LEUKEMIA AND LYMPHOMA East and West are Together
LEUKEMIA AND LYMPHOMA East and West are Together
LEUKEMIA AND LYMPHOMA East and West are Together
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<strong>LEUKEMIA</strong> <strong>AND</strong> <strong>LYMPHOMA</strong><br />
<strong>East</strong> <strong>and</strong> <strong>West</strong> <strong>are</strong> <strong>Together</strong><br />
September 17–21, 2011<br />
Dubrovnik, Croatia<br />
Organizers:<br />
The University of Texas, MD Anderson Cancer Center<br />
<strong>and</strong><br />
Clinical Hospital Center Zagreb, School of Medicine<br />
University of Zagreb<br />
SUPLEMENT<br />
LIJE^ VJESN 133:1–130 4 ZAGREB, 2011.
Utemeljen 1877. Founded 1877<br />
SAVJET / ADVISORY BOARD<br />
PREDSJEDNIK / PRESIDENT<br />
Mladen Belicza<br />
TAJNIK / SECRETARY<br />
Miroslav Hromadko<br />
^LANOVI / MEMBERS<br />
Ivan Bakran (Zagreb) – Tomislav Dasovi} (Zagreb) – Hedviga Hricak (New York) – Miroslav Hromadko (Zagreb) – Mirko Jung<br />
(Zürich) – Ivica Kostovi} (Zagreb) – Mladen Kri` (Rijeka) – Ante Padjen (Montreal) – Marko Pe}ina (Zagreb) – Dinko Podrug<br />
(New York) – Miljenko Pukani} (Sydney) – Smiljan Pulji} (Upper Saddle River, New Jersey) – Petar Rei} (Split) – Berislav Tomac<br />
(Hagen) – Marko Turina (Zürich) – Ljiljana Zergollern-^upak (Zagreb) – @ivojin @agar (Zagreb)<br />
UREDNI^KI ODBOR / EDITORIAL BOARD<br />
Branimir Ani} (Zagreb) – Darko Anti~evi} (Zagreb) – Alen Babacanli (Zagreb) – @elimir Bradamante (Zagreb) – Nada ^ike{<br />
(Zagreb) – Vladimir Duga~ki (Zagreb) – @eljko Feren~i} (Zagreb) – Rudolf Gre gurek (Zagreb) – Smilja Kaleni} (Zagreb) – Ni kola<br />
M<strong>and</strong>i} (Osijek) – August Miji} (Zagreb) – Davor Mili~i} (Zagreb) – Stojan Poli} (Split) – @eljko Reiner (Zagreb) – Darko Richter<br />
(Zagreb) – Zvonko Rumboldt (Split) – Juraj Sep~i} (Rijeka) – Zdenko Sonicki (Zagreb) – Davor [timac (Rijeka)<br />
GLAVNI I ODGOVORNI UREDNIK / EDITOR-IN-CHIEF<br />
Branimir Ani}<br />
TAJNIK UREDNI^KOG ODBORA / SECRETARY OF THE EDITORIAL BOARD<br />
@eljko Feren~i}<br />
Osniva~ i izdava~ / Founder <strong>and</strong> Publisher<br />
HRVATSKI LIJE^NI^KI ZBOR<br />
Glavni i odgovorni urednik / Editor-in-Chief<br />
BRANIMIR ANI]<br />
Tajnica redakcije / Secretary of the Editorial Offi ce<br />
DRA@ENKA KONTEK<br />
Rje{enje naslovne stranice / Front Page Design<br />
BRANKO VUJANOVI]<br />
Tehni~ki urednik / Technical Editor<br />
JOSIP VLAHOVI]<br />
Slog / Typesetting<br />
»GREDICE« – Zagreb, Horva}anska 67<br />
Tisak / Printed by<br />
PRINTERA GRUPA – Zagreb<br />
Web stranica / Web page<br />
ALEN BABACANLI<br />
Zagreb 2011.<br />
Naklada 200 primjeraka<br />
Rukopis i svi ~lanci {alju se Uredni{tvu Lije~ni~kog vjesnika, Zagreb, [ubi}eva ul. 9, tel. (01) 46-93-300. ^lanarina,<br />
pretplata i sve nov~ane po{iljke {alju se Hrvatskomu lije~ni~kom zboru, Zagreb, [ubi}eva ulica 9, odnosno na `irora~un<br />
br. 2360000-1101214818 ili devizni ra~un br. 2100060384, Zagreba~ka banka d.d., Savska c. 60, Zagreb, Swift:<br />
Zaba HR 2X, IBAN HR7423600001101214818, OIB 60192951611. ^lanarina Hrvatskoga lije~ni~kog zbora iznosi<br />
200 kuna; za lije~nike pripravnike i obiteljska ~lanarina iznosi 100 kuna. Pretplata za Lije~ni~ki vjesnik je 270 kuna.<br />
Radi redovitog primanja potrebno je odmah svaku promjenu adrese i boravka javiti Uredni{tvu. ^asopis se {alje<br />
svim ~lanovima besplatno. Svaki ~lan Hrvatskoga lije~ni~kog zbora ima pravo besplatno objaviti ~lanak u Lije~ni~kom<br />
vjesniku; autori koji nisu ~lanovi Zbora moraju platiti naknadu u iznosu od 150 kuna.<br />
Lije~ni~ki vjesnik citiraju: MEDLINE/Index Medicus i EMBASE/Excerpta Medica.
MEETING CHAIRMAN:<br />
Emil Freireich (USA)<br />
Hagop Kantarjian (USA)<br />
Boris Labar (Croatia)<br />
Ranka Serventi Seiwerth (Croatia)<br />
Srdjan Verstovsek (USA)<br />
SCIENTIFIC SECRETARY:<br />
S<strong>and</strong>ra Basic Kinda (Croatia)<br />
Mirta Mikulic (Croatia)<br />
MEETING VENUE:<br />
Hotel Palace, Dubrovnik<br />
September 17–21, 2011<br />
Dear Colleagues,<br />
It is our pleasure to welcome you for 2nd Leukemia <strong>and</strong> Lymphoma Meeting to Dubrovnik,<br />
Croatia, September 17–21, 2011. The organizers <strong>are</strong> MD Anderson Cancer<br />
Center, Houston, TX, USA <strong>and</strong> University Hospital Center, Zagreb, School of Medicine<br />
University of Zagreb, Croatia.<br />
During this 5-day meeting, we will explore the most relevant <strong>and</strong> recent evidencebased<br />
data on treatment of hematological neoplasms. We will discuss the same topics as<br />
in the 1st Leukemia <strong>and</strong> Lymphoma Meeting; however, in order to encourage audience<br />
participation <strong>and</strong> interaction, we added new sessions:<br />
Meet the professor <strong>and</strong> Lunch with Experts which will break into informal discussion<br />
groups.<br />
End of the Day debate to discuss controversies in the treatment of hematological<br />
malignancies.<br />
Many distinguished invited speakers from Europe <strong>and</strong> USA will participate again.<br />
Welcome to Dubrovnik!<br />
ORGANIZERS
Golden sponsor<br />
Sponsors<br />
Contributors
Contents<br />
Scientific program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii<br />
SA01 State of the art I.: Acute leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3<br />
OP01-73 Symposia/Special Lectures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17<br />
OP01-04 Presidential Symposium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17<br />
OP05-10 Symposium: AML – Risk adapted therapy I. . . . . . . . . . . . . . . . . . . . . . . . . . 20<br />
OP11-13 Symposium: AML – Risk adapted therapy II. . . . . . . . . . . . . . . . . . . . . . . . . . 23<br />
OP14-19 Symposium: MDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23<br />
OP20-25 Symposium: Myeloproliferative Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . 31<br />
OP26-31 Symposium: CML . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35<br />
OP32-35 Symposium: Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46<br />
OP36-43 Symposium: ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48<br />
OP44-48 Symposium: CLL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53<br />
OP49-57 Symposium: Stem Cell Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . 54<br />
OP58 Special Lecture I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60<br />
OP59-66 Symposium: Non- Hodgkin Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 61<br />
OP67-73 Symposium: Hodgkin Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63<br />
MP01-10 Meet the Professor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71<br />
SA02 State of the art II.: Diagnostic <strong>and</strong> Treatment Approach<br />
for Acute Myeloblastic Leukemia - Report from Central <strong>and</strong> <strong>East</strong>ern European<br />
Leukemia Group (CELG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81<br />
PP01-64 Poster Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87<br />
PP01-07 Acute leukemia I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87<br />
PP08-13 Ph + Chronic Myeloid Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90<br />
PP14-20 Stem Cell Transplantation I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93<br />
PP21-27 Lymphoma I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97<br />
PP28-34 Myeloproliferative neoplasm <strong>and</strong> miscelaneus . . . . . . . . . . . . . . . . . . . . . . . . 101<br />
PP35-40 Multiple myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
PP41-47 Acute Leukemia II. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107<br />
PP48-54 Lymphoma II. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110<br />
PP55-60 Stem Cell Transplantation II. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113<br />
PP61-64 Miscelaneus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116<br />
SP01-13 Satellite Symposia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119<br />
Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Scientific Program<br />
Friday, 16. September 2011<br />
<strong>LEUKEMIA</strong> <strong>AND</strong> <strong>LYMPHOMA</strong><br />
<strong>East</strong> <strong>and</strong> <strong>West</strong> <strong>are</strong> <strong>Together</strong><br />
Dubrovnik, Croatia, September 17–21, 2011<br />
Organizers:<br />
The University of Texas, MD Anderson Cancer Center<br />
<strong>and</strong><br />
Clinical Hospital Center Zagreb, School of Medicine<br />
University of Zagreb<br />
Meeting Venue: Hotel Palace, Dubrovnik<br />
15.00 – 19.00 Meeting: Central <strong>and</strong> <strong>East</strong>ern European Leukemia Group<br />
15.00 – 15.45 Registration of the CELG Group<br />
15.45 – 16.30 Acute Leukemia<br />
16.30 – 17.00 Coffee break<br />
17.00 – 17.45 CML<br />
17.45 – 18.30 Myelofibrosis<br />
18.30 – 19.00 New proposals for CELG Activity<br />
Saturday, 17. September 2011.<br />
13.30 – 15.30 Lunch Satellite Symposium: Therapy of fungal infections in immunocompromised patients<br />
Chair: Boris Labar (Croatia)<br />
14.00 – 14.05 Boris Labar (Croatia)<br />
Welcome <strong>and</strong> introduction<br />
14.05 – 14.30 Lubos Drgona (Slovakia)<br />
Hematologic patients dying of IFI? Trends in IFI epidemiology (SP01)<br />
14.30 – 14.55 Michael Girschikofsky (Austria)<br />
Invasive aspergillosis in hematological patients – from empirical to early pre-emptive therapy (SP02)<br />
14.55 – 15.20 Ben De Pauw (The Netherl<strong>and</strong>s)<br />
Management of Invasive aspergillosis:guidelines at the bedside (SP03)<br />
15.20 – 15.30 Boris Labar (Croatia)<br />
Panel discussion <strong>and</strong> meeting close<br />
16.15 – 17.45 Satellite Symposium: Iron chelation therapy for MDS<br />
Chair: Ranka Serventi Seiwerth (Croatia)<br />
16.15 – 16.40 Heather A. Leitch (Canada)<br />
Role of Iron Chelation in Myelodysplastic Syndrome (SP04)<br />
16.40 – 17.05 Aristoteles Giagounidis (Germany)<br />
Which MDS patients <strong>are</strong> eligible for iron chelation therapy? (SP05)<br />
17.05 – 17.30 Theo De Witte (The Netherl<strong>and</strong>s)<br />
Deferasirox in iron-overloaded patients with transfusion-dependent MDS (SP06)<br />
17.30 – 17.45 Panel discussion <strong>and</strong> closing of the Symposium<br />
vii
Scientific Program Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
18.00 – 20.00 OPENING CEREMONY <strong>and</strong> PRESIDENTIAL SYMPOSIUM<br />
18.00 – 18.20 Opening Ceremony<br />
18.20 – 20.00 Presidential Symposium<br />
Chair: Hagop Kantarjian (USA), Boris Labar (Croatia), Srdjan Verstovsek (USA),<br />
Ranka Serventi-Seiwerth (Croatia)<br />
18.20 – 18.45 Emil Freireich (USA)<br />
White blood cell transfusion <strong>and</strong> leukemia therapy (OP01)<br />
18.45 – 19.10 Roel Willemze (The Netherl<strong>and</strong>s)<br />
Presence <strong>and</strong> future of treatment of acute myeloid leukemia in patients under the age of 60 (OP02)<br />
19.10 – 19.35 Michael Keating (USA)<br />
CLL: how close is the cure? (OP03)<br />
19.35 – 20.00 Hans-Jochem Kolb (Germany)<br />
From donor »Buffy Coat« to vaccination (OP04)<br />
20.30 – 23.00 CONCERT <strong>AND</strong> WELCOME COCKTAIL<br />
Sunday 18.09. 2011.<br />
08.30 – 12.30 SYMPOSIUM AML – Risk adapted therapy<br />
Chair: Hagop Kantarjian (USA) Sergio Amadori (Italy)<br />
08.30 – 08.45 Torsten Haferlach (Germany)<br />
AML in adults – what we need for diagnosis (OP05)<br />
08.45 – 09.00 Joop Jansen (The Netherl<strong>and</strong>s)<br />
Mutation of epigenetic regulators in AML <strong>and</strong> MDS (OP06)<br />
09.00 – 09.15 Alan Burnett (United Kingdom)<br />
Therapy for younger adults with AML (OP07)<br />
09.15 – 09.30 Sergio Amadori (Italy)<br />
Therapy for elderly AML (OP08)<br />
09.30 – 09.45 Miguel Angel Sanz (Spain)<br />
Do we need chemotherapy for APL treatment? (OP09)<br />
09.45 – 10.00 Farhad Rav<strong>and</strong>i (USA)<br />
FLT3 inhibitors – too much expectations?! (OP10, SA01)<br />
10.00 – 10.30 Coffee break<br />
Chair: Ranka Serventi-Seiwerth (Croatia), Steven Z. Pavletic (USA)<br />
10.30 – 10.45 Marry Horowitz (USA)<br />
Allogeneic SCT for AML – when to treat (OP11)<br />
10.45 – 11.00 Didier Blaise (France)<br />
Allogeneic SCT for AML with reduced intensity conditioning (OP12)<br />
11.00 – 11.15 Hagop Kantarjian (USA)<br />
Novel drugs for AML (OP13, SA01)<br />
11.15 – 11.45 Questions <strong>and</strong> Answers<br />
12.15 – 13.45 Lunch Satellite Symposium Recent innovations in leukemia <strong>and</strong> lymphoma treatment<br />
– new hope?!<br />
Chair: Arnold Ganser (Germany)<br />
12.15 – 12.35 Raphael Duarte (Spain)<br />
More patients for autologous transplantation<br />
12.35 – 12.55 Kai Huebel (Germany)<br />
Further development in Stem Cell Mobilization <strong>and</strong> transplantation<br />
12.55 – 13.15 Arnold Ganser (Germany)<br />
Future Perspectives for Adult Myeloid Leukemia<br />
viii
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Scientific Program<br />
13.15 – 13.35 Rupert H<strong>and</strong>gretinger (Germany)<br />
Allogeneic Transplant Strategies for the Treatment of Pediatric Acute Leukemias<br />
13.35 – 13.45 Panel Discussion <strong>and</strong> Closing of the Symposium<br />
14.00 – 15.15 Lunch/Poster Session<br />
Poster presentation: Session 1. Acute leukemia I.<br />
Chair: Drago Batinic (Croatia)<br />
14.00 – 14.10 Rapamycin enhances dimethyl sulfoxide-mediated growth arrest in human myelogenous<br />
leukemia cells (PP01)<br />
Lalic H, Lukinovic-Skudar V, Banfic H, Visnjic D. Department of Physiology & CIBR,<br />
School of Medicine, University of Zagreb<br />
14.10 – 14.20 Ikaros transcription factors expression in cell differentiation (PP02)<br />
Antica M1 , Paradzik M1 , Matulic M2 , Batinic D3 , Labar B3 . 1Division of Molecular Biology,<br />
Ru|er Bo{kovi} Institute, Zagreb, 2Department of Molecular Biology, Faculty of Science, Zagreb,<br />
3University Hospital Center Zagreb <strong>and</strong> School of Medicine University of Zagreb, Croatia.<br />
14.20 – 14.30 Multicenter Perforomance Evaluation of the Multifrugquant Assay Kit (PP03)<br />
Márki-Zay J1 , Tauber Jakab K1 , Sipka S2 , Nagy G2 , Baráth S2 , Gyimesi E2 , Hevessy Zs3 , Sziráki Kiss V3 ,<br />
Szabó P5 , Tõkés-Füzesi M5 , Nagy É7 , Trucza É7 , Udvardy M4 , Borbényi Z8 , Dávid M6 , Kappelmayer J3 .<br />
1 2 3 Solvo Biotechnology, Szeged, Hungary; Regional Immunological Laboratory, Department of Clinical<br />
Biochemistry <strong>and</strong> Molecular Pathology, 42nd Department of Internal Medicine, University of Debrecen-<br />
Medical <strong>and</strong> Health Science Center, Debrecen, Hungary; 5Department of Laboratory Medicine,<br />
University of Pécs-Medical School, 61st Department of Internal Medicine, Pécs, Hungary; 7Department of Laboratory Medicine, 82nd Department of Medicine <strong>and</strong> Cardiology, University of Szeged – Albert<br />
Szent-Györgyi Clinical Center, Szeged, Hungary<br />
14.30 – 14.40 NPM1 mutations in AML detected by fragment analysis <strong>and</strong> Sanger sequencing (PP04)<br />
Crncec I, Musani V, Marusic Vrsalovic M, Livun A, Pejsa V, Jaksic O, Haris V, Ajdukovic R,<br />
Stoos Veic T, Kusec R. Departments of Hematology, Divison of molecular diagnostics <strong>and</strong> genetics<br />
<strong>and</strong> Cytology, Universtiy hospital Dubrava <strong>and</strong> Zagreb School of Medicine, Division of molecular<br />
medicine, Institute Rudjer Boskovic, Zagreb, Croatia.<br />
14.40 – 14.50 NPM1 mutation A <strong>and</strong> FLT3/ITD in AML with myelodysplasia-related changes (PP05)<br />
Radic Antolic M1 , Ries S2 , Zadro R1 , Davidovic S3 , Labar B4 . 1Department of Clinical Laboratory,<br />
2 3 4 Department of Pathology, Deaprtment of Pediatric, Department of Medicine, Clinical Hospital Center<br />
<strong>and</strong> School of Medicine, University of Zagreb, Croatia<br />
14.50 – 15.00 Prognostic Significance of CD56 Antigen Expression in Patients with Acute Myeloid<br />
Leukemia (PP06)<br />
Djunic I, Virijevic M, Djurasinovic V, Novkovic A, Colovic N, Kraguljac-Kurtovic N, Vidovic A,<br />
Suvajdzic-Vukovic N, Tomin D. Clinic of hematology, Clinical Center Serbia, Belgrade, Serbia<br />
15.00 – 15.10 FLT3 internal t<strong>and</strong>em duplication is a poor risk factor in patients with AML with diverse<br />
cytogenetic features (PP07)<br />
Mikulic M1 , Zadro R2 , Davidovic S3 , Serventi Seiwerth R1 , Sertic D1 , Nemet D1 , Batinic J1 , Batinic D2 ,<br />
Gjadrov K4 , Ries S4 , Labar B1 . 1Division of Hematology, 1Department of Medicine, 2Department of<br />
Clinical Laboratory, 3Department of Pediatric, 4Department of Pathology, Clinical Hospital Center<br />
<strong>and</strong> School of Medicine, University of Zagreb, Croatia<br />
Poster presentation: Session 2. Ph+ Chronic Myeloid Leukemia<br />
Chair: Martin Mistrik (Slovakia)<br />
14.00 – 14.10 A Philadelphia-negative Chronic Myeloid Leukemia with a BCR/ABL Fusion Gene (PP08)<br />
Lasan Trcic R 1 , Kardum I 2 , Jaksic B 2 , Jaksic O 3 , Kusec R 3 , Pejsa V 3 , Zadro R 4 , Batinic D 4 , Labar B 5 ,<br />
Begovic D 1 . 1 Division of Medical Genetics, Department of Paediatrics Univesity Hospital Center<br />
Zagreb, Zagreb, Croatia. 2 Division of Hematology, Department of Internal Medicine, Clinical Hospital<br />
Merkur, Zagreb, Croatia. 3 Division of Hematology Departmrnt of Internal Medicine, Clinical Hospital<br />
Dubrava, Zagreb, Croatia. 4 Clinical Laboratory Diagnostics, University Hospital Center Zagreb,<br />
Zagreb, Croatia 5 Division of Hematology, Department of Internal Medicine Univesity Hospital Center<br />
Zagreb, Zagreb, Croatia<br />
ix
Scientific Program Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
14.10 – 14.20 Croatian CML Registry based on European LeukemiaNet CML Registry (PP09)<br />
Sertic D1 , Peric Z1 , Sincic-Petricevic J2 , Lozic D3 , M<strong>and</strong>ac-Rogulj I4 , Duletic-Nacinovic A5 ,<br />
Gveric-Krecak V6 , Corovic-Arneri E7 , Pejsa V8 , Suvic-Krizanic V9 , Skunca Z10 , Babok-Flegaric R11 ,<br />
Krmek-Zupanic D12 , Carzavec D13 , Lazic-Prodan V14 , Coha B15 , Ajdukovic R8 , Romic I7 , Zadro R1 ,<br />
Davidovic S1 , Lasan-Trcic R1 , Labar B1 . Croatian Cooperative Group for Hematologic Diseases-CML<br />
Group: 1University Hospital Center Zagreb, 2University Hospital Center Osijek, 3University Hospital<br />
Center Split, 4Clinical Hospital Merkur Zagreb, 5University Hospital Center Rijeka, 6General Hospital<br />
[ibenik, 7General Hospital Dubrovnik, 8Clinical Hospital Dubrava-Zagreb, 9General Hospital Sisak,<br />
