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Supplementary Table 1 from Sequential Valproic Acid/All-trans Retinoic Acid Treatment Reprograms Differentiation in Refractory and High-Risk Acute Myeloid Leukemia

Epigenetic alterations of chromatin due to aberrant histone deacetylase (HDAC) activity and transcriptional silencing of all-trans retinoic acid (ATRA) pathway are events linked to the pathogenesis of acute myeloid leukemia (AML) that can be targeted by specific treatments. A pilot study was carried out in eight refractory or high-risk AML patients not eligible for intensive therapy to assess the biological and therapeutic activities of the HDAC inhibitor valproic acid (VPA) used to remodel chromatin, followed by the addition of ATRA, to activate gene transcription and differentiation in leukemic cells. Hyperacetylation of histones H3 and H4 was detectable at therapeutic VPA serum levels (≥50 μg/mL) in blood mononuclear cells from seven of eight patients. This correlated with myelomonocytic differentiation of leukemic cells as revealed by morphologic, cytochemical, immunophenotypic, and gene expression analyses. Differentiation of the leukemic clone was proven by fluorescence in situ hybridization analysis showing the cytogenetic lesion +8 or 7q− in differentiating cells. Hematologic improvement, according to established criteria for myelodysplastic syndromes, was observed in two cases. Stable disease and disease progression were observed in five and one cases, respectively. In conclusion, VPA-ATRA treatment is well tolerated and induces phenotypic changes of AML blasts through chromatin remodeling. Further studies are needed to evaluate whether VPA-ATRA treatment by reprogramming differentiation of the leukemic clone might improve the response to chemotherapy in leukemia patients. (Cancer Res 2006; 66(17): 8903-11)

Background: Allogeneic transplant is an effective salvage therapy in patients with Hodgkin lymphoma (HL) relapsed or refractory to previous treatments. In recent years, immunotherapies (conjugated antibody and checkpoint inhibitors) showed interesting results and were used as bridge therapies to allotransplant. Aim: The aim of this retrospective study in Lazio Region was to evaluate the impact of these new therapies on outcome after allogeneic hematopoietic stem cell transplantation (allo-SCT) in comparison with standard chemotherapies used in the past. Methods: We selected all consecutive patients with diagnosis of HL transplanted in four Hematology Transplant Unit and we collected data obtained from patients’ records concerning all the treatments before allo-SCT. Results: A total of 56 patients were enrolled into this study. All patients underwent allo-SCT for relapsed or refractory HL. Seventeen patients (30%) received chemotherapy prior to allo-SCT (group B), they were treated between 2008 and 2015, and 39 patients (70%) received BV or CPI or both before allo-SCT as bridge to transplant (group A), they were treated between 2012 and 2020. Twenty-five patients were treated with BV alone, 2 with CPI alone and 12 first with BV and then with CPI. No patient received concomitant BV and CPI. At five years from allo-SCT, OS was 59% and PFS was 65%. No statistical differences in OS or PFS were observed between patients of group A and B. Relapse was significantly associated with a lower survival. The only factor associated with a reduced risk of relapse was development of any grade acute GVHD (p>0.02). Conclusions: This regional real-world experience shows the changes that have taken place in the last 10 years in R/R HL using new drugs to render a patient eligible to allo-SCT. This strategy appears to guarantee an impressive disease control with an increased risk of complications, as aGVHD, that appear to nullify this advantage at least in part.

The incidence of non-Hodgkin lymphoma in patients 80 years of age or older is 50 times higher than in 20- to 24-year-olds. Very elderly patients are often not treated with standard immunochemotherapy because of poor performance status, comorbidities, and toxicity concerns. We retrospectively analyzed data for 29 patients diagnosed with diffuse large B-cell lymphoma or grade 3B follicular lymphoma and treated with rituximab in combination with nonpegylated liposomal doxorubicin between January 2010 and August 2015. The median age was 84 years. The overall 3-year survival, cause-specific survival, and progression-free survival rates were 46%, 55%, and 44%, respectively. Among prognostic factors, only the achievement of complete remission strongly correlated with overall survival, cause-specific survival, and progression-free survival rates. Treatment caused very mild toxicity, without treatment-related hospitalization or toxic deaths.

