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Lenalidomide-RCHOP (R2-CHOP21) has been shown to be safe and effective in patients with untreated diffuse large B-cell lymphoma (DLBCL). The aim of this analysis is to report long-term outcome and toxicities in newly diagnosed DLBCL patients who received R2-CHOP21 in two independent phase 2 trials, conducted by Mayo Clinic (MC) and Fondazione Italiana Linfomi (FIL). All patients received R-CHOP21 plus lenalidomide. Long-term progression-free survival (PFS), time to progression (TTP), overall survival (OS) and late toxicities and second tumors were analyzed. Hundred and twelve patients (63 MC, 49 FIL) were included. Median age was 69 years, 88% were stage III–IV. At a median follow-up of 5.1 years, 5y-PFS was 63.5%, 5y-TTP 70.1% and 5y-OS 75.4%; according to cell of origin (COO): 5y-PFS 52.8% vs 64.5%, 5y-TTP 61.6% vs 69.6% and 5y-OS 68.6% vs 74.1% in germinal center (GCB) vs non-GCB respectively. Four patients experienced grade 4–5 late toxicities. Grade ≤ 3 toxicities were infections (N = 4), thrombosis (N = 1) and neuropathy (N = 3). Seven seconds tumors were observed. Long-term follow-up demonstrates that R2-CHOP21 efficacy was maintained with high rates of PFS, TTP, and OS. Lenalidomide appears to mitigate the negative prognosis of non-GCB phenotype. Incidence of therapy-related secondary malignancies and late toxicities were low.

Central nervous system (CNS) relapse of diffuse large B-cell lymphoma (DLBCL) is a devastating event occurring in ~ 5% of patients treated with R-CHOP. We hypothesized that adding lenalidomide to R-CHOP (R2CHOP) may decrease the risk of CNS relapse. We analyzed records for patients with DLBCL from two R2CHOP trials. We assessed variables pertinent to the CNS-International Prognostic Index (CNS-IPI) scoring system and classified patients into groups of low, intermediate, and high risk of CNS relapse. The 2-year CNS relapse rate for each risk group was estimated using the Kaplan–Meier method and compared with reported rates in cohorts treated with contemporary chemoimmunotherapy. A total of 136 patients were included. Mean age was 65 and median follow-up was 48.2 months. 10.3, 71.3, and 18.4% of patients were classified into low, intermediate, and high-risk CNS-IPI groups, respectively. Only one of 136 patients developed CNS relapse, corresponding to an incidence of 0.7% and an estimated 2-year CNS relapse rate of 0.9% for the entire R2CHOP cohort. The estimated 2-year CNS relapse rates for the low, intermediate, and high-risk groups were 0, 0, and 5.0%, respectively. Frontline therapy with R2CHOP in patients with DLBCL is associated with a lower-than-expected rate of CNS relapse.

Background. The outcome of relapsed/refractory diffuse large-B cell lymphoma (DLBCL) patients after first line chemoimmunotherapy is poor, and the choice of the best salvage treatment is challenging. Acisplatin-containing regimen (DHAP, cisplatin, high-dose citarabine, dexamethasone) is worldwide accepted as induction pre-stem cell transplantation (SCT). Bortezomib had proven activity in aggressive lymphomas. On these bases, the Fondazione Italiana Linfomi designed the FIL-VERAL12 trial, aimed at evaluating whether the addition of bortezomib to rituximab-DHAP (BR-DHAP) increases complete response rate (CR, according to Lugano 2007 criteria) prior SCT compared to standard R-DHAP. Methods. FIL-VERAL12 was a prospective, multicenter, two-arm randomized phase II trial (NCT01805557).The primary study endpoint wasCR after 4 courses of R-DHAP or BR-DHAP, assuming a 30% CR for the standard arm and a 50% CR in experimental arm. Inclusion criteria were: patients aged 18-65 years with relapsed/refractory DLBCL after first line chemoimmunotherapy, eligible to high-dose therapy. A centrally histological review and classification according to cell of origin profile was planned. Patients were stratified by relapsed or refractory and randomized 1:1 to receive: a) the standard salvage therapy R-DHAP every 28 days for 4 cycles and b) subcutaneous 1.5 mg/sqm bortezomib on days 1 and 4 of each 4-week cycle in addition to the same regimen. Restaging, mobilization and harvesting of peripheral stem cell were performed after the second course. Results. From January 2013 to November 2018, 114 patients were screened; 108 eligible patients were enrolled into the trial and randomized to receive R-DHAP or BR-DHAP (54 patients in each arm). Principal clinical characteristics were: median age 57 years (IQR: 48;62); stage III/IV 81 patients (75%); IPI risk >3 32 (30%). All patients received rituximab and anthracycline-based regimens as first line treatment. Considering the time at relapse, 52 patients (48%) were registered as relapsed (median time at relapse 10.8 months, IQR: 6.9;20.9) and 46 (43%) as refractory (0.9 months, IQR 0.52;1.3); in the remaining 10 patients the data is missing at the time of this analysis. 51 (47%) patients completed the planned 4 cycles of therapy; 57 did not, due to progressive disease in 20, adverse events in 2, unknown causes in 35 cases. Intermediate response after 2 courses was: CR 16 (15%), partial response (PR) 37 (34%), stable disease (SD) 16 (15%); 24 (22%) were in progression (PD) and 15 (14%) were not available for response. At the end of treatment, the pre-ASCT response was: : CR 30 (28%), PR 10 (9%), SD 13 (12%), PD 38 (35%), NA 17 (16%). According to arm of randomization, the primary end point was not met, with CR 30% for R-DHAP and 26% for BR-DHAP (Pr 0.667). 38 patients performed a consolidation SCT, autologous SCT in 38, allogeneic SCT in 4. The addition of bortezomib to standard R-DHAP did not impact the mobilization: only one patient was poor mobilizer and the median number of CD34+ collected was 6.9 x 10^6 cells CD34/kg (IQR: 4.8; 9.7), with no differences between the two arms. No toxic deaths were recorded into the trial. On 294 cycles with data available, haematological and extra-haematological toxicities were: grade 3-4 neutropenia in 152 of 294 courses (52%), g 3-4 thrombocytopenia in 209 (71%); g 3-4 febrile neutropenia in 4 (1%), g3-4 infection in 5 (2%), g3-4 neurotoxicity in 5 (2%); the incidence of adverse events were similar in the two arms. At a median follow-up of 9.8 months, 12-months PFS was: overall 48.8% (38.4-58.4), 44.6% (30.4-57.8) and 53.1% (37.9-66.1) for R-DHAP and BR-DHAP, respectively (log rank, p 0.464). At a median follow-up of 15.9 months, 12-months OS was: overall 69% (58.2-77.7), 62.7% (46.4-75.3) and 75.1% (59.6-85.4) for R-DHAP and BR-DHAP, respectively (log rank, p 0.628). Conclusions. In the FIL-VERAL12 phase II randomized trial, the addition of bortezomib to R-DHAP did not improve the outcome of relapsed/refractory DLBCL patients eligible to high-dose therapy plus SCT. This series of patients is mainly represented by true refractory patients after first line chemoimmunotherapy and the results underline the poor outcome of such patients. The treatment for these patients is still an unmet clinical need. The role of immunotherapies such as the integration of CAR-T therapy in this setting of patients should be investigated. Disclosures Chiappella: Teva: Speakers Bureau; Celgene: Other: advisory board, Speakers Bureau; Janssen: Other: advisory board, Speakers Bureau; Servier: Other: advisory board, Speakers Bureau; Roche: Speakers Bureau. Corradini:Amgen: Honoraria; Janssen: Honoraria, Other: Travel Costs; Servier: Honoraria; KiowaKirin: Honoraria; Sanofi: Honoraria; Gilead: Honoraria, Other: Travel Costs; Jazz Pharmaceutics: Honoraria; Kite: Honoraria; Novartis: Honoraria, Other: Travel Costs; Roche: Honoraria; Takeda: Honoraria, Other: Travel Costs; Daiichi Sankyo: Honoraria; Celgene: Honoraria, Other: Travel Costs; AbbVie: Consultancy, Honoraria, Other: Travel Costs; BMS: Other: Travel Costs. Liberati:Novartis: Other: Clinical trial support; Janssen: Honoraria; AbbVie: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Clinical trial support; Roche: Other: Clinical trial support; Amgen: Membership on an entity's Board of Directors or advisory committees, Other: Clinical trial support; Celgene: Honoraria, Other: Clinical trial support; Bristol-Myers Squibb: Honoraria; Takeda: Membership on an entity's Board of Directors or advisory committees; Servier: Honoraria, Membership on an entity's Board of Directors or advisory committees; Incyte: Consultancy. Nassi:Merck: Consultancy; Janssen: Consultancy; Takeda: Consultancy. Vitolo:Janssen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Juno Therapeutics: Membership on an entity's Board of Directors or advisory committees; F. Hoffmann-La Roche: Speakers Bureau; Gilead: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Abbvie: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Kite: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. OffLabel Disclosure: the use of subcutaneous bortezomib is not registered in diffuse large B-cell lymphoma. Bortezomib was provided free by Janssen