10 11 12 13 General Hospital Zadar, General Hospital Vara`din, General Hospital Sv.Duh-Zagreb, Clinical<br />
Hospital Center Sestre milosrdnice-Zagreb, 14General Hospital Pula, 15General Hospital Slavonski Brod<br />
14.20 – 14.30 Use of Imatinib mesylate in Chronic Phase CML in Clinical Practice – Our Experience (PP10)<br />
Miljkovic E, Markovic D, Cojbasic I, Nikolic V, Marjanovic G, Govedarovic N,<br />
Macukanovic-Golubovic L, Vucic M, Pavlovic M, Vukicevic T, Tijanic I, Simonovic O. Clinic of<br />
hematology, Clinical Center Nis, Serbia<br />
14.30 – 14.40 Imatinib for CML as a frontline therapy – Zagreb Experience (PP11)<br />
Sertic D1 , Zadro R2 , Nemet D1 , Davidovic S3 , Lasan-Trcis R3 , Radic Antolic M2 , Horvat I2 ,<br />
Frani} Simic I3 , Roncevic P1 , Radman I1 , Basic-Kinda S1 , Aurer I1 , Labar B1. 1Division of Hematolofy<br />
Department of Medicine, 2Department of Clinical Laboratory, 3Department of Pediatric, Clinical<br />
Hospitral Center <strong>and</strong> School od Medicine, University of Zagreb, Croatia<br />
14.40 – 14.50 Frequency of 4 bcr-abl1 kinase domain mutations in chronic myeloid leukemia patients resistant<br />
to imatinib mesylate therapy (PP12)<br />
Horvat I1 , Radic Antolic M1, Zadro R1 , Sertic D2 , Labar B2 . 1Department of Clinical Laboratory,<br />
2Department of Medicine, Clinical Hospital Center <strong>and</strong> School of Medicine, University of Zagreb,<br />
Croatia<br />
14.50 – 15.00 Imatinib mesylate in Patients with CML Relapse after Allogeneic Transplantation (PP13)<br />
Serventi Seiwerth R1 , Sertic D1 , Radic Antolic M2 , Mrsic M1 , Zadro R2 , Davidovic S3 , Grubic Z2 ,<br />
Mikulic M1 , Labar B1 . 1Department of Medicine, 2Department of Clinical Laboratory, 3Department of<br />
Pediatric, Clinical Hospital Center <strong>and</strong> School of Medicine, University of Zagreb, Croatia<br />
Poster presentation: Session 3. Stem Cell Transplantation I.<br />
Chair: Alois Gratwohl (Switzerl<strong>and</strong>)<br />
14.00 – 14.10 Long-term survival <strong>and</strong> late-onset complications after reduced-intensity conditioning (RIC)<br />
allogeneic stem cell transplantation (allo-SCT) (PP14)<br />
Peric Z, Clavert A, Chevallier P, Brissot E, Malard F, Guillaume T, Delaunay J, Ayari S, Dubruille V,<br />
Le Gouill S, Mahe B, Gastinne T, Blin N, Harousseau JL, Moreau P, Milpied N, Mohty M. Service<br />
d’Hématologie Clinique, Centre Hospitalier et Universitaire (CHU) de Nantes, Nantes, France<br />
14.10 – 14.20 Factors predicting overall survival in patients with advanced chronic graft versus host disease<br />
diagnosed by NIH consensus criteria (PP15)<br />
Grkovic L1,2 , Steinberg SM1 , Baird K1 , Williams KM1 , Cowen EW1 , Mitchell SA1 , Pulanic D1,2 ,<br />
Avila DN1 , Taylor TN1 , Wroblewski SG1 , Serventi-Seiwerth R1,2 , Gress RE1 , Pavletic SZ1 . 1National Cancer Institute, National Institutes of Health, Bethesda, USA, 2Department of Medicine, Clinical<br />
Hospital Center Zagreb, Croatia<br />
14.20 – 14.30 Secondary Systemic Immunosuppressants (SSI) after Myeloablative HLA Matched Related<br />
<strong>and</strong> Unrelated Bone Marrow Transplantation (BMT) using High Dose Cyclophosphamide (Hi Cy)<br />
as sole GVHD prophylaxis (PP16)<br />
Durakovic N1 , Bolaños Meade J1 , Zahurak M2 , Kowalski J2 , Fuchs EJ1 , Jones RJ1 , Luznik L1 . 1Oncology, Johns Hopkins University, Baltimore, Maryl<strong>and</strong>, United States <strong>and</strong> 2Oncology Biostatistics, Johns<br />
Hopkins University, Baltimore, Maryl<strong>and</strong>, United States<br />
14.30 – 14.40 Allogeneic transplantation from HLA matched unrelated donor – single Center experience (PP17)<br />
Serventi Seiwerth R1 , Mikulic M1 , Mrsic M1 , Grubic Z2 , Bojanic I3 , Durakovic N1 , Stingl K2 , Labar B1 .<br />
1 2 3 Division of Hematology, Department of Medicine, Department of Clinical Laboratory, Department of<br />
Transfusiology, Clinical Hospital Center <strong>and</strong> School of Medicine, University of Zagreb, Croatia<br />
14.40 – 14.50 Extracorporeal Photochemotherapy in Treatment of Chronic Graft-versus-Host Disease (PP18)<br />
Bojanic I1 , Serventi Seiwerth R2 , Golubic Cepulic B1 , Mazic S1 , Lukic M1 , Raos M1 , Plenkovic F1 ,<br />
Golemovic M1 , Dubravcic K3 , Perkovic S3 , Batinic D3 , Labar B2 . 1Department of Transfusiology,<br />
2 3 Division of Hematology, Department of Medicine, Department of Clinical Laboratory, Clinical<br />
Hospital Center <strong>and</strong> School of Medicine University of Zagreb, Croatia.<br />
x
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Scientific Program<br />
14.50 – 15.00 Wernicke’s encephalopathy in an adolescent after allogeneic hematopoietic stem cell<br />
transplantation: a case report (PP19)<br />
Rajic Lj1 , Pavlovic M1 , Femenic R1 , Bilic E1 , Krnic N1 , Barisic N1 , Ozretic D1 , Tesovic G4 , Dusek D4 ,<br />
Zadro R2 , Serventi Seiwerth R3 , Mikulic M3 , Konja J1 , Labar B3 . 1Department of Pediatric, 2Department of Clinical Laboratory, 3Department of Medicine, Clinical Hospital Center Zagreb, 4Clinical Hospital<br />
for Infectious Diseases, 1,2,3,4School of Medicine University of Zagreb, Croatia<br />
15.00 – 15.10 Need + Information + Satisfaction (PP20)<br />
Vieira S, Monroe D, Librojo M, London, United Kingdom<br />
Poster presentation: Session 4. Lymphoma<br />
Chair: Vlatko Pejsa (Croatia)<br />
14.00 – 14.10 CD43 expression is associated with inferior survival within activated B-cell group of diffuse large<br />
B-cell lymphoma (PP21)<br />
Mitrovic Z1,4 , Iqbal J1 , Fu K1 , Smith LM2 , Weisenburger DD1 , Greiner T1 , Auon P1 , Bast M3 , Armitage<br />
JO3 , Vose JM3 , Chan WC1 . Departments of 1Pathology/Microbiology <strong>and</strong> 3Hematology/Oncology, 2 4 College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA, School of<br />
Medicine University of Zagreb, Croatia<br />
14.10 – 14.20 Association of Interleukin-10,TNF-Alpha <strong>and</strong> TGF-Beta Gene Polymorphisms on The Outcome<br />
of Diffuse Large B-cell Lymphoma (PP22)<br />
Tarabar O, Tukic Lj, Cikota B, Milanovic N, Aleksic A, Magic Z. Military Medical Academy, Belgrade,<br />
Serbia<br />
14.20 – 14.30 Dose Adjusted EPOCH – Rituximab as First Line Treatment for High Risk Diffuse Large B-Cell<br />
Lymphoma: A Single Center Experience (PP23)<br />
Pejsa V, Prka Z, Lucijanic M, Jaksic O, Pirsic M, Ajdukovic R, Kusec R. Division of Hematolofy,<br />
Department of Medicine, Universiti Hospital Dubrava <strong>and</strong> School of Medicine, University of Zagreb,<br />
Croatia<br />
14.30 – 14.40 Immunoblastic Morphology as a Possible Prognostic Indicator for the Outcome of the Patients<br />
with Diffuse Large B cell Lymphoma in Era of the Rituximab Based Treatment: Single Centre<br />
Experience (PP24)<br />
Trajkova S, Panovska-Stavridis I, Stojanovik A, Petrusevska G, Dukovski D, Cevreska L. Department of<br />
Hematology, Medical Faculty, Skopje, Republic of Macedonia<br />
14.40 – 14.50 Primary Mediastinal Large B-Cell Lymphoma – Results of our Center (PP25)<br />
Miljkovic E, Marjanovic G, Cojbasic I, Tijanic I, Markovic D, Nikolic V, Macukanovic-Golubovic L,<br />
Govedarovic N, Vucic M. Clinic of hematology, Clinical Center Nis, Serbia<br />
14.50 – 15.00 Dose-Intense BACOP for Treatment of High-Risk Peripheral T-Cell NHL (PP26)<br />
Aurer I, Dujmovic D, Basic-Kinda S, Nemet D, Radman I, Ilic I, Stern-Padovan R, Santek F, Sertic D,<br />
Cigrovski N, Labar B. Departments of Internal Medicine, Pathology, Radiology <strong>and</strong> Oncology,<br />
University Hospital Center Zagreb, Zagreb, Croatia<br />
15.00 – 15.10 Oral lomustine, chlorambucil, etoposide <strong>and</strong> prednisolone (CCEP) for treatment of patients<br />
with advanced lymphoma (PP27)<br />
Radman I, Vodanovic M, Mitrovic Z, Aurer I, Basic-Kinda S, Labar B. Division of Hematology,<br />
Department of Medicine, Clinical Hospital Center <strong>and</strong> School of Medicine, University of Zagreb,<br />
Croatia<br />
Poster presentation Session 5. Myeloproliferative neoplasm <strong>and</strong> miscelaneous<br />
Chair: Rajko Kusec (Croatia)<br />
14.00 – 14.10 Efficacy <strong>and</strong> Safety of Ruxolitinib, a JAK1 <strong>and</strong> JAK2 Inhibitor, in Patients With Myelofibrosis:<br />
Results From a R<strong>and</strong>omized, Double-Blind, Placebo-Controlled, Phase III Trial (COMFORT-I)<br />
(PP28)<br />
Verstovsek S 1 , Mesa R 2 , Gotlib J 3 , Levy R 4 , Gupta V 5 , DiPersio J 6 , Catalano J 7 , Deininger M 8 , Miller C 9 ,<br />
Silver R 10 , Talpaz M 11 , Winton E 12 , Harvey J 13 , Arcasoy M 14 , Hexner E 15 , Lyons R 16 , Paquette R 17 ,<br />
Raza A 18 , Vaddi K 4 , Erickson-Viitanen S 4 , Koumenis I 4 , Sun W 4 , S<strong>and</strong>or V 4 , Kantarjian H 1 . 1 The<br />
University of Texas MD Anderson Cancer Center, Houston, TX, USA; 2 Mayo Clinic, Scottsdale, AZ,<br />
USA; 3 Stanford Cancer Center, Stanford, CA, USA; 4 Incyte Corporation, Wilmington, DE, USA;<br />
5 Princess Marg<strong>are</strong>t Hospital, Toronto, Canada; 6 Washington University School of Medicine, St. Louis,<br />
MO, USA; 7 Frankston Hospital, Frankston, Australia; 8 University of Utah Huntsman Cancer Institute,<br />
Salt Lake City, UT, USA; 9 Saint Agnes Cancer Institute, Baltimore, MD, USA; 10 Weill Cornell Medical<br />
xi
Scientific Program Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
College, New York, NY, USA; 11 University of Michigan, Ann Arbor, MI, USA; 12 Emory University School<br />
of Medicine, Atlanta, GA, USA; 13 Birmingham Hematology & Oncology, Birmingham, AL, USA; 14 Duke<br />
University Health System, Durham, NC, USA; 15 University of Pennsylvania Health System, Philadelphia,<br />
PA, USA; 16 Cancer C<strong>are</strong> Center of South Texas, San Antonio, TX, USA; 17 UCLA Medical Hematology &<br />
Oncology, Los Angeles, CA, USA; 18 Columbia Presbyterian Medical Center, New York, NY, USA.<br />
14.10 – 14.20 Prevalence of the JAK2 V617F Mutation in Croatian Patients with Classic Ph-Negative<br />
Myeloproliferative neoplasm (PP29)<br />
Duletic Nacinovic A, Dekanic A, Hadzisejdic I, Seili I, Grahovac B, Grohovac D, Valkovic T, Host I,<br />
Petranovic D, Jonjic N. Department of Medicine <strong>and</strong> Deppartment of Pathology, Clinical Hospital<br />
Center <strong>and</strong> School of Medicine, University of Rijeka, Croatia<br />
14.20 – 14.30 Frequency <strong>and</strong> Clinical Correlates of JAK2 46/1 Haplotype in Essential Thrombocythemia:<br />
Single Center Experience (PP30)<br />
Panovska-Stavridis I, Matevska N, Ivanovski M, Trajkova S, Dukovski D, Pivkova-Veljanovska A,<br />
Cevreska L, Dimovski A. Department of Hematology, Medical Faculty, Skopje, Republic of Macedonia<br />
14.30 – 14.40 Myeloid sarcoma – diagnostic <strong>and</strong> therapeutic pitfals (PP31)<br />
Antic D, Elezovic I, Perunicic Jovanovic M, Suvajdzic N, Djunic I, Mitrovic M, Tomin D.<br />
Clinic of hematology, Clinical Center Serbia, Belgrade, Serbia<br />
14.40 – 14.50 The Risk of Hematopoetic Malignancy in Children Born after in vitro Fertilization (PP32)<br />
Bilic E, Stemberger L, Slipac J, Stojsavljevic S, Bilic E, Konjevoda P, Konja J, Femenic R, Rajic Lj.<br />
Department of Pediatrics <strong>and</strong> Departmen of Neurology, Clinical Hospital Center <strong>and</strong> School of<br />
Medicine, University of Zagreb, Croatia<br />
14.50 – 15.00 H1N1 Influenza pneumonia in patient with chronic lymphocytic leukemia – case report (PP33)<br />
Vince A 1 , Barsic B 1 , Dusek D 1 , Vrhovac R 2 , Kutlesa M 1 , Santini M 1 . 1 University Hospital for Infectious<br />
Diseases »Dr. Fran Mihaljevic«, Zagreb, Croatia, 2 Department of Medicine, Division of Hematology.<br />
University Hospital »Merkur« Zagreb Croatia.<br />
15.00 – 15.10 Treatment of paroxismal nocturnal hemoglobinuria – a case report (PP34)<br />
Boban A 1 , Serventi Seiwerth R 1 , Basic-Kinda S 1 , Peric Z 1 , Dubravcic K 2 , Batinic D 2 , Labar B 1 . 1 Division<br />
of Hematology, Department of Medicine, 2 Department of Clinical Laboratory, Clinical Hospital Center<br />
<strong>and</strong> School of Medicine, University of Zagreb, Croatia<br />
15.30 – 17.15 SYMPOSIUM MDS<br />
Chair: David Steensma (USA), Pierre Wijermans (The Netherl<strong>and</strong>s)<br />
15.30 – 15.45 Ross Levine (USA)<br />
Molecular pathogenesis of myelodysplastic syndromes (OP14)<br />
15.45 – 16.00 David Steensma (USA)<br />
Risk models in MDS (OP15)<br />
16.00 – 16.15 Luca Malcovati (Italy)<br />
Transfusion iron overload <strong>and</strong> iron chelation therapy in MDS (OP16)<br />
16.15 – 16.30 Pierre Wijermans (The Netherl<strong>and</strong>s)<br />
Progress with epigenetic therapy in MDS (OP17)<br />
16.30 – 16.45 Theo de Witte (The Netherl<strong>and</strong>s)<br />
Hematopoietic cell transplantation for MDS: New Developments (OP18)<br />
16.45 – 17.00 Hagop Kantarjian (USA)<br />
Novel Agents in MDS (OP19)<br />
17.00 – 17.15 Questions <strong>and</strong> Answers<br />
17.15 – 17.45 Coffee Break<br />
17.45 – 19.15 MEET THE PROFESSOR<br />
Martin Mistik (Slovakia)<br />
Chronic myeloid leukemia (MP01)<br />
Petro Petrides (Germany)<br />
Essential Thrombocythaemia (MP02)<br />
17.45 – 19.15 END OF THE DAY DEBATE<br />
Moderator: Theo de Witte (The Netherl<strong>and</strong>s)<br />
AML vs MDS – what is similar<br />
Participants: Luca Malcovati (Italy)<br />
David Steensma (USA)<br />
xii
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Scientific Program<br />
Monday 19.09. 2011.<br />
08.30 – 10.30 MYELOPROLIFERATIVE NEOPLASM<br />
Chair: Srdjan Verstovsek (USA), Lidija Cevreska (Macedonia)<br />
08.30 – 08.45 Richard Van Etten (USA)<br />
Pathophysiology of MPNs <strong>and</strong> role of JAK2 mutations (OP20)<br />
08.45 – 09.00 Srdjan Verstovsek (USA)<br />
JAK2 inhibitors (OP21)<br />
09.00 – 09.15 Petro E. Petrides (Germany)<br />
Individualized MPN management–long term experience with anagrelide (OP22)<br />
09.15 – 09.30 Richard Silver (USA)<br />
Interferon as therapy for PV (OP23)<br />
09.30 – 09.45 Nicolaus Kröger (Germany)<br />
Allogeneic Hematopoietic Stem Cell Transplantation for Myelofibrosis (OP24)<br />
09.45 – 10.00 Vesna Najfeld (USA)<br />
Jumping 1q Translocations <strong>are</strong> Clonal Markers of Myeloid Malignancies Associated<br />
with Transformation to AML. (OP25)<br />
10.00 – 10.30 Question <strong>and</strong> Answers<br />
10.30 – 11.00 Coffee Break<br />
11.00 – 13.00 SYMPOSIUM CML<br />
Chair: Dubravka Sertic (Croatia), Elias Jabbour (USA)<br />
11.00 – 11.15 Rudiger Hehlmann (Germany)<br />
Prognostic tools in CML (OP26)<br />
11.15 – 11.30 David Marin (United Kingdom)<br />
Imatinib, still the best first line therapy?(OP27)<br />
11.30 – 11.45 Elias Jabbour (USA)<br />
Second line TKI – when, which one? (OP28)<br />
11.45 – 12.00 Gianantonio Rosti (Italy)<br />
Second line TKI – the best first line therapy? (OP29)<br />
12.00 – 12.15 Elias Jabbour (USA)<br />
How to monitor CML therapy (OP30)<br />
12.15 – 12.30 Alois Gratwohl (Switzerl<strong>and</strong>)<br />
Stem cell transplants for chronic phase CML (OP31)<br />
12.30 – 13.00 Questions <strong>and</strong> Answers<br />
13.15 – 14.45 Lunch Satellite Symposium: The optimal management of CML<br />
Chair: Gianantonio Rosti (Italy) Boris Labar (Croatia)<br />
13.15 – 13.25 Gianantonio Rosti (Italy)<br />
Introduction<br />
13.25 – 13.45 Giuseppe Saglio (Italy)<br />
Nilotinib versus Imatinib for Newly Diagnosed CML patients: ENESTnd study results (SP07)<br />
13.45 – 14.05 Francis Giles (Irel<strong>and</strong>)<br />
Optimal 1st line treatment for CML (SP08)<br />
14.05 – 14.25 Martin M. Mueller (Germany)<br />
The importance of molecular monitoring in CML patients (SP09)<br />
14.25 – 14.45 Boris Labar (Croatia)<br />
Panel discussion <strong>and</strong> conclusion<br />
xiii
Scientific Program Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
15.00 – 16.15 Poster Session<br />
Poster presentation: Session 6. Multiple myeloma<br />
Chair: Joan Bladé (Spain)<br />
15.00 – 15.10 Anti-proliferative <strong>and</strong> pro-apoptotic action of the combined cytostatic/immunosuppressive<br />
treatment of myeloma cell lines in vitro (PP35)<br />
Zelic A1 , Ivcevic S1 , Kovacic N1 , Kusec R2 , Grcevi} D1 . 1Zagreb University School of Medicine;<br />
2Dubrava University Hospital; Zagreb, Croatia<br />
15.10 – 15.20 T<strong>and</strong>em Transplantation in Multiple Myeloma – Single Center Experience (PP36)<br />
Batinic J1 , Durakovic N1 , Sertic D1 , Bojanic I2 , Batinic D3 , Golubic-Cepulic B2 ,<br />
Mazic S2 , Radman Livaja I1 , Basic Kinda S1 , Aurer I1 , Labar B1 , Nemet1 . 1Division of Hematology, Department of Medicine, 2Department of Transfusiology, 3Department of Clinical<br />
Laboratory, Clinical Hospital Center <strong>and</strong> School of Medicine, University of Zagreb, Croatia<br />
15.20 – 15.30 The Role of Thalidomide as Maintenance Therapy in Multiple Myeloma (PP37)<br />
Bila J1,2 , Bodrozic J2 , Todorovic M1,2 , Sefer D2 , Kraguljac N2 , Antic D2 , Andjelic B2 , Elezovic I1,2 ,<br />
Tomin D1,2 , Gotic M1,2 , Mihaljevic B1,2 . 1Medical Faculty, University of Belgrade, 2Clinic of Hematology,<br />
CCS, Belgrade<br />
15.30 – 15.40 Modificated dosing of the VMP /Velcade + melphalan + prednisone/ regime in multiple myeloma<br />
/MM/ patients (PP38)<br />
Masarova K, Stefanikova Z, Mistrik M. Department of Hematology <strong>and</strong> Transfusiology, University<br />
Hospital, Bratislava, Slovakia<br />
15.40 – 15.50 Tevagrastim <strong>and</strong> Plerixafor as first line mobilizing regimen in patients with lymphoma<br />
<strong>and</strong> Multiple Myeloma (PP39)<br />
Andreola G, Babic A, Negri M, Drera M, Martinelli G, Laszlo D. Department of Haematology,<br />
European Institute of Oncology, Milan, Italy<br />
15.50 – 16.00 Does Prelixafor do the trick in mobilising Stem Cells? (PP40)<br />
Vieira S, Monroe D, Librojo M. London, United Kingdom<br />
Poster presentation: Session 7. Acute leukemia<br />
Chair: Dragica Tomin (Serbia)<br />
15.00 – 15.10 Multidrug Resistance: From Research to Clinics (PP41)<br />
Tauber Jakab K1 , Márki-Zay J1 , Kis E1 , Udvardy M2 , Borbényi Z3 , Dávid M4 , Krajcsi P1 . 1Solvo Biotechnology, Szeged, Hungary; 22nd Department of Internal Medicine, University of Debrecen-<br />
Medical <strong>and</strong> Health Science Center, Debrecen, Hungary; 32nd Department of Medicine <strong>and</strong> Cardiology,<br />
University of Szeged – Albert Szent-Györgyi Clinical Center, Szeged, Hungary; 41st Department of<br />
Internal Medicine, Pécs, Hungary<br />
15.10 – 15.20 P-glycoprotein activity <strong>and</strong> Flt3 internal t<strong>and</strong>em duplication in 39 patients with acute myeloid<br />
leukemia (PP42)<br />
