS risk MDS, resistant or not suitable for alternative treatments. The efficacy may improve if at least 4 cycles are administered.

Autoimmune hemolytic anemia (AIHA) is a well-known complication of chronic lymphocytic leukemia (CLL). In recent years the anti-CD20 monoclonal antibody rituximab has been used for the therapy of steroid-refractory AIHA and autoimmune thrombocytopenia, either idiopathic or in association with CLL. We report the results of rituximab treatment for 14 patients suffering from CLL-associated AIHA. They developed a direct antiglobulin test positive AIHA at a mean time of 47 months (range 0-135 months) from the diagnosis of CLL. In 3 cases AIHA was diagnosed at the same time as CLL. Only 1 patient had fludarabine-related AIHA. All patients received steroids as first-line treatment. At a mean time of 46 days (range 1-210 days) from the diagnosis of AIHA all patients received rituximab at a dosage of 375 mg/m(2)/weekly for 4 weeks. All patients except 3 (2 died of cardiac failure or sepsis soon after the third cycle and 1 HCV-positive patient experienced a rise in serum amino transferases) completed the scheduled four programmed cycles. First injection side effects of rituximab were minimal. All but 2 patients showed an increase in hemoglobin levels in response to rituximab (mean value 3.6 g/dl; range 0.7-10 g/dl) and a reduction in the absolute lymphocyte count and lymph nodes and spleen volume. Nine patients required packed red cell transfusions before starting rituximab; 5 no longer needed transfusions just after the second cycle and another patient after the fourth cycle. Three patients (22%) were considered to fully respond and 7 (50%) only responded partially. At a mean follow-up of 17 months, 8 patients were still alive, 6 of them transfusion-free. Our results prove that the anti-CD20 monoclonal antibody is an effective and well-tolerated alternative treatment for CLL-associated AIHA.

In recent years, an increasing number of reports have pointed out the association between osteonecrosis of the jaws (ONJ) and the use of bisphosphonates as therapy of neoplastic bone disease or benign osteoporosis.[1][1],[2][2] The pathogenesis of this complication is unknown, although

INTRODUCTION: Secondary central nervous system (CNS) dissemination is a lethal event in patients (pts) with aggressive lymphomas. A few studies focused on the treatment of this condition are available, confirming the dismal prognosis and the high rate of severe neurotoxicity in pts managed with radiotherapy-based induction. Thus, the most effective treatment for secondary CNS lymphoma remains an important, unmet clinical need. Herein, we report the final results of a multicenter phase II trial addressing a new treatment in pts with aggressive B-cell lymphoma and CNS involvement (NCT00801216). Experimental treatment is based on the encouraging experiences with high doses of antimetabolites in pts with primary CNS lymphoma (Ferreri et al. Lancet 2009), and with high-dose sequential chemotherapy combined with rituximab (R-HDS) and supported by autologous stem cell transplant (ASCT) in pts with relapsed aggressive B-cell lymphoma (Tarella et al. JCO 2008). METHODS: Selection criteria were: 1) histological diagnosis of diffuse large B-cell lymphoma (DLBCL), mantle cell lymphoma blastoid variant (MCLb) or grade-3 follicular lymphoma (FL); 2) secondary CNS involvement at diagnosis or relapse; 3) age 18-70 years; 4) ECOG PS ≤3; 5) absence of HIV infection; 6) adequate organ functions. Pts with primary CNS lymphoma (exclusive CNS disease at diagnosis) were excluded. Experimental treatment consisted of an induction phase with 2 courses of methotrexate 3.5 g/m2 d1 + cytarabine 2 g/m2 x2/d d2-3, followed by an intensification phase with R-HDS (cyclophosphamide 7 g/m2 d1; cytarabine 2 g/m2 x2/d d22-25; pts with residual extra-CNS disease received also etoposide 2 g/m2 d43) and a consolidation phase with BCNU-thiotepa conditioning + ASCT (figure). Treatment included 8 doses of rituximab and 4 of intrathecal liposomal cytarabine. The primary endpoint was 2-year PFS; the planned accrual was 38 pts. RESULTS: 39 pts were registered (age 32-70 ys, median 59; M/F ratio 1.5): 33 had DLBCL, 3 MCLb, 3 FL. CNS disease (brain 21, meninges 5, spinal cord 2, multiple 11) was detected at diagnosis in 16 pts (all with extra-CNS disease) and at relapse in 23 (8 with extra-CNS disease). The median TTP from the previous treatment line was 3 months (range 0-77 months). Thirty-four pts completed the induction phase; 73 (93%) of 78 planned courses were actually delivered; G4 neutropenia, thrombocytopenia and anemia were recorded in 77%, 63% and 5% of courses, G3-4 febrile neutropenia in 16%, CMV reactivation in 3 pts. Transient G4 transaminases increase (3% of courses) was the only G4 non-hematological toxicity. Drugs dose reduction was indicated in 3 pts. Response after induction phase was complete in 11 pts and partial in 19 (ORR= 77%; 95%CI=64-90%). Thirty pts were referred to intensification phase (figure); 58 (97%) of 60 planned courses were actually delivered; G4 neutropenia, thrombocytopenia and anemia were recorded in 67%, 60% and 7% of courses, G3-4 febrile neutropenia in 22%, G4 sepsis in 8%. CMV reactivation was diagnosed in 4 pts, pulmonary aspergillosis in 1. No cases of G4 extra-hematological toxicity were recorded. Response after intensification phase (before conditioning) was complete in 22 pts and partial in 2 (ORR= 62%; 95%CI=47-77%). ASCs were collected in 21/22 (95%) pts (median 9.5 x 106/kg; range 6-19); 20 pts underwent ASCT. Response at the end of the whole program was complete in 23 pts and partial in 1 (ORR= 62%, 95%CI= 47-77%), 1 pt had SD, 10 experienced PD (all in the CNS), and 4 died of toxicity (sepsis 2, stroke, acute tracheal obstruction). Importantly, no pt was irradiated to the brain to achieve lymphoma remission, and no evidence of neurotoxicity was recorded in pts with a survival longer than 3 years. One pt was referred to sibling-donor transplant due to sMDS, and is alive and NED at 91 months of follow-up. At a median follow-up of 42 months, 16 pts remain relapse-free, with a 2-yr PFS of 42±8%. Sixteen pts are alive, with a 2-yr OS of 42±8%; 2-yr OS of transplanted pts was 72±11%. Extra-CNS and/or meningeal disease did not affect outcome, and survival was similar in both pts treated at presentation or at relapse. CONCLUSION: This radiotherapy-free combination of high doses of antimetabolites, R-HDS and ASCT is feasible and effective in pts ≤70 ys with secondary CNS lymphoma. Toxicity is usually haematological and manageable. Survival benefit is attainable also in pts with meningeal and/or concomitant extra-CNS disease. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Introduction: Ph+ ALL management has changed since the introduction of tyrosine kinase inhibitors (TKI). In the GIMEMA LAL 1509 protocol for adult Ph+ ALL, Dasatinib was administered in combination with steroids as induction treatment, and chemotherapy and/or allogeneic transplantation (HSCT) was given if patients did not reach a sustained complete molecular response (CMR) after induction. Methods: Steroids were administered from day -6 to day 31. Dasatinib (140 mg/day) was given between days 1 and 84. Patients reaching a confirmed CMR (i.e. BCR/ABL to ABL ratio=0) at the end of induction (day +85), continued Dasatinib for 6 additional months. Patients in complete hematologic remission (CHR), but not in CMR, were stratified according to HSCT eligibility: those with a promptly available donor underwent directly a HSCT; if the donor was not readily available, a consolidation cycle with clofarabine and cyclophosphamide was administered. HSCT non-eligible patients received two cycles of clofarabine and cyclophosphamide of 5 and 3 days, respectively. Dasatinib was administered until disease progression. Molecular testing was used to identify the presence of a BCR/ABL transcript, define the fusion protein and quantify BCR/ABL levels at baseline and at follow-up. Mutational screening was performed in relapsed cases. Results: Sixty of the 64 enrolled patients were eligible. Median age was 41.9 years (range: 18.7-59.1), 34 were males and 26 females; the median WBC count was 12.5 x 109/l (range 1.4-178.0); the p190 fusion product was detected in 33 patients, p210 in 18 and p190/p210 in 9. Median follow-up is 17.6 months (range 4.1-31.6). After the steroid pre-phase, 38 patients (63%) had a blast reduction ≥75%. At day 85, 58 patients achieved a CHR (97%) and 2 were non-responders (1 hematologic relapse and 1 disease progression): notably, both had a p210 fusion transcript. A CMR was obtained in 11 patients (18.6%): of these, 72% had a p190 fusion transcript. Overall, 24% of p190+ patients and 11% of p210+ or p190/210+ cases obtained a CMR. As previously reported in other GIMEMA trials, no deaths in induction occurred. Among the CMR patients, only 1 experienced a hematologic relapse and harbored a T315I mutation. Among the 46 non-CMR cases, 17/27 eligible patients underwent a HSCT, while 9 did not; 5 relapses occurred in the non-transplanted group, while 1 was observed in the HSCT group. Of the 19 HSCT non-eligible patients, 14 received the planned therapy: in this group, 2 relapses occurred. At 24 months, the overall survival (OS) is 69.1% (95%CI: 55.3-86.3), with a disease-free survival (DFS) at 18 months of 61.6% (95%CI: 47.6.0-79.8). A better DFS was observed in patients who obtained a CMR at day +85. Dasatinib exerted a rapid blast clearance, that was highly significant (p Conclusions: We confirm that a chemo-free induction approach for adult Ph+ ALL patients results in a very high CHR rate (97%), with no deaths in induction. In this Dasatinib-based protocol, a sustained CMR is achieved after induction in >18% of cases, suggesting that a subset of patients may be spared further intensive treatment. We witnessed an increase in p190/p210-p210+ cases compared to earlier studies; these patients showed a worse prognosis as underlined by a lower susceptibility to TKI, lower blast clearance and greater incidence of relapses (58%). At this first analysis, OS and DFS are at least comparable to those obtained in previous GIMEMA studies, despite the higher incidence of p210+ patients – which accounted for 45% of cases in this cohort – and which may require an intensified approach. Disclosures Martinelli: Pfizer: Consultancy; BMS: Consultancy, Speakers Bureau; Novartis: Consultancy, Speakers Bureau; ARIAD: Consultancy.