Several studies suggested that staging bone marrow biopsy (BMB) could be omitted in patients with classical Hodgkin's lymphoma (cHL) when a positron emission tomography/computed tomography (PET/CT) is performed at baseline.To address the concordance between BMB and PET/CT in the detection of bone marrow involvement (BMI) and the BMB role in determining the Ann Arbor stage, we retrospectively collected data on 1244 consecutive patients with cHL diagnosed from January 2007 to December 2013. One thousand eighty-five patients who had undergone both BMB and PET/CT were analyzed, comparing the Ann Arbor stage assessed with PET/CT only to that resulting from PET/CT combined with BMB.One hundred sixty-nine patients (16%) showed at least one focal skeletal lesion (FSL) at PET/CT evaluation. Only 55 patients had a positive BMB (5.1%); 34 of them presented at least one FSL at PET/CT. To the contrary, 895 out of 1030 patients with a negative BMB did not show any FSL (86.9%). Positive and negative predictive values of PET/CT for BMI were 20 and 98%, respectively; sensitivity and specificity were 62 and 87%, respectively. Fifty-four out of 55 patients with a positive BMB could have been evaluated as an advanced stage just after PET/CT; only one patient (0.1%) would have been differently treated without BMB.Our data showed a very high negative predictive value of PET/CT for BMI and a negligible influence of BMB on treatment planning, strengthening the recent indications that BMB could be safely omitted in cHL patients staged with PET/CT.

The European Organization for Research and Treatment of Cancer and the Mycosis Study Group (EORTC-MSG) radiological definitions of invasive pulmonary aspergillosis (IPA) may lack diagnostic sensitivity. We evaluated applying less restrictive radiological criteria, when supported by specific microbiological findings, to define IPA in acute myeloid leukaemia (AML), lymphoproliferative diseases (LD) and allogeneic stem cell transplant (allo-SCT) patients. Overall, 109 consecutive episodes of proven/probable IPA in 56 AML, 31 LD and 22 allo-SCT patients diagnosed from February 2006 through to January 2011 were considered. IPA was diagnosed with EORTC-MSG criteria (control group, 76 patients) or without prespecified radiological criteria (study group, 33 patients). The latter differed from the former by the inclusion of patients with pulmonary infiltrates not fulfilling the three EORTC-MSG IPA specific findings of dense, well-circumscribed lesions with or without halo sign, air crescent sign or cavity. All the analysed clinical and mycological characteristics, 3-month response to antifungal therapy and 1- and 3-month cumulative survival were comparable in the control and study groups in AML, LD and allo-SCT patients. Seventeen of 33 (51.5%) patients of the study group fulfilled EORTC-MSG radiological criteria at subsequent imaging performed a median of 15 days (range, 6-40 days) after documentation of the pulmonary infection. Our study seems to confirm the possibility of revising the EORTC-MSG criteria by extending the radiological suspicion of IPA to less specific chest computerized tomography scan findings when supported by microbiological evidence of Aspergillus infection in high-risk haematological patients.

Mantle cell lymphoma (MCL) is an aggressive neoplasm with a short survival. Cases with leukaemic MCL and splenomegaly without adenopathies (non-nodal MCL) may have a more indolent course. To gain insights into the biological features underlying this presentation, we investigated the gene expression profile (GEP) and the IGHV mutational status in a cohort of leukaemic MCL cases. Comparison of MCL with other lymphoproliferative disorders (i.e. splenic marginal zone lymphoma, follicular lymphoma, chronic lymphocytic leukaemia) revealed a MCL signature enriched for the following gene categories: mitochondrion, oxidoreductase activity, response to stress, to DNA damage and TP53-pathway. Furthermore, GEP analysis revealed that non-nodal MCL cases were characterized by the down-modulation of the following gene categories: cell projection, actin cytoskeleton organization, cell adhesion (ITGAE, CELSR1, PCDH9) and tumour invasion/progression (PGF, ST14, ETS1, OCIAD1, EZR). Many down-modulated genes were related to the TP53-pathway and to DNA damage response. IGHV status proved unmutated in all nodal and mutated in all non-nodal MCL. Non-nodal leukaemic MCLs display a peculiar clinical presentation, with distinctive biological features, such as mutated IGHV and a transcriptional profile lacking tumour invasion properties, that might contribute to the absence of nodal involvement and to the less aggressive clinical course.

In this article, the pharmacological, microbiological and clinical development progress from Phase II and III clinical trials with the new generation triazoles albaconazole, isavuconazole, posaconazole, ravuconazole and voriconazole are reviewed. These drugs exhibit a favorable toxicity profile and possess high activity against resistant and emerging fungal pathogens. Pharmacokinetic may be affected by variability in metabolism and/or gastrointestinal absorption. Only voriconazole and posaconazole have been adequately investigated and are now indicated in the treatment and prophylaxis of invasive fungal diseases. Other triazoles; albaconazole, isavuconazole and ravuconazole are under development; therefore, their future use is unknown.