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.

Forty consecutive adult patients under the age of 50 with acute non-lymphoblastic leukemia (ANLL) in first complete remission, underwent autologous bone marrow transplantation (ABMT) between March 1984 and April 1990. The conditioning regimen employed included cyclophosphamide and total body irradiation, followed by the administration of unpurged ABMT. The median time from diagnosis to transplant was 7 months (3-15 months), and the median time from complete remission to ABMT was 4 months (range 3-9 months). Twenty-two (51%) patients remain in complete remission 6-81 months (median 24 months) after ABMT. The causes of death were, recurrent leukemia (11 patients), parenchymal toxicities such as acute respiratory distress syndrome and veno-occlusive disease (3 patients), hemorrhage (2 patients) and infection (2 patients). Eleven patients relapsed after 3-12 months (median 5 months). This study has produced survival data comparable to those of other institutions employing TBI for either allo or autotransplants.

Introduction.The recommended treatment for newly diagnosed nodal Peripheral T-cell lymphomas (PTCLs) patients eligible to high-dose therapy is cyclophosphamide-doxorubicin-vincristine plus etoposide (CHOEP) followed by autologous stem cell transplantation (auto-SCT) in chemo-sensitive disease. However, 25-30% of patients experienced primary refractoriness or early progression. Romidepsin (Ro), a histone deacetylase inhibitor, showed antitumor activity and a manageable toxicity profile in PTCLs. On these bases, we designed the FIL-PTCL13 phase Ib/II study (NCT02223208), aimed to define the maximum tolerated dose (MTD) of Ro in addition to CHOEP followed by consolidation with auto or allogeneic-SCT according to clinical response, and to evaluate the safety and the efficacy of this combination as first line in PTCLs. Patients and methods. Inclusion criteria were: untreated PTCL not otherwise specified, angioimmunoblastic, ALK negative anaplastic lymphoma at stage II-IV, aged 18-65. Treatment scheme was: an induction with 6 courses of CHOEP every 21 days combined with Ro at the allocated dose, at day 1 and 8 of each cycle (Ro-CHOEP). Patient in complete (CR) or partial response (PR) without an available donor, received one course of cisplatin, citarabine, desamethasone (DHAP) followed by stem cell harvest and proceeded to auto-SCT; patients in PR and with an available donor, were sent to upfront allogeneic-SCT. Romidepsin dose allocation for sequential cohorts of 3 patients at each dose was defined according to the Continual Reassessment Method (O'Quigley and Zohar, 2006). Dose-limiting toxicity (DLT) of Ro-CHOEP were: any grade ≥ 3 non-hematologic toxicity (according to the NCI Common Terminology Criteria for Adverse Events, version 4.0) or a delay >15 days of planned cycle date, observed during the first 2 cycles. The MTD of Ro was defined as the dose that achieved a DLT in 33% of patients. Four dose levels of Ro were tested, namely 8, 10, 12 and 14 mg/ms. Results. From September 2014 to July 2017, 21 patients were enrolled into the phase Ib part of the study. Clinical characteristics were: median age 57 years (IQR 53;61); bone marrow involvement in 6 (29%) patients; stage III-IV in 18 (86%); International Prognostic Index (IPI) risk ≥3 in 8 (38%). The first cohort of 3 patients was treated with Ro at 12 mg/ms, and no DLTs were observed; the subsequent 6 cohorts were treated with Ro at 14 mg/ms. Nine DLTs were reported in 7 patients: 3 events of grade (g)3 mucositis and one event of g3 maculopapular rash, g3 fatigue, g3 fever, g3 respiratory failure, g3 typhlitis and g4 neutropenic fever. The observed toxicity was 35.2% (95%CI: 17.1%-56.5%) and prompted to define 14 mg/ms the recommended dose of Ro in addition to CHOEP. No unexpected toxicities and no toxic deaths were reported. The most frequent toxicities reported during Ro-CHOEP were g3-4 neutropenia in 38% and thrombocytopenia in 45% of all the performed 117 courses. Severe extra-hematological toxicities by patients were: g3 arrhythmia in one (5%), g3 gastrointestinal in 3 (14%) and g3-4 infections in 5 (24%). The addition of Ro during induction did not impact the harvest, with a median of 4.3 × 10⁶ (IQR 3.4-5.71) peripheral blood CD34-positive cells/Kilogram collected. At least 90% of the planned dose of doxorubicine, cyclophosphamide, etoposide and vincristine were administered in: 87%, 86%, 83% and 89% of Ro-CHOEP, respectively. Median interval time between Ro-CHOEP was 21 days (range 19-36). At the end of induction 12/21 (57%) patients obtained CR and underwent auto-SCT, one patient (5%) in PR received auto-SCT due to lack of identical donor; 8 (38%) did not perform SCT due to lymphoma progression in 7 and to toxicity in one. At a median follow-up of 26 months, 12-months Progression Free Survival was 52% (95%CI: 29-71) and 12-months Overall Survival was 76% (95%CI: 52-89). Biomarkers and biological analysis are ongoing. The enrollment of the phase II part of the study is still open. Conclusions.The phase Ib FIL-PTCL13 part of the study defined Romidepsin 14 mg/ms on day 1 and day 8 as the MTD, when administered in combination to CHOEP as induction prior consolidation with up-front SCT, in untreated young PTCLs patients. The addition of Ro to chemotherapy did not impact the feasibility of CHOEP, without unexpected toxicities. The efficacy of this scheme is under investigation in the phase II part of the study. Disclosures Chiappella: Nanostring: Other: lecture fees; Teva: Other: lecture fees; Celgene: Membership on an entity's Board of Directors or advisory committees, Other: lecture fees; Amgen: Other: lecture fees; Roche: Other: lecture fees; Janssen: Membership on an entity's Board of Directors or advisory committees, Other: lecture fees.