Backgrounds: Treatment of patients with relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL) not eligible to high dose therapy represents an unmet medical need. Histone deacetylases (DACs) regulate chromatin structure and function and are involved in crucial mechanisms of lymphoma cell growth. Panobinostat showed encouraging therapeutic activity in Hodgkin lymphoma, cutaneous T-cell lymphoma and other non-Hodgkin lymphomas, in studies conducted in lymphoma cell lines and in vivo in patients with advanced hematologic malignancies. Moreover, recent studies showed a potent activity of Panobinostat in DLBCL. Purpose: On this basis we performed a prospective, multicenter, phase II single arm study, to evaluate safety and efficacy of single agent Panobinostat as salvage therapy for R/R DLBCL adult patients and to evaluate a possible relationships between response and any biological features. Patients and Methods: Adult patients with R/R DLBCL who already performed high-dose chemotherapy followed by autologous stem cell transplantation (ASCT) or were not eligible for ASCT were included. The treatment plan included 6 induction courses with Panobinostat monotherapy followed by other 6 courses of consolidation; patients achieving complete response (CR), partial response (PR) or stable disease (SD), underwent maintenance for a maximum of 36 courses. In each 28-days course, Panobinostat was administered orally at the dosage of 40 mg/day three-times every week; dose adjustments for patients unable to tolerate the protocol-specified schedule were provided. The primary objective was to evaluate Panobinostat activity in terms of overall response (OR) according to the Cheson 1999 criteria; secondary objectives were: CR rate, time to response (TTR), progression-free survival (PFS), safety and feasibility of Panobinostat. We included evaluation of the impact of pharmacogenetics, immunohistochemical patterns and patient's specific gene expression and mutations as potential predictors of response to Panobinostat as explorative objectives. To this aim a pre-enrollment new tissue biopsy was mandatory. Results Thirty-five patients, 21 males (60%), were enrolled between June 2011 and March 2014. Clinical characteristics were: median age 73 (range 65-75), stage IV in 18 (55%), B-symptoms in 9 (28%), increased LDH in 24 (69%), high-intermediate or high International Prognostic Index (IPI) in 18 (51%). Patients received a median of 2 prior lines of therapy (range 1-4). At the end of induction phase, 7 responses (20%) were observed, including 4 CR (11%), while 28 patients (80%) discontinued treatment due to progressive disease (PD) in 21 (60%) or adverse events in 7 (20%). Median TTR in 9 responders was 2.6 months (range 1.8-12). With a median follow up of 6 months (range 1-34), the estimated 12 months PFS and OS were 27% and 30.5%, respectively. In univariate analysis, favourable IPI score and cutaneous involvement at enrollment showed a trend toward a higher ORR (p=0.007 and 0.061, respectively); pharmacogenetics, immunohistochemical and gene expression profile studies are still ongoing. No toxic deaths were reportewd; 18 patients died, 17 due to lymphoma progression and one for allogeneic transplant related complications, performed after PD. Grade 3-4 thrombocytopenia and neutropenia were the most common toxicities (in 29 (83%) and 12 (34%) patients, respectively), while grade 3-4 extra-hematological toxicity included diarrhoea in 4 (12%), infectious complications in 1 (3%) and supraventricular arrhythmia in 2 patients (6%). Conclusions The results of this study indicate that Panobinostat might be remarkably active in some patients with R/R DLBCL, showing durable CR. Feasibility was impaired by relevant hematological toxicity, mainly frequent and dose limiting grade 3-4 thrombocytopenia. Data that will be obtained from biological exploratory studies could hopefully be useful to better address the use of Panobinostat in peculiar subsets of patients. Figure 1 Figure 1. Figure 2 Figure 2. Disclosures Off Label Use: Panobinostat in DLBCL.

8577 Background: This is a phase II trial addressing a new treatment in pts with BCL and CNS disease (NCT00801216). Treatment is based on the encouraging experiences with high doses of antimetaboli...

Backgrounds Histone deacetylases (DACs) are involved in chromatin structure regulation and function. Treatment with DACs inhibitors leads to the activation or repression of genes regulating apoptosis, proliferation, differentiation, angiogenesis, immune responses. These agents resulted to be active for the treatment of T and B-cell lymphoma and other haematological malignancies. Previous in vitro studies underlined the possible pathophysiological role of DACs in diffuse large B-cell lymphoma (DLBCL). In FIL-PanAL10 we evaluate the therapeutic activity and safety of Panobinostat, a potent pan-DACs inhibitor, in patients with relapsed or refractory (R/R) DLBCL. Methods FIL-PanAL10 (NCT01523834) is a phase II, prospective multicenter trial of the Fondazione Italiana Linfomi (FIL). Enrolled patients are ≥ 18 years old with R/R DLBCL, following ≥ 1 line of chemo-immunotherapy (R-CHOP) including high dose therapy with autologous stem cell support (ASCT) in eligible patients. Patients with > 5 prior systemic lines of treatment, CNS involvement, HIV positivity, impaired cardiac function (according to the protocol) are excluded. Patients are scheduled to receive Panobinostat po 40 mg three-times every week as part of a 4-weeks treatment cycle up to disease progression, unacceptable toxicity, or patient’s refusal. The primary endpoint of the study is to explore the antitumor activity of Panobinostat in terms of overall response (ORR) according to the Cheson criteria 1999. Secondary objectives are the evaluation of complete response (CR), time to response (TTR), progression free survival (PFS), overall survival (OS) and safety. Exploratory objectives evaluate the predictive role of pharmacogenetics, immunohistochemical and specific gene expression in relation to the response to Panobinostat; for this aim a new lymph node or other pathologic tissue biopsy is requested before starting treatment. With the null (P0) and P1 hypothesis of overall response (ORR) corresponding to Results Between February 2011 and May 2013, 23 patients were enrolled on this study. Patients’ median age is 73 years (range 44-83 years); 7 (30%) patients received ≥ 3 previous lines of chemotherapy. Five patients responded to Panobinostat (ORR= 22%) including 3 CR (13%) and 2 (9%) partial response (PR): 1 patient had (4%) stable disease (SD). TTR was 2.5 months (range 2-3 months ). All 6 patients with ORR or SD are still in treatment with Panobinostat after 4, 5, 12, 12, 15, 24, months; 17 patients discontinued therapy because of progression (15) or side effects (2). After a median period of observation of 11 months from the beginning of treatment, 1-year PFS and OS are 22% and 28%, respectively. Most common observed grade 3-4 adverse events were hematological and included thrombocytopenia (88%) and neutropenia (34%); grade 3-4 diarrhoea was present in 3 (13%). The therapeutic schedule was modified from the three times week to three times every other week in 15 patients; a further dose reduction from 40 mg to 30 mg resulted to be necessary in 8 patients. The analysis of exploratory biologic objectives and of their relationship with outcome is still under investigation and will be ready for December 2013. Conclusions The preliminary results of this study indicates that Panobinostat is an active salvage therapy in nearly 20% of heavily pretreated R/R DLBCL patients; the relatively short TTR observed allows a prompt shift to other rescue treatments in non responders. The analysis of biologic biomarkers will hopefully better address Panobinostat therapy to a specific biologic subgroup. Disclosures: Zaja: Mundipharma: Consultancy, Honoraria; Roche: Consultancy, Honoraria; Celgene: Consultancy; GSK: Consultancy, Honoraria; Amgen: Consultancy. Off Label Use: Panobinostat in DLBCL.