Batinic D1 , Perkovic S1 , Zadro R1 , Labar B2 . 1Department of Clinical Laboratory, 2Division of Hematology, Clinical Hospital Center <strong>and</strong> School of Medicine, University of Zagreb, Croatia<br />
15.20 – 15.30 The pretreatment risk factors <strong>and</strong> importance of comorbidity index for overall survival,<br />
complete remission <strong>and</strong> early death in patients with acute myeloid leukemia (PP43)<br />
Djunic I, Virijevic M, Novkovic A, Djurasinovic V, Colovic N, Vidovic A, Suvajdzic-Vukovic N,<br />
Tomin D, Clinic of hematology, Clinical Center Serbia, Belgrade, Serbia<br />
15.30 – 15.40 Treatment of Adolescents with Acute Lymphoblastic Leukemia (PP44)<br />
Konja J, Rajic Lj, Bilic E, Femenic R, Anicic M. Department of Pediatric, Clinical Hospital Center<br />
<strong>and</strong> School of Medicine, University of Zagreb, Croatia<br />
15.40 – 15.50 FLAG-IDA as the Salvage Regime for Relapsed <strong>and</strong> Refractory Acute Leukemias (PP45)<br />
Virijevic M, Suvajdzic N, Djunic I, Novkovic A, Djurasinovic V, Colovic N, Vidovic A, Tomin D.<br />
Clinic for hematology, Clinical Center Serbia, Belgrade, Serbia<br />
15.50 – 16.00 Clinical outcome <strong>and</strong> prognosis related factor in acute promyelocytic leukemia patients treating<br />
with PETHEMA LPA 099 protocol (PP46)<br />
Mitrovic M, Suvajdzic N, Bogdanovic A, Novkovic A, Kraguljac N, Sretenovic A, Antic D, Djunic I,<br />
Vidovic A, Colovic N, Virijevic M, Djurasinovic V, Elezovic I, Tomin D. Clinic of hematology,<br />
Clinical Center Serbia, Belgrade, Serbia<br />
xiv
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Scientific Program<br />
16.00 – 16.10 Acute myeloid leukemia with t(8;21)(q22;q22); RUNX1-RUNX1T1 – case report (PP47)<br />
Radic Antolic M, Rajic Lj, Femenic R, Bilic E, Pavlovic M, Perkovic S, Lasan R,<br />
Markovic-Glamocak M, Zadro R. Department of Clinical Laboratory <strong>and</strong> Department of Pediatrics,<br />
Clinical Hospital Center <strong>and</strong> School of Medicine, University of Zagreb, Croatia<br />
Poster presentation: Session 8. Lymphoma<br />
Chair: Igor Aurer (Croatia)<br />
15.00 – 15.10 Successful treatment of B-cell prolymphocytic leukemia (B-PLL) with FCR-Lite protocol (PP48)<br />
Batar P, Telek B, Udvardy M. Department of Hematology, University of Debrecen Health Sciences<br />
Center, Debrecen, Hungary<br />
15.10 – 15.20 Combination of rituximab <strong>and</strong> high-dose chlorambucil in therapy of small lymphocyte lymphoma<br />
/ chronic lymphocytic leukemia (PP49)<br />
Aurer I, Hude I, Basic Kinda S, Dujmovi} D, Nemet D, Radman I, Ilic I, Stern-Padovan R, Santek F,<br />
Sertic D, Labar B. Departments of Internal Medicine, Pathology, Radiology <strong>and</strong> Oncology, University<br />
Hospital Center Zagreb, Zagreb, Croatia<br />
15.20 – 15.30 Atypical Blastoid Variant of Hairy Cell Leukemia: a Case Report (PP50)<br />
Hadji-Pecova L, Petrusevska G, Panovska I, Stojanovski Z, Stojanovic A. Department of Hematology,<br />
Medical Faculty, Skopje, Republic of Macedonia<br />
15.30 – 15.40 Intravascular T-cell lymphoma presented as a subcutaneous panniculitis-like lymphoma:<br />
A case report (PP51)<br />
Ilic I(1), Basic Kinda S (2), Bosnic D (2), Aurer I 2(2), Dotlic S (2), Gasparovic V (1).<br />
1 2 Department of Pathology, Department of Medicine, Clinical Hospital Center <strong>and</strong> School of Medicine,<br />
University of Zagreb, Croatia<br />
15.40 – 15.50 Primarily Localized non Hodgkin Lymphoma of Testes with Relapse Localized in Buccal Area<br />
– Case Report (PP52)<br />
Hotic-Laz<strong>are</strong>vic S, Kezic Lj, M<strong>and</strong>ic D, Stojcic B, Malinovic J, Mrdja J. Division of Hematology,<br />
Department of Internal Medicine, Clinical Center Banja Luka, Banja Luka, Bosnia <strong>and</strong> Herzegovina<br />
15.50 – 16.00 A 48 Year Old Woman with a R<strong>are</strong> Case of a Midline Destructive Disease Presenting<br />
as Having both Midline <strong>and</strong> Nonmidline Lesions – a Case Report (PP53)<br />
Fern<strong>and</strong>ez S, Lapus F, B<strong>are</strong>z MY. Davao Medical Center, Davao City, Philippines<br />
16.00 – 16.10 Successful mobilisation with Plerixafor – clinical report (PP54)<br />
Babic A. Istituto Europeo di Oncologie, Divisione di Ematologia, Milan, Italy<br />
Poster presentation: Session 9. Stem Cell Transplantation II.<br />
Chair: Mirta Mikulic (Croatia)<br />
15.00 – 15.10 Isolation <strong>and</strong> in vitro cell culture of mesenchymal stem cells from human umbilical cord<br />
blood (PP55)<br />
Mazic S (1), Golemovic M (1), Skific M (1), Bojanic I (1), Humar I (2), Golubic Cepulic B (1).<br />
1 2 Department of Transfusiology, Deaprtment of Clinical Laboratory, Cliniacal Hospital Center, Zagreb,<br />
Croatia<br />
15.10 – 15.20 Biological properties of human mesenchymal stem cells exp<strong>and</strong>ed in vitro in media supplemented<br />
with human platelet lysate (PP56)<br />
Skific M (1), Golemovic M (1), Mazic S (1), Bojanic I (1), Humar I (2), Davidovic S (3),<br />
Crkvenac Gornik K (3), Ilic I (4), Durakovic N (5), Mikulic M (5), Serventi-Seiwerth R (5), Labar B (5),<br />
Golubic Cepulic B (1). 1Department of Transfusiology, 2Department of Clinical Laboratory, 3Department of Pediatric, 4Department of Pathology, 5Department of Medicine, Clinical Hospital Center <strong>and</strong> School of<br />
Medicine, Universiuty of Zagreb, Croatia<br />
15.20 – 15.30 Croatian Cord Blood Bank: the first 4 years (PP57)<br />
Mazic S (1), Bojanic I (1), Zlopasa G (2), Mrsic M (3), Plenkovic F (1), Lukic M (1), Raos M (1),<br />
Gojceta K (1), Golemovic M (1), Skific M (1), Tomac G (1), Burnac IL (1), Novoselac J (1), Vidovic I<br />
(1), Biskup M (1), Labar B (3), Golubic Cepulic B (1). 1Department of Transfusiology, 2Department of<br />
Gynecology <strong>and</strong> Obstetrics, 3Department of Medicine, Clinical Hospital Center <strong>and</strong> School of Medicine,<br />
Universiuty of Zagreb, Croatia<br />
15.30 – 15.40 Italian nurses group in mobilisation <strong>and</strong> apheresis (GIIMA): ideation <strong>and</strong> activity (PP58)<br />
Babic A, Laszlo D, Galgano L, Marchi E, Orl<strong>and</strong>o L, Martinelli G. Istituto Europeo di Oncologia,<br />
Divisione di Ematologia, Milan, Italy<br />
xv
Scientific Program Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
15.40 – 15.50 Unrelated Donor Search Experience in the Croatian Hematopoietic Stem Cell Transplantation<br />
Program (PP59)<br />
Grubic Z1 , Stingl K1 , Serventi Seiwerth R2 , Labar B2 , Zunec R1 . 1Tissue Typing Centre, 2Department of<br />
hematology, Clinical Hospital Centre Zagreb, Croatia<br />
15.50 – 16.00 Following the Chimerism Status of Patients after Hematopoietic Stem Cell Transplantation<br />
– Ten Years Experience (PP60)<br />
Stingl K1 , Grubic Z1 , Serventi Seiwerth R2 , Labar B2 , Rajic Lj3 , Vrhovac R4 , Zunec R1 . 1Tissue Typing<br />
Centre, 2Department of Medicine, 3Clinic of pediatrics, Clinical Hospital Centre, 4Department of<br />
Medicine, Clinical Hospital Merkur, Zagreb, Croatia<br />
Poster presentation: Session 10. Miscalenous<br />
Chair: Ivo Radman (Croatia)<br />
15.00 – 15.10 Venous access for Apheresis <strong>and</strong> Photopheresis procedures (PP61)<br />
Babic A. Istituto Europeo di Oncologia, Divisione di Ematologia, Milan, Italy<br />
15.10 – 15.20 Pure red cell aplasia preceding a DLBCL with 6 years (PP62)<br />
Barca G, Marin S, Nada S, Dragan C, Barbu D, Angelescu S, Tevet M, Saguna C, Bizu I, Lupu AR.<br />
Coltea Clinical Hospital, Hematology Clinic, Buch<strong>are</strong>st, Romania<br />
15.20 – 15.30 Can Platelet be Unnecessary (PP63)<br />
Vieira S, Monroe D, Librojo M, London, United Kingdom<br />
15.30 – 15.40 Transfuse or Not to Transfuse? (PP64)<br />
Vieira S, Monroe D, Librojo M, London, United Kingdom<br />
16.15 – 17.30 SYMPOSIUM MULTIPLE MYELOMA <strong>AND</strong> RELATED DISORDERS<br />
Chair: Bart Barlogie (USA), Damir Nemet (Croatia),<br />
16.15 – 16.30 Christoph J. Heuck (USA)<br />
Pathophysiology of Myeloma (OP32)<br />
16.30 – 16.45 Joan Blade (Spain)<br />
Bortezomib in the Treatment of Multiple Myeloma (OP33)<br />
16.45 – 17.00 Robert P. Gale (USA)<br />
IMIDs in Myeloma (OP34)<br />
17.00 – 17.15 Bart Barlogie (USA)<br />
Curing Multiple myeloma – the facts behind the claim (OP 35)<br />
17.15 – 17.30 Questions <strong>and</strong> Answers<br />
17.45 – 19.15 End of the Day Debate<br />
Moderator: Damir Nemet (Croatia)<br />
SCT in Myeloma – for all young patients?<br />
Participants: Bart Barlogie (USA)<br />
Joan Blade (Spain)<br />
Tuesday 20. 09. 2011.<br />
07.00 – 08.15 Satellite Symposium: Optimal management of PNH<br />
Chair: Peter Hillmen (United Kingdom) Boris Labar (Croatia)<br />
07.00 – 07.15 Boris Labar (Croatia)<br />
PNH – Morbidities & Mortality (SP10)<br />
07.15 – 07.40 Peter Hillmen (United Kingdom)<br />
Shifting the Paradigm in PNH Management (SP11)<br />
07.40 – 07.50 Jaroslav Cermak<br />
Acute renal failure <strong>and</strong> PNH – Case report (SP12)<br />
07.50 – 08.00 Ana Boban (Croatia)<br />
Treatment of Paroxismal nocturnal hemoglobinuria – a case report (SP13)<br />
08.00 – 08.15 Q & A <strong>and</strong> Summary<br />
xvi
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Scientific Program<br />
08.30 – 10.30 SYMPOSIUM ALL<br />
Chair: Jean Pierre Marie (France), Susan O’Brien (USA)<br />
08.30 – 08.45 Dieter Hoelzer (Germany)<br />
Adult ALL treatment approach for B-ALL (OP36)<br />
08.45 – 09.00 Stefan Faderl (USA)<br />
T-ALL current treatment (OP37, SA01)<br />
09.00 – 09.15 Jean Pierre Marie (France)<br />
Young adult with ALL – how to treat (OP38)<br />
09.15 – 09.30 Oliver Ottman (Germany)<br />
Ph+ALL – Current treatment options (OP39)<br />
09.30 – 09.45 Deborah Thomas (USA)<br />
MRD – criteria for postremission therapy (OP40)<br />
09.45 – 10.00 Mohamad Mohty (France)<br />
SCT for ALL: st<strong>and</strong>ard vs mini-allo (OP41)<br />
10.00 – 10.15 Sebastian Giebel (Pol<strong>and</strong>)<br />
Autologous SCT for ALL – stil the chalange (OP42)<br />
10.15 – 10.30 Susan O’Brien (USA)<br />
Novel drugs for ALL (OP43, SA01)<br />
10.30 – 11.00 Questions <strong>and</strong> Answers<br />
11.00 – 11.30 Coffee Break<br />
11.30 – 13.15 SYMPOSIUM CLL<br />
Chair: Aless<strong>and</strong>ra Ferrajoli (USA) Branimir Jaksic (Croatia)<br />
11.30 – 11.45 William Wierda (USA)<br />
Prognostic impact of Biologic factors in CLL (OP44)<br />
11.45 – 12.00 Susan O’Brien<br />
Frontline therapy for CLL (OP45)<br />
12.00 – 12.15 Aless<strong>and</strong>ra Ferrajoli (USA)<br />
Antibodies for CLL – alone or in combinations (OP46)<br />
12.15 – 12. 30 Peter Hillmen (United Kingdom)<br />
New <strong>and</strong> old drugs in CLL – we can do better (OP47)<br />
12.30 – 12.45 Issa Khouri (USA)<br />
SCT for CLL – when? (OP48)<br />
12.45 – 13.15 Questions <strong>and</strong> Answers<br />
13.30 – 15.00 Meet the Professor<br />
– Jiri Hollowiecki (Pol<strong>and</strong>) Acute myeloid leukemia (MP03)<br />
– Boris Labar (Croatia) Stem cell transplantation (MP04)<br />
– Deborah Thomas (USA) Acute lymphoblastic leukemia (MP05)<br />
– Petra Muus (The Netherl<strong>and</strong>s) Myelodysplastic syndrome (MP06)<br />
– Branimir Jaksic (Croatia) Chronic lymphocytic leukemia (MP07)<br />
– Srdjan Verstovsek (USA) Myelofibrosis (MP08)<br />
– Igor Aurer (Croatia) Non-Hodgkin Lymphoma (MP09)<br />
– Damir Nemet (Croatia) Multiple Myeloma (MP10)<br />
13.30 – 15.00 Lunch with Experts (1 expert on 10 registered particip.)<br />
Hagop Kantarijan (USA) Acute Myeloid Leukemia<br />
Dieter Hoelzer (Germany) Acute lymphoblastic Leukemia<br />
David Steensma (USA) Myelodysplastic Syndrome<br />
Rudiger Hehlmann (Germany) Chronic myeloid leukemia<br />
Peter Hillmen (United Kingdom) Chronic lymphocytic leukemia<br />
Bart Barlogie (USA) Multiple myeloma<br />
Patrice Carde (France) Hodgkin lymphoma<br />
xvii
Scientific Program Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
15.15 – 18.45 SYMPOSIUM STEM CELL TRANSPLANTATION<br />
Moderator: Boris Labar (Croatia)<br />
15.15 – 15.30 Introduction<br />
15.30 – 15.45 Alois Gratwohl (Switzerl<strong>and</strong>)<br />
Prognostic score for SCT (OP49)<br />
15.45 – 16.00 Mary Horowitz (USA)<br />
Consideration in choosing the optimal stem cell source (OP50)<br />
16.00 – 16.15 Mohamad Mohty (France)<br />
Source of stem cells in the allogeneic transplant setting: bone marrow versus peripheral blood stem<br />
cells (OP51)<br />
16.15 – 16.45 Dietger Niederwieser (Germany), John Barrett (USA)<br />
Conditioning for SCT – the impact of disease?! (OP52) (OP53)<br />
16.45 – 17.15 Coffee break<br />
17.15 – 18.15 Complications – anything new in prevention/treatment<br />
17.15 – 17.30 Finn Bo Petersen (USA)<br />
Infectious Complications of Stem Cell Transplantation (OP54)<br />
17.30 – 17.45 Leo Luznik (USA)<br />
Old drug, new tricks in prevention of graft-versus-host disease (GVHD): Development <strong>and</strong> clinical<br />
applicability of high-dose cyclophosphamide (OP55)<br />
17.45 – 18.00 Steven Z. Pavletic (USA)<br />
Chronic Graft-versus-Host Disease – Anything New in Prevention <strong>and</strong> Treatment? (OP56)<br />
18.00 – 18.15 Michael Bishop (USA)<br />
Relapse after Allogeneic Hematopoietic Stem Cell Transplantation – The Necessity for New Strategies<br />
<strong>and</strong> Treatments (OP57)<br />
18.15 – 18.45 Round table Discussion <strong>and</strong> Conclusion:<br />
Perspective of SCT<br />
19.00 – 19.20 SPECIAL LECTURE:<br />
Chair: Roel Willemze (The Netherl<strong>and</strong>s)<br />
19.00 – 19.20 Stefan Suciu (Belgium)<br />
Design, conduct <strong>and</strong> analysis of clinical trials in acute leukemia: the keys of success (OP58)<br />
20.30 – 24.00 F<strong>are</strong>well Dinner<br />
Wednesday 21. 09. 2011.<br />
08.30 – 11.45 SYMPOSIUM NON-HODGKIN <strong>LYMPHOMA</strong><br />
Chair: Nathan H. Fowler (USA) Igor Aurer (Croatia)<br />
08.30 – 08.45 Nathan H. Fowler (USA)<br />
Front line therapy for indolent B-cell lymphoma (OP59)<br />
08.45 – 09.00 Ofer Sphilberg (Israel)<br />
Rituximab maintenance treatment in indolent lymphoma (OP60)<br />
09.00 – 09.15 M<strong>are</strong>k Trneny (Czech Republic)<br />
Risk adapted treatment for patients with B-DLBCL (OP61)<br />
09.15 – 09.30 Piere Luiggi Zinzani<br />
Therapy for peripheral T-cell lymphoma (OP62)<br />
09.30 – 09.45 Christian H. Geisler (Denmark)<br />
Therapy of Mantle cell Lymphoma (OP63)<br />
19.45 – 10.00 Piere Luiggi Zinzani (Italy)<br />
Is there a role of radioimmunotherapy in NHL (OP64)<br />
10.00 – 10.30 Coffee Break<br />
10.30 – 10.45 Anas Younes (USA)<br />
Therapy for relapsed/refractory aggressive NHL (OP65)<br />
xviii
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Scientific Program<br />
10.45 – 11.00 Luis Fayad (USA)<br />
Alternative monoclonal antibodies for the treatment of NHL (OP66)<br />
11.00 – 11.30 Questions <strong>and</strong> Answers<br />
12.00 – 14.30 Symposium/Central <strong>and</strong> <strong>East</strong>ern European Leukemia Group<br />
CELG-AML-1 Study<br />
Chair: Zita Borbenyi (Hungary), Agnieszka Wierzbowska (Pol<strong>and</strong>), Georgi Mihajlov (Bulgaria)<br />
12.00 – 12.15 Boris Labar (Croatia)<br />
Design <strong>and</strong> Objective of the CELG-AML-1 Study<br />
12.15 – 12.30 Dragica Tomin (Serbia)<br />
Cytomorphology for diagnosis of AML (CELG-AML-1 Study)<br />
12.30 – 12.45 Zita Borbenyi (Hungary)<br />
Immunophenotyping for diagnosis of AML (CELG-AML-1 Study)<br />
12.45 – 13.05 Agnieszka Wierzbowska (Pol<strong>and</strong>)<br />
Cytogenetic <strong>and</strong> Molecular diagnostic for diagnosis of AML (CELG-AML-1 Study)<br />
13.05 – 13.25 Georgi Mihajlov (Bulgaria)<br />
CELG-AML-1 Study – Induction therapy <strong>and</strong> Consolidation<br />
13.25 – 13.40 Lidija Cevreska (Macedonia), Irina Panovska (Macedonia)<br />
CELG-AML-1 Study – Autologous SCT<br />
13.40 – 13.55 Labar B. (Croatia)<br />
CELG-AML-1 Study – Allogeneic SCT<br />
13.55 – 14.10 Panel Discussion <strong>and</strong> Conclusion<br />
Plerixafor for Stem Cell Mobilization<br />
Chair: Ines Bojanic (Croatia)<br />
14.10 – 14.30 Grzegorz Wladyslaw Basak<br />
Novel aspects of stem cell mobilization with plerixafor <strong>and</strong> G-CSF based on CELG data<br />
15.00 – 17.15 SYMPOSIUM HODGKIN <strong>LYMPHOMA</strong><br />
Patrice Carde (France), S<strong>and</strong>ra Basic-Kinda (Croatia)<br />
15.00 – 15.15 Patrice Carde (France)<br />
Early favorable <strong>and</strong> unfavorable Hodgkin lymphoma in adults, st<strong>and</strong>ards <strong>and</strong> directions (OP67)<br />
15.15 – 15.30 Berthe Aleman (The Netherl<strong>and</strong>s)<br />
Radiation therapy for Hodgkin’s lymphoma (OP68)<br />
15.30 – 15.45 Bastian von Tresckow (Germany)<br />
Improving Outcome in High Risk Hodgkin’s lymphoma (OP69)<br />
15.45 – 16.00 Martin Hutchings (Denmark)<br />
What is the role of PET in Hodgkin’s lymphoma (OP70)<br />
16.00 – 16.15 Igor Aurer (Croatia)<br />
Treatment of Relapsed/Refractory Hodgkin’s lymphoma (OP71)<br />
16.15 – 16.30 Ana Sureda (Spain)<br />
Allogeneic SCT for Hodkin’s lymphoma (OP72)<br />
16.30 – 16.45 Anas Younes (USA)<br />
New Drugs in the treatment of Hodkin’s lymphoma (OP73)<br />
16.45 – 17.15 Questions <strong>and</strong> Answers<br />
17.15 – 17.30 Adjourn<br />
xix
<strong>LEUKEMIA</strong> <strong>AND</strong> <strong>LYMPHOMA</strong><br />
<strong>East</strong> <strong>and</strong> <strong>West</strong> <strong>are</strong> <strong>Together</strong>
State of the Art I.<br />
SA01 Acute Leukemias<br />
Elias Jabbour, Susan O’Brien, Stefan Faderl,<br />
Farhad Rav<strong>and</strong>i, Jorge Cortes, Hagop Kantarjian,<br />
Department of Leukemia, U.T. M.D. Anderson Cancer<br />
Center, Houston, TX, USA<br />
Abstract: Acute leukemias <strong>are</strong> clonal malignant hematopoietic<br />
disorders resulting from genetic alterations in normal<br />
hematopoietic stem cells. These alterations induce differentiation<br />
arrest <strong>and</strong>/or excessive proliferation of abnormal<br />
»leukemic« cells or »blasts«. Acute leukemias <strong>are</strong> classified<br />
as those of myeloid or lymphoid lineage. Over the<br />
past several decades, improvements in chemotherapeutic<br />
regimens have improved outcomes in both acute myeloid<br />
leukemia (AML) <strong>and</strong> acute lymphoblastic leukemia (ALL).<br />
Better underst<strong>and</strong>ing of the biology of both AML <strong>and</strong> ALL<br />
has resulted in the identification of new therapeutic targets.<br />
Despite current optimism, most patients with AML still die<br />