Purpose To assess the role of [18F]fluorodeoxyglucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT) after rituximab and anthracycline-containing chemoimmunotherapy in patients with primary mediastinal large B-cell lymphoma (PMLBCL). Patients and Methods Among 125 patients prospectively enrolled, 115 were eligible for central review of PET/CT scans at the completion of standard chemoimmunotherapy, by using a five-point scale. Consolidation radiotherapy (RT) was permitted and given to 102 patients. Results Fifty-four patients (47%) achieved a complete metabolic response (CMR), defined as a completely negative scan or with residual [18F]FDG activity below the mediastinal blood pool (MBP) uptake. In the remaining 61 patients (53%), the residual uptake was higher than MBP uptake but below the liver uptake in 27 (23%), slightly higher than the liver uptake in 24 (21%), and markedly higher in 10 (9%). CMR after chemoimmunotherapy predicted higher 5-year progression-free survival (PFS; 98% v 82%; P = .0044) and overall survival (OS; 100% v 91%; P = .0298). Patients with residual uptake higher than MBP uptake but below liver uptake had equally good outcomes without any recurrence. Using the liver uptake as cutoff for PET positivity (boundary of score, 3 to 4) discriminated most effectively between high or low risk of failure, with 5-year PFS of 99% versus 68% (P < .001) and 5-year OS of 100% versus 83% (P < .001). Conclusion More than 90% of patients are projected to be alive and progression-free at 5 years, despite a low CMR rate (47%) after chemoimmunotherapy. This study provides a basis for using PET/CT to define the role of RT in PMLBCL.

About 60% of patients with diffuse large B-cell lymphoma (DLBCL) may be cured by primary chemotherapy with an R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) regimen. Most of the rest will die of the disease, mainly due to the occurrence of tumor drug resistance. Many efforts have been made to explain the molecular mechanisms of drug resistance in patients with cancer, including those with DLBCL. This exploratory study was designed to correlate the mRNA expression levels of candidate genes mainly involved in the doxorubicin pathway (ABCB1, GSTP1, TOPO2α, BCL2, PKCβII) with the outcome of 54 patients with DLBCL undergoing a dose-dense R-CHOP regimen. After multivariate analysis, high GSTP1 (p = 0.003) and TOPO2α (p = 0.02) gene expressions were associated with shorter overall survival and progression-free survival, respectively, suggesting that these genes may represent an unfavorable prognostic factor in the case of R-CHOP treatment. These biomarkers may be useful for selecting patients eligible for personalized chemotherapy after validation in an independent set.

Introduction: The initial approach to elderly patients with Diffuse Large B-cell lymphoma (DLBCL) is usually based on the subjective judgment of the physician on the individual patient's ability to tolerate treatment with curative intent. "Comprehensive Geriatric Assessment" (CGA) is based on the use of the ADL (Activity of Daily Living), IADL (Instrumental ADL) and CIRS-G (Comorbidity Index Rating Scale for Geriatrics) scales and represents a tool to standardize initial patients fitness assessment and for planning systemic therapy. So far CGA has been rarely used in prospective studies and lacks a formal validation in patients with lymphoma. Objectives: FIL is conducting a prospective study with the aim of validating the use of CGA on a large series of elderly patients with DLBCL and to test a CGA based approach to the patient. CGA results will be used to define treatment goals that are the cure for the FIT subjects, and palliation for the FRAILs. Treatment goal for the UNFIT is cure with less toxic regimens. Methods: This study is conducted using a web based platform, accessible from the reserved area of the FIL website, to perform a quick and objective CGA evaluation of consecutive patients ≥ 65 years with untreated DLBCL. Patients younger than 80 years, without impairment of ADL and IADL and without severe comorbidities were considered FIT; those with intermediate fragility or those older than 80 years with FIT profile were classified as UNFIT (UN); those with severe impairment of ADL, IADL and CIRS and those older than 80 years with an UN profile were classified as FRAIL (FR). Informed consent was required to enrol patients in this study; the planned sample size was 1000 patients. Results: The study started in December 2013. At time of current analysis 792 patients have been registered by 45 centres: 328 (41%), 207 (26%), and 257 (33%) were classified as FIT, UN and FR, respectively. Median age was 77 years (yrs) (65-95); 73 (65-79), 80 (65-95) and 81 (65-95) yrs for FIT, UN and FR patients respectively; overall 65% were in stage III-IV. By univariate analysis, the three categories differed in terms of median age (p1 (p Fourty-nine percent of cases were defined as UN only because of age (≥80 yrs); other reasons for UN were impairment of IADL, ADL in 30% and 18%, respectively. Only 3% of cases were UN due to CIRS (5-8 comorbidities of grade 2). Regarding FRAIL patients 27% of patients were classified in this group due to CIRS impairment, 24% and 18% due to IADL and ADL impairment, respectively. In remaining 31%, patients were FRAIL due to age ≥80 yrs (Figure 1). The most frequent altered ADL items among UN and FR patients were continence (15%) and bathing (30%), respectively; regarding IADL the most frequent altered items were buying and food preparation for either UN (19% and 12%) and FR (53% and 41%). Most frequent grade 3 comorbidities among the 257 FR patients were those referred to heart (16%), vascular system (9%), muscoloskelatal (7%), and genitourinary (5%). Data on planned treatment were available in 643 patients. Rituximab was used in all but 6 (2%), 18 (12%), and 35 (17%) FIT, UN, and FR cases. Treatment with curative intent (full doses R-CHOP-like regimens) was used in 94% and 65% of FIT and UNFIT cases; surprisingly curative intent was declared also in 38% of FRAIL cases. Six percent, 25% and 26% of FIT, UN and FR patients were treated with an attenuated R-CHOP-like immuno-chemotherapy regimens. Palliative regimens were used in 36% and 10% of FR and UN patients respectively. Conclusion: The preliminary data of Elderly Project showed that, with the CGA criteria as adopted in this study, the 59% of elderly patients with DLBCL at diagnosis were not FIT. Rituximab and doxorubicin containing regimen seems to be the reference treatment for FIT, UN and also for a significant proportion of FR patients but the actual value of using this approach for non-FIT patients is not clear and will be assessed with this project. Figure 1 Contribution of Activity of Daily Living (ADL), Instrumental ADL (IADL), Comorbidity Index Rating Scale for Geriatrics (CIRS-G) scales and Age to Fitness Status Figure 1. Contribution of Activity of Daily Living (ADL), Instrumental ADL (IADL), Comorbidity Index Rating Scale for Geriatrics (CIRS-G) scales and Age to Fitness Status Disclosures Merli: Teva Pharmaceuticals Industries: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees. Luminari:Roche: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accomodations, Expenses; Takeda: Other: Travel, Accomodations, Expenses; Teva Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Pfizer: Honoraria. Cavallo:JANSSEN: Honoraria; CELGENE: Honoraria; ONYX: Honoraria. Chiappella:Roche: Speakers Bureau; Amgen: Speakers Bureau; Pfizer: Speakers Bureau; Teva: Speakers Bureau; Janssen-Cilag: Speakers Bureau; Celgene: 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.