Introduction The role of interim-PET (i-PET), after two cycles of chemotherapy, in advanced stage Hodgkin's lymphoma is well defined; the same role in diffuse large B cell lymphoma (DLBCL) is still controversial. The Fondazione Italiana Linfomi planned a prospective randomized phase III trial, addressed to young poor prognosis DLBCL patients at the diagnosis, with a 2x2 factorial design aimed at investigating the possible benefit of intensification with R-HDC+ASCT after R-dose-dense chemotherapy delivered at two different level of dose (R-CHOP14/R-MegaCHOP14). During this study an ancillary study was designed to define the prognostic impact of i-PET on progression free survival (PFS) after two cycles of immunochemotherapy in all treatments arms. Patients and methods As described by Vitolo et al (oral communication, abs 688 ASH 2012), patients were stratified according to aa-IPI and randomized at diagnosis to receive: R-CHOP14 x 8 cycles; R-MegaCHOP14 (1200 mg/sqm Cyclophosphamide, 70 mg/sqm Doxorubicin, standard dose Vincristine and Prednisone) x 6; R-CHOP14 x 4 + R-HDC (Rituximab + High Dose Cytarabine + Mitoxantrone + Dexamethasone) followed by BEAM and ASCT; R-MegaCHOP14 x 4 + R-HDC + BEAM and ASCT. G-CSF support was mandatory. Seventeen centers agreed to participate in the study and enrolled patients. All evaluable patients had performed basal PET and i-PET. A visual dichotomous criteria, according to Deauville Criteria (First Consensus Conference, 2009), was used to define the i-PET result. The final response was identified according to 2007 Cheson response criteria. Results From June 2005 to September 2010, 399 patients were randomized in the overall DLCL04 study and 130 were enrolled for the ancillary PET study , 69 in the R-HDC+ASCT and 61 in R dose dense therapy respectively. The clinical characteristics, as in the overall DLCL04 study, were well balanced among the four arms of therapy excluding a selection bias in the group of patients studied with i-PET. The i-PET result was positive in 74 patients and negative in 56 patients, no differences were observed between negative and positive i-PET results according to clinical characteristics and group of treatment. In particular, in R-dose dense arm 27 were negative and 34 positive, in R-HDC+ASCT 29 were negative and 40 positive, according to immunochemotherapy scheme in R-CHOP14 29 were negative and 40 were positive, in MegaCHOP14 27 were negative and 34 were positive. With a median follow-up of 36 months, 3-year PFS and 3-year Overall Survival (OS) rates for the whole series were: 64% (95% CI:59-69) and 79% (95% CI:74-83) respectively. No differences in PFS was reported according to i-PET result. In particular 3-year PFS were 87%(95% CI:75-94) in i-PET negative patients and 76% (95% CI: 65-85) in i-PET positive patients respectively (p: 0.09 The 3-year PFS according to I- PET results in the different treatment arm were: in the R-HDT+ASCT group i-PET negative or i-PET positive patients had a 3-year PFS of 83% (95% CI:63-92) and 79% (95% CI:63-89) respectively; in the R-dose dense i-PET negative or i-PET positive patients had a 3-year PFS of 92% (95% CI:73-98) and 72% (95% CI:54-85) with a p value near the significance (0.07). According to OS, i-PET negative and i-PET positive patients had a 3-year OS of 89%(95% CI:76-95) and 83%(95% CI:72-90) respectively, p=0.219. Conclusions In our multicenter prospective study, addressed to young poor prognosis DLBCL patients at the diagnosis, i-PET, performed after two immunochemotherapy cycles and analyzed with a visual method, is not able to identify two different risk population. To confirm our data, we are planning in the near future a centralized revision of all evaluable PET. In conclusion, our feeling is that the i-PET after two cycles in poor prognosis DLBCL patients is too early to predict a chemorefractory disease and more parameters must be considered to define clinical response in these patients. Disclosures: No relevant conflicts of interest to declare.

Abstract 425 Introduction. FDA and EMA have approved Deferasirox for iron chelation therapy for transfusion dependent MDS patients after a limited experience in selected MDS patients. Therefore we felt the need of a large, prospective, trial to verify Deferasirox safety, compliance, efficacy and effect on erythroid function in a large, “real world,” MDS population. Patients and Methods. One hundred fifty-two consecutive MDS IPSS lower risks (62 low and 90 intermediate1) transfusion dependent (minimum transfusion history 20 units received) patients were enrolled in 37 Italian centres. Patients received Deferasirox at the starting dose of 20 mg/kg. Characteristics of patients have been summarized by means of cross-tabulations for categorical variables and by means of median and range for continuous data. Adverse events (AEs) were defined according to CTCAE.3 (2003) definition. Disease progression was defined as advance to higher IPPS score group, development of acute leukemia or death. Efficacy of the treatment was measured by monitoring monthly serum ferritin levels. Transfusion independence was defined as three consecutive months without PRBC requirement with a minimum stable Hb level of 9 g/dl. The probability of drop out and transfusion independence were estimated using the appropriate non-parametric method, considering death and progression disease as a competing risk. Differences in univariate analysis were evaluated by Gray test. Fine and Gray model was used to evaluated prognostic factors in multivariate analysis. FriedmanÕs test was performed to evaluate differences in serum ferritin levels, hemoglobin level and transfusions input over time. Results. Ninety-six males and 56 females were enrolled. Median age was 72 years (66–77). Median interval diagnosis-enrolment was 32 months (17–54). Patients have been receiving regular blood transfusions for a median of 21 months (10–36) with a median number of units received of 37 (22–63). At baseline median CIRS co-morbidity score was 0 (0–1), CIRS severity score 0 (0–1), and Charlson co-morbidity score 0(0–1). Eighty-four patients (55%) prematurely interrupted the study while 68 (45%) completed the planned year of treatment. Risk of drop out was 18.8% and 28% at 6 and 12 months, respectively. Risk of disease progression or death was 12.7% and 25% at 6 and 12 months, respectively. In multivariate analyses significant risk factors for treatment interruption were shorter diagnosis-enrolment interval (P=0.0008), lower Deferasirox dose (p=0.008) and higher serum ferritin level (P=0.004). During the study 304 AEs were reported in 107 distinct patients. Of these events 93 (66 patients = 43%) were defined as possible-probably-certain drug related. Of these 93 related events fourteen in 11 distinct patients (7%) were superior to grade 2. Features of AEs were similar to those already reported. Serum ferritin significantly decreased during the study from a median starting value of 1966 ng/ml (1416–2998) to a median final value of 1475 ng/ml (915–2010), (P Conclusion. Less than 50% of the enrolled population was able to complete the planned year of treatment because of drop out (risk 28%) and progression (risk 25%) despite a limited number of >2 grade AEs. Noteworthy >69% of the AEs was not drug related indicating a basic vulnerability of this population. Deferasirox was effective in reducing serum ferritin levels. Clinical benefit was also related to erythroid improvement that was clinically significant reducing transfusion need in a relevant percentage of patients. ClinicalTrials.gov Identifier: NCT00469560 Disclosures: Angelucci: Novartis : Chair of Steering Committee of the Telesto trial Other. Vallisa:CELGENE CORPORATION: Research Funding.