of their disease, <strong>and</strong> only about 30–40% of adults achieve<br />
long-term disease-free survival in ALL. With better molecular<br />
definition <strong>and</strong> elucidation of the physiopathology of<br />
AML <strong>and</strong> ALL subtypes, <strong>and</strong> development of new <strong>and</strong> targeted<br />
therapies, a better outcome for acute leukemias may<br />
be achievable in the future.<br />
Epidemiology <strong>and</strong> Etiology<br />
The incidence of acute myeloid leukemia (AML) is 2.7 per<br />
100,000 while acute lymphoblastic leukemia (ALL) occurs<br />
at a rate of approximately 1 to 1.5 per 100,000 persons1–4 The median age at presentation for AML is 65 years. Along<br />
with its precursor myelodysplasia, AML appears to be rising,<br />
particularly in the population over the age of 60 <strong>and</strong> represents<br />
the most common type of acute leukemia in adults. ALL<br />
exhibits a bimodal distribution, with an early peak in children<br />
4 to 5 years old (4 to 5 per 100,000 persons), followed<br />
by a second peak at approximately 50 years of age (2 per<br />
100,000 persons). 4 ALL represents the most common childhood<br />
acute leukemia representing about 80% of acute leukemias,<br />
while it comprises only 20% of adult leukemias. 4,5<br />
The incidence of AML is slightly higher in males <strong>and</strong> in<br />
populations of European descent. Acute promyelocytic leukemia<br />
(APL), a distinct subtype of AML, is more common<br />
among populations of Latino or Hispanic background. 6,7 An<br />
increased incidence of AML is seen in patients with disorders<br />
associated with excessive chromatin fragility such as<br />
Bloom’s syndrome, Fanconi’s anemia, Kostmann’s syndrome,<br />
<strong>and</strong> with Wiskott-Aldrich syndrome or ataxia-telangiectasia.<br />
Other syndromes like Down’s (trisomy of chromosome<br />
21), Klinefelter (XXY <strong>and</strong> variants) <strong>and</strong> Patau<br />
(trisomy of chromosome 13) have also been associated with<br />
a higher incidence of AML. 8–11<br />
Survivors of the atomic bombs in Japan had an increased<br />
incidence of myeloid leukemias that peaked 5 to 7 years<br />
following exposure. 8 Therapeutic radiation increases AML<br />
risk, particularly if given with alkylating agents. There <strong>are</strong><br />
two main types of therapy-related AML. The »classic« alkylating-agent<br />
type (e.g. cyclophosphamide, melphalan,<br />
nitrogen mustard) has a latency period of 4 to 8 years, <strong>and</strong> is<br />
often associated with abnormalities of chromosome 5 <strong>and</strong>/<br />
or 7. Exposure to agents that inhibit the DNA repair enzyme<br />
topoisomerase II (e.g. etoposide, teniposide) <strong>are</strong> associated<br />
with secondary AML with a shorter latency period, usually<br />
1 to 3 years, with chromosome 11q23 at the location of the<br />
MLL gene, <strong>and</strong> with an M4 or M5 morphology. 8,12,13 Drugs<br />
such as chloramphenicol, phenylbutazone, chloroquine, <strong>and</strong><br />
methoxypsoralen can induce marrow damage that may later<br />
evolve into AML. Benzene, smoking, dyes, herbicides <strong>and</strong><br />
pesticides have been implicated as potential risk factors for<br />
development of AML. 9,10<br />
AML may also be secondary to progression of a myelodysplastic<br />
process or of a chronic bone marrow »stem cell«<br />
disorder, such as polycythemia vera, chronic myelogenous<br />
leukemia, primary thrombocytosis, or paroxysmal nocturnal<br />
hemoglobinuria. 10–14<br />
The etiology of ALL remains unknown. Chromosomal<br />
translocations occurring in utero during fetal hematopoiesis<br />
have been suggested as the primary cause for pediatric ALL,<br />
while postnatal genetic events <strong>are</strong> suggested as secondary<br />
contributors. A higher incidence of ALL is noted among<br />
mono <strong>and</strong> di-zygotic twins of patients with ALL, reflecting<br />
possible genetic predisposition. 5 Patients with trisomy 21,<br />
Klinefelter’s syndrome <strong>and</strong> inherited diseases with excessive<br />
chromosomal fragility such as Fanconi’s anemia,<br />
Bloom’s syndrome, <strong>and</strong> ataxia-telangiectasia have a higher<br />
risk of developing ALL. Implications have also been made<br />
towards infectious etiologies. 15–17 Associations between human<br />
T-cell lymphotrophic virus type 1 <strong>and</strong> adult T-cell<br />
leukemia/lymphoma, as well as HIV <strong>and</strong> lymphoproliferative<br />
disorders have been established. In addition, associations<br />
with varicella <strong>and</strong> influenza viruses have also been<br />
suggested.<br />
Clinical Presentation<br />
Fatigue, bruising or bleeding, fever <strong>and</strong> infection, reflecting<br />
a state of bone marrow failure, <strong>are</strong> common in both<br />
AML <strong>and</strong> ALL. Only 10% of AML patients present with<br />
white blood cell (WBC) counts greater than 100 x 109 /L. 2,18<br />
These patients <strong>are</strong> at higher risk of tumor lysis syndrome<br />
<strong>and</strong> leukostasis, both of which <strong>are</strong> considered oncologic<br />
emergencies <strong>and</strong> require prompt recognition <strong>and</strong> management.<br />
Tumor lysis syndrome can be due to spontaneous or<br />
treatment-mediated cell destruction <strong>and</strong> is characterized by<br />
hyperuricemia, renal failure, acidosis, hypocalcemia <strong>and</strong><br />
3
State of the Art Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
hyperphosphatemia. 19 Manifestations of leukostasis include<br />
dyspnea, chest pain, headache, altered mental status, cranial<br />
nerve palsies, <strong>and</strong>/or priapism. In addition, physical findings<br />
in AML may include organomegaly, lymphadenopathy,<br />
sternal tenderness, <strong>and</strong> retinal hemorrhages. Monocytic<br />
variants, M4 or M5, commonly display infiltration of gingivae,<br />
skin, soft tissues or meninges. 3 Disseminated intravascular<br />
coagulopathy (DIC) with bleeding diathesis is a common<br />
presentation in APL<br />
Whereas symptoms related to hyperleukocytosis can occur<br />
in AML, they <strong>are</strong> r<strong>are</strong> in ALL, even in the presence of<br />
high white cell counts. »B-symptoms« such as fever, night<br />
sweats, or weight loss can occur in ALL. Central nervous<br />
system (CNS) involvement (cranial neuropathies, meningeal<br />
infiltration) at presentation, common in mature B-ALL<br />
(Burkitt leukemia) occurs in 5% to 8% of patients. 20 Abdominal<br />
masses <strong>and</strong> significant spontaneous tumor lysis<br />
syndrome <strong>are</strong> more likely with mature B ALL. Lymphadenopathy<br />
<strong>and</strong> hepatosplenomegaly, r<strong>are</strong>ly symptomatic, <strong>are</strong><br />
noted in 20% of the patients, with a higher incidence in T<br />
<strong>and</strong> mature B cell ALL. The combination of hypercalcemia<br />
<strong>and</strong> lytic bone lesions <strong>are</strong> suggestive of adult T cell leukemia/lymphoma<br />
(ATLL). Chin numbness (mental nerve involvement),<br />
when elicited in the history or exam, is suggestive<br />
or mature B-cell ALL (Burkitt’s).<br />
Diagnosis <strong>and</strong> Classification<br />
The diagnosis of leukemia is often demonstrated by increased<br />
number of blasts in the bone marrow, or peripheral<br />
blood. By the French-American-British (FAB) Cooperative<br />
Group criteria, acute leukemia is diagnosed when a<br />
200-cell differential reveals the presence of 30% or more<br />
blasts in a marrow aspirate. 21 The minimal criterion has<br />
recently been changed to 20% by the World Health Organization<br />
(WHO). 22 Patients with the cytogenetic abnormalities<br />
t(8;21)(q22;q22), inversion(16)(p13q22) or<br />
t(16;16)(p13;q22), <strong>and</strong> t(15;17)(q22;q12) should be considered<br />
to have AML regardless of the blast percentage. After<br />
establishing the diagnosis, the blasts lineage (myeloid,<br />
lymphoid, or undifferentiated) is determined. The distinction<br />
is important <strong>and</strong> dictates specific therapy. Lineage determination<br />
is made using cytochemical stains (Figure 1). If<br />
3% or more blasts stain positive for myeloperoxidase (MPO)<br />
or Sudan Black B, the diagnosis is AML. If the blasts <strong>are</strong><br />
peroxidase negative, but stain for butyrate or non-specific<br />
esterase, acute monocytic leukemia is diagnosed. 1 If not,<br />
lineage determination is based on the blasts expressing surface<br />
antigens associated with the myeloid (equivalently<br />
monocytic, erythroid, or megakaryocytic), or lymphoid immunophenotype.<br />
Myeloid antigens <strong>are</strong> CD13, CD33, c-kit,<br />
CD 14, CD64 (the latter 2 <strong>are</strong> monocytic markers), glycophorin<br />
A (an erythroid marker), <strong>and</strong> CD41 (a megakaryocytic<br />
marker). Lymphoid markers <strong>are</strong> CD10, CD19, CD20<br />
(pre-B or B cells) <strong>and</strong> CD2, CD3, CD4, CD5, <strong>and</strong> CD8<br />
(T-cells). 23,24 A minority of MPO negative <strong>and</strong> Sudan Black<br />
B-negative cases <strong>are</strong> AML, <strong>and</strong> may include minimally differentiated<br />
(M0), <strong>and</strong> megakaryocytic leukemias (M7) that<br />
require flow cytometry for characterization. 1,25,26<br />
If the blasts <strong>are</strong> peroxidase <strong>and</strong> butyrate negative <strong>and</strong> express<br />
none of the myeloid or lymphoid antigens noted<br />
4<br />
Figure 1. Acute leukemia diagnostic algorithm<br />
above, the diagnosis is acute undifferentiated leukemia,<br />
which is treated like AML. The initial marrow aspirate may<br />
be a »dry tap«, reflecting marrow fibrosis. In this case, a<br />
biopsy is needed to exclude acute megakaryocytic leukemia<br />
or hairy cell leukemia. 26,27 If the marrow contains >50% normoblasts<br />
<strong>and</strong> pronormoblasts, the blast percent is based<br />
only on the non-erythroid cells; in these cases, the diagnosis<br />
is typically acute erythroid leukemia (M6), which can be<br />
confirmed if glycophorin A expression on the surface of the<br />
blasts.<br />
The WHO classification incorporates molecular, cytogenetic,<br />
<strong>and</strong> clinical features (prior hematological disorder) to<br />
the morphologic characteristics to better recognize the diversity<br />
of the disease, <strong>and</strong> its response to therapy. For example,<br />
AML with multilineage dysplasia by the WHO classification<br />
has no exact counterpart in the FAB classification.<br />
Several chromosomal abnormalities <strong>and</strong> mutations have<br />
been identified: The t (8;21), t(16;16) <strong>and</strong> inv 16 mutations<br />
<strong>are</strong> associated with a better prognosis, while alterations of<br />
11q23, leading to the MLL rearrangement. (mixed-lineage<br />
leukemia) portends a worse outcome (Table 1). The mutation<br />
in FLT3 (tyrosine kinase receptor) is the most common<br />
mutation in AML <strong>and</strong> is associated with poor clinical outcome<br />
(Table 2). T(15;17) is always associated with acute<br />
promyelocytic leukemia (APL), <strong>and</strong> leads to a mutation in<br />
retinoic acid receptor implicated in hematopoeitic differentiation.<br />
The FAB Cooperative Group distinguishes three ALL<br />
groups (L1 to L3) based on morphologic criteria (cell size,<br />
cytoplasm, nucleoli, basophilia, vacuolation). 21 The morphologic<br />
distinction between L1 <strong>and</strong> L2 has lost its prognostic<br />
significance. L3 morphology is associated with mature<br />
B-cell ALL (Burkitt’s leukemia). The WHO proposed<br />
new guidelines for the diagnosis of Neoplastic Diseases of<br />
Hematopoietic <strong>and</strong> Lymphoid Tissues or Lymphomas. 28 In<br />
addition to lowering the blast count to ≥20% as sufficient<br />
for an ALL diagnosis, the morphologic distinction of L1,<br />
L2, <strong>and</strong> L3 morphologies is ab<strong>and</strong>oned as no longer relevant.<br />
Both FAB <strong>and</strong> WHO classification systems continue<br />
to rely heavily on morphological assessment. 29 Identification<br />
of the immunophenotype has become a major part of
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) State of the Art<br />
Karyotype % Frequency<br />
Table 1. AML cytogenetic risk group.<br />
% Complete<br />
Remission<br />
% Event-free<br />
Survival<br />
Favorable<br />
t(8;21) 5–10 90 60–70<br />
inv(16) 5–10 90 60–70<br />
t(15;17)<br />
Intermediate<br />
5–10 80–90 70<br />
Diploid, -Y<br />
Unfavorable<br />
40–50 70–80 30–40<br />
–5 / –7 20–30 50 5–10<br />
+8 10 60 10–20<br />
11q23, 20q- , other 10–20 60 10<br />
Table 2. Prognostic factors in AML.<br />
Relapse Rate Survival<br />
↑ BAACL NS ↓<br />
FLT3 ITD/mutation ↑ ↓<br />
MLL PTD ↑ NS<br />
↑ BCL2 <strong>and</strong> WT1 mRNA ↑ ↓<br />
↑ EVI1 mRNA ↑ ↓<br />
p53 mutation NS ↓<br />
CEBPA mutation ↓ ↑<br />
c-kit mutation ↑ ↓<br />
BAACL: Brain And Acute Leukemia Cytoplasmic; FLT3: Fms-like tyrosine<br />
kinase 3; MLL: Mixed lineage leukemia; BCL2: B-cell CLL lymphoma 2;<br />
WT1: Wilms tumor 1;<br />
EVI1: Ecotropic viral integration site 1; CEBPA: CCAAT/enhancer binding<br />
protein-alpha; NS: Not significant.<br />
Table 3. Immunophenotypic classification of ALL 30,33<br />
B Lineage T Lineage<br />
CD19/CD79a/CD22 CD3 (surface/cytoplasmic)<br />
Pre-pre-B ALL – Precursor T ALL CD1a, CD2, CD5,<br />
CD7, CD8, cCD3<br />
Common ALL CD10 (CALLA) Mature T ALL Surface CD3<br />
(plus any other<br />
T cell markers)<br />
Pre-B ALL Cytoplasmic IgM<br />
Mature B ALL Cytoplasmic or<br />
surface Igκ or λ<br />
ALL diagnosis (Table 3). 30–33 Three broad groups can be distinguished:<br />
precursor B-cell, mature B-cell, <strong>and</strong> T-cell ALL.<br />
Treatment (AML)<br />
Achievement of a complete remission (CR) significantly<br />
improves survival in AML, therefore the objective of therapy<br />
is to produce <strong>and</strong> maintain CR. 34 Criteria for CR include:<br />
platelet count ≥100 x 109 /l, neutrophil count ≥1 x<br />
109 /l, <strong>and</strong> ≤5% blasts present in the bone marrow. 35 The<br />
probability of AML recurrence sharply declines to less than<br />
10% after 3 years in CR, <strong>and</strong> patients in continuous CR for<br />
3 or more years can be considered »potentially cured«. 36 In<br />
recent years additional response criteria have been proposed,<br />
such as »CR with incomplete platelet recovery«<br />
(CRp), defined as CR with platelet count greater than 30 x<br />
109 /l, but less than 100 x 109 /l. 37<br />
Once AML is diagnosed <strong>and</strong> the decision to treat is made,<br />
the need for emergency therapy must be assessed. Emergency<br />
treatment is required in cases of APL, if the circulating<br />
blast count is > 50–100 x 10 9 /l, in the presence of DIC<br />
or organ dysfunction (especially pulmonary) attributed to<br />
leukemic infiltration (most seen in patients with > 10 x 10 9 /l<br />
circulating blasts <strong>and</strong>/or M4 or M5 FAB morphology). In<br />
the latter situation, it is important to initiate immediate chemotherapy.<br />
Leukapheresis for severe leukocytosis <strong>and</strong>/or<br />
leukostasis should be considered.<br />
Conventional treatment for AML, divided into remission<br />
induction <strong>and</strong> post-remission therapy, has been with combinations<br />
of anthracyclines <strong>and</strong> cytarabine. Traditionally, the<br />
anthracycline (i.e. idarubicin, daunorubicin) is usually administered<br />
daily for 3 days, <strong>and</strong> cytarabine is given at 100–<br />
200 mg/ m 2 daily for 7 days by continuous infusion (3+7<br />
regimen). In clinical practice, a bone marrow aspirate is<br />
usually obtained 2–3 weeks after beginning therapy. A biopsy<br />
is only needed if the quality of the aspirate does not<br />
permit determination of cellularity. If the marrow continues<br />
to show blasts <strong>and</strong> is cellular, a second course of the same<br />
therapy is often given, sometimes at a reduced total dose (2<br />
days anthracycline + 5 days cytarabine). If the day 14 or 21<br />
marrow is hypoplastic, therapy is usually delayed until it is<br />
clear that leukemia has reappe<strong>are</strong>d, at which time the second<br />
course begins. A second repeated course of therapy can<br />
produce remissions, but these <strong>are</strong> usually of shorter duration<br />
than remissions produced after one course of therapy, although<br />
this is controversial. 38 The timing of a second course<br />
with persistent AML is controversial. Several cooperative<br />
group studies advocated starting a second course if there is<br />
persistent AML on day 10–15 of chemotherapy. With highdose<br />
cytarabine (HDAC), a delay of a second course with<br />
persistent disease on day 21–28 may be indicated if the<br />
blasts <strong>are</strong> decreasing because most (90%) CRs <strong>are</strong> obtained<br />
after the first course, <strong>and</strong> response to a second course is<br />
poor. It is important to recognize that the initial marrow obtained<br />
after a period of hypoplasia may demonstrate up to<br />
30–50% blasts as a reflection of the regeneration of normal,<br />
not »leukemic,« marrow recovery. In this circumstance, follow-up<br />
(e.g. at 1–2 week intervals) marrows show reduction<br />
in blast percentages concomitant with a rise in neutrophils<br />
<strong>and</strong> platelets. Administration of a colony-stimulating factor<br />
may have an impact on the bone marrow findings.<br />
Three types of post-remission therapy can be distinguished.<br />
Maintenance therapy is usually defined as therapy<br />
less myelosuppressive than that used to produce remission.<br />
The doses used in consolidation therapy usually approach,<br />
whereas those in intensification therapy may surpass, the<br />
doses used during induction. Typically, once in remission<br />
after treatment with the »3 + 7« regimen, patients receive<br />
maintenance therapy, with the same drugs given during induction<br />
administered at approximately monthly intervals<br />
for 4–12 months. The need for a prolonged duration of<br />
maintenance therapy may depend on the intensity of induction<br />
<strong>and</strong> post-remission therapy. 39,40 For example, a r<strong>and</strong>omized<br />
German AML Cooperative Group (AMLCG) trial noted<br />
that addition of 3 years of maintenance improved the<br />