Introduction: Lenalidomide (Len) in association with standard Rituximab-CHOP (R2CHOP21) has been shown to be safe and effective in newly diagnosed Diffuse Large B-cell Lymphomas (DLBCL) [Nowakowski et al. JCO 2014, Vitolo et al. Lancet Oncol 2014]. The addition of lenalidomide appears to benefit primarily patients with non-Germinal Center B-cell (non-GCB) phenotype as determined by immunohistochemistry (IHC). These early results led to currently ongoing randomized trial in ABC subtype of DLBCL, however efficacy of R2CHOP in ABC DLBCL as defined by Gene Expression Prophyling (GEP) has not been reported. In the present combined analysis of two independent phase 2 studies, we report the long-term follow-up (FU) outcome in DLBCL patients treated with R2CHOP, comparing GCB and ABC according to Nanostring Platform. Methods: We included all newly diagnosed histologically-confirmed de-novo DLBCL patients enrolled in two R2CHOP21 phase 2 trials, conducted by Mayo Clinic (MC) and Italian Lymphoma Foundation (FIL). Inclusion criteria in the two trials were similar, main differences included: all age and all International Prognostic Index (IPI) vs age between 60 and 80 years old and IPI >1, in MC vs FIL study, respectively. All pts received R-CHOP21 plus Len at 25 mg/day for 10 days/cycle and 15 mg/day for 14 days/cycle in MC and FIL trial, respectively. Cell of origin (COO) was determined by IHC, according to Hans algorithm, and retrospectively, in patients with available pathological material, by Nanostring, performed according to Scott algorithm and Masque-Soler signature in MC and FIL study, respectively. We analyzed the long-term FU outcome in terms of progression-free survival (PFS), time to progression (TTP), overall survival (OS), comparing between GCB and ABC phenotypes according to GEP. Results: A total of 112 DLBCL pts (63 MC, 49 FIL) were included. Main characteristics were: median age 69 years (y) (range 22-87), male 65 (58%) pts, advanced stage III-IV in 94 (84%), B symptoms in 38 (34%), International Prognostic Index (IPI) intermediate-high/high in 71 (63%). At a median follow-up of 5.1 years (y), 5y-PFS was 63.5%, 5y-TTP 70.1% and 5y-OS 75.4%. A total of 32 relapses were observed, with only 2 cases of Central Nervous System (CNS) relapse. Late relapse occurring beyond 3 years was observed in 4 cases (3 cases with GCB phenotype and one case with missing COO data). In a subgroup analysis by IPI 0-2 vs 3-5 were: 5y-PFS, 5y-TTP and 5y-OS were: 69.0% vs 59.0% (p=0.100), 73.2% vs 67.4% (p=0.285) and 82.3% vs 70.2% (p=0.059), respectively. Regarding for COO defined by IHC, GCB phenotype vs non-GCB were 45 (40%) vs 41 (37%) patients respectively; 26 (23%) patients were not evaluable. 5y-PFS, 5y-TTP and 5y-OS were: 52.8% vs 64.5% (p=0.198), 61.6% vs 69.6% (p=0.444) and 68.6% vs 74.1% (p=0.238) in GCB vs non-GCB, defined by IHC, respectively. Regarding Nanostring analysis, GCB vs ABC vs Unclassified (Uncl) were 31 (46%) vs 22 (32%) vs 15 (22%) respectively; 44 pts were not evaluable. 5y-PFS, 5y-TTP and 5y-OS were: 62.3% vs 70.8% vs 64.2% (p=0.645), 68.1% vs 79.8% vs 64.2% (p=0.662) and 76.0% vs 74.8% vs 79.0% (p=0.658) in GCB vs ABC vs Uncl, defined by Nanostring, respectively (Table1, Fig1). Conclusions: The association of Len with R-CHOP21 appears to overcome the negative prognostic impact of ABC phenotype determined by GEP, with high PFS, TTP and OS rate, maintained at a long-term FU analysis. Figure 1. Figure 1. Disclosures Chiappella: Teva: Other: lecture fees; Janssen: Membership on an entity's Board of Directors or advisory committees, Other: lecture fees; Nanostring: Other: lecture fees; Roche: Other: lecture fees; Amgen: Other: lecture fees; Celgene: Membership on an entity's Board of Directors or advisory committees, Other: lecture fees. Gaidano:Roche: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Gilead: Consultancy, Honoraria; AbbVie: Consultancy, Honoraria; Morphosys: Honoraria. Witzig:Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Vitolo:Janssen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Takeda: Speakers Bureau; Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Sandoz: Speakers Bureau; Gilead: Speakers Bureau.

Background and Aims. Minimal residual disease (MRD) detection by PCR-based methods is a relevant outcome predictor in MCL, however it is not clear which might represent the most effective methodology (nested vs real-time quantitative PCR, RQ-PCR), the most informative tissue source (bone marrow, BM, vs peripheral blood, PB), the best timing of analysis (midterm vs post-therapy) and the added value of performing multiple MRD determinations. To address these issues a systematic MRD detection program was performed in the Fondazione Italiana Linfomi (FIL) MCL0208 trial (NCT02354313), a prospective, randomized phase III trial comparing lenalidomide maintenance vs observation after an intensive citarabine containing chemo-immunotherapy (R-HDS) program followed by ASCT in 300 frontline MCL patients Disclosures Vitolo: Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Sandoz: Speakers Bureau; Gilead: Speakers Bureau; Takeda: Speakers Bureau; Janssen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.