Diffuse large b cell lymphoma (DLBCL) is the most common type of non-Hodgkin's lymphoma. Gene-expression profiling in DLCBL has brought insight into the biological heterogeneity of the disease. two major subgroups have been identified: germinal center B (GCB) cell and non-germinal center (non-GCB). The aim of this study was to define retrospectively by immunohistochemistry the B-cell origin of 69 patients treated with R-CHOP14 and to evaluate if dose-dense therapy could improve their clinical outcome. According to immunohistochemistry analysis 28 patients were derived from germinal center and 41 from non-germinal center. After a median period of observation of 46 months (range 3-101 months) the overall survival (OS) was 75% and progression-free survival (PFS) was 53% and no differences were observed according to cell origin. In conclusion, we can point out that intensification could enhance the efficacy of the R-CHOP regimen and improve overall survival in patients with non germinal lymphoma.

To report the clinical findings and long-term results of front-line, third-generation MACOP-B (methotrexate, doxorubicin, cyclophosphamide, vincristine, prednisone, and bleomycin) chemotherapy and mediastinal involved-field radiotherapy (IFRT) in 85 consecutive, previously untreated patients with primary mediastinal large B cell lymphoma (PMLBCL) diagnosed and managed at a single institution.Between 1991 and April 2004, 92 consecutive, untreated patients with PMLBCL were treated at our institution. The median age was 33 years (range, 15-61 years), 46 patients (50%) showed a mediastinal syndrome at onset; 52 patients (57%) showed a low/low-intermediate (0 to 1) and 40 patients (43%) an intermediate-high/high (2 to 3) International Prognostic Index (IPI) score. Eighty-five patients were treated with standard chemotherapy (MACOP-B), and 80 underwent mediastinal IFRT at a dose of 30-36 Gy.After a MACOP-B regimen, the overall response rate was 87% and the partial response rate 9%. After chemotherapy, (67)Ga scintigraphy/positron emission tomography results were positive in 43 of 52 patients (83%), whereas after IFRT 11 of 52 patients (21%) remained positive (p0.0001). After a median follow-up of 81 months (range, 2-196 months), progression or relapse was observed in 15 of 84 patients (18%). The projected 5-year overall survival and progression-free survival rates were 87% and 81%, respectively. The 5-year overall survival and progression-free survival rates were better for patients with an IPI of 0 to 1 than for those with an IPI of 2 to 3 (96% vs. 73% [p = 0.002] and 90% vs. 67% [p = 0.007], respectively).Combined-modality treatment with intensive chemotherapy plus mediastinal IFRT induces high response and lymphoma-free survival rates. Involved-field RT plays an important role in inducing negative results on (67)Ga scintigraphy/positron emission tomography in patients responsive to chemotherapy.