Abstract 688 Introduction. The prognosis of young DLBCL patients at high risk treated with standard R-CHOP is still rather poor. The role of intensified HDC+ASCT in first line treatment is still a matter of debate in the Rituximab era. The FIL planned a prospective randomized phase III trial with a 2×2 factorial design aimed at investigating the possible benefit of intensification with R-HDC+ASCT after R-dose-dense chemotherapy delivered at two different level of dose (R-CHOP14/R-MegaCHOP14). Patients and methods. The primary end-point was to increase 2-year Progression Free Survival (PFS) from 50% of the standard dose-dense arm (R-dose-dense chemotherapy) to 65% in the experimental arm (R-dose-dense chemotherapy followed by R-HDC +ASCT). Secondary end-point was the comparison between two different schemes of dose dense chemotherapy, R-CHOP14 and R-MegaCHOP14. Inclusion criteria were: age 18–65; untreated DLBCL; age-adjusted IPI (aa-IPI) score 2 or 3. Patients were stratified according to aa-IPI and randomized at diagnosis to receive: R-CHOP14 × 8 cycles; R-MegaCHOP14 (1200 mg/sqm Cyclophosphamide, 70 mg/sqm Doxorubicin, standard dose Vincristine and Prednisone) × 6; R-CHOP14 × 4 + R-HDC (Rituximab + High Dose Cytarabine + Mitoxantrone + Dexamethasone) followed by BEAM and ASCT; R-MegaCHOP14 × 4 + R-HDC + BEAM and ASCT. G-CSF support was mandatory. Central nervous system prophylaxis was done according to the Italian Society of Hematology guidelines. Results. From June 2005 to September 2010, 412 patients were enrolled. Histology was centrally reviewed in 90% of cases. Thirteen patients were excluded because of different histological subtypes in 10 and active hepatitis HCV and HBV in 3. 399 patients were eligible and randomized: 199 to R-HDC+ASCT and 200 to R-dose-dense chemotherapy without ASCT; according to the type of chemotherapy 203 were randomized to RCHOP14 and 196 to R-MegaCHOP14. All patients were evaluable for analysis. Clinical characteristics were: median age 49 (range 18;65); stage II/III/IV 6/29/65%; LDH higher than normal value 89%; ECOG PS >1 43%; aa-IPI score 2/3 74/26%; all characteristics were well balanced between patients treated with or without ASCT. In the R-HDC+ASCT group, 151 patients (76%) completed the treatment and 177 (88%) in the R-dose-dense chemotherapy arms. Complete Remission (CR) was seen in 296 (74%) patients; CR was 76% in R-HDC+ASCT vs. 72% in the R-dose-dense chemotherapy arms. Overall 26 patients (7%) had a partial remission and 64 (16%) did not respond. Treatment-related deaths occurred in 13 (3%) patients: 8 (4%) in the R-HDC+ASCT arms vs. 5 (2.5%) in R-dose-dense arms. Grade III/IV extrahematological toxicities were reported in 85 patients (43%) in the R-HDC+ASCT vs. 38 (19%) in R-dose-dense arms. With a median follow-up of 36 months, 3-year PFS and 3-year Overall Survival (OS) rates for the whole series were: 64% (95% CI:59–69) and 79% (95% CI:74–83) respectively. Patients randomized to R-HDC+ASCT had a 3-year PFS of 70% (95% CI:63–76) compared to 59% of those treated with R-dose-dense only (95% CI:51–66); p = .010 (Figure 1) with a HR of 0.64 (95% CI: 0.46–0.91, p = .012). No difference in 3-year PFS was observed between R-CHOP14 and R-MegaCHOP14. According to aa-IPI, 3-year PFS in R-HDC+ASCT vs R-dose-dense arms were: aa-IPI score 2 74% (95%CI:65–80) vs. 63% (95%CI:54–71) p = .047; aa-IPI score 3 59% (95% CI:45–71) vs. 46% (95% CI:32–59), p= .121. At the time of this analysis, 3-year OS is 81% (95% CI:74–86) in R-HDC+ASCT vs. 78% (95% CI:70–83) in R-dose-dense chemotherapy patients, p= .556. In a Cox-model including the four arms and assuming R-CHOP14 as reference, the risk of relapse was significantly reduced in both ASCT arms with a major effect in the R-CHOP14+R-HDC+ASCT arm (HR=0.58, 95% CI=0.36–0.93, p= .025) and a slight minor HR reduction in the R-MegaCHOP14+R-HDC+ASCT arm (HR=0.68, 95% CI=0.42–1.09 p= .109). Moreover PFS in both arms (ASCT vs no ASCT) was further compared within pre-planned subgroups analysis according to the type of dose-dense chemotherapy, age, gender, aa-IPI and bone marrow involvement: the benefit of R-HDC+ASCT in PFS was maintained across all subgroups with no statistically significant interaction. Conclusions. R-dose-dense chemotherapy followed by R-HDC and BEAM with ASCT significantly reduced the risk of progression compared to standard dose-dense chemotherapy (R-CHOP14 or R-MegaCHOP14) in young patients with high-risk DLBCL. Disclosures: Vitolo: Roche: Membership on an entity's Board of Directors or advisory committees. Zaja:Roche: Membership on an entity's Board of Directors or advisory committees.

Abstract 3596 Intensive chemotherapy (IC) is associated with significant mortality and morbidity in elderly with acute myeloid leukemia (AML); particularly in patients aged ≥ 70 years, it is currently debated whether or not to deliver IC. Recent findings suggest that hypomethylating agents have encouraging clinical and biological activity in AML, with limited toxicity. Based on this background we wanted to evaluate retrospectively: 1) the efficacy of azacitidine (AZA) in elderly patients with untreated AML, diagnosed according to WHO criteria; 2) the impact of AZA on overall survival (OS) of this category of patients. For comparative purposes a historical group of matched patients who received IC was also analyzed. The AZA group included 57 patients, median age was 76 yrs (range 63–88) with 91% (52) of the patients being 70 yrs old or more, 32 were males and 25 females. Forty-two (78%) had a white blood cell count (WBCc) < 10×109/L, 17 (30%) a secondary AML supervening after an antecedent hematological disorder and 28 (49%) a bone marrow (BM) blast count < 30%. Karyotype was evaluable in 38 (67%) patients and, according to the refined Medical Research Council criteria, 27 (47%) had intermediate-risk abnormalities (25 normal karyotype) and 11 (20%) an unfavorable risk karyotype. A diagnosis of AML according to WHO classification, absence of uncontrolled infections, adequate renal and hepatic function, life expectancy longer than 4 months were the criteria to receive AZA. IC historical control group consisted in 83 patients enrolled sequentially in the AML13 and AML17 EORTC/GIMEMA protocols between 1995 and 2008. In these prospective trials patients aged 61–80 years received an induction course consisting in mitoxantrone, cytarabine (ARA-C), and etoposide (ICE) followed by 2 consolidation cycles including idarubicin, ARA-C, and etoposide (mini-ICE). In AML17 trial, the patients were also randomized to receive or not gemtuzumab ozogamicin, during induction and consolidation courses. Median age was 67 yrs (range 61–78) with 34% (28) of the patients being 70 years old or more, 47 were males and 36 females; 43 (52%) had a WBCc < 10×109/L and 79 (95%) a BM blast count ≥ 30%. Karyotype was evaluable in 65 (78%) patients: 52 (63%) belonged to the intermediate category (43 normal karyotype), 2 (2%) and 11 (13%) carried a favorable and unfavorable risk karyotype, respectively. Thirty-nine patients (68%) received AZA subcutaneously at the conventional dose of 75 mg/m2, the remaining 18 at a flat dose of 100 mg daily; all patients were given a schedule of 7 consecutive days per month. The median number of cycles delivered was 6 (range 1–39) and 77% of the patients received at least 4 cycles of therapy. Median follow up was 244 days (range 30–1281). Overall response rate, estimated according to the revised recommendation of the International Working Group in AML, was 17% and consisted in 11 (8%) complete remission (CR), 4 (3%) CR with incomplete blood count recovery (CRi) and 9 (6%) partial remission (PR). The chance of obtaining a response to AZA was significantly associated with a WBCc < 10×109/L (p=0.002). The median duration of response was 183 days (range 60–1067). Projected 2-years OS for patients on AZA treatment vs IC was 14% and 38%, respectively (p=0.008). Since the median age of the AZA group was 76 years, we broke down the analysis focusing on patients aged 70 years or more. By doing so, we observed that the projected 2-years OS for patients receiving AZA vs those receiving IC was 12% and 28%, respectively (p=0.11). Finally, among the category of patients aged ≥ 70 yrs, we extrapolated those who achieved a response with AZA (22 patients) or IC (22 patients); for these individuals, 2-years OS rate was 25% and 36%, respectively (p=0.46). In conclusion, our retrospective analysis suggests that in AML patients aged ≥ 70 yrs and with a WBCc < 10×109/L, AZA is as effective as IC and could be considered a valid therapeutic option. In this context, the manageable and limited toxicity of AZA will also allow for the quality of life objective to be accomplished. Patients aged < 70 yrs or those who, whatever the age, have a WBCc ≥ 10×109/L are likely to benefit more from IC than AZA. Controlled, randomized, clinical trials are warranted to further explore this matter and confirm our conclusions. Disclosures: No relevant conflicts of interest to declare.