Introduction: Standard of care for previously untreated patients (pts) with diffuse large B-cell lymphoma (DLBCL) is rituximab (R) plus 6-8 cycles of CHOP (R-CHOP). While the RICOVER trial (Pfreundschuh et al. Lancet Oncol 2008) showed no benefit of 6 versus 8 cycles of R-CHOP administered at 2-weekly intervals, this has not been assessed with the standard 3-weekly regimen, and many centers continue to administer 8 cycles. GOYA (NCT01287741) was an open-label, randomized, Phase III study of the efficacy and safety of R-CHOP versus obinutuzumab (GA101; G) plus CHOP in previously untreated pts with DLBCL. The current exploratory analysis compared investigator (INV)-assessed progression-free survival (PFS) and overall survival (OS) in pts receiving 6 or 8 cycles of CHOP in combination with 8 cycles of R in GOYA. Methods: Eligible pts were aged ≥18 years with histologically documented, CD20-positive DLBCL and ≥1 bi-dimensionally measurable lesion, ECOG PS 0-2, IPI score ≥2, and adequate hematologic function. Low-risk pts with IPI score 1 not due to age alone or 0 with bulky disease (1 lesion ≥7.5cm) were also eligible. Pts who were randomized to R-CHOP received 8 cycles of R (375mg/m2) in combination with 6 (CHOP6) or 8 (CHOP8) cycles of CHOP. Centers elected upfront to administer either 6 or 8 CHOP cycles to all pts enrolled at that site. Efficacy was evaluated in all pts who were randomized to R-CHOP (intent-to-treat population; data cut-off: January 31, 2018). Safety was assessed in all pts who completed the 6th treatment cycle and received R in the 7th cycle (CHOP6 safety population: no additional CHOP cycles; CHOP8 safety population: at least 7 or 8 CHOP cycles received). Only AEs starting during or after the 7th cycle were considered. Statistical analyses included Kaplan-Meier estimates and Cox-regression, with and without propensity score adjustment to correct for baseline imbalances. Results: Results are reported for 712 pts who were randomized to R-CHOP (CHOP6, n=526; CHOP8, n=186; safety population: CHOP6, n=461; CHOP8, n=144). In the CHOP6 group, 55% were male and median age was 62 years (range 54-70). In CHOP8, 49% were male and median age was 60 years (range 47-67). Baseline characteristics were broadly comparable across treatment groups, except for geographic region (CHOP6 vs CHOP8: Asia, 32% vs 49%, respectively; Eastern Europe, 10% vs 24%; Western Europe, 36% vs 13%; North America, 18% vs 8%; other, 4% vs 5%). In CHOP6, 89% completed 6 cycles of R-CHOP, while in CHOP8, 76% completed 8 cycles. Three-year INV-assessed PFS rates were comparable between groups: 68.7% in CHOP6 versus 66.8% in CHOP8 (HR 0.92; 95% CI: 0.69, 1.23; Figure 1a). Three-year OS rates appeared higher in the CHOP6 group (83.2% vs 76.2% in CHOP8; HR 0.65; 95% CI: 0.46, 0.91; Figure 1b). PFS and OS comparisons were unchanged after propensity score adjustment for the prespecified baseline characteristics, including age, gender, disease stage, geographic region, IPI score, extranodal sites, body surface area, bulky disease, LDH, and COO (PFS: HR 0.96, 95% CI: 0.70, 1.32; OS: HR 0.66, 95% CI: 0.45, 0.97). Interim treatment response (by CT) did not influence these findings. Model-based subgroup analysis according to baseline pt characteristics did not identify any pt subgroups benefitting from 8 versus 6 cycles of CHOP (Figure 1c). Incidence of grade 3-5 adverse events (AEs) was lower in the CHOP6 group than in the CHOP8 group (17.8% vs 38.9%, respectively); cardiac AEs (all grade: 2.4% vs 6.3%; grade 3-5: 1.3% vs 3.5%) and infections (all grade: 10.6% vs 23.6%) were also less common. In support of these findings, similar results were achieved after repeating the same efficacy analysis in pts who received 6 or 8 cycles of CHOP in combination with 8 cycles of obinutuzumab. Conclusions: In this exploratory analysis of 712 previously untreated DLBCL pts in GOYA, in which the number of CHOP cycles was selected upfront by each site, no additional PFS benefit was observed with 8 cycles of R-CHOP compared with 6 cycles of R-CHOP plus 2 cycles of R, even after adjusting for baseline differences, including COO and IPI. Slow response, assessed by interim CT, did not influence these findings. Furthermore, incidence of grade 3-5 AEs (including cardiac) and any grade infections was markedly higher in pts receiving 8 cycles of CHOP versus 6 cycles. These results suggest that rituximab with 6 cycles of 3-weekly CHOP should be considered standard of care. Disclosures Sehn: Janssen: Consultancy, Honoraria; Morphosys: Consultancy, Honoraria; Merck: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Lundbeck: Consultancy, Honoraria; Seattle Genetics: Consultancy, Honoraria; Roche/Genentech: Consultancy, Honoraria; TG Therapeutics: Consultancy, Honoraria; Karyopharm: Consultancy, Honoraria. Culligan:JAZZ: Honoraria; Celgene: Other: Support to attend conferences; Takeda: Honoraria, Other: Support to attend conferences; Daiichi-Sankyo: Other: Support to attend conferences; Abbvie: Other: Support to attend conferences; Pfizer: Honoraria; Merck Sharp & Dohme (MSD): Honoraria. Ogura:Cellgene: Honoraria; Celltrion: Research Funding; Takeda: Honoraria; SymBio: Research Funding. Launonen:Roche: Employment, Other: Travel, accommodation, expenses; Novartis: Consultancy, Equity Ownership, Other: Ownership interests none PLC; Travel. accommodation, expenses; Launonen: Other: Ownership interests none PLC; Travel, accommodation, expenses. Nielsen:F. Hoffmann-La Roche Ltd: Employment, Other: Ownership interests PLC. Sellam:Roche: Employment. Trněný:Morphosys: Membership on an entity's Board of Directors or advisory committees, Other: Advisory board; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Advisory board; Incyte: Membership on an entity's Board of Directors or advisory committees, Other: Advisory board; F. Hoffman-La Roche Ltd: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Advisory board, Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees, Other: Advisory board; Gilead: Honoraria; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Advisory board; Sandoz: Honoraria; Abbvie: Honoraria, Research Funding. Vitolo:Gilead: Speakers Bureau; Janssen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Takeda: Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Sandoz: Speakers Bureau. Martelli:Servier: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Gilead: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Mundipharma: Membership on an entity's Board of Directors or advisory committees; Sandoz: Membership on an entity's Board of Directors or advisory committees; F. Hoffman-La Roche: Membership on an entity's Board of Directors or advisory committees.

7562Background: The combination of lenalidomide (Len) with Rituximab-CHOP (R2CHOP21) has been shown to be safe and effective. These early results [Nowakowski et al. JCO 2014, Vitolo et al. Lancet O...

Haemopoietic growth factors (HGF), i.e. erythropoietin [recombinant human erythropoietin (rHEPO)] or granulocyte colony stimulating factor (G-CSF), alone or in combination, have largely been used to treat anemia in myelodysplastic syndromes (MDS), but whether combined rHEPO and G-CSF is really superior to rHEPO alone is still under debate. In particular, randomized studies comparing front-line rHEPO vs rHEPO+G-CSF are still lacking. The aim of this study was to compare the effects of "standard" doses of rHEPO with the combination of rHEPO and G-CSF in the treatment of anemic patients with low-risk MDS in a prospective randomized trial. Anemic patients with low-risk MDS were randomly assigned to receive either rHEPO (10,000 IU s.c. three times a week) or the same dosage of rHEPO+G-CSF (300 mug s.c. twice a week) for a minimum of 8 weeks. Patients who were unresponsive to rHEPO were offered the combination therapy for another 8 weeks, whereas non-responders to rHEPO+G-CSF were considered "off study". Responders continued the treatment indefinitely. Both haematological response and changes in quality-of-life (QoL) scores (Functional Assessment of Cancer Therapy-Anemia) were recorded and evaluated. Thirty consecutive patients [10 refractory anemia (RA), 5 RA with ringed sideroblasts, 7 refractory cytopenia with multilineage dysplasia, 5 RA with less than 10% blasts and 3 5q-syndrome] were enrolled in the study. All of them (15 in the rHEPO arm and 15 in the rHEPO+G-CSF arm) were valuable after the first 8 weeks of treatment. Erythroid response was observed in 6/15 (40%) patients in the rHEPO arm and in 11/15 (73.3%) patients in the rHEPO+G-CSF arm. In 4/9 (44.4%) patients who were unresponsive to rHEPO, the addition of G-CSF induced erythroid response at 16 weeks. No relevant adverse effects were recorded for either treatment in any of the study patients. Erythroid response to HGF was associated with a relevant improvement in QoL. Twenty responders continued the treatment. Afterwards, 8/20 (40%) discontinued therapy because of the following: losing response (2), progression to high-risk MDS (3) and death due to other causes (3). The remaining 12 are still responding and continuing treatment, with a median follow-up of 28 months. Progression to acute leukemia was cumulatively observed in 4/30 (13.3%) patients (2 in each arm). Although our data were obtained from a relatively small cohort of patients, they indicate that the rHEPO+G-CSF treatment is more effective than rHEPO alone for correcting anemia in low-risk MDS patients and for making a relevant improvement in their QoL.