probability of 3-year relapse-free survival (RFS) from 7%<br />
to 30%. However, a similarly r<strong>and</strong>omized trial by the same<br />
5
State of the Art Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
group found no difference in RFS or survival when patients<br />
in the no maintenance arm received a more intensive induction<br />
treatment <strong>and</strong> one intense post-remission course .41–43<br />
Some maintenance therapy may be needed if intensive postremission<br />
therapy is not contemplated. However, any benefit<br />
from traditional maintenance after the administration of<br />
3–4 months of consolidation is relatively small, <strong>and</strong> perhaps<br />
nonexistent, with respect to survival. 44<br />
R<strong>and</strong>omized trials have attempted to identify which anthracycline<br />
(e.g. idarubicin [IDA], daunorubicin [DNR],<br />
mitoxantrone [MTZ], aclarubicin) is better. 45–47 Based on<br />
several such r<strong>and</strong>omized studies, IDA (12 mg/m 2 daily days<br />
1 through 3) has been proposed as the anthracycline of<br />
choice. 48 However, this may be misleading since the anthracyclines<br />
(IDA versus DNR) were not administered at equally<br />
toxic doses. 46 In several studies, st<strong>and</strong>ard-dose cytarabine<br />
plus MTZ 12 mg/m 2 daily x 3 has been comp<strong>are</strong>d with cytarabine<br />
plus DNR at 45 mg/m 2 daily x 3. Overall, the CR<br />
rates with the two regimens were similar, <strong>and</strong> there were no<br />
significant differences in the incidence or the severity of<br />
toxicities. In a three-arm r<strong>and</strong>omized study, there was no<br />
advantage when comparing DNR, IDA, <strong>and</strong> MTZ as part of<br />
the induction regimen for patients over 55 years of age. 49 In<br />
contrast, the three-arm r<strong>and</strong>omized trial, conducted by the<br />
EORTC <strong>and</strong> GIMEMA, comparing DNR to MTZ <strong>and</strong> IDA,<br />
reported that 5-year disease free survival (DFS) <strong>and</strong> overall<br />
survival (OS) were significantly better for patients receiving<br />
IDA <strong>and</strong> MTZ (p=0.03 <strong>and</strong> 0.02, respectively). Of note, the<br />
recovery time was longer with IDA <strong>and</strong> MTZ (p
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) State of the Art<br />
appear to be intrinsically more resistant to st<strong>and</strong>ard chemotherapy<br />
<strong>and</strong> the presence of comorbid conditions <strong>and</strong> decreased<br />
marrow reserve contribute to the poor outcomes.<br />
The approximate CR rate of 45% in patients over age 60 is<br />
considerably lower than younger patients. In addition, elderly<br />
patients experience shorter remissions, minimal longterm<br />
<strong>and</strong> overall survival, <strong>and</strong> considerable treatment related<br />
mortality. Factors contributing to worse outcome in elderly<br />
AML <strong>are</strong>: age > 75 years, unfavorable karyotype (mostly<br />
complex), poor performance status <strong>and</strong> organ dysfunction,<br />
<strong>and</strong> longer duration of AHD. Treatment should be individualized<br />
<strong>and</strong> may include st<strong>and</strong>ard intensive therapy for patients<br />
with none or at most one adverse factor, or low-intensity<br />
investigational therapies for those with multiple adverse<br />
factors. Targeted therapies, low dose cytarabine, nucleoside<br />
analogs, <strong>and</strong> palliative regimens may be considered as lowintensity<br />
options. Investigational treatment or palliative c<strong>are</strong><br />
options become more plausible in poorer-prognosis elderly<br />
AML.<br />
Relapsed/Refractory AML<br />
Recurrent AML is common with approximately 10–50%<br />
of newly-diagnosed patients not achieving CR (»primary<br />
refractory«). The most important predictive factor for outcome<br />
of therapy in relapsed/refractory AML (salvage therapy)<br />
is duration of first CR. 64 Salvage therapy produces CR<br />
rates of 40% to 60% in patients with duration of first CR of<br />
one year or longer, but only 10% to 15% in those with shorter<br />
first CR duration. Allogeneic transplant appears superior<br />
to HDAC or idarubicin <strong>and</strong> cytarabine containing regimens<br />
in patients with first CR duration less than 1 year; the great<br />
majority of these transplants were from HLA-matched sibling<br />
donor. 65–68 However, since very few patients <strong>are</strong> cured<br />
with conventional therapy, all patients with relapsed or refractory<br />
AML should be treated in clinical trials.<br />
Mechanisms to lengthen remission duration require further<br />
evaluation. Beneficial effects of T-cells <strong>and</strong> natural<br />
killer cells on preventing relapse of AML have been recognized.<br />
69,70 However, the addition of recombinant interleukin-<br />
2 (rIL-2) during maintenance therapy has not led to improved<br />
outcomes. 54<br />
Investigational Agents<br />
Investigational therapies should be considered when expectations<br />
with st<strong>and</strong>ard therapy <strong>are</strong> low, either because of<br />
high mortality or high relapse rates. These include: 1) poor<br />
performance status 3–4; 2) age 80 years or older; 3) poor<br />
risk cytogenetics; or 4) intermediate prognosis cytogenetic<br />
group, but with an AHD, FLT3 mutation or (MDR)1 positivity.<br />
If investigational therapy is not feasible, palliative<br />
c<strong>are</strong> or low-dose cytarabine alone or with hydroxyurea may<br />
be considered in patients age 65 or older with poor performance<br />
status 3–4, or in patients 80 years or older regardless<br />
of performance status.<br />
Current investigational approaches include targeted therapy<br />
against surface antigens with monoclonal antibodies<br />
such as GO, signal transduction targeting (FLT3, farnesyl<br />
transferase inhibitors [FTIs], methylation, angiogenesis,<br />
inhibition of bcl-2 with antisense therapy) <strong>and</strong> new formu-<br />
lations of established drugs (e.g. liposomal formulations,<br />
pegylated formulations). Multidrug resistance (MDR)-reversing<br />
agents or nucleoside analogs like clofarabine, decitabine<br />
<strong>and</strong> azacitidine in different regimens <strong>are</strong> also of<br />
interest. 71–73<br />
Clofarabine, a nucleoside analog, has demonstrated activity<br />
with acceptable toxicity in elderly patients. 74 In newly<br />
diagnosed patients with 2 or more poor prognostic factors,<br />
39% of patients 70 years of age or older achieved CR with<br />
clofarabine 30 mg/m 2 administered intravenously daily for<br />
5 days. 75 Induction related mortality was reduced to 10%<br />
with clofarabine in comparison to conventional chemotherapy<br />
regimens for older AML patients that report 30 <strong>and</strong> 60<br />
day mortality ranging from 27% to above 60%. 76,77 In another<br />
study, a lower dose of clofarabine (20 mg/m 2 administered<br />
intravenously daily for 5 days) in combination with<br />
subcutaneously administered cytarabine led to higher rates<br />
of CR (59%), with similar induction mortality (9%). 78 Survival<br />
was longer with this combination (11.3 months) versus<br />
idarubicin <strong>and</strong> cytarabine (8.7 months), though this did<br />
not reach statistical significance. 79<br />
Decitabine, a pyrimidine analogue with significant antileukemic<br />
activity, induced an overall response rate of 32%<br />
(9 CRs <strong>and</strong> 7 PRs) among 50 patients with recurrent-refractory<br />
hematologic malignancies treated in a phase I study. 80<br />
In combination with valproic acid, the response rate was<br />
22%. 81 Decitabine has also displayed favorable response<br />
when used in combination with vorinostat. 82 A similar agent,<br />
azacitidine, has also been evaluated for elderly patients unfit<br />
for intensive chemotherapy. In a front-line investigation<br />
with or without valproic acid, CR of 17% <strong>and</strong> improvements<br />
in cytopenias were reported with azacitidine, both translating<br />
to survival benefit. 83<br />
Early clinical trials have demonstrated the activity of<br />
FLT3 inhibitors, particularly in patients who harbor FLT3<br />
mutations in their leukemic blasts. 84 Their role in combination<br />
with other agents is undergoing further investigation.<br />
CR was achieved in 88% (22/25) of newly diagnosed AML<br />
patients under the age of 65 years with the addition of<br />
sorafenib, an oral multi-kinase inhibitor, to idarubicin <strong>and</strong><br />
cytarabine. 85 A second generation FLT3 inhibitor, AC220,<br />
has demonstrated responses in a Phase 1 study, with phase<br />
II investigations ongoing. 86<br />
Another novel treatment for AML is the nucleoside analogue,<br />
sapacitabine, which displayed activity against AML<br />
<strong>and</strong> MDS patients in phase I study. Current evaluations have<br />
targeted the drug for patients 70 years of age or older with<br />
newly diagnosed AML or in first relapse. 87 Different dosing<br />
regimens have led to overall response rates ranging from<br />
25–45%, with mild to moderate toxicities reported that include<br />
fatigue, nausea, diarrhea, anemia, febrile neutropenia,<br />
thrombocytopenia, <strong>and</strong> peripheral edema.<br />
Acute promyelocytic leukemia (AML)<br />
This is a distinct subtype of AML accounting for 5% to<br />
15% of cases, with unique clinical, morphologic, <strong>and</strong> cytogenetic<br />
features. APL results from translocations between<br />
the retinoic acid α (RARα) locus on chromosome 17 <strong>and</strong><br />
the »promyelocytic leukemia« protein (PML) locus located<br />
7
State of the Art Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
on chromosome 15, demonstrable in 95–100% of cases. 88,89<br />
Independent risk factors for a diagnosis of APL in a patient<br />
with AML <strong>are</strong> younger age, Hispanic background, <strong>and</strong> obesity.<br />
7 The main clinical presentation is bleeding diathesis<br />
resulting both from plasmin-dependent primary fibrinolysis<br />
<strong>and</strong> disseminated intravascular coagulation. 90 Cognition of<br />
APL is crucial because appropriate treatment is different<br />
than for other types of AML <strong>and</strong> is curative in most patients<br />
with APL. 91,92<br />
Anthracyclines were historically the first effective treatment<br />
inducing a cure rate of 30–40% in APL. Addition of<br />
ATRA, 45 mg/m 2 daily, to chemotherapy (idarubicin) increases<br />
CR rate, <strong>and</strong> more dramatically the cure rate from<br />
40% to 70%. 93–95 Data suggests ATRA should be used together<br />
with anthracyclines during induction <strong>and</strong>, probably,<br />
during post-remission therapy. The major toxicity of ATRA<br />
is a potentially fatal leukocytosis syndrome (APL differentiation<br />
syndrome) characterized by fever <strong>and</strong> leakage of<br />
fluid into the extravascular space producing fluid retention,<br />
effusions, dyspnea, <strong>and</strong> hypotension. It is effectively treated<br />
with dexamethasone. 96 Use of frequent transfusions of platelets,<br />
cryoprecipitate, <strong>and</strong> fresh frozen plasma makes the use<br />
of heparin (historically recommended) unnecessary. The<br />
comparison of ATRA, arsenic trioxide (As 2 O 3 ) , <strong>and</strong> ATRA +<br />
As 2 O 3 in 61 patients with untreated APL (all patients also<br />
received consolidation chemotherapy <strong>and</strong> maintenance) displayed<br />
favorable response with combination therapy. 97<br />
ATRA <strong>and</strong> As 2 O 3 for induction <strong>and</strong> consolidation (without<br />
chemotherapy) induced a CR rate of 86%, molecular remission<br />
rate of 94% <strong>and</strong> 2-year event-free survival of 85%<br />
among 37 newly diagnosed APL patients. 98 The results of<br />
several studies support the role of As 2 O 3 in front-line therapy.<br />
99,100<br />
A stratification system has been developed that distinguishes<br />
newly-diagnosed patients with APL into low, intermediate,<br />
or high risk. Low risk patients present with WBC<br />
count less than 10 x 10 9 /l <strong>and</strong> platelet count above 40 x 10 9 /<br />
l; a WBC count above 10 x 10 9 /l identifies high-risk patients.<br />
Others <strong>are</strong> at intermediate risk. Anticipated cure rates<br />
<strong>are</strong> close to 100%, 90%, <strong>and</strong> 70%, respectively. Low-risk<br />
patients may only require 3–4 courses of post-remission<br />
therapy, following which PCR tests can be done every 3<br />
months for 1 year. Intermediate risk patients may require a<br />
longer duration of post-remission treatment (e.g. 6 months).<br />
High-risk patients have both a higher early death rate from<br />
hemorrhage <strong>and</strong> a higher risk of relapse. These patients may<br />
benefit from more intense post-remission therapy. More frequent<br />
PCR testing (e.g. monthly in CR) may also be advisable.<br />
Treatment (ALL)<br />
Therapy of ALL remains among the most complex therapies<br />
of anticancer programs. Multiple drugs <strong>are</strong> molded into<br />
regimen-specific sequences of dose- <strong>and</strong> time-intensity with<br />
the goal to reconstitute normal hematopoiesis, prevent<br />
emergence of resistant subclones, provide adequate prophylaxis<br />
of sanctuary sites (e.g. central nervous system (CNS),<br />
testicles), <strong>and</strong> eliminate minimal residual disease through<br />
post-remission consolidation <strong>and</strong> maintenance. 5 Three dis-<br />
8<br />
tinct phases <strong>and</strong> 4 components <strong>are</strong> distinguished: induction,<br />
intensified consolidation, maintenance, <strong>and</strong> CNS prophylaxis<br />
in the fourth component that accompanies induction<br />
<strong>and</strong> consolidation.<br />
The combination of vincristine, corticosteroids, <strong>and</strong> anthracyclines<br />
represents the backbone of ALL induction regimens.<br />
This combination achieves complete remission (CR)<br />
rates of 72% to 92% with a median remission duration of<br />
around 18 months. 101 Dexamethasone is often substituted<br />
for prednisone because of better in vitro antileukemic activity<br />
<strong>and</strong> achievement of higher drug levels in the cerebrospinal<br />
fluid (CSF). 102,103 While L-asparaginase is an important<br />
agent in the treatment of pediatric ALL, its role in adult<br />
ALL is not entirely well defined. Hematopoietic growth factors<br />
during induction accelerate recovery from myelosuppression<br />
<strong>and</strong> allow timely administration of dose-intense<br />
treatment regimens. 104 Consolidation represents a repetition<br />
of a modified induction schedule, rotational consolidation<br />
programs, or stem cell transplantation. Novel strategies try<br />
to emphasize subtype- <strong>and</strong> risk-oriented approaches of consolidation<br />
programs.<br />
Daily 6-mercaptopurine, weekly methotrexate, <strong>and</strong> monthly<br />
pulses of vincristine <strong>and</strong> prednisone, given over 2 to 3<br />
years <strong>are</strong> the mainstay of maintenance therapy. Extension of<br />
maintenance beyond 3 years, as well as omission or shortening<br />
of therapy is not beneficial. No maintenance therapy<br />
is given in mature B-cell ALL as these patients have a high<br />
cure rate with short-term dose-intense regimens, <strong>and</strong> relapses<br />
beyond the first year in remission <strong>are</strong> r<strong>are</strong>. The best maintenance<br />
for patients with Ph-positive ALL remains disputed,<br />
but should incorporate effective BCR-ABL tyrosine kinase<br />
inhibitors.<br />
Although CNS disease is uncommon at diagnosis (
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) State of the Art<br />
liposomal cytarabine, <strong>and</strong> thiotepa. In the absence of IT<br />
therapy, isolated CNS recurrence can account for 10% to<br />
16% of relapses, warranting the inclusion of IT chemotherapy<br />
in CNS prophylactic regimens. The use of IT chemotherapy<br />
in combination with the hyper-CVAD regimen (hyperfractionated<br />
cyclophosphamide, vincristine, doxorubicin,<br />
dexamethasone alternating with methotrexate <strong>and</strong> highdose<br />
cytarabine), reduced the incidence of CNS relapse to<br />
4%. 105 The number of IT injections depend on the risk of<br />
CNS relapse (two IT treatments per course). Mature B-cell<br />
ALL, serum lactate dehydrogenase (LDH) levels, <strong>and</strong> a high<br />
proportion of bone marrow cells in a proliferative state<br />
(>14% of cells in S+G2M phase of the cell cycle) have been<br />
associated with a higher risk of CNS disease in adults. 118<br />
Patients with low-risk CNS disease receive six IT treatments,<br />
those with undetermined risk eight, <strong>and</strong> those with<br />
high-risk disease 16 IT treatments including all patients<br />
with mature B cell ALL. 119<br />
Philadelphia (Ph) chromosome-positive ALL<br />
Philadelphia chromosome (Ph) positivity is the most<br />
common cytogenetic abnormality in adults with ALL, occurring<br />
in 20–30% of patients. The outcome of patients with<br />
Ph-positive ALL with conventional chemotherapy remains<br />
poor with long-term disease-free survival (DFS) rates of<br />
State of the Art Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
Minimal residual disease (MRD) in adult ALL<br />
MRD describes the presence of disease below the threshold<br />
of detection by conventional methods (light microscopy<br />
<strong>and</strong> cytochemical stains). Different methodologies <strong>are</strong> available<br />
to detect <strong>and</strong> monitor MRD, including fluorescence in<br />
situ hybridization (FISH), multicolor flow cytometry, <strong>and</strong><br />
polymerase chain reaction (PCR) assays, especially real<br />
time quantitative (RQ) PCR. Multicolor flow cytometry <strong>and</strong><br />
PCR techniques take advantage of either fusion transcripts<br />
resulting from chromosome abnormalities (e.g. BCR-ABL,<br />
MLL-AF4, TEL-AML1) or patient-specific junctional regions<br />
of rearranged immunoglobulin <strong>and</strong> T cell receptor<br />
genes.<br />
Measurement of MRD in ALL has become an increasingly<br />
important prognostic factor for assessing risk of relapse.<br />
To which extent MRD needs to be controlled or eliminated<br />