Philadelphia positive (Ph+) chronic myeloid leukaemia (CML) presenting synchronously or following non-Hodgkin lymphoma (NHL) has only rarely been reported. Herein, we refer on a case of Ph+ CML occurring after a breast cancer and a NHL with multiple relapses. After obtaining complete cytogenetic remission with imatinib, the patient presented a new NHL relapse, that was treated with rituximab concomitantly to imatinib. Therapy was well tolerated and the patient is presently alive in complete remission of either NHL and CML. We also reviewed the literature relating the uncommon association of these two unrelated diseases.

Epigenetic alterations of chromatin due to aberrant histone deacetylase (HDAC) activity and transcriptional silencing of all-trans retinoic acid (ATRA) pathway are events linked to the pathogenesis of acute myeloid leukemia (AML) that can be targeted by specific treatments. A pilot study was carried out in eight refractory or high-risk AML patients not eligible for intensive therapy to assess the biological and therapeutic activities of the HDAC inhibitor valproic acid (VPA) used to remodel chromatin, followed by the addition of ATRA, to activate gene transcription and differentiation in leukemic cells. Hyperacetylation of histones H3 and H4 was detectable at therapeutic VPA serum levels (≥50 μg/mL) in blood mononuclear cells from seven of eight patients. This correlated with myelomonocytic differentiation of leukemic cells as revealed by morphologic, cytochemical, immunophenotypic, and gene expression analyses. Differentiation of the leukemic clone was proven by fluorescence in situ hybridization analysis showing the cytogenetic lesion +8 or 7q− in differentiating cells. Hematologic improvement, according to established criteria for myelodysplastic syndromes, was observed in two cases. Stable disease and disease progression were observed in five and one cases, respectively. In conclusion, VPA-ATRA treatment is well tolerated and induces phenotypic changes of AML blasts through chromatin remodeling. Further studies are needed to evaluate whether VPA-ATRA treatment by reprogramming differentiation of the leukemic clone might improve the response to chemotherapy in leukemia patients. (Cancer Res 2006; 66(17): 8903-11)

All-trans retinoic acid (ATRA) has markedly improved the outcome of APL: however, the incidence of thrombotic events seems to be higher in the ATRA treated patients. To assess the true incidence of such complications, we compared 2 different cohorts of APL patients: 37 patients (M/F 17/20, median age 37 years, range 14 – 58) treated with chemotherapy (CHT) alone (GIMEMA 0389-group A) and 90 patients (M/F 40/50, median age 43.5 years, range 19 – 75) treated with ATRA + CHT (AIDA and AIDA 2000 protocols-group B). In the group A, no patient had thrombotic complications during induction or consolidation treatment: however, among 15 patients who relapsed and received a reinduction treatment with ATRA +/− CHT, 3 (20%) developed a thrombotic disease [1 acute myocardial infarction (AMI), 1 pulmunary embolism, 1 deep venous thrombosis (DVT)]. In the group B, 11/90 patients (M/F 5/6, median age 60 years, range 32 – 71) (12%) had a thrombotic event. Of them, 8 patients developed it during induction (4 episodes of unstable angina, 2 right ventricular thrombosis, 2 DVT), after a median time of 26 days from ATRA treatment (range 3 – 78), a median PLTS count of 208 x 109/l (3/8 patients showed a PLTS count < 50 x 109/l when the thrombotic event occurred) and without prothrombotic biochemical abnormalities. The remaining 3 patients developed a DVT during consolidation phase, after 31, 34 and 37 days respectively from start of 1st consolidation cycle and with a normal PLTS count. No association was observed with ATRA syndrome or haemorrhagic diathesis at presentation, whereas 8/11 patients showed the presence of FLT3-ITD at diagnosis. Phenotypic characterization revealed a classic panel in all patients (CD13+, CD33+, CD9+, MPO+), but a peculiar positivity for CD2 was seen in 7 patients, for CD15 in 3 patients and for both antigens in 1 patient. CD2 antigen is normally found on T cells and mediates adhesion to CD58: it is possible that this aberrant expression on the surface of APL cells play a role in the leuko-agglutination during ATRA treatment, contributing to thromboses in peculiar site, such as right ventriculum. In the 3 patients CD2 negative, we found a similar aberrant expression of CD15, that has been reported in literature as an antigen normally modulated by ATRA, together with other adhesion molecules. The association between CD2 expression, short type of bcr transcript and FLT3 abnormalities has been also confirmed. Our data outline the increase of thrombotic risk linked to ATRA treatment in APL patients, with an incidence of 10 – 15% to be confirmed in other series. We suggest a possible and crucial role of aberrant features at diagnosis, such as phenotype and molecular abnormalities, to explain this high thrombotic incidence: thus, further prospective studies are warranted to analyse clinical and biological factors predisposing to thrombotic disease in such patients.