Summary Background Up to 40% of elderly patients with untreated diffuse large B-cell lymphoma (DLBCL) given a regimen of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone every 21 days (R-CHOP21) relapse or develop refractory disease. Lenalidomide has high activity in relapsed or refractory aggressive B-cell lymphomas. In phase 2 of the REAL07 trial, we aimed to establish the safety and efficacy of the combination of lenalidomide and R-CHOP21 in elderly patients with untreated DLBCL. Methods REAL07 was an open-label, multicentre trial that was done in 13 centres in Italy and one in Germany. Eligible patients were aged 60–80 years; had newly diagnosed, untreated, CD20-positive, Ann Arbor stage II–IV DLBCL or grade 3b follicular lymphoma; had an Eastern Cooperative Oncology Group performance status of 0–2; had an International Prognostic Index (IPI) risk of low-intermediate, intermediate-high, or high; and were fit according to comprehensive geriatric assessment. Participants were to receive 15 mg oral lenalidomide on days 1–14 of six 21-day cycles, and standard doses of R-CHOP21 chemotherapy (375 mg/m 2 intravenous rituximab, 750 mg/m 2 intravenous cyclophosphamide, 50 mg/m 2 intravenous doxorubicin, and 1·4 mg/m 2 intravenous vincristine on day 1, and 40 mg/m 2 oral prednisone on days 1–5). The primary endpoint was frequency of overall response (complete response [CR] and partial response [PR]), which was assessed by 18 F-fluorodeoxyglucose ( 18 F-FDG) PET at the end of the treatment. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00907348. Findings 49 patients were included in phase 2: nine had been enrolled into phase 1 between Oct 23, 2008, and June 4, 2009, and had received the maximum tolerated dose of 15 mg lenalidomide; and 40 were enrolled into phase 2 between April 28, 2010, and June 3, 2011. 45 patients (92%, 95% CI 81–97) achieved a response (42 [86%] CR; three [6%] PR). Three patients (6%) did not respond and one (2%) died for reasons unrelated to treatment or disease. 277 (94%) of 294 planned cycles of lenalidomide and R-CHOP21 were completed. Grade 3–4 neutropenia was reported in 87 cycles (31%), grade 3–4 leukopenia in 77 (28%), and grade 3–4 thrombocytopenia in 35 (13%). No grade 4 non-haematological adverse events were reported. No patients died during the study as a result of toxic effects. Interpretation Lenalidomide with R-CHOP21 is effective and safe in elderly patients with untreated DLBCL. Funding Fondazione Italiana Linfomi and Celgene.

Background Central nervous system (CNS) relapse of diffuse large B-cell lymphoma (DLBCL) is a devastating event occurring in approximately 5% of patients treated with standard R-CHOP (Thanarajasingam et al, ASH 2015, abs 1456). Isolated CNS relapse is associated with significant morbidity and mortality. New treatment regimens with agents that cross the blood-brain barrier (BBB) are needed. The combination of lenalidomide with R-CHOP (R2CHOP) has shown promising results in activated B-cell (ABC) type DLBCL in phase 2 studies and is currently being evaluated in randomized trials. Lenalidomide crosses the BBB and has been demonstrated to have single-agent activity in relapsed CNS lymphoma. Accordingly, the addition of lenalidomide to R-CHOP may decrease the risk of CNS relapse. Here we characterize the combined incidence of isolated CNS relapse in a population of DLBCL patients who received R2CHOP for induction therapy in two independent phase 2 studies. Methods We analyzed the incidence of isolated CNS relapse in patients with histologically-confirmed DLBCL enrolled in two R2CHOP phase 2 trials - one conducted by Mayo Clinic (MC) and the other by Italian Lymphoma Foundation (FIL) - in the context of clinical variables that included age, gender, disease stage, cell of origin, and administration of CNS prophylaxis. We assessed CNS-International Prognostic Index (CNS-IPI) factors (age, stage, lactate dehydrogenase level, ECOG performance status, extranodal sites, adrenal/kidney involvement) and classified patients into groups of low, intermediate, and high risk of CNS relapse. The risk of CNS relapse in R2CHOP-treated patients was then estimated and compared against published rates in RCHOP-treated patients based on CNS-IPI score. Results One hundred thirty-six patients with DLBCL from both cohorts (87 MC patients, 49 FIL patients) were included in this analysis. Mean age was 65 and median follow-up in 104 patients still alive was 48.2 months (range: 2.1-88.5). 61.8% of patients were male; 86.0% had stage III disease or higher; 44.1% had ECOG performance status of 0; cell of origin phenotype by immunohistochemistry according to Hans algorithm was germinal center B-cell (GCB), non-GCB (ABC), and not available in 43.4%, 36.8%, and 19.8%, respectively; 14.7% received intrathecal (IT) methotrexate for CNS prophylaxis per local practice. No patients received intravenous methotrexate. 10.3%, 71.3%, and 18.4% of patients were classified into low, intermediate, and high-risk CNS-IPI groups, respectively. Only one of 136 patients developed isolated CNS relapse, corresponding to an estimated incidence of CNS relapse of 0.007 (0.7%). Conclusions Despite a large proportion of patients with intermediate and high risk of CNS relapse treated in both phase 2 studies, induction therapy with R2CHOP in patients with DLBCL is associated with a lower-than-expected rate of isolated CNS relapse. The latter is unlikely to be explained by use of IT chemotherapy, which is considered to be marginally effective in this setting and was implemented only in a small proportion of patients. This suggests that addition of CNS-penetrating small molecules, such as lenalidomide, to R-CHOP may decrease the risk of CNS relapse. Disclosures Chiappella: Celgene: Speakers Bureau; Teva: Speakers Bureau; Roche: Speakers Bureau; Pfizer: Speakers Bureau; Janssen-Cilag: Speakers Bureau; Amgen: Speakers Bureau. Nowakowski:Morphosys: Research Funding; Celgene: Research Funding; Bayer: Consultancy, Research Funding. Cavallo:Janssen-Cilag: Honoraria; Onyx: Honoraria; Celgene: Honoraria. Gaidano:Roche: Consultancy, Honoraria, Speakers Bureau; Karyopharm: Consultancy, Honoraria; Morphosys: Consultancy, Honoraria; Gilead: Consultancy, Honoraria, Speakers Bureau; Janssen: Consultancy, Honoraria, Speakers Bureau; Novartis: Consultancy, Honoraria, Speakers Bureau. Spina:Mundipharma: Membership on an entity's Board of Directors or advisory committees, Other: Speaker Fee; Teva Pharmaceuticals Industries: Membership on an entity's Board of Directors or advisory committees, Other: Speaker Fee. Vitolo:Takeda: Other: Honoraria for lectures; Gilead: Other: Honoraria for lectures; Janssen: Membership on an entity's Board of Directors or advisory committees, Other: Honoraria for lectures; Roche: Membership on an entity's Board of Directors or advisory committees, Other: Honoraria for lectures.