Abstract 5168 Background: Myeloproliferative neoplasms (MPNs) are a group of diseases characterized by clonal expansion of single or multiple lineages of myeloid subset (i.e. granulocytic, erythroid, megakaryocytic and mast cell). Since 2008, the WHO included the detection of JAK2 mutations (the common V617F and the less common exon 12 mutations), into the diagnostic criteria of MPNs. The specific pathogenic implication of JAK2 mutations in MPNs is still under investigation. Preliminary data emerging from the treatment of Idiopathic Myelofibrosis patients with JAK2 inhibitors have shown only clinically significant benefits (improvement of splenomegaly and constitutional symptoms) but not a clear evidence of disease-modifying activity. Several techniques (e.g. ASO-PCR, ARMS-PCR, Direct sequencing, HRM, DHPLC, etc) have been used to detect the JAK2 V617F mutation, but all of them were low sensitive and time-consuming. We developed a PNA-clamping competitive PCR assay able to detect JAK2 V617F mutation with a very high level of sensitivity and specificity. Methods: In order to promote the selective amplification of the JAK2 V617F mutant allele, a specific PNA oligonucleotide, full matching with the wild-type (wt) sequence of the portion of JAK2 gene containing the V617F mutation, was designed to compete with the reverse primer used in the PCR assay. It was experimentally demonstrated that a PNA concentration of 6 μmol/L occurred for the complete clamping of 100 ng of wt genomic DNA used as template for the PCR reaction. The sensitivity of the assay was determined by a serial dilution (100% through 0.01%) of genomic DNA containing JAK2 V617F mutation, obtained from HEL cell line, with wt DNA obtained from healthy donors. The specificity of PCR products was assessed by sequencing in both forward and reverse directions. The thermal dissociation profile of PNA/DNA and DNA/DNA duplexes was studied by monitoring the Enthalpy as function of the temperature (range 20–100°C), with an heating/cooling rate of 1°C/min. Results: PNA-clamping competitive PCR was able to detect JAK2 V617F mutation with a sensitivity of 0.01%. Thermodynamic studies clearly showed that the melting temperature (Tm) of fully matched PNA/DNA duplex is always higher than Tm of the corresponding DNA/DNA duplex. The enthalpy values for the hybrid PNA/DNA are always greater than the corresponding DNA/DNA duplex and a single mismatch has an energetic cost higher in a PNA/DNA than in DNA/DNA duplex. This energetic cost is more evident in the melting temperature with a ΔTm of 16°C and 7°C for the PNA/DNA and DNA/DNA duplex, respectively. In the PCR assay the PNA complementary to the JAK2 wild type sequence strongly compete with the primer resulting in a complete knock out of the wild type allele. In a blind screening of samples obtained from 308 MPN patients, PNA clamping competitive PCR was able to detect JAK2 V617F mutation in 61.4% cases of Polycythemia Vera, 54.4% of Essential Thrombocythemia, 57.9% of Idiopathic Myelofibrosis and in 21.4% of Ph negative-MPNs, respectively. In 40 unselected patients, PNA clamping PCR results were confirmed by other techniques such as ASO-PCR, ARMS-PCR and direct sequencing. Conclusions: The PNA-clamping competitive PCR assay could be used as convenient, high-sensitive and reliable diagnostic test for detection of JAK2 V617F mutation both on genomic DNA and cDNA samples. As suggested from the thermodynamic studies, a similar technique could be developed for the detection of any known single point mutation, widely contributing to the improvement of molecular diagnostic tests usable in clinical practice. Disclosures: No relevant conflicts of interest to declare.

Abstract 2928 Introduction. The recent development of a safe and efficient once daily oral iron chelator (Deferasirox, ExjadeÒ) made possible regular chelation therapy in transfusion dependent MDS patients. However in this category of patients the reported clinical experience is limited to selected populations. For this reason the GIMEMA group developed a phase IIIb prospective trial to test safety and efficacy of Deferasirox in a large population of patients comparable to general MDS population. Methods. One hundred and fifty-nine transfusion dependent IPSS low-intermediate1 risk MDS patients were enrolled. Analysis has been performed on 123 patients who had completed the planned year of treatment. Baseline characteristics were the following (data are expressed as median with upper and lower quartile unless specifically indicated): median age was 72 years (range 24 – 87); 48 were IPSS low risk and 75 Intermediate1; duration of transfusion dependency before treatment was 20 months (12-36) corresponding to 38 (22-70) packed red blood cells transfusions received. Baseline serum ferritin was 2000 ng/ml (1471-3000). Baseline Charlson and CIRS comorbity scores were 1 (0-1) and 0.2 (0.1-0.4), respectively. Patients started treatment with the standard 20 mg/kg Deferasirox dose but dose adjustments on clinical indications were allowed. Results. 61 patients (49%) prematurely interrupted the study (drop out), 62 (51%) patients completed the planned year of treatment. In logistic model for drop out rate high Charlson co-morbidity score showed a trend as significant risk factors (p=0.06). Drops out were related to: ten patients (8%) had progression to acute leukemia during the study; twenty patients (16%) experienced MDS related clinical problem (three had cardiac failure, seven had severe infectious diseases, four had severe bleeding, three died at home, three presented others MDS related problems); five patients underwent hemopoietic stem cell transplantation and thirteen discontinued treatment for unrelated problems. Drug related toxicity was drop out cause in 13 patients (11% of the entire population). Main causes of toxicity related drops out were increase of creatinine and gastro-intestinal disturbance. Out of 123 patients analyzed for adverse events only 4 (3%) presented grade 3–4 drug related adverse events. Severe adverse events with suspected relationship with study drug were diarrhea and increase of liver enzymes. Serum ferritin was monthly recorded in the 62 patients who completed the protocol with a statistically significant decrement during the 12 months follow up: median baseline value 2000 ng/ml (interquartile range 1471–3000), median final value 1550 ng/ml (interquartile range 775–2200) P < 0.001, Friedman test analyzing the entire study period. Analysis of quality of life is ongoing. One patient showed a complete erythroid response to Deferasirox treatment acquiring transfusion independence that is still ongoing after 18 months. Discussion. Preliminary results from the GIMEMA MDS0306 study confirmed feasibility of Deferasirox therapy in transfusion dependent MDS patients. Drop out rate, toxicity related drop out and severe side effects were similar to those reported in other trials even if the present population presented clinical characteristics of more advanced disease and age. The rate of progression is coherent with prolonged disease story. Serum ferritin behavior confirms Deferasirox efficacy. The serum ferritin reduction was more evident in the more heavily overloaded population indicating successful iron depletion in this group of patients as clinically requested. ClinicalTrial.gov identifier NCT00469560. Disclosures: Angelucci: Novartis: Honoraria. Saglio:Novartis: Consultancy, Honoraria; Bristol Myers Squibb: Consultancy, Honoraria.