remains uncertain. Several questions remain: i) what<br />
<strong>are</strong> the most appropriate time points for measurement of<br />
MRD. Persistence of MRD early in CR does typically not<br />
have the same significance as detection of residual disease<br />
in later stages of therapy; ii) Is there a definable threshold of<br />
residual disease by quantitative assays that would predict<br />
high relapse probability; iii) is it necessary to revise response<br />
criteria <strong>and</strong> introduce the concept of a »molecular<br />
relapse«. It should be emphasized that molecular relapse<br />
does not always predict clinical relapse, <strong>and</strong> intensification<br />
of therapy under these circumstances may not be appropriate;<br />
iv) can quantitation of MRD over time lead to a new<br />
risk classification with impact on choice of consolidation<br />
<strong>and</strong> maintenance strategies. Most of our current knowledge<br />
about MRD <strong>and</strong> its kinetics derive from studies in childhood<br />
ALL <strong>and</strong> differences in pattern <strong>and</strong> dynamics of clearance<br />
of MRD between adult <strong>and</strong> childhood ALL. Marrow<br />
samples from 33 adults <strong>and</strong> 21 children were analyzed by<br />
PCR for immunoglobulin heavy chain gene rearrangements<br />
at specific time points after diagnosis. 131 Among patients<br />
who remained in CR, a decrease in the MRD positivity occurred<br />
during the first 12 months. The proportion of positive<br />
tests decreased faster in children than in adults, suggesting<br />
more rapid resolution of MRD, particularly in the first 6<br />
months of CR.<br />
Salvage therapy<br />
Outcome of salvage therapy in adult ALL remains poor.<br />
CR rates r<strong>are</strong>ly exceed 50% <strong>and</strong> long-term DSF is r<strong>are</strong>. Independent<br />
prognostic factors associated with achieving CR<br />
include duration of first CR <strong>and</strong> platelet count. 132 Short duration<br />
of first CR, thrombocytopenia, elevated percent bone<br />
marrow blasts, <strong>and</strong> low albumin level represent factors associated<br />
with poor survival rates (Table 4). Salvage regimens<br />
<strong>are</strong> structured according to outcomes from frontline<br />
therapy. Newer agents have been approved in the relapsed<br />
setting, while the role of novel formulations of conventional<br />
active agents <strong>are</strong> being further investigated.<br />
Clofarabine demonstrates activity in acute leukemias. In<br />
phase 2 trials of clofarabine in relapsed or refractory pediatric<br />
leukemias, 31% of patients with ALL responded including<br />
12% CR, 8% CRp, <strong>and</strong> 10% partial response. 133 Based<br />
on the response rate in pediatric relapsed ALL, clofarabine<br />
10<br />
Table 4. Prognostic factors in relapsed ALL 123<br />
Poor prognostic factors for CR Poor prognostic factors for survival<br />
Albumin level < 3 g/L* Albumin level < 3 g/L*<br />
Duration of first CR < 36 months* Duration of first CR < 36 months*<br />
Hemoglobin level < 10 g/dL Hemoglobin level < 10 g/dL<br />
Platelet count ≤ 50 x 109 /L* Platelet count ≤ 50 x 109 /L*<br />
Percent bone marrow blasts > 50 % Percent bone marrow blasts > 50%*<br />
Peripheral blood blasts ≥ 1% Percent peripheral blood blasts ≥ 1%<br />
White blood cell count > 20 x 109 /L<br />
All prognostic factors listed significantly reduced rate of CR <strong>and</strong> survival.<br />
*Independent prognostic factors identified by multivariate analysis.<br />
was FDA approved for this indication. The maximum tolerated<br />
dose in adults with leukemia is 40 mg/m 2 /day for 5<br />
days, 20 times the MTD studied in solid tumors. 133 Unlike<br />
other purine analogs, clofarabine is not associated with neurotoxicity.<br />
Hepatotoxicity, skin rashes, drug fever, <strong>and</strong> palmoplantar<br />
erythrodyethseia have been reported. 133–136 Studies<br />
exploring the combinations of clofarabine with known<br />
active agents for ALL <strong>are</strong> ongoing.<br />
Nelarabine, an araguanosine analogue, has been shown to<br />
be very active as a single agent in recurrent T-cell ALL with<br />
a response rate more than 50% in first bone marrow relapse.<br />
When administered on an alternate day schedule of 1.5 mg/<br />
m 2 /day (day 1, 3, <strong>and</strong> 5) to relapsed/refractory T-cell ALL,<br />
31% of patients achieved CR. 129 Neurotoxicity with nelarabine<br />
has been of concern since initial studies. Concurrent<br />
intrathecal chemotherapy should be cautioned as the combination<br />
may compound the risk of neurotoxicity. Nelarabine<br />
in combination with hyper-CVAD is currently under investigation<br />
in newly diagnosed T-Cell ALL. Nelarabine given<br />
at 650 mg/m 2 daily x 5 days every 28 days for two courses<br />
as consolidation following completion of the hyper-CVAD<br />
sequence was feasible, however the true impact on survival<br />
has yet to be determined. 137<br />
Vincristine, a key component to the backbone of ALL<br />
therapy, causes peripheral neuropathy necessitating dose reductions<br />
or omission from the chemotherapy regimens. Liposomal<br />
formulations of chemotherapeutic agents generally<br />
produced reduced toxicity <strong>and</strong> increased efficacy. Activity<br />
has been observed in relapsed ALL with use of sphingosomal<br />
vincristine with minimal neurotoxicity comp<strong>are</strong>d<br />
with the conventional formulation. 138 While capping doses<br />
of conventional vincristine at 2 mg has become common<br />
practice, sphingosomal vincristine may be administered<br />
without dose capping. 139 Preliminary results <strong>are</strong> encouraging,<br />
with further studies planned.<br />
The role of pegaspargase in adult ALL requires further<br />
exploration. Although critical to DNA <strong>and</strong> RNA synthesis,<br />
asparagine can not be produced by ALL cells <strong>and</strong> it’s depletion<br />
through break down by asparaginase results in death of<br />
leukemic calls. Applying variations of pediatric regimens to<br />
adults may improve outcomes. Pegaspargase, E-Coli asparaginase<br />
liked to polyethylene glycol, minimizes reactions<br />
while maintaining the enzymatic activity of asparaginase.<br />
Combinations with pegaspargase <strong>are</strong> critical to determine<br />
the efficacy in adult ALL. When substituted for L-asparaginase<br />
in the BFM regimen (prednisone, vincristine, daunoru-
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) State of the Art<br />
bicin, L-asparaginase followed by cyclophosphamide, cytarabine,<br />
mercaptopurine <strong>and</strong> IT methotrexate), CR was reported<br />
at 96%. 140,141<br />
Modifications to the hyper-CVAD regimen mimicking<br />
approaches from pediatric regimens improve the outcomes<br />
in relapsed/refractory ALL. The design of the »augmented«<br />
hyper-CVAD regimen intensified the dosages of vincristine<br />
<strong>and</strong> dexamethasone, with the addition of L-asparaginase.<br />
With each course of »augmented« hyper-CVAD, vincristine<br />
dosed at 2 mg <strong>and</strong> L-asparaginase dosed at 20,000 units<br />
were administered on day 1, 8 <strong>and</strong> 15. 142,143 Additionally,<br />
dexamethasone was increased from the st<strong>and</strong>ard hyper-<br />
CVAD regimen to 80 mg daily on days 1–4 <strong>and</strong> days 15–18.<br />
Of 49 patients treated, 45% achieved CR with a median remission<br />
duration of 4.75 months. 143 L-asparaginase related<br />
toxicities were frequent with 5% of patients removed from<br />
study due to intolerance. The role of pegaspargase in combination<br />
with this regimen is currently under investigation.<br />
Specific sequencing of medications enhances antileukemic<br />
effect. For example, asparaginase increases the sensitivity<br />
of leukemic cells to methotrexate <strong>and</strong> administration<br />
24 hours after methotrexate reduces the toxicity of methotrexate.<br />
144 In previously treated ALL, combining sequential<br />
moderate-dose methotrexate (100–225 mg/m 2 ) <strong>and</strong> asparaginase<br />
with vincristine <strong>and</strong> dexamethasone (MOAD) proved<br />
beneficial in attaining remission. CR was achieved in 11 of<br />
14 (79%) previously treated patients. The median duration<br />
of CR was 7.5 months <strong>and</strong> the median survival was 11.2<br />
month.<br />
Stem cell transplant is recommended for all patients with<br />
Ph-chromosome positive ALL in first CR. For Ph-chromosome<br />
positive patients not eligible for transplant, survival is<br />
minimal. Acquired resistance to imatinib results from mutations<br />
in the kinase domain of ABL <strong>and</strong> BCR-ABL amplification.<br />
Second generation tyrosine kinase inhibitors appear<br />
promising in the management of imatinib resistant ALL.<br />
While imatinib only binds to BCR-ABL in the closed conformation,<br />
dasatinib binds in both the open <strong>and</strong> closed conformation,<br />
resulting in an increased affinity to BCR-ABL.<br />
The ability of dasatinib to inhibit src activity may provide<br />
advantage over imatinib by blocking BCR-ABL activity<br />
through a separate mechanism. Dasatinib, in combination<br />
with chemotherapy (hyper-CVAD) was evaluated in 14 patients<br />
with relapsed Ph-chromosome positive ALL or CML<br />
with lymphoid blast crisis. 145 Seventy-one percent of patients<br />
achieved CR while 29% attained complete response<br />
without platelet recovery (CRp). Major molecular response<br />
was achieved in 64%. Of four patients that had relapsed,<br />
two acquired the T315I mutation, resistant to currently<br />
available tyrosine kinase inhibitors.<br />
Stem Cell Transplant (SCT)<br />
High-dose chemotherapy with or without radiation followed<br />
by hematopoietic stem cell transplantation (SCT) is<br />
increasingly used as therapy for acute leukemia. AML in<br />
first CR, particularly in patients with poor-risk factors such<br />
as deletion of 5q <strong>and</strong> 7q, trisomy 8, t(6;9), t(9;22), <strong>and</strong> a<br />
history of myelodysplasia or AHD <strong>are</strong> c<strong>and</strong>idates for SCT.<br />
With a possible advantage of allogeneic transplantation in<br />
patients with poor-risk cytogenetic features, there <strong>are</strong> no<br />
subgroups identified in whom there is a clear advantage to a<br />
particular modality. 146 An exception is patients with inversion<br />
16, or t(8;21) who do better with chemotherapy. 147 Two<br />
other exceptions <strong>are</strong> patients younger than 20 years in whom<br />
transplant-related mortality is relatively low <strong>and</strong> who may<br />
do better with allogeneic stem cell transplantation, <strong>and</strong> patients<br />
older than 60 years in whom excessive mortality excludes<br />
the possibility of conventional myeloablative transplant.<br />
148,149 If allogeneic transplant is proposed, data suggest<br />
there is no advantage in giving consolidation chemotherapy<br />
before transplantation. 150<br />
The outcome with SCT versus continuation of chemotherapy<br />
in ALL has been debated. Although SCT is superior<br />
to chemotherapy with long-term disease-free survival rates<br />
of 20% to 40% in salvage, only 30% to 40% of patients who<br />
achieve a second CR <strong>are</strong> eligible for SCT <strong>and</strong> fewer than<br />
half have enough time prior to relapse to undergo SCT. Traditionally,<br />
SCT has been reserved for patients with Ph-positive<br />
ALL or in patients considered high risk (age greater<br />
than 35 years, B lineage with white blood cell count ≥ 100 x<br />
10 9 /L, T lineage with white blood cell count ≥ 30 x 10 9 /L). 151<br />
However, survival at 5 years was not significantly different<br />
between patients treated with a matched related donor SCT<br />
<strong>and</strong> those treated with continued chemotherapy or autologous<br />
SCT in high-risk patients. Improvements in survival at<br />
5 years were significantly greater in patients treated with a<br />
matched related donor SCT in patients not considered highrisk.<br />
SCT reduced the rate of relapse comp<strong>are</strong>d with chemotherapy<br />
or autologous SCT in both risk groups of patients.<br />
The use of chemotherapy is favored over autologous SCT<br />
for patients without a suitable donor.<br />
Conclusion<br />
The biology of both AML <strong>and</strong> ALL is now better understood.<br />
Following a period of paucity in discoveries, new<br />
strategies <strong>are</strong> finally evolving that may help patients with<br />
AML. Better definition of the complex process initiating<br />
<strong>and</strong> sustaining the leukemic process will lead to a better<br />
definition of targets for therapeutic intervention that may<br />
translate into improved cure rates. Specific attention must<br />
be given to prognostic factors that identify subsets of AML.<br />
Progress in the underst<strong>and</strong>ing of the biology <strong>and</strong> pathogenesis<br />
of adult ALL has helped improve outcome <strong>and</strong> prognosis.<br />
More intensive regimens combined with targeted therapy<br />
<strong>are</strong> being evaluated with encouraging results. As in other<br />
leukemias, the key to further improving prognosis of adult<br />
ALL lies in an appreciation <strong>and</strong> recognition of the heterogeneity<br />
of ALL. Novel strategies under investigation as monotherapy<br />
or in combination with chemotherapy provide improvements<br />
in the treatment of relapsed disease. Development<br />
of new drugs <strong>and</strong> agents tailored to subset-specific<br />
cytogenetic-molecular characteristics remains vital to the<br />
success in adult ALL. Progress in adults has been marked by<br />
utilization of intensive regimens proven beneficial in pediatric<br />
patients as well as the inclusion of new targeted therapy.<br />
Treatment remains highly successful in pediatric ALL <strong>and</strong><br />
with continuous investigation, adults may soon achieve<br />
comparable long term-survival.<br />
11
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15
Oral Presentations<br />
OP01 White blood cell transfusion <strong>and</strong> leukemia<br />
therapy<br />
Emil Freireich, The University of Texas MD Anderson<br />
Cancer Center, Houston, Texas, USA<br />
The leading cause of morbidity <strong>and</strong> mortality in leukemia<br />
patients results from uncontrolled infection. Since the late<br />
50s, it has been clear that leucopenia is a major contributing<br />
factor to the occurrence of infection. Both the severity <strong>and</strong><br />
duration of leucopenia result in increased incidence of infection.<br />
Similarly, thrombocytopenia is the major contributing<br />
cause to hemorrhage. Transfusion of allogeneic platelets<br />
has been very effective in controlling hemorrhage, <strong>and</strong> decreasing<br />
hemorrhage as a cause of morbidity <strong>and</strong> mortality.<br />
However, for infections, replacement of leucocytes by transfusion<br />
has been frustrated by inability to technically collect<br />
a sufficient number of leucocytes to increase the number of<br />
leucocytes in the circulation, <strong>and</strong> the physiology of the leucocytes<br />
where a great majority of the cells (over 95%) <strong>are</strong><br />
located outside of the vasculature. Thus, the volume of distribution<br />
is at least 20 fold that of red cells. First efforts to<br />
overcome this limitation were the studies of the transfusion<br />
of allogeneic leucocytes collected from donors with uncontrolled<br />
chronic myeloid leukemia (CML), which allowed<br />
transfusion of between 10 <strong>and</strong> 100 billion cells to leucopenic<br />
children with acute leukemia. These studies demonstrated<br />
that with an adequate dose of these cells, even abnormal<br />
granulocytes from CML patients, doses of 50–100 billion<br />
cells was uniformly effective in controlling established infection.<br />
To reach these concentrations of normal cells required<br />
the development of an efficient <strong>and</strong> semi-automated<br />
continuous blood flow cell separator; the application of a<br />
safe <strong>and</strong> largely degradable macromolecule to increase separation<br />
efficiency of the granulocytes; <strong>and</strong> the discovery of<br />
the granulocytes stimulating colony factors to mobilize myeloid<br />
cells from the bone marrow into the blood to allow<br />
collection. With these advances, it became possible to regularly<br />
collect 30–50 billion leucocytes from a single volunteer<br />
donor <strong>and</strong> transfusion of these cells into severely leucopenic<br />
patients with existing infection resulted in significant<br />
reversal of infection in 40% of patients who received a minimum<br />
of 4 consecutive daily transfusions. These data were<br />
reported in the late 1970s, <strong>and</strong> in several centers leucocyte<br />
transfusion was practiced. In the mid 80s, following several<br />
anecdotal reports of a syndrome resembling Graft vs Host<br />
Disease (GVHD) were reported in literature. These were<br />
single or two patient reports. However, these reports result<br />
in radiating all leucocyte transfusion products from the mid<br />
80s to 2008. It is important to recognize that several metaanalyses<br />
of all the published reports of transfusion associated<br />
GVHD did not support the conclusion that such a syndrome<br />
resulted from leucocyte transfusion.<br />
While radiation of the transfusion product did not have a<br />
major effect on neutrophil function in vitro, it completely<br />
eliminated lymphoid cells <strong>and</strong> thus was considered to be<br />
free of any possibility of transfusion associated Graft vs<br />
Host Disease (TAGVHD). In vitro studies subsequently demonstrated<br />
that in addition to the effect on lymphoid cells,<br />
the mononuclear monocytes <strong>and</strong> macrophages were completely<br />
inactivated by doses of radiation administered. But<br />
perhaps most importantly since the GCSF mobilized leucocytes<br />
collections were demonstrated to have myeloid hemapoietic<br />
stem cells <strong>and</strong> a large number of undifferential<br />
myeloid cells which, in the recipient, were able to continue<br />
to mature into granulocytes. The consequence was that the<br />
half life of measured granulocytes post non-radiated transfusions<br />
was approximately 24 hours, whereas the half life of<br />