Abstract 2871 Introduction. The addition of Rituximab to standard CHOP chemotherapy has improved outcome of DLBCL; however, 30–40% of patients do not response or relapse after induction treatment. The use of Lenalidomide, as single-agent in relapsed or refractory aggressive NHL has been encouraging, with an overall response rate (ORR) of 19% for DLBCL. Preclinical evidence suggests that Lenalidomide may be synergistic with Rituximab. However the safety and efficacy of Lenalidomide combined with R-CHOP is not yet fully evaluated. Aims. On these basis, the IIL is running a prospective multicenter dose finding phase I-II pilot trial to evaluate efficacy and safety of Lenalidomide treatment plus R-CHOP21 (LR-CHOP21) for elderly patients with untreated DLBCL (registered at http://www.clinicaltrials.gov, NCT00907348). The primary endpoint for the phase I part of the study was: definition of Dose Limiting Toxicity (DLT) considered as the maximum dose inducing any grade ≥3 non-hematologic toxicity, or a >15 days delay of planned cycle date. The primary endpoint for the phase II part of the study was: complete response (CR) and ORR. Herein we report the results of phase I. Patients and Methods. Inclusion Criteria were: age 60–80; histologically proven CD20+ DLBCL; no prior chemotherapy and no prior malignancies in the last 3 years; Ann Arbor stage II, III, IV; International Prognostic Index (IPI) at low-intermediate, intermediate-high or high risk score. Treatment consisted of 6 courses of R-CHOP21 in association with Lenalidomide for days 1–14 at the established dose level (5, 10, 15, 20 mg), with Peg-Filgrastim support and prophylactic sc. low-molecular weight heparin. Phase I of the study was planned to define the Maximum Tolerated Dose (MTD) that is the dose that achieves a DLT in 33% or less patients evaluated after the first three courses of LR-CHOP21. The study was designed with the Continual Reassessment Method, a Bayesian “memory design” that begins with a subjective prediction of the dose-response relationship and uses, as dose allocation rule of the sequentially incoming patients, the re-estimated probability of toxicity based on the results obtained for the patients already observed. Four doses of Lenalidomide were tested: 5, 10, 15 and 20 mg. By decision of the steering committee of the study, a dose of 10 mg was administered to the first cohort of 3 patients; in the light of the observed toxicity the probability model assigned the next cohort to the dose with the higher probability to met the required MTD. At the end of each cohort, the dose level associated with an updated DLT probability closest to 33% was recommended to be administered to the next patient cohort. Results. In phase I, from May 2008 to February 2010, 21 patients were enrolled. Median age was 69 years (61-78), stage II/III/IV were 4/4/13 respectively, B symptoms in 11, PS 2 in 8, bone marrow involvement in 6, abnormal LDH in 8, intermediate-high or high IPI score in 15. Patient allocation by Lenalidomide dose was: none patients received 5 mg/day, nine patients received 10 mg/day, nine patients 15 mg/day and three patients 20 mg/day on days 1–14 of each LR-CHOP21 courses. The flow of the dose allocation and the observed DLTs are shown in figure 1. DLTs in the first three courses were recorded in seven patients (see figure 1 for details). These data, according to the continual reassessment method, determined Lenalidomide 15 mg as MTD in association to R-CHOP21. One-hundred-fifteen courses of LR-CHOP21 were performed in the whole series of 21 patients. Overall hematological toxicity was moderate: grade III or IV thrombocytopenia occurred in 10%, anemia in 4% and neutropenia in 28% of the courses. Extra-hematological toxicities were mild: only one patient with grade IV (increase of CPK), two patients with grade III cardiac, three with grade III neurological toxicities, and three patients with grade III infections (two pneumonias and one febrile neutropenia with diarrhea). At the end of six LR-CHOP21 courses, 15/21 patients achieved CR, 1/21 partial remission and 5/21 were not responsive. Conclusions. Lenalidomide 15 mg on days 1–14 in association with R-CHOP21 is the MTD for LR-CHOP. This schedule is safe and well tolerated in a population of elderly DLBCL patients. Preliminary efficacy results are promising. The ongoing phase II part of the LR-CHOP21 trial aims at evaluating the efficacy of 15 mg of Lenalidomide in association with R-CHOP21. Disclosure: Vitolo: Roche Italy: advisory committee; Celgene Italy: advisory committee; Janssen-Cilag: lecture-fee. Off Label Use: The use of Lenalidomide is off-label in untreated DLBCL.

In the attempt to induce graft-vs-host disease (GVHD) in patients undergoing autologous bone marrow transplantation (ABMT) or blood stem cell transplantation (BSCT), 12 consecutive patients received cyclosporin A (CyA) post transplant. CyA was given at a dose of 1.5 mg/kg/day intravenously for 28 days, starting on the day of transplant. Histologically proven acute GVHD of the skin occurred in seven patients 9-14 days after ABMT and lasted 7-11 days. CyA-induced GVHD after ABMT resembles mild GVHD after allogeneic bone marrow transplantation (BMT). Although the preliminary data reported here show that it is possible to induce GVHD in patients undergoing ABMT, it is not yet known whether GVHD after ABMT will have an antitumor activity.

Chronic graft-vs.-host disease (cGVHD) is the most common cause of late morbidity and mortality after allografting. Patients who fail to respond to steroid-based therapy have poor outcome [1]. Ther...

Introduction The standard treatment for elderly untreated diffuse large B-cell lymphoma (DLBCL) is RCHOP21, however up to 40% of patients experienced failures. Lenalidomide showed activity in heavily pretreated DLBCL and in vivo and in vitro data demonstrated a synergism with rituximab. In the phase I trial REAL07 (Chiappella et al, Haematol 2013), FIL demonstrated that the association of LRCHOP21 was feasible in elderly untreated DLBCL and identified 15 mg lenalidomide from day 1 to day 14 as the maximum tolerated dose in combination with RCHOP21. Patients and methods. The phase II trial REAL07 was designed based on Simon's two stage design to demonstrate an improvement of overall response rate (ORR) of 15% in LRCHOP21 compared to 70% of standard RCHOP21. Secondary endpoints were progression-free survival (PFS), overall survival (OS), event-free survival (EFS) and to correlate outcome with cell of origin (COO) profile. Response was evaluated according to 2007 Cheson criteria. Inclusion criteria were: age 60-80 FIT at the comprehensive geriatric assessment; untreated CD20+ DLBCL; Ann Arbor stage II/III/IV; international prognostic index (IPI) at low-intermediate/intermediate-high/high (LI/IH/H) risk. Treatment plan was: RCHOP21 plus 15 mg lenalidomide from day 1 to 14 for 6 courses. All cases were centrally reviewed by expert pathologist; COO profile analysis was conducted with immunohistochemistry according to Hans' algorithm and with gene expression profile (DASL assay). Results. From April 2010 to May 2011, 49 patients were enrolled. Clinical characteristics were: median age 69 years (range 61-80); stage III/IV 43 (88%), IPI IH/H 30 (61%). At the end of 6 LRCHOP21, ORR was 92%. Complete remissions (CR) were 42 (86%) and partial remission 3 (6%); 3 patients (6%) did not respond and one (2%) died for homicide. At a median follow-up of 28 months, 2-year OS was 92% (95% CI: 79-97), 2-year PFS was 80% (95% CI: 64-89) and 2-years EFS was 70% (95% CI: 55-81); 2-year PFS for IPI LI was 89% (95% CI: 62-97) and for IPI IH 76% (95% CI: 47-90) and for IPI H 72% (95% CI: 36-90). Hematological and extra-hematological toxicities were mild, with no grade IV extra-hematological events and no toxic deaths during treatment. Of the 294 planned courses of LRCHOP21, 277 (94%) were administered; median dose of lenalidomide delivered was 1185 mg (94% of the planned dose); at least 90% of the planned dose of each drug was administered in 91% of the RCHOP21 courses. Median interval time between RCHOP21 courses was 21 days (range 19-48). All 49 cases underwent central pathology review and diagnosis of DLBCL was confirmed. Regarding COO analysis, tissue block or stained slides were collected in 40/49 (82%), of which 32 were adequate for analysis. At the time of this abstract, COO analysis was reported according to immunohistochemistry data; DASL analysis is ongoing. Clinical characteristics between germinal center (GCB, 16 patients) and non-GCB (16 patients) were superimposable, excepted for a majority of H IPI risk in non-GCB group (p 0.067). ORR for GCB and non-GCB were 88% (CR 81%) and 88% (CR 88%), respectively. At a median follow-up of 28 months, 2-year PFS was 71% (95% CI: 40-88) in GCB-group and 2-years PFS was 81% (95% CI: 51-93) in non-GCB-group (Figure 1). Conclusions. In conclusion, LRCHOP21 is effective, also in poor risk patients, namely in non-GCB subgroup. These encouraging data warrant a future phase III randomized trial comparing LRCHOP21 vs. RCHOP21 in untreated non-GCB DLBCL. Disclosures: Off Label Use: lenalidomide in first line DLBCL is off lable. drug provided free by Celgene. Vitolo:Roche: Speakers Bureau; Celgene: Speakers Bureau; Takeda: Speakers Bureau.