Abstract 1662 Poster Board I-688 Introduction Bendamustine is an alkylating agent with a nitrogen mustard group and a purine like benzimidazol group. Recently this drug was introduced in Italy. We analized all pts treated in sixteen haematological Italian centers with Bendamustine alone or in combination with anti-CD20 antibody. Patients and methods On an intention to treat basis pts who have received at least one complete cycle were evaluable for response and toxicity. The treatments consisted of: Bendamustine 60-90 mg/m2 days 1,2 alone or in combination with Rituximab 375 mg/m2 day 0, every 21 or 28 days. 173 pts were analized, median age was 67 (range 31-87), 114 were male, 63 chronic lymphatic leukaemia 41 indolent non-follicular lymphoma, 26 diffuse large B cell lymphoma, 26 follicular lymphoma, 15 mantle cell lymphoma, 2 Peripheral T cell lymphoma. Pts were heavily pretreated, the median number of previous treatments was 3,5 (range 1-8), 121 pts have experienced more than three chemotherapy schemes. One hundred and twenty-seven pts were previously treated with Rituximab and 24 performed an autologous peripheral blood stem cell transplantation. The Bendamustine pre-treatment condition was: 70 relapsed pts, 40 with refractory disease and 63 with a progressive disease after partial response. The median number of Bendamustine cycles was 4.3 (range 1-11). Results All patients were evaluable for response: 48 pts (28%) obtained a complete remission, 78 (45%) a partial response or stable disease with an overall response rate of 73% and 47 were non responders. According to histotype we observed that 10/15 pts (67%) with mantle cell lymphoma obtained a response (6 CR;4 PR), 37/41 (9 CR; 28 PR) indolent non follicular lymphoma and 25/26 (96%) follicular lymphoma obtained a response (12 CR;13 PR), 46/63 CLL obtained a response and 8/26 (31%) DLBCL obtained a response to therapy (4 CR;4 PR), none of the two T lymphoma pts responded to therapy. With a median period of observation of 12 months (1-46) 121 (70%) pts are alive and 83 pts are in complete remission or with stable disease without any other treatment. The overall survival was 82%, 72%, 68% and 27% respectively for indolent, CLL, mantle cell and diffuse large B cell lymphoma. The progression free survival was 31%, 27%, 15% and 10% respectively for indolent, CLL, mantle cell and diffuse large B cell lymphoma. Fifthy-two pts died, 47 for progressive disease, 11 due to infection and sepsis (6%) and 2 due to other causes not related with therapy or disease. In this group of heavily pretreated pts 760 cycles were performed. The extrahematological toxicity was mild the most important problem were infections (Herpes Zooster, pneumonia, enteritis) reported in 16 pts, hepatic in 4 and cardiologic in 2 pts. The hematological toxicity was trombocytopenia grade 3-4 in 20 pts (12%), neutropenia grade 3-4 in 40 pts (23%) and anemia grade 3-4 in 19 pts (11%). Discussion In conclusion this retrospective study shows that treatment with Bendamustine alone or in combination with Rituximab is a safe and efficacy regimen in a subset of pluriresistent patients. This data shows also that the best results could be obtained in indolent lymphoma and CLL incouraging data in mantle cell lymphoma are reported. Disclosures No relevant conflicts of interest to declare.

Complete response (CR) is an important objective of autologous stem-cell transplantation (ASCT) in multiple myeloma (MM). In comparison with conventional induction treatments, newer combinations of novel agents may effect increased rates of CR and near CR (nCR), a benefit potentially translating into even higher frequencies of CR/nCR after ASCT and improved clinical outcome. We designed a phase III study to detect an increase in CR+nCR rates from 10–15% with conventional Thalidomide-Dexamethasone (TD) to 20–30% with Velcade added to TD (VTD) in newly diagnosed MM. Both TD and VTD were given as three 21-day cycles in preparation for double ASCT. In the present analysis, CR+nCR rates by the two induction treatments were examined in relationship to baseline prognostic variables in 399 evaluable pts aged ≤65 years, of whom 199 randomized to VTD and 200 to TD. All analyses were intent to treat. In comparison with TD, VTD effected higher rates of CR+nCR (12% vs 33%, P190 U/L (33% vs 9%, P10 g/dL (P=0.01). In the VTD arm, a positive correlation was observed with del(13) (P=0.006) and t(4;14) (P=0.02). Response to first ASCT with melphalan 200 mg/m2 could be evaluated in 297 pts, of whom 145 randomized to VTD and 152 to TD. Randomization to VTD was closely associated with increased CR+nCR rates (54% vs 29% with TD, P

Introduction . BEAM (carmustine, etoposide, aracytin, melphalan) is a conditioning regimen used in autologous hemopoietic stem cell transplantation for Hodgkin Lymphoma and non Hodgkin Lymphoma, with acceptable toxicity and high efficacy. In our study we replaced the carmustine with fotemustine, an analogous chloroethylnitrosourea. Primary end-point was to valuate the feasibility of this modified conditioning regimen. Patients and Methods . 86 patients were consecutively conditioned in seven BM-Units with FEAM before receiving aHSCT. 44 patients (63%) were male, 32 (37%) female. Median age was 51 years (range, 18–77). 23 patients (27%) had HL, 60 (70%) had NHL (2 SLL, 1 LPL, 1 MZL, 2 FL, 6 MCL, 37 DLBCL, 3 BL, 1 B-LBL, 1 T-LBL, 4 u-PTCL, 2 AIL), 1 patient had a B-CLL, 1 a B-ALL FAB L3 and 1 an aggressive NK-cell leukemia. In the lymphoma group, 22 patients (27%) were in stage II (10 with bulky disease), 20 (24%) in stage III and 41 (49%) in stage IV. Among lymphoma patients, 19 (23%) had a bone marrow involvement, 5 (6%) a central nervous system involvement, including 2 primary central nervous system lymphoma. At the time of transplantation, 41 patients (48%) were in CR, 3 (3%) in VGPR, 32 (37%) in PR, 10 (12%) had a resistant-progressive disease (R/PD); 30 patients (35%) were at first line of therapy, 56 (65%) had received more than one line of therapy. Patients received fotemustine 150 mg/m2 on days -7, -6, etoposide 200 mg/m2 and aracytin 400 mg/m2 on day -5, -4, -3, -2, and melphalan 140 mg/m2 on day -1. The median number of CD34+ cells infused was 3.8 × 106/Kg recipient body weight (range, 1–21.8). Results . Only 2 patients were not evaluated for engraftment and toxicity. Among evaluable patients, all engrafted. The median time to neutrophil (N >0.5 × 106/L) and platelet (PLT >20 × 109/L) recovery was 11 (range, 9–19) and 13 days (range, 6–105) respectively. 55 patients (65%) received trasfusions of red blood cell units, with a median of 2 units (range, 1–8). All patients received platelet trasfusions with a median of 2 units (range, 1–15). Toxicity . No chemotherapy-induced nausea and vomiting (CINV) was observed in 17 patients (20%), 53 patients (63%) had CINV grade I–II, 14 patients (17%) grade III, no grade IV was observed. No mucositis was observed in 16 patients (19%), 45 patients (54%) had mucositis grade I–II, 17 patients (20%) grade III, 6 patients (7%) grade IV. No diarrhea was observed in 50 patients (60%), 29 patients (34%) had diarrhea grade I–II, 5 patients (6%) grade III, no grade IV was observed. No epatic toxicity was observed in 80 pts (95%), 1 patient had epatic toxicity grade I, 1 patient grade II and 2 patients grade III, no grade IV was reported. Only one patient had a transient renal toxicity grade II. No pulmonary toxicity was observed. Fever >38, 5°C was documented in 68 patients (81%) with a median duration of 4 days (range 1–25). GRAM-were identified in 15 patients, GRAM+ in 14 patients, yeasts were isolated in 3 patients and there was only one infection by Pneumocystis Carinii. In the other 35 patients (51%) no organism was identified as the source of the fever which was classified as FUO. Outcome . At a median follow-up of 5 months (range, 1–16), 79 patients (92%) are alive. On 75 evaluated patients, fifty-nine (79%) are alive and free from disease. Among the seven deceased patients, three died for PD at day +111, +110 and +75 from transplantation respectively, one died for bacterial meningitis at day +45 from transplantation, after a complete hematologic recovery, one in PR died for gastric haemmorrhage from tumor site, and two (1 CR, 1 VGPR) died for comorbidity, respectively at day +150 and +240 from transplantation. TRM at 100 days was 1%. Among the 75 patients who were evaluated after aHSCT, thirty-five patients, out of thirty-six who were in CR before aHSCT, maintained the CR after, for the other thirty-nine, twenty-seven (69%) achieved the CR (three of these had a CNS involvement before aHSCT), one achieved a VGPR, two a PR (ORR 77%), four had a stable disease and five progressed. Considering as treatment failure the relapse, the progression or the death for any cause, in our study the treatment failure was assessed on 16%. Conclusions . Our study demonstrated the feasibility and the safety of the FEAM, regard its toxicity it was not superior with respect to BEAM. However, a longer follow-up is needed to valuate the efficacy of this modified conditioning regimen in term of clinical response.