The anti-CD33 antibody calicheamicinconjugate gemtuzumab ozogamicin (GO) was used to treat 16 patients with acute promyelocytic leukemia (APL) who had relapsed at the molecular level. Of these patients, 8 were experiencing a first, 5 a second, 2 a third, and 1 a fourth relapse. GO was administered at 6 mg/m2 for 2 doses, and patients achieving a new molecular remission (MR) (ie, negativity of the reverse transcriptase-polymerase chain reaction [RT-PCR] test for PML/RARalpha) received a third dose. MR was obtained in 9 (91%) of 11 patients tested after 2 doses and in 13 (100%) of 13 patients tested after the third dose. Of the 3 remaining patients, 1 achieved MR after one GO administration and received no further therapy owing to hepatic toxicity, and 2 showed disease progression during treatment. Quantitative RT-PCR studies showed that responding patients experienced a dramatic decline (at least 2 logs) of the PML/RARalpha transcript after the first GO dose. Of 14 responders, 7 remained in sustained MR for a median of 15 months (range, 7-31 months) while 7 experienced relapse at 3 to 15 months. GO was administered again in 2 patients with relapse, and both obtained a new MR. These data indicate that GO is highly effective as a single treatment for patients with molecularly relapsed APL including those with very advanced disease.

The anti-epileptic drug valproic acid (VPA) acts as an inhibitor of histone deacetylases. In combination with retinoic acid (RA), VPA triggers myeloid differentiation of primary acute myeloid leukemia (AML) blasts in vitro. In vivo, VPA posses an antineoplastic activity as indicated by pre-clinical studies in murine models of leukemia, renal and lung metastatic tumors. Therefore, we have designed a phase II clinical study in which VPA was combined with RA (VPA-RA) in the AML treatment. Eigth chemotherapy-resistant or high risk AML patients not eligible for additional intensive therapy (median age 61.5 yrs), were treated at the Hematology Units of the Universities “La Sapienza” and “Tor Vergata” Rome-Italy. VPA (Depakin[Sanofi-Wintrop]) was administrated from day 1 to day 28, at the initial dosage of 10 mg/kg/die p.o. with dose escalation until optimal VPA plasma levels (80–110ug/ml). RA (Vesanoid [Roche]) at the dosage of 45 mg/m2 p.o./d, divided in two administrations, was added once the optimal VPA plasma levels were reached or at day 14 and continued until day 28. Four patients had a history of MDS, three patients had a FAB M0, M1 and M2 de novo AMLs, while the remaining case was a myeloid blast crisis (FAB M0) of a Ph+ve CML. Cytogenetic characterization in the other patients revealed normal karyotype in one case, a pseudodiploid [der(12)] in one, hyperdiploid (+8) in one, complex K with a 7q- alteration in one, while in the three remaining cases the karyotype was not evaluable. Pre-treatment leukemic infiltration ranged from 22% to 95%. VPA plasma level >60mg/ml was reached between 8 to 28 days (median 14.5 days). In three patients, VPA-RA treatment induced hyperleukocytosis (>50x 109/l) at day 16, 21 and 24, respectively, that was treated with chemotherapy (HU in two cases and low dose Ara-C in 1 case). Hematological improvement (≥50% decrease in packed red blood cell or platelet transfusion requirement) was observed in one case, a stable disease in five cases and disease progression in two cases. Peripheral blood and/or bone marrow samples were collected at day 0,3,7,14,21,28 for morphologic, immunophenotypic, cytogenetic and molecular studies. All patients showed features of myeloid-monocytic and/or erythroid differentiation of the leukemic clone, as revealed by morphologic, cytochemical, immunophenotypic analyses and by Q-RT-PCR of myeloid gene expression (GATA 1, MPO, CSF2Rb, etc.). Of note that high degree of myeloid differentiation correlated with early achievement of therapeutic VPA plasma levels and histone hyper-acetylation, as measured by immunocytochemistry and immunoblotting using antiacetylated histone H3 and H4 antibodies. Finally, differentiation of the leukemic clone was proven by FISH analysis showing the presence of the +8 and 7q- in maturing elements in patients whose leukemia blasts carried these cytogenetic lesions. The VPA-RA combination is a well tolerated treatment that induces phenotypic changes of the leukemic clone through chromatine remodelling. Further studies are needed to optimise this regimen with the aim of improving clinical response in leukemia patients.