Introduction A randomized multicenter study of 134 Follicular Lymphoma (FL) patients, selected for age less than 60 yrs. and poor prognostic features according to age-adjusted IPI (2-3) and IIL-score (3 or greater) was conducted between March 2000 and May 2005, among 30 Italian Centers. The study compared efficacy and tolerability of CHOP-R vs. R-HDS with autograft as primary treatment in poor-risk FL. Initial results have been already reported (Ladetto M et al, Blood 2008), showing superior disease control with R-HDS without any survival advantage. We have recently updated the long-term outcome and the results at long-term are here presented at a median follow-up of 9.5 yrs. Patients and Methods Of the original 134 randomized patients, the long-term outcome has been updated for 125 patients, 61 of CHOP-R and 64 of R-HDS arms. Clinical characteristics at study entry and treatment schedules have been already reported. Briefly, the main features of the updated patients included: median age 51 yrs. (22-60), M/F ratio 74/51, aaIPI 2-3 90%, FLIPI >2 (retrospectively assigned) 60%, high LDH 49%, bulky disease 62%, B-symptoms 45%, BM involvement 86%. Clinical characteristics were balanced among the two arms. Treatment schedule consisted of: i. standard arm: 6 courses of cyclo-phosphamide/doxorubicin/vincristine/prednisone followed by 4-weekly rituximab courses (CHOP-R); ii. experimental arm: rituximab-supplemented high-dose sequential chemotherapy with autografting (R-HDS). The analysis was intention to treat with event-free survival as the primary endpoint. Minimal residual disease was evaluated post treatment in 58 patients with a bcl-2/IgH MBR or mcr translocation confirmed at diagnosis by nested PCR. The trial was registered at www.clinicaltrials.gov as no. NCT00435955. The long-term outcome has been updated in July 2013 by 28 out of 30 participating Centers accounting for 125 patients (93% of the whole series). Results Complete remission (CR) was achieved by 88 (70.4%) patients, including 35 (57%) with CHOP-R and 53 (83%) with R-HDS (p < .001); in addition, 37 out of 58 (64%) patients achieved a Molecular Remission (MR). At a median follow-up (MFU) of 9.5 yrs., 88 patients (70.4%) are alive. Overall, 19 patients died for lymphoma progression (11 in the CHOP-R, 8 in the R-HDS arms), there were nine deaths for secondary malignancy (3 in the CHOP-R, 6 in the R-HDS arms), nine more patients died for other causes, including four early toxic deaths. The overall survival projection for the whole series is 78% and 70% at 5 and 10 yrs., respectively. As shown in Figure 1, there were no main differences in the long-term OS between the two arms, with 5 and 10 yrs projections respectively of 75% and 70% for CHOP-R and 81% and 70% for R-HDS (p=0.96). Response to primary treatment had a major impact on the OS, with 5 and 10 yr survival projections respectively of 90% and 80% for patients achieving CR, and of 49 and 43 for those with less than CR (p < .001) (Figure 2A). Similarly, MR achievement was associated with prolonged overall survival, with 5 and 10 yr survival projections respectively of 89% and 83% for patients with PCR-ve on BM cells, and of 76 and 57 for those with persistent PCR-positivity (p = .03) (Figure 2B). Conclusion The long-term follow-up of the randomized CHOP-R vs. R-HDS trial indicate that: i. poor risk FL may now experience a prolonged survival, with approximately 70% of patients alive at 10 yrs., due to the combined efficacy of both primary chemo-immunotherapy and salvage treatments; ii. the superior disease control of R-HDS compared to CHOP-R does not translate in any survival advantage, with analogous OS regardless of which treatment is used; iii. also in FL like in other lymphoproliferative malignancies, achieving CR and MR is crucial not only for the disease control but also for long-term overall survival; iv. lymphoma progression remains the major cause of death, while secondary neoplasms, in particular secondary leukemias represent the second cause of treatment failure. Thus, efforts are still needed in order to increase the anti-tumor efficacy while reducing any potential late effect in treatment options for FL. Disclosures: Tarella: Roche Co.: support and honoraria for Conference participation Other. Ladetto:Roche: Honoraria, Research Funding, Speakers Bureau.

In the attempt to evaluate the role of Autologous and Allogeneic Bone Marrow Transplantation, we have retrospectively analyzed 159 patients with Acute Myeloid Leukemia in first complete remission treated in our Unit, most of whom were referred from other Institutions. High-dose therapy was uniform and consisted of cyclophosphamide 60 mg/kg/d on two consecutive days and TBI in a single dose (10 Gy) for ABMT patients and in fractionated doses (3.3 Gy × 3 days) for BMT patients. Eight years actuarial survival was similar in two groups (52% for BMT and 49% for ABMT). The actuarial risk of relapse for BMT and ABMT was 29% and 43%, respectively. Considering that none of ABMT patients was “purged” with in vitro technique, this review seems to confirm the importance of “in vivo” purging with postremission intensification, immediately before the harvesting. Of course, more patients and a longer follow-up are needed to drow final conclusions.

A group of 13 patients with advanced, diffuse Hodgkin's disease, poorly responding to the most widely employed primary chemotherapy regimens, were treated with massive chemotherapy (MCH) followed by rescue with non-frozen autologous bone marrow infusion (ABMT). Complete remission (CR) was obtained in 8 13 patients (61.5%) and partial remission in two. Hematopoietic recovery occurred in 12 cases. These preliminary results would seem to indicate that MCH with non-frozen ABMT may be successfully used in patients with resistant or relapsed Hodgkin's disease.

Thirty-one unselected patients with untreated acute non lymphoblastic leukemia (ANLL) ranging in age from 15 to 76 years received two courses of a new high-dose induction regimen consisting of idarubicin, etoposide and cytarabine. Patients who entered complete remission (CR) were then allocated to post-remission intensification (PRI). Patients under 40 years of age with a HLA-compatible donor were given bone marrow transplantation (BMT); those without an HLA identical donor received either autologous BMT (ABMT) or no subsequent therapy. Twenty-five out of 31 patients (80.6%) achieved CR (93.3% in young and 68.7% in old patients) and 14 (56%) after the first cycle. Six patients (five out six greater than 40 years) died of cerebral hemorrhage and/or infection during the induction phase and four additional patients (three elderly) died on the PRI for the same cause without recurrent disease. Eleven out 25 patients are disease-free survivors 2-34 months (median 10 months) after achievement of CR. In conclusion, this intensive chemotherapy regimen is effective both in young and older patients but the post-remission intensification is too aggressive in elderly patients.

Ten patients with advanced, diffuse Hodgkin's and non-Hodgkin's lymphomas responding poorly to the most widely employed primary chemotherapy regimens were treated with a high-dose chemotherapy (HDC) followed by rescue with non-frozen autologous bone marrow infusion (ABMT). Complete remission (CR) was obtained in seven of ten patients (70%) and partial remission in two. Hemopoietic recovery occurred in nine cases. These preliminary results appear to indicate that HDC and non-frozen ABMT may be successfully used in patients with resistant or relapsed lymphomas.