the radiated products was approximately 6 hours. In 2008<br />
we undertook a prospective r<strong>and</strong>omized double-blind study<br />
comparing unradiated granulocytes with the same product<br />
which has been radiated in vitro. The goal of this study was<br />
primarily to determine the risk of TAGVHD was, <strong>and</strong> secondly,<br />
to quantitatively measure the effect of radiation on<br />
post transfusion increments <strong>and</strong> granulocyte levels in patients.<br />
The study was closed on July 14 th 2011 <strong>and</strong> we found,<br />
after the study of 109 patients, that in the 49 patients who<br />
received irradiated granulocytes transfusion, there were no<br />
patients who developed any syndrome resembling GVHD.<br />
While the 30 day survival <strong>and</strong> the response rates <strong>and</strong> overall<br />
survival were not significantly different, the increments<br />
measured post transfusion were more than twice in the recipients<br />
of non irradiated transfusions than those in the radiated<br />
transfusions. This study led to two conclusions – first,<br />
the unradiated leucocytes transfusions have the potential of<br />
being effective in helping control infectious complications<br />
in leucopenic patients <strong>and</strong> secondly, that such transfusions<br />
<strong>are</strong> demonstrated to be safe.<br />
OP02 Presence <strong>and</strong> future of treatment of acute<br />
myeloid leukemia in patients under the age<br />
of 60<br />
Roel Willemze 1 , Stefan Suciu S, Giovanna Meloni, Boris<br />
Labar, Halkes S, Petra Muus, David Selleslag D, Marko<br />
Vignetti, Sergio Amadori, Theo de Witte T, Jean-Pierre<br />
Marie, on behalf of the EORTC <strong>and</strong> GIMEMA Leukemia<br />
Groups, 1 Department of Hematology, Leiden University<br />
Medical Center, the Netherl<strong>and</strong>s<br />
The age of the patient still determines the choice of treatment<br />
<strong>and</strong> outcome in acute myeloid leukemia (AML). In<br />
patients, younger than 60 years, 65% to 80% enter complete<br />
remission after several anthracycline-cytarabine-based combinations.<br />
Dosing of these drugs influences the prognosis of<br />
17
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
the patients. Intermediate high dose cytarabine is recently<br />
reported to lead to the same results as st<strong>and</strong>ard dose cytarabine,<br />
while high dose cytarabine may improve results comp<strong>are</strong>d<br />
to st<strong>and</strong>ard dose cytarabine. A similar phenomenon is<br />
true for different kinds of anthracyclines or dosages of anthracyclines.<br />
Although much is still unclear, it still looks<br />
like more antileukemic drug, in addition to improvements in<br />
supportive c<strong>are</strong> (new antibiotics <strong>and</strong> bloodbank support),<br />
leads to a better outcome. One consolidation course consisting<br />
of high-dose cytarabine is considered necessary although<br />
firm proof is lacking. The intensity of the induction<br />
schedule appears to influence the duration of the hematological<br />
recovery phase <strong>and</strong> the number of autologous stem<br />
cell that can be harvested after consolidation, <strong>and</strong> the relapse<br />
risk after this consolidation course. These findings<br />
may indicate that in certain patients the sensitivity of normal<br />
hematopoietic stem cells for certain antileukemic drugs<br />
parallels the sensitivity of leukemic stem cells. Further consolidation<br />
of the remission status using repeated high-dose<br />
cytarabine courses or a stem cell transplantation decreases<br />
relapse rate <strong>and</strong> increases remission duration, allogeneic<br />
stem cell transplantation in the younger patients being superior<br />
to autologous stem cell transplantation or high-dose<br />
cytarabine. Although the administration of IL-2 after autologous<br />
stem cell transplantation or intensive consolidation<br />
therapy did not affect the duration of remission in most<br />
studies, the combination of low-dose of interleukin-2 <strong>and</strong><br />
histamine as maintenance prolonged remission in one study.<br />
Outcome improved by allogeneic stem cell transplantation<br />
using sibling donors, especially in patients under the age of<br />
50 with intermediate or bad risk AML. Currently, due to<br />
improved HLA-matching techniques, the outcome of allogeneic<br />
stem cell transplantation using matched unrelated<br />
donors equals the results obtained by sibling donors. Adoptive<br />
cellular immunotherapy after allogeneic stem cell transplantation<br />
using donor lymphocytes or in vitro cultured T<br />
cells <strong>are</strong> under investigation but preliminary results look<br />
promising with respect to the control of molecular or cytogenetic<br />
relapses. Acute myeloid leukemia appears to be a<br />
high heterogenous disease where an increasing number of<br />
cytogenetic <strong>and</strong> molecular aberrations of the leukemic cells<br />
determines the prognosis. These differences led already to a<br />
subdivision of AML in good, intermediate <strong>and</strong> bad or very<br />
bad risk subgroups where different treatment strategies need<br />
to be applied. However some molecular aberrations may be<br />
present across these prognostic subtypes, complicating the<br />
study of the value of drugs specifically designed against<br />
these aberrations. Relatively few new drugs have been approved<br />
for AML in the last two decades. Gemtuzumab ozogamicin<br />
is the first example of antibody directed chemotherapy<br />
targeting the CD33 epitope. Its use in combination<br />
with chemotherapy has been denied in Europe due to the<br />
lack of benefit in overall survival. Studies targeting the<br />
FLT3 mutation have shown limited activity as monotherapy<br />
but r<strong>and</strong>omized trials in combination <strong>are</strong> underway. Targeting<br />
RAS <strong>and</strong> other farnesylated peptides <strong>and</strong> P-glycoprotein<br />
has been disappointing. Demethylating agents such as<br />
decitabine, have shown superior antileukemic activity in the<br />
past, appear useful in the management of patients with myelodysplasia,<br />
<strong>and</strong> <strong>are</strong> currently reintroduced in the treatment<br />
18<br />
of AML. A new agent, clofarabine, shows increased hematological<br />
toxicity <strong>and</strong> a high complete remission rate at the<br />
maximum tolerated dose in phase I/II trials but requires r<strong>and</strong>omized<br />
evidence to evaluate its real impact on duration of<br />
remission <strong>and</strong> overall survival.<br />
In conclusion, the outcome of AML under the age of 60<br />
has improved considerably during the last 25 years due to<br />
the use of more intensive chemotherapy <strong>and</strong> stem cell transplantation<br />
<strong>and</strong> improvements in supportive c<strong>are</strong>. Currently<br />
<strong>and</strong> in the next future the improved knowledge on tumor<br />
immunology <strong>and</strong> on molecular aberrations of leukemic cells<br />
will lead to an extreme subdivision of AML in subgroups<br />
with specific treatment requirements. In this personalised<br />
treatment era, patients available to enter into a phase III trial<br />
will become quite limited. This development necessitates<br />
worldwide cooperation of Leukemia Groups in order to collect<br />
sufficient patients of a specific subgroup of AML.<br />
OP03 CLL: how close is the cure?<br />
Michael Keating, The University of Texas M. D. Anderson<br />
Cancer Center, Houston, Texas, USA<br />
Dramatic changes have occurred in the outcome of patients<br />
with chronic lymphocytic leukemia (CLL) over the<br />
last 25 years. Using modern day criteria for response, the<br />
complete remission (CR) rate with alkylating agent regimens<br />
was approximately 5%. As fludarabine entered into<br />
frontline treatment, the CR rate increased to 20–25%, going<br />
to 30–35% for fludarabine plus cyclophsomide (F+C), <strong>and</strong><br />
more recently with the FCR regimen, adding rituximab to<br />
FC, the CR rate is 50–70%. An important part of the development<br />
of evaluation criteria were provided by the NCI<br />
working group guidelines 1 <strong>and</strong> more recently the iwCLL<br />
guidelines 2 for indications for treatment <strong>and</strong> response evaluation<br />
in CLL. In most tumors when the complete remission<br />
rate gets above 50% there is a fraction of patients who <strong>are</strong><br />
cured of their disease. This question is increasingly being<br />
asked in chronic lymphocytic leukemia.<br />
It is clear that there is a close correlation of the time to<br />
progression (TTP) of complete <strong>and</strong> partial responders (CR<br />
+ PR) according to the quality of the remission <strong>and</strong> other<br />
parameters such as the mutation status <strong>and</strong> FISH genetics.<br />
Patients who achieve CR using NCI WG criteria have a significantly<br />
longer time to progression than nodular partial<br />
remissions (NPR) who again have a longer remission duration<br />
than other partial responders. An analysis of 300 patients<br />
treated with the FCR regimen (FCR300) previously<br />
published 3 has demonstrated that there is a clear association<br />
of time to progression with the mutation status of the immunoglobulin<br />
variable sequence of the heavy chain (IgVH) 4 .<br />
The mutated patients have a very significantly greater likelihood<br />
of being 5 <strong>and</strong> 10 years in remission than patients who<br />
<strong>are</strong> unmutated. There is also evidence that patients that<br />
achieve minimal residual disease (MRD) negativity have a<br />
greater probability of being long term remissions. The technology<br />
for measuring MRD has evolved over time so that<br />
the more recent strict criteria of flow cytometry identifying<br />
1 in 10 4 cells has only recently been applied. Most of these
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
clinical trials evaluating FCR regimens or other regimens<br />
combining purine analogs with monoclonal antibodies such<br />
as rituximab <strong>are</strong> too immature to evaluate true long term<br />
remissions.<br />
We now have complete follow-up of patients treated with<br />
FCR (300). The percent of patients who <strong>are</strong> free of recurrence<br />
at 10 years <strong>are</strong> 46% for CR, 26% for NPR <strong>and</strong> 17%<br />
for other PR.<br />
The FISH evaluation was not available for the FCR 300<br />
patients <strong>and</strong> we cannot make such projections. However, it<br />
is clear that more recent CR + PR patients who <strong>are</strong> mutated<br />
have a 61% likelihood of being free of relapse at seven years<br />
but only 18% if unmutated. Within the unmated group of<br />
patients it is app<strong>are</strong>nt that shorter times to remission occur<br />
in patients with deletion of chromosome 11q.22-23 (del<br />
11q). Older patients have not f<strong>are</strong>d as well, but in the small<br />
proportion of patients 70 years of age or older who were CR<br />
or PR in the first FCR study, 36% <strong>are</strong> still alive. 53% have<br />
relapsed <strong>and</strong> 17% have died in remission. A substantial<br />
number of patients <strong>are</strong> dying of other illnesses while still in<br />
remission of their disease which is functionally a cure of<br />
their disorder.<br />
Now that subsets of patients who <strong>are</strong> at high risk of relapse<br />
can be more readily identified, post remission strategies<br />
with monoclonal antibodies, lenalidomide <strong>and</strong> stem<br />
cell transplantation <strong>are</strong> being applied. The prospects for<br />
long term survival of patients with 17p deletion or p53 mutation<br />
is still grim with stem cell transplantation the only<br />
reasonable option to give long term control. The 11q group<br />
of patients have a very high propensity of relapse, but they<br />
have a good second remission rate so that opportunities <strong>are</strong><br />
present to prolong remission by intervention during their<br />
first <strong>and</strong> later remissions. All other subsets including trisomy<br />
chromosome 12, 13q deletion <strong>and</strong> negative patients have<br />
the same likelihood of being free of disease. With the development<br />
of new therapies such as the B cell Receptor signaling<br />
antagonists such as CAL-101 <strong>and</strong> PCI-32765, improved<br />
transplant options for patients up to 75 years of age <strong>and</strong> immune<br />
modulating agents such as lenalidomide, prospects<br />
for all subsets of patients is improving.<br />
R E F E R E N C E S<br />
1. Cheson BD, Bennett JM, Grever M, Kay N, Keating MJ, O’Brien S, Rai<br />
KR. National Cancer Institute-sponsored Working Group guidelines for<br />
chronic lymphocytic leukemia: revised guidelines for diagnosis <strong>and</strong><br />
treatment. Blood 1996;87(12):4990–7.<br />
2. Hallek M, Cheson BD, Catovsky D, Caligaris-Cappio F, Dighiero G,<br />
Döhner H, Hillmen P, Keating MJ, Montserrat E, Rai KR, Kipps TJ.<br />
Guidelines for the diagnosis <strong>and</strong> treatment of chronic lymphocytic leukemia:<br />
a report from the International Workshop on Chronic Lymphocytic<br />
Leukemia updating the National Cancer Institute-Working Group<br />
1996 guidelines. Blood 2008;111(12):5446–56.<br />
3. Tam CS, O’Brien S, Wierda W, Kantarjian H, Wen S, Do KA, Thomas<br />
DA, Cortes J, Lerner S, Keating MJ. Long-term results of the fludarabine,<br />
cyclophosphamide, <strong>and</strong> rituximab regimen as initial therapy of<br />
chronic lymphocytic leukemia. Blood 2008;112(4):975–80.<br />
4. Lin KI, Tam CS, Keating MJ, Wierda WG, O’Brien S, Lerner S,<br />
Coombes KR, Schlette E, Ferrajoli A, Barron LL, Kipps TJ, Rassenti L,<br />
Faderl S, Kantarjian H, Abruzzo LV. Relevance of the immunoglobulin<br />
VH somatic mutation status in patients with chronic lymphocytic leukemia<br />
treated with fludarabine, cyclophosphamide, <strong>and</strong> rituximab<br />
(FCR) or related chemoimmunotherapy regimens. Blood 2009;113(14):<br />
3168–71.<br />
OP04 From donor buffy coat to vaccination<br />
Hans-Jochem Kolb 1 , Helga Schmetzer 2 , Arndt Borckhardt 3 .<br />
1 3. Med. Klinik, Techn. Universitaet Muenchen,<br />
1 Helmholtz Zentrum München, National Reserch Center<br />
for Environmental Health, 2 3. Med. Klinik, Universitaet<br />
München, Germany, 3 Kinderklinik Univ. Düsseldorf,<br />
Germany<br />
Chimerism <strong>and</strong> transplantation tolerance can be achieved<br />
with allogeneic stem cell transplantation. The state of chimerism<br />
provides the chance for adoptive immunotherapy<br />
using donor lymphocytes exerting strong immune effects on<br />
leukemia <strong>and</strong> other malignancies of the host without being<br />
rejected. The risks of allogeneic lymphocytes <strong>are</strong> development<br />
of graft-versus-host disease (GVHD) as well as tolerance<br />
toward the malignant disease. Delay of donor lymphocyte<br />
transfusions after cessation of the cytokine storm of<br />
conditioning treatment <strong>and</strong> establishment of some form of<br />
peripheral tolerance <strong>and</strong> c<strong>are</strong>ful treatment in escalating doses<br />
starting at a low dose has facilitated the treatment of relapse<br />
of chronic myeloid leukemia <strong>and</strong> prevention of acute<br />
myeloid leukemia without severe GVHD. However, preemptive<br />
transfusion of donor lymphocytes has been limited<br />
to a minority of patients because of early relapses <strong>and</strong> acute<br />
GVHD. The hypothesis that myeloid leukemia respond better<br />
to donor lymphocytes because of their differentiation to<br />
dendritic cells has been supported by the demonstration of<br />
dendritic cells with the karyotype of the leukemia <strong>and</strong> the<br />
improved response following treatment with interferon-a<br />
<strong>and</strong> GM-CSF. However in the case of rapidly progressive<br />
relapse cytotoxic therapy may be necessary <strong>and</strong> subsequently<br />
donor lymphocytes may produce GVHD. Therefore we<br />
<strong>and</strong> others have studied lymphocytes of treated patients for<br />
the recognition of antigens that <strong>are</strong> overexpressed in leukemia<br />
blasts like WT-1, PR-1 <strong>and</strong> PRAME. We found overexpression<br />
of these proteins in acute myeloid leukemia. Moreover<br />
we found 4 new antigens overexpressed inAML coded<br />
by the Y-chromosome. Unfortunately the number of CD8cells<br />
with multimer staining for peptides of these antigens<br />
were few <strong>and</strong> gamma-interferon release low. We also studied<br />
splice variants of a Y-chromosome associated antigen<br />
UTY for tissue restriction. We could demonstrate a multitude<br />
of splice variants, but no specific tissue restriction.<br />
These findings <strong>are</strong> in contrast to the selection of T cells using<br />
antigenic peptides of EBV covering more than 90% of<br />
HLA-antigens; these cells could be selected <strong>and</strong> transfused<br />
inducing rapid remissions in patients with EBV-associated<br />
post-transplant lymphoma. This has been proven as a life<br />
saving cost effective procedure that would be ideal for the<br />
treatment of leukemia, if an antigen of similar strength<br />
could be defined for leukemia. Genome wide screening for<br />
SNPs using T-cells of stem cell transplant patients has<br />
shown a few new minor histocompatibility antigens. The<br />
cumulative frequency of genes for minor H-antigens may<br />
thus increase <strong>and</strong> more patients could benefit of immunotherapy<br />
directed against mHA. We have tried to test the generation<br />
of T cells in vitro against dendritic cells of leukemic<br />
origin, <strong>and</strong> we found two results: first patients with blasts<br />
differentiating into DC have a better chance to respond to<br />
19
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
door lymphocytes, secondly cytotoxic T cells generated to<br />
dendritic cells of leukemia origin in vitro have T cell receptors<br />
( Vß-chain) found in the patients post transplantation.<br />
Several Vß chain clones <strong>are</strong> represented in more than 1 sample;<br />
they may represent dominant clones that can be recognized<br />