orrigendum to “Atypical presentation of anaplastic large T-cell ymphoma mimicking an articular relapse of rheumatoid arthritis in a atient treated with etanercept. A case report and literature review” Leuk. Res. 36 (2012) e199–e201] ederico De Angelisa,∗, Alice Di Roccoa, Clara Minotti a, Guido Valesinib, Claudio Cartonia, ara Riminucci c, Fabrizio Contib, Erica Finolezzia, Daniele Armientoa, S. Grammaticoa, . Massarob, A. Famaa, G. Colafigli a, C. Viccaronea, R. Foaa, M. Martelli a

Abstract 1566 Background. Response-tailored management of PMLBCL is a major challenge in everyday practice, mostly due to the persistence of post-treatment residual masses of uncertain nature. PET/CT is now widely used in the definition of response and as a prognostic indicator, in Hodgkin lymphoma (HL) and diffuse large B cell lymphoma (DLBCL), while its role in patients with PMLBCL remains to be defined. Aim of the study. The IELSG-26 study was designed to prospectively evaluate the clinical role of PET/CT after rituximab and anthracycline-containing immunochemotherapy (R-CHT) in patients with PMLBCL. Methods. Between January 2007 and July 2010, 125 patients (pts) with PMLBCL were enrolled in 21 institutions and treated with R-CHOP-like (20 pts), R-VACOP-B (34 pts) or R-MACOP-B (71 pts) regimens according to the local policy; consolidation with mediastinal involved field radiotherapy (IFRT) as indicated by local guidelines was allowed. PET/CT scans were planned at baseline, at 3–4 weeks after R-CHT and at 12 weeks after radiotherapy. Central PET/CT review was performed at the end of treatment using the Deauville score (Meignan et al. Leuk Lymphoma 2009) and complete response (CR) was defined as a negative PET scan or one having minimal residual uptake lower than mediastinal blood pool (MBP) activity in regions which were FDG-PET positive at baseline according to the criteria of the International Harmonization Project in Lymphoma (Juweid et al. JCO 2007). Results. Treatment was administered as initially planned in 119 pts (including IFRT in 106); there were 6 early withdrawals (4 with early progression and 2 with stable disease receiving second-line chemotherapy). PET imaging was not done (n=2) or not evaluable due to technical problems (n=2) in 4 pts, therefore, central review of PET/CT was possible in 115/119 patients. PET/CT visual assessment at 3–4 weeks post-R-CHT showed metabolic CR in 54/115 patients (47%; 95% CI, 36%–56%): in 12 cases (10%; 95% CI, 6%–18%) PET/CT scan was completely negative (score 1 according to the Deauville criteria), while in 42 (37%; 95% CI, 28%–46%) there were small residual masses with an uptake less than MBP (score 2). PET/CT scans showed a positive residual mass after R-CHT in 61/115 pts (53%; 95% CI, 44%–62%). The residual uptake was higher than MBP but below the liver uptake (score 3) in 27 pts (23%; 95% CI, 16%–32%), slightly higher than the liver uptake (score 4) in 24 pts (21%; 95% CI, 14%–29%) and markedly higher than the liver uptake (score 5) in 10 pts (9%; 95% CI, 4%–15%). Despite only 47% of patients attaining a CR -defined by the uptake below MBP activity- after R-CHT, at a median follow-up of 2.8 years, the estimated 5-year overall survival (OS) and progression-free survival (PFS) rates were 96% (95% CI, 89%–98%) and 91% (95% CI, 84%–95%), respectively. The achievement of a CR at 3–4 weeks after R-CHT predicted a longer PFS (p=0.015) with high sensitivity but poor specificity (negative predictive value of 0.98 but positive predictive value of only 0.15) and showed a borderline impact (p=0.052) on OS. Patients with Deauville score 3 had a clinical outcome identical to that of ‘PET negative’ (score 1–2) pts and ROC analysis suggested that moving the cut-point for the definition of CR from the MBP to the liver uptake, will increase specificity while maintaining sensitivity. Indeed, defining the response using the liver uptake as a cutpoint is a better predictor for both PFS (p Conclusions. Using the MBP cut-point, the PET-positive rate (Deauville score>2) after R-CHT in PMLBCL was higher (53%) than in DLBCL. However, more than 90% of pts are projected to be alive and progression-free at 5 years post treatment and a negative PET/CT after R-CHT is significantly associated with a longer PFS. Pts with score 4 and 5 had a significantly worse PFS and OS. Hence, the liver uptake may represent a more appropriate cut-point than MBP to identify poor-risk pts who may need early intensification of therapy. The frequent use of IFRT in this study precludes any clear conclusion about its role, but the new IELSG-37 randomized trial will assess whether mediastinal irradiation can be safely omitted in PMLBCL pts achieving a CR after R-CHT. Disclosures: No relevant conflicts of interest to declare.