Thalidomide-containing regimens are currently being used as standard initial therapy for both younger and elderly pts with multiple myeloma (MM), but are associated with an increased risk of venous thromboembolism (VTE) which necessitates routine thromboprophylaxis. Controversies exist concerning the best thromboprophylactic regimen to be used in these pts. To address this issue, the Italian Myeloma Network GIMEMA designed a phase III sub-study aimed at prospectively investigating the efficacy and safety of low molecular weight heparin (LMWH) or fixed low-dose warfarin (WAR) or low-dose aspirin (ASA) as prophylaxis against VTE in newly diagnosed MM pts who were randomized to receive primary induction therapy with thalidomide-containing regimens in the context of 2 phase III studies conducted by the same group. In one of these studies, pts with ≤65 years of age were randomly assigned to receive Velcade-Thalidomide-Dexamethasone (VTD) or Thalidomide-Dexamethasone (TD) before autologous transplantation. In the other study, Velcade-Melphalan-Prednisone (VMP) was compared with VMP plus thalidomide (VMPT) for elderly patients aged >65 years. The daily dose of Thalidomide was 200 mg in both VTD and TD, and 50 mg in VMPT. Pts randomized to VTD or TD received a total Dexamethasone dose of 320 mg/cycle, while those assigned to VMP or VMPT were given a total Prednisone dose of 240 mg/m2/cycle. By sub-study design, pts treated on VTD or TD or VMPT were randomly assigned to receive thromboprophylaxis with LMWH (Enoxaparin, 40 mg/d) or WAR (1.25 mg/d) or ASA (100 mg/d) for the duration of induction therapy. At the opposite, pts randomized to VMP did not receive any prophylaxis and were used as controls. Sub-study end points included incidence of VTE, acute cardiovascular events, sudden death, bleeding and any other serious adverse events. At the time of the present analysis, 703 pts who received at least 3 cycles of induction therapy were evaluated. Of these pts, 164 treated on VMP were the control group, while the remaining 539 pts (of whom, 209 treated on VTD, 211 on TD and 119 on VMPT) were randomized to receive either LMWH (n=178) or WAR (n=180) or ASA (n=181). Baseline pts characteristics and risk factors for VTE were comparable in all sub-groups. Overall, the risk of VTE was 3.9% with WAR vs 4.5% with LMWH vs 5.5% with ASA (P values not significant for comparisons between different sub-groups), whereas it was 1.8% among the controls. Median times to onset of VTE for pts treated on LMWH or WAR or ASA were 2.66 vs 2.96 vs 2.10 months, respectively. Pts receiving Velcade-containing regimens (VTD or VMPT) had a VTE frequency in the range of approximately 3%, as compared to 5.8% for pts on TD (P value not significant). The rates of cardiovascular events were 0.6% in each of sub-groups including LMWH, WAR and controls, vs 1.1% for pts treated on ASA. No sudden deaths were reported. The incidence of all grades bleeding was 0.6% with LMWH vs 1.1% with WAR vs 3.3% with ASA (P values not significant for comparisons between different sub-groups), while it was 3.7% among the controls. In conclusion, results of the present analysis show that the overall risk of VTE among sub-groups of pts treated with different thalidomide-containing regimens was not superior to that expected during the natural course of MM. No significant relationship was found between the frequency of VTE and thromboprophylactic regimens, induction treatments (e.g. containing or not Velcade) and age of pts (e.g. young vs elderly). In comparison with LMWH and WAR, there was a higher, albeit marginal, risk of VTE and bleeding complications associated with ASA prophylaxis. Finally, a finding not previously well recognized, fixed low-dose WAR was not inferior to LMWH in reducing the risk of VTE among newly diagnosed MM pts receiving thalidomide-containing regimens. For these pts, LMWH, WAR and ASA are likely to be effective thromboprophylactic regimens.

Autologous stem cell transplantation (ASCT) is widely used in young/adult patients with acute myeloid leukemia (AML). However, ASCT is also feasible in elderly AML patients with encouraging results in terms of relapse rate reduction. The combination of fludarabine (F) with cytarabine (ARA-C) is effective in poor risk AML and advanced myelodysplastic syndromes (MDS); however, the administration of F can result in insufficient collection of CD34+ cells. We investigated the mobilization capacity from 28 untreated non M3 elderly AML patients who achieved complete remission (CR) after F plus ARA-C given as continuous sequential infusion (CI-FLA). F was administered at a loading dose of 10 mg/sqm over 15 min at day 0 followed by a continuous infusion (CI) of 20 mg/sqm/24h for 72 hours. ARA-C was given at a loading dose of 390 mg/sqm over 15 min three hours and half after F and then as CI over 96 hours at 1440 mg/sqm/24h. G-CSF was added at day +15 at 5 microg/kg. Patients in CR were programmed to receive an identical course. However, after the first 20 patients, consolidation was reduced by one day because of excessive toxicity. G-CSF at 10 microg/kg was added at day +15 with the aim of shortening neutropenia and mobilizing CD34+ cells. Between December 2001 and April 2004, 62 patients with a median age of 69 years (61–81) received the therapeutic program. In 24 cases (39%) a previously diagnosed MDS preceded the onset of AML. According to MRC criteria, 29 patients (47%) had intermediate karyotype, 23 (37%) adverse karyotype, 1 (2%) favorable karyotype and 9 (14%) no evaluable metaphases. Overall, 41 patients (66%) achieved CR, all following one course of CI-FLA. Among these, 34 (83%) received the programmed consolidation, while in 7 cases therapy was discontinued due to toxicity (n=5), death from cerebral hemorrage (n=1), loss to follow-up (n=1). There were 6 deaths after consolidation (4 from infections and 2 from miocardial infarction apparently unrelated to chemotherapy). Finally, 28 patients were monitorized for the mobilization which was successful in 22/28 patients (78%), with a median collection of 7.5x10E6 CD34+ cells (2,1–60,3). The median number of apheresis was 2 (1–3). The median age of mobilizers was 68 years (61–77); of note, 12/28 of them (43%) had secondary AML and 9 (41%) were aged over 70 years. There was no difference in CD34+ mobilization between patients consolidated with three or four days of therapy (p=0.78). Median time from the beginning of consolidation to first collection was 19 days (17–29). Overall, 17 patients (27% of the whole population, 41% of remitters and 77% of mobilizers) received ASCT, in absence of transplant related death. The median age of autografted patients was 66 years (61–77). Reasons for not autografting included early relapse (n=1), refusal (n=1), infection (n=2), severe uncontrolled diabetes resulting in left foot gangrene (n=1). In conclusion, this study demonstrates that continuous sequential infusion of F + ARA-C is effective in elderly AML patients with acceptable toxicity and high rate of CD34+ cell mobilization. In particular, our results compare favorably with classical combination of anthracyclines plus ARA-C or conventional F+ARA-C in terms of mobilization. We suggest that F, when given as continuous infusion, results in negligible stem cell damage and therefore in less impairment of mobilization capacity.