Thirty patients with chronic granulocytic leukemia (CGL), were given cyclophosphamide 60 mg/kg on each of 2 consecutive days, followed by total body irradiation (TBI) 10 Gy and an HLA-identical bone marrow transplant (BMT). Eleven patients were in the accelerated phase of their disease (CGLacc) or in second/secondary chronic phase (CGL-2CP), with a median age of 33 years: four patients died of transplant related complications, and four of recurrent leukemia; three patients are alive and well 19, 31, 33 months from BMT. The actuarial 33-month survival is 27%. The actuarial relapse rate is 50%. Nineteen patients were in their first chronic phase (1CP), with a median age of 32 years: three died of graft versus host disease (GvHD), two of infection, and two of acute respiratory distress syndrome (ARDS); 12 are alive and well 6 to 29 months post-BMT. The actuarial 29-month survival is 63%. The actuarial survival of patients younger than 30 years is 63%, compared to 62% for patients older than 30 (P = 0.1). The survival of patients grafted within or after 24 months from the onset of CGL is respectively 87% and 45% (P = 0.04). None of the patients grafted in 1CP had a true hematologic-cytogenetic relapse. The Ph' chromosome was detected on one occasion in two patients 12, 13 months post-BMT: they both remain hematologically normal and Ph1-negative 3 to 6 months later, after discontinuation of cyclosporin A. This study confirms that survival exceeding 60% can be obtained in CGL in the first chronic phase, whereas less than 30% of patients will survive if grafted in accelerated, second/secondary chronic phase, mainly because of leukemic relapse. The duration of the disease seems to be relevant to the outcome of the transplant. The effect of post-transplant immunosuppression, in our case cyclosporin A, on the interaction between normal and Ph1-positive hemopoietic cells, may deserve further attention.

Twenty-five adults with previously treated acute leukemia were treated with 4-demethoxydaunorubicin (Idarubicin) with a daily dose of 8 mg/m2 for 3 days intravenously. Complete remission was achieved in 3 of 18 patients with acute nonlymphoblastic leukemia (ANLL) and 2 of 6 with lymphoblastic leukemia. Complete remissions were observed in two of eight ANLL patients refractory to cytarabine, anthracycline, and m-Amsa (amsacrine), indicating a lack of cross-resistance between these drugs and Idarubicin. The median duration of remission was 8 weeks. The main major toxicity of Idarubicin therapy, severe myelosuppression, cannot be considered a toxic effect because it was desired in this case list. Our preliminary results indicate that Idarubicin has significant activity against refractory adult acute leukemia.

Abstract 903 Introduction. R-CHOP21 is the standard treatment for untreated elderly DLBCL, however up to 40% of patients fail. There is a need to improve the efficacy of R-CHOP21; an option may be the addition of novel drugs in first line induction therapy. Lenalidomide has a complex mechanism of action as immunemodulation, antiangiogenesis, restoration of immunesynapses and direct antitumor effects. Lenalidomide monotherapy exhibits significant activity in patients with relapsed aggressive B-cell NHL and has in vitro synergy with rituximab and cytotoxic therapy. This rationale prompted FIL to conduct a prospective multicenter dose finding phase I-II trial aimed at evaluating toxicity and activity of lenalidomide plus R-CHOP21 (LR-CHOP21) in elderly untreated DLBCL (NCT00907348). In the dose-finding phase I study, 21 patients were enrolled, and 15 mg lenalidomide from day 1 to day 14 was identified as the maximum tolerated dose (MTD) in combination with R-CHOP21 (Vitolo, Ann Oncol 2011;22(4):331a). Patients and Methods. Based on the phase I results, 15 mg of lenalidomide in combination to R-CHOP21 was tested in a phase II study. Phase II was designed according to Simon's two stage design; primary endpoint was an improvement of overall response rate (ORR) of 15% in LR-CHOP21 compared to 70% of standard R-CHOP21 and the study would be considered of interest if at least 16/23 in step 1 and 39/49 in step 2 responses occurred. Response was evaluated according to 2007 Cheson criteria. PET scan was mandatory at the end of the treatment; patients in partial remission (PR) who underwent radiotherapy were considered as failure in progression free survival (PFS) analysis. Inclusion criteria were: age 60–80 FIT at the comprehensive geriatric assessment; untreated CD20+ DLBCL; Ann Arbor stage II/III/IV; IPI at LI/IH/H risk. Treatment plan was: R-CHOP21 plus 15 mg lenalidomide from day 1 to 14 for 6 courses. Mandatory supportive care included: GCSF or PegGCSF, cotrimoxazole as Pneumocystis Jiroveci prophylaxis and low molecular weight heparin or low dose aspirin as deep venous thrombosis prophylaxis. Results. From April 2010 to May 2011, 49 patients were enrolled in the phase II study including 9 patients treated at the MTD during phase I. Clinical characteristics were: median age 69 years (range 61–80); stage III/IV 43 (88%), performance status >1 31 (63%), IPI IH/H 30 (61%). The step-1 of the trial showed an ORR of 22/23. At the end of 6 LR-CHOP21, ORR was 45/49 (92%). Complete remissions (CR) were 42 (86%) and PR 3 (6%); 3 patients (6%) did not respond and one (2%) died for violent death. At a median follow-up of 18 months, overall survival (OS) was 94% (95% CI: 82–98) and PFS was 75% (95% CI: 57–86). (Figure 1). Of the 294 planned courses of LR-CHOP21, 277 (94%) were administered, of which 221 (75%) with lenalidomide as planned, 40 (14%) with dose and/or day reduction and 16 (5%) without lenalidomide. Median dose of lenalidomide delivered in 49 patients was 1185 mg (IQR 900–1260), i.e. 94% of the planned dose (1260 mg). The most frequent cause of lenalidomide reduction or withdrawal was neutropenia. At least 90% of the planned dose of doxorubicine, cyclophosphamide and vincristine were administered, in: 91%, 95% and 83% of the R-CHOP21 courses, respectively. Median interval time between R-CHOP21 courses was 21 days (range 19–48). Hematological toxicity was mild: grade III/IV thrombocytopenia occurred in 13% of courses, anemia in 5% and neutropenia in 33%, with only 4% of febrile neutropenia. No grade IV extra-hematological toxicities were observed. Grade III non-hematological toxicities were reported in 7 patients: cardiologic, gastroenteric and renal in one patient respectively, grade III neurological toxicities, sensory and motorial neuropathy in two, thromboembolic event in one not receiving anti-thrombotic prophylaxis, and skin rash in one. No toxic deaths occurred during treatment. One patient died three months off therapy while in CR, due to aeromonas hydrophila sepsis and multi-organ failure. Conclusions. The addition of 15 mg lenalidomide on days 1–14 to R-CHOP21 is safe, feasible and effective in elderly untreated DLBCL. The primary objective of the phase II study was met, with 92% of ORR of which 86% CR and promising PFS rates. The addition of lenalidomide did not impair the administration of R-CHOP21. Based on these data, the efficacy of LR-CHOP21 needs to be investigated in a large phase III randomized trial in elderly DLBCL. Disclosures: Off Label Use: Trial partially supported by a research grant by Celgene. Lenalidomide was provided free by Celgene. The use of Lenalidomide is off-label in untreated DLBCL. Dreyling:Roche: Membership on an entity's Board of Directors or advisory committees. Vitolo:Roche: Membership on an entity's Board of Directors or advisory committees.