Abstract 2478 Diffuse large B cell lymphoma (DLBCL) is one of the most common types of non-Hodgkin's lymphoma. Approximately half of patients will be cured of their disease by primary therapy, including the R-CHOP regimen (rituximab, doxorubicin, cyclophosphamide, vincristine, desamethasone). The remaining die of the disease, mainly because of the occurrence of tumor drug resistance. Many efforts have been made to explain the biochemical and molecular mechanisms involved in resistance to the drugs used in the treatment of cancer patients, including those with DLBCL. A dose-intense therapy regimen (e.g. R-CHOP14) may help to improve the treatment outcome of DLBCL patients. We have carried out a retrospective study aimed at correlating the mRNA expression levels of genes involved in metabolism, mechanisms of action and resistance to doxorubicin (i.e. MDR1, GSTP1, TOPO-2a, Bcl-2, PKC-b2) that represents the backbone of the R-CHOP regimen with treatment outcome data of 54 patients at various stages of disease. The expression of the 5 above mentioned genes was determined in formalin-fixed paraffin-embedded samples from DLBCL using real time RT-PCR. A threshold analysis to identify a cut-off distinguishing recurrent or non-recurrent disease was used. The correlations between gene expression data and clinical/pathological characteristics as well as survival parameters have been evaluated by standard statistical tests. The case series included 32 males and 22 females; 6 patients had follicular lymphoma grade IIIb and 48 diffuse large B cell lymphoma; 19 presented symptoms at diagnosis. Thirty patients showed abnormal LDH values, the IPI was intermediate-high risk or high risk in 14 patients. Forty-six patients (85.2%) obtained a complete remission and 8 (14.8%) a partial response. The median overall survival (OS) as well as the median progression free survival (PFS) have not yet been reached after a median follow-up of 43.6 months. The mRNA expression levels of TOPO-2a and GSTP1 were detectable in all samples, that of PKC-b2 in 52 samples, that of MDR1 and bcl-2 in 34 and 29 samples, respectively. A high degree of interpatient variation in relative tumor expression of the study gene was observed: from 0.008 for TOPO-2a to >100.000 for PKCbII. Threshold analysis indicated significant inverse relationships between PKC-b2 and PFS (p=0.046): higher gene expression was associated with shorter PFS. Conversely, higher expression of ABCB1 was associated with prolonged PFS (p=0.039). This kind of analysis also showed associations between OS and TOPO-2a, GSTP1and PKC-b2: higher gene expression was associated with shorter OS. Overall, our results confirm that the high expression of some genes such as TopoIIa, GSTP1 and PKCβII may represent a prognostic factor in case of an intensified anthracycline-based chemotherapy with immunotherapy. Moreover, our results suggest that intensified immunochemotherapy could affect the role of bcl2, ABCB1, GSTP1 and TopoIIa in predicting tumor response. These results and others from related studies may help to identify gene profiles useful for selecting patients eligible for more intensified or personalized chemotherapy. Prospective larger studies are warranted. Supported by a grant from Associazione Giacomo Onlus, Castiglioncello (LI). Disclosures: No relevant conflicts of interest to declare.

Velcade (PS-341, Bortezemib), a proteasome inhibitor, has recently been approved for the treatment of relapsed and refractory multiple myeloma (MM). We hereby report the results obtained using this new drug at our center. Between April 2003 and December 2004 we treated 23 patients with MM. The patient population consists of 13 males and 10 females, with a median age of 53 years (range 32–72); 16 were IgG MM, 6 IgA, 1 light chain. All patients were in stage III of their disease, with a median time of observation (from diagnosis to Velcade therapy) of 59 months (range 11–120), were pretreated with at least two lines of therapies and were refractory or in relapse after the last treatment. Velcade 1.3 mg/m2 was scheduled on days 1, 4, 8 and 11 of a 21-day treatment cycle for 8 cycles according to the tolerability and response. All cycles were delivered in day hospital. A median of 6 cycles (range 3–8) were administered to the overall population. Eleven patients concluded their program, while 12 discontinued the treatment: 1 because she received an allogeneic stem cell transplantation, 7 for adverse events and 4 due to disease progression. In this heavily pretreated population, our primary end point was to obtain a decline in the monoclonal component (MC) of at least 25%. All patients were considered evaluable for response because treated with at least 3 cycles of therapy. Thirteen patients responded to treatment: 1 (4%) obtained a disappearance of the MC, 4 (17%) achieved a reduction of the MC level >75% and 8 (34%) >50%. Six further patients (26%) obtained a decline in the MC