Cyclin-dependent kinase inhibitors (CKI) regulate cell division resulting aberrantly expressed in many types of cancer. Alterations of CKI have been reported in acute leukemia, as the result of gene promoter methylation. Despite the common frequency of these alterations, little has been reported on the role of CKI aberrant protein expression and results are less clear, especially in acute lymphoblastic leukemia (ALL). The aim of this study was to analyze p21, p15 and p16 protein expression and their gene methylation status in primary cells from adult ALL cases enrolled in the LAL2000 GIMEMA protocol. Normal peripheral blood lymphocytes (PBL) and 91 primary samples from untreated ALL patients were evaluated in this study. The p21, p15 and p16 protein expression was analyzed by Western blot using the specifically MoAbs. The CKI gene methylation status was investigated using a widely accepted method based on bisulfite modification of DNA, followed by the use of the methylation-specific PCR assay (MSP). This assay was further validated in vitro by SSI methylase. Normal PBL from 10 healthy donors, as described, did not expressed all CKIs and resulted unmethylated. The p21 expression was found in 28/91 cases (30.8%); in contrast, samples were found constantly unmethylated. The p15 expression was found in 44/85 cases (51.8%) and its gene methylated in 41.7%; a significant correlation was found between absence of protein expression and gene methylation (P=0.040). The p16 resulted never expressed in adult ALL, while its promoter was found methylated in 8/42 cases (19.1%). A significant association (P=0.037) was observed between p21 expression and immunophenotype; in fact, 3/24 (12.5%) T-ALL and 24/65 (36.9%) B-lineage ALL expressed this protein. The p16 methylation was associated with T-ALL (P=0.082). Achievement of CR was not influenced by single protein expression, nor by gene methylation status. However, the co-expression of p15 and p21 was associated with failure to induction treatment; in fact, only 6/67 (9%) of patients co-expressing p15 and p21 achieved CR (P=0.021). In summary, in adult ALL p21 is not methylated and p16 is never found expressed, and CR achievement is adversely affected by the co-expression of p21 and p15. In conclusion, we report that in addition to CKI methylation, aberrant expression of CKI, namely p21 and p15, is associated with poor outcome in adult ALL, suggesting that chemotherapy resistance may be promoted in these cases by cell cycle arrest and/or abnormal survival.

The superiority of intensive versus standard chemotherapy for aggressive (I: intermediate; H: high grade) NHL is still debated; increased antitumor activity may be counterbalanced by increased toxicity. We have designed a first-line five-drug regimen (vincristine, idarubicin, cyclophosphamide, etoposide and deflazacort), with the aim of potentiating the CHOP protocol without losing tolerability and ease of administration. Seventy-one patients (33\% aged > or = 65) entered the study. CR was obtained in 66.7\% of patients (I: 74\%; H: 56\%), PR in 19.7\%: overall response rate was 86.4\%. Six patients were resistant, two died during treatment. With a median follow up of two years, relapse has occurred in 14 patients (8 I, 6 H). At 3 years, overall survival was projected to be 62.5\% (I 73.5\%; H 31.4\%), disease free survival 66\% (I 71\%, H 56.3\%). No organ toxicity occurred. Myelosuppression was moderate, with a nadir on the 14th day. Febrile episodes occurred in 16\% of courses, dose delay in 19\% of courses; dose reduction in 3\% of patients. No patient required hospitalization. G-CSF was only occasionally used. This regimen has shown a potent antitumor effect with an excellent tolerance, even in elderly patients.

Abstract 2821 Epidemiological studies demonstrated that HCV is associated with B-cell NHL. A precise prognostication of HCV+ NHL is not available; in particular, the impact of liver toxicity on the outcome of pts treated with (immuno)-chemotherapy is not fully clarified. Aim of the present study was to analyse clinical and virological characteristics, toxicity and prognosis of a large series of indolent and aggressive HCV+ NHL. We studied 1,043 pts with HCV+ NHL diagnosed and treated from January 1993 to December 2009 in 15 italian hematologic institutions; 539 cases were aggressive NHL (522 DLBCL) and 504 indolent NHL (265 MZL). All pts were HIV negative, 3% carried HBsAg and 91% were HCV-RNA+. Thirteen out of 56 HCV-RNA negative pts cleared HCV by means of antiviral therapy before NHL diagnosis. An (immuno)-chemotherapy regimen was administered as first-line treatment in 859 pts: 537 received CHOP-like regimen (+ Rituximab 243), 66 III generation regimen, 174 alkylators, 30 purine analogues, 31 other regimens, 21 R alone. Doses of chemotherapy since first cycle were reduced in 31% of pts. A watch-and-wait policy was adopted in 82 pts, other treatments in 68 pts and anti-HCV antiviral therapy in 34 pts with indolent NHL (12 of whom obtained both a complete virologic and hematologic response). Hepatic toxicity was evaluable in 597 patients: among 347 pts with normal ALT at NHL diagnosis, 52 (15%) developed WHO hepatic toxicity ≥ grade 2; among 250 pts (42%) with abnormal ALT, 26 (11%) experienced ALT increase >3.5 times baseline value. Overall, a significant liver toxicity developed in 78 pts (13%) (15% of aggressive NHL and 10% of indolent NHL). Use of Rituximab was not associated with significant liver toxicity (p=0.4); particularly, in DLBCL, R-CHOP and CHOP showed the same rate of significant hepatic toxicity (15%, p=ns), although maximum grade of liver toxicity was registered earlier in patients treated with R-CHOP than in those treated with CHOP (before 3rd cycle respectively in 57% vs 41%, p=0.006). Planned treatment was not completed in 134 pts (29 for liver toxicity). After a median F-UP of 2.6 years, 321 pts died (24 for liver failure). 5-yrs OS was 76% for indolent NHL and 62% for DLBCL. In indolent NHL, the parameters associated with a shorter OS in univariate analysis were: elevated LDH (p 60 yrs (p106 UI/ml (p 60 yrs (HR 2.11, p=0.02), AA stage III-IV (HR 2.0, p=0.04), no antiviral therapy at any time (HR 2.56, p=0.01). In DLBCL, the parameters associated with a shorter OS in univariate analysis were: elevated LDH (p 60 yrs (p=0.003), liver involvement by lymphoma (p=0.02), B symptoms (p1.7 (p=0.01), Child score (p106 UI/ml (p9 and/or fibrosis stage >2 at liver biopsy (p=0.03). Moreover IPI, aaIPI and R-IPI were predictive for OS (p106 UI/ml (HR 3.59, p=0.001), serum albumin Disclosures: No relevant conflicts of interest to declare.

Abstract 3836 Background. In essential thrombocythemia (ET) patients history of thrombosis and age over 60 y are validated risk factors for thrombosis; the thrombocytosis is a constitutive abnormality associated with both thrombotic and hemorrhagic risk; JAK2 V617F mutation, leukocytosis, and male gender are candidate thrombotic risk factors. Aims. To evaluate in ET patients clinical-biological characteristics at diagnosis and their relationship with thrombosis occurrence before and after diagnosis. Methods. A cohort of ET patients of the Registro Italiano Trombocitemia (RIT) was retrospectively analysed. This preliminary report in detail considers data on thrombosis history. Results. A total of 977 patients, 387 males and 590 females, presented at diagnosis: median age 55 y, median PLT count 783 × 109/L, median WBC count 8.8 × 109/L, median Hb 14.1 g/dL, bone marrow fibrosis (grade >0) in 33% of cases, history of thrombosis in 189 cases (19.3%). The patients at high risk (age over 60 y and/or history of thrombosis) were 511 (52 %). The thrombosis history in univariate analysis was significantly related to: age over 60 y (p 0.001), male gender (p 0.045), low thrombocytosis (PLT 8.8 x109/L, p 0.01), and JAK2 V617F mutation (p 0.006). No relationship was found with the bone marrow fibrosis. The 977 patients, when both PLT count and WBC count at diagnosis were considered, were subdivided in four groups: group 1: 202 pts with low thrombocytosis and leukocytosis; group 2: 270 pts with low thrombocytosis and no leukocytosis; group 3: 272 pts with high thrombocytosis and leukocytosis; group 4: 197 pts with high thrombocytosis and no leukocytosis. In those patients, the thrombosis history was: 26.7% in the group 1(both risk factors); 24.1% in the group 2 (PLT risk factor); 20.2% in the group 3 (WBC risk factor); 7.6% in the group 4 (no risk factors). The rate of thrombosis history in patients with one or two of these risk factors was significantly (p 0.001) higher than in patients with no risk factors. The thrombotic events during the follow up (4088 pt-y) are still object of analysis. Conclusion. In this cohort of ET patients the rate of thrombosis history in univariate analysis was related to age over 60 y. Moreover, a significant relationship was found with PLT count at diagnosis below the median value (783 x109/L), WBC count at diagnosis over the median value (8.8 x109/L), JAK2 V617F mutation, and male gender. Disclosures: No relevant conflicts of interest to declare.