in vitro <strong>and</strong> sometimes even in the donor. There is a<br />
good chance that they can be selected <strong>and</strong> used for immunotherapy<br />
without further analysis of the antigens against<br />
which they <strong>are</strong> directed.<br />
Major histocompatibility antigen may cause more vigorous<br />
reactions including early cellular reactions <strong>and</strong> antibody<br />
production. Of particular interest is NK reactivity against<br />
hematopoietic cells missing own HLA-antigens, transplantation<br />
across cross-reactive HLA-C groups sharing killer<br />
inhibitor receptors have a strong graft-versus-leukemia effect<br />
in acute leukemia, not in lymphoma. Maternal transplants<br />
have a superior GVL effect to paternal grafts indicating<br />
immune memory against paternal antigens. For alternate<br />
donor transplants we prefer HLA-haploidentical transplants<br />
for younger patients <strong>and</strong> cord blood transplants for elderly<br />
patients. Double cord transplants have a strong GVL activity<br />
for as yet unknown reasons. Non-inherited maternal antigens<br />
<strong>and</strong> graft-versus-graft reactions may play a role. Major<br />
histocompatibility antigens may not only be a strong<br />
target for alloimmune reactions, they may as well present<br />
peptide of autologous antigens in an immunogenic way <strong>and</strong><br />
provide a major activating stimulus to reactions against minor<br />
HA. Several recent observations support the necessity<br />
of strong costimulation in order to prevent tolerance toward<br />
leukemia-associated antigens <strong>and</strong> minor HA. Repeat vaccination<br />
with WT1 <strong>and</strong> PR1 peptides induced non-reactivity<br />
(Rezvani et al. 2011) even in the presence of memory T<br />
cells (Pospori et al, 2011). We discuss mechanisms of immune<br />
escape in leukemia <strong>and</strong> possible ways to overcome it<br />
with interferon-a, GM-CSF <strong>and</strong> bispecific antibody treatment.<br />
Future donors have not only to selected according to<br />
histocompatibility, but also according to their immune repertoire.<br />
In future immunotherapy not only target antigens<br />
<strong>and</strong> effector cells have to be considered, but also immune<br />
escape <strong>and</strong> mechanisms to maintain immune tolerance.<br />
OP05 AML in adults – what we need for diagnosis<br />
Torsten Haferlach, MLL Munich Leukemia Laboratory,<br />
Munich, Germany<br />
The diagnosis of AML is getting more <strong>and</strong> more comprehensive<br />
but also complicated. First of all, making the diagnosis<br />
does not always mean to classify AML: according to<br />
the WHO classification as published in 2008 1 , several hierarchical<br />
steps have to be fulfilled:<br />
To make it easier for application, one could first discriminate<br />
between »treatment-related AML« following radiation<br />
<strong>and</strong>/or chemotherapy <strong>and</strong> »de novo AML«. Thus, the history<br />
of the patient has to be known to the physician but also to<br />
the diagnostic laboratory.<br />
As a second step, »AML with recurrent cytogenetic aberrations«<br />
<strong>are</strong> defined by the WHO. This for sure needs chromosomal<br />
b<strong>and</strong>ing analysis, even if in some cases molecular<br />
techniques such as PCR screening may be helpful. But not<br />
20<br />
all entities subcategorized in this »AML with recurrent genetic<br />
abnormalities« can be detected by PCR, as such st<strong>and</strong>ard<br />
chromosomal b<strong>and</strong>ing analysis accompanied by FISH<br />
<strong>and</strong>/or PCR <strong>are</strong> necessary. As a matter of fact, these techniques<br />
have a turn around time of three to ten days in experienced<br />
laboratories. Therefore, the diagnosis cannot rely<br />
only <strong>and</strong> primarily on this classification aspects, chromosomal<br />
b<strong>and</strong>ing analysis.<br />
In the next step of the hierarchy, »AML with myelodysplasia-related<br />
changes« have to be taken into account.<br />
Again, these cases <strong>are</strong> based on their respective history of<br />
the patient (AML following MDS or MDS/MPN overlap)<br />
but also include in addition or only cytogenetic changes,<br />
mostly known from MDS, <strong>and</strong>/or dysplastic features, socalled<br />
multilineage dysplasia. Also in this category, as it is a<br />
combination of different methods, turn around time <strong>and</strong><br />
availability make it not easy to get this category implemented<br />
into a daily routine diagnostic workflow.<br />
Finally, those cases not fulfilling the above-mentioned<br />
criteria <strong>are</strong> classified according to the formally known morphologic<br />
criteria as defined in the FAB classification. In<br />
these cases, at least cytomorphology is important.<br />
In addition, several other aspects <strong>are</strong> included today more<br />
<strong>and</strong> more in st<strong>and</strong>ard approaches to AML diagnostics: molecular<br />
markers such as NPM1 <strong>and</strong> CEBPA have been suggested<br />
to be »provisional entities« according to WHO classification,<br />
especially within a normal karyotype, other genes<br />
should be investigated as well such as FLT3-ITD, MLL-<br />
PTD <strong>and</strong> newer markers my also be implemented in the near<br />
future such as DNMT3A. In addition, the expression of several<br />
genes such as EVI1, WT1 <strong>and</strong> BAALC have to be taken<br />
into account, which makes it even more difficult to follow<br />
up with the complete WHO scenario for diagnosis of AML<br />
in a routine setting 2 .<br />
Therefore, several guidelines have been suggested or different<br />
scenarios, the most important one was published by a<br />
cooperating initiative of the ELN 3 . The authors clearly elaborate<br />
on the specific diagnostic algorithms in AML in adults,<br />
discriminating between st<strong>and</strong>ard diagnostic approaches in<br />
general <strong>and</strong> clinical studies:<br />
From clinical perspective it seems m<strong>and</strong>atory that for patients<br />
who may undergo st<strong>and</strong>ard treatment approaches,<br />
cytomorphology (leading to the diagnosis at the same day)<br />
accompanied by immunophenotyping (same turn around<br />
time) is m<strong>and</strong>atory. This has to be performed together with<br />
st<strong>and</strong>ard cytogenetic analysis, as cytogenetic results still<br />
provide the most important prognostic factor in AML 4 . In<br />
addition, cytogenetic results <strong>are</strong> m<strong>and</strong>atory to fulfil baseline<br />
diagnostic criteria according to the WHO classification<br />
2008.<br />
If allogeneic transplantation may be an option, also the<br />
investigation of molecular markers such as NPM1, FLT3-<br />
ITD <strong>and</strong> CEBPA, especially in the normal karyotype AML<br />
subset, seems important 5 . It further has to be discussed that<br />
minimal residual disease studies in AML with molecular<br />
markers such as PML-RARA, CBFB/MYH11 but also NPM1<br />
may help to further subclassify <strong>and</strong> guide treatment in the<br />
individual AML patient.<br />
The next future will also demonstrate that new molecular<br />
markers such as DNMT3A 6 , TET2 <strong>and</strong> others may not only
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
add important diagnostic value for AML but also will guide<br />
treatment <strong>and</strong> define prognosis. However, it has to be admitted<br />
that the diagnosis of AML is still getting more complicated,<br />
labour intensive <strong>and</strong> expensive. The next few years<br />
will demonstrate, if techniques such as next-generation sequencing<br />
(NGS) will help us to better characterize AML<br />
patients not only in clinical studies but also in the daily routine<br />
setting.<br />
We have to realize that many patients still die with the<br />
diagnosis of AML <strong>and</strong> it is highly appreciated that any new<br />
diagnostic <strong>and</strong> therapeutic approach has be followed to be<br />
investigated within clinical studies <strong>and</strong> to be implemented<br />
for all patients after validation in a short timeframe.<br />
R E F E R E N C E S<br />
1. WHO Classification of Tumours of Haematopoietic <strong>and</strong> Lymphoid Tissues.<br />
Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H<br />
et al., editors. 4th. 2008. Lyon, International Agency for Research on<br />
Cancer (IARC).<br />
2. Marcucci G, Haferlach T, Döhner H. Molecular genetics of adult acute<br />
myeloid leukemia: prognostic <strong>and</strong> therapeutic implications. J Clin Oncol<br />
2011;29:475–486.<br />
3. Döhner H, Estey EH, Amadori S, Appelbaum FR, Buchner T, Burnett<br />
AK, et al. Diagnosis <strong>and</strong> management of acute myeloid leukemia in<br />
adults: recommendations from an international expert panel, on behalf<br />
of the European LeukemiaNet. Blood 2010;115:453–474.<br />
4. Grimwade D, Hills RK, Moorman AV, Walker H, Chatters S, Goldstone<br />
AH, et al. Refinement of cytogenetic classification in acute myeloid leukemia:<br />
determination of prognostic significance of r<strong>are</strong> recurring chromosomal<br />
abnormalities among 5876 younger adult patients treated in<br />
the United Kingdom Medical Research Council trials. Blood 2010;116:<br />
354–365.<br />
5. Schlenk RF, Dohner K, Krauter J, Frohling S, Corbacioglu A, Bullinger<br />
L, et al. Mutations <strong>and</strong> treatment outcome in cytogenetically normal<br />
acute myeloid leukemia. N Engl J Med 2008;358:1909–1918.<br />
6. Ley TJ, Ding L, Walter MJ, McLellan MD, Lamprecht T, Larson DE, et<br />
al. DNMT3A mutations in acute myeloid leukemia. N Engl J Med 2010;<br />
363:2424–2433.<br />
OP06 Mutation of epigenetic regulators in AML<br />
<strong>and</strong> MDS<br />
Joop Jansen, Laboratory of Hematology, Radboud<br />
University Nijmegen Medical Centre St. Radboud <strong>and</strong><br />
Nijmegen Centre for Molecular Life Sciences, Nijmegen,<br />
The Netherl<strong>and</strong>s<br />
Aberrant epigenetic modifications have been described in<br />
many types of cancer. In myeloid malignancies aberrant<br />
methylation patterns may be observed, <strong>and</strong> it has been proposed<br />
that repression of genes that <strong>are</strong> crucial for the cessation<br />
of the cell cycle <strong>and</strong> the induction of differentiation<br />
may contribute to the malignant transformation of normal<br />
hematopoietic cells. In the past years, various genes were<br />
shown to be mutated in AML <strong>and</strong> MDS, <strong>and</strong> this has been<br />
accelerated by the application of novel technologies like<br />
high-resolution SNP-array analysis <strong>and</strong> next generation sequencing.<br />
Strikingly, several of the newly identified genes<br />
(ASXL1, UTX, TET2, EZH2, DNMT3A) function to regulate<br />
gene expression by epigenetically changing chromatin. The<br />
TET2 gene is currently the most frequently mutated gene in<br />
MDS known so far (20–25% of the cases), <strong>and</strong> is also mutated<br />
in AML (10% of the cases) <strong>and</strong> various types of MPN<br />
(including CMML, where it is mutated in 30–40% of the<br />
cases). It was shown to convert methylated cytosines (correlating<br />
with repression of gene expression) into 5-hydroxymethyl<br />
cytosine, of which the functional consequences <strong>are</strong><br />
under investigation. Mutations of the DNA-methyltransferase<br />
3A gene (DNMT3A) were found both in AML <strong>and</strong> in<br />
MDS, which also provides a direct link between gene mutations<br />
<strong>and</strong> DNA methylation. Furthermore, mutations in<br />
genes that regulate the epigenetic modifications of histones<br />
have been found, such as the polycomb-repressor complex-<br />
2 (PRC2) component EZH2. It will be interesting to see<br />
whether the patients who carry mutations in the genes that<br />
regulate epigenetic chromatin changes <strong>are</strong> responding differently<br />
to the novel epigenetic therapies (like hypomethylating<br />
agents) that <strong>are</strong> currently being investigated.<br />
OP07 Therapy for younger adults with AML<br />
Alan Burnett, Department of Haematology, Cardiff<br />
University School of Medicine, Heath Park, Cardiff,<br />
United Kingdom<br />
Survival in younger patients (arbitrarily defined as patients<br />
less than 60 years) has improved in the last 20 years<br />
such that 45 to 50% can now be cured, but may have reached<br />
the limit of the potential with »st<strong>and</strong>ard chemotherapy.<br />
St<strong>and</strong>ard of c<strong>are</strong> comprises 7+3 Ara-C + Daunorubicin for<br />
induction followed by high dose Ara-C (3 g/m 2 ) for consolidation<br />
or allogeneic transplant for non-favourable cases<br />
for who a donor is available. However higher remission<br />
rates have been consistently shown with alternative inductions<br />
such as a 10 day Ara-C schedule, but intensification of<br />
Ara-c in induction has not been consistently of benefit. Similarly<br />
comparisons of different anthracylcine or anthracyline-like<br />
agents have not shown consistent superiority over<br />
Daunorubicin once dose equivalence has been taken into<br />
account. Recently a Daunorubicin dose of 90 mg/m 2 has<br />
been shown to have improved induction <strong>and</strong> in some cases<br />
survival. However the comparator <strong>are</strong> only produced a 57%<br />
CR rate. However Idarubicin is equivalent to Daunorubicin<br />
80 mg/m 2 . Many consider that a 60 mg/m 2 the optimum<br />
dose. The addition of mylotarg to a Daunorubicin dose of<br />
45 mg was equivalent to a 60 mg dose, however in the largest<br />
trial testing the addition of mylotarg to a 3+10 schedule<br />
significantly improved survival by 10% in 70% of patients<br />
with high risk disease. Inclusion of other nucleoside analogues<br />
such as Fludarabine/ Cladrabine or clofarabine has<br />
potential to be more effective induction.<br />
High dose Ara-C is st<strong>and</strong>ard of c<strong>are</strong> in consolidation but<br />
what dose <strong>and</strong> how many courses is still under study. The<br />
MRC AML15 trial comp<strong>are</strong>d 3 g vs a 1.5 g dose <strong>and</strong> found<br />
no overall difference. Three consolidation courses was not<br />
superior to two. In this trial, two courses of FLAG-Ida in<br />
induction did not improve overall survival, although it significantly<br />
reduced the risk of relapse, but because of more<br />
myelosuppression there was less compliance with consolidation<br />
therapy. However the survival of patients who received<br />
2 courses of FLAG-Ida only was the same as for patients<br />
who received all planned four courses. The survival<br />
21
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
for patients who received FLAG-Ida X 2 <strong>and</strong> Ara-C consolidation<br />
X 2 was 64%.<br />
Stem cell transplantation is clearly superior to chemotherapy<br />
in high risk disease, although far from satisfactory<br />
for this difficult subgroup in which there has been no improvement<br />
in the last 30 years.There is continuing controversy<br />
concerning which intermediate risk patients should<br />
have SCT in CR1. This is usually initially defined by cytogenetics,<br />
however of other important prognostic factors <strong>are</strong><br />
used to identify further high risk groups (inadequate marrow<br />
response to course 1/secondary disease/ high white<br />
count/ male gender) the remaining patients may not need<br />
transplantation. Younger patients ( 10 x 10 9 /L) seem<br />
to benefit from treatments including cytarabine in the ATRA<br />
plus chemotherapy scheme, whereas st<strong>and</strong>ard risk patients<br />
can be successfully managed with less intensive regimens<br />
containing ATRA <strong>and</strong> anthracycline-based chemotherapy.<br />
More recently, arsenic trioxide (ATO), which as a single<br />
agent is the most effective drug for APL, has unquestionably<br />
emerged as the most exciting »new drug« to be included<br />
in the treatment strategy for this disease. Following the<br />
outst<strong>and</strong>ing results with ATO in the treatment of APL relapse,<br />
several clinical trials have been reported by single<br />
institutions in relatively small <strong>and</strong> non-comparative studies.<br />
Although published studies <strong>are</strong> lacking, there <strong>are</strong> currently<br />
at least two ongoing r<strong>and</strong>omized trials comparing ATObased<br />
versus chemotherapy-based approaches. One conducted<br />
by the Italian GIMEMA group for patients with WBC<br />
count < 10 x 10 9 /L <strong>and</strong> another by the British NCRI for all<br />
patients with APL Further to explore the role of ATO in<br />
front-line therapy with the aim of minimizing or even eliminating<br />
the use of chemotherapy, other clinical trials have<br />
been designed to assess the use of ATO to reinforce st<strong>and</strong>ard<br />
ATRA plus chemotherapy regimens <strong>and</strong> further improve the<br />
outcome of APL. In this regard, a recent report of a large<br />
r<strong>and</strong>omized study by the US Intergroup showed significantly<br />
better outcomes in patients receiving two courses of ATO<br />
immediately after achieving complete remission <strong>and</strong> before<br />
the st<strong>and</strong>ard consolidation with ATRA <strong>and</strong> chemotherapy.<br />
Currently other major cooperative groups, such as the<br />
French-Belgian-Swiss group <strong>and</strong> the PETHEMA-HOVON<br />
group, <strong>are</strong> also conducting studies to assess the role of ATO<br />
in consolidation therapy of ATRA plus chemotherapy regimens.<br />
The opportunities offered by the incorporation of<br />
ATO into the therapeutic armamentarium of APL, not only<br />
to minimize or even eliminate the use of chemotherapy, but<br />
also to optimize the st<strong>and</strong>ard approach, will be discussed in<br />
this presentation.<br />
OP10 FLT3 inhibitors – too much expectations?!<br />
Farhad Rav<strong>and</strong>i, University of Texas – MD Anderson<br />
Cancer Center, Houston, Texas, USA [see SA01]<br />
The FLT3 receptor kinase is highly expressed in acute<br />
leukemias. FLT3 gene mutations <strong>are</strong> among the most com-
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
mon molecular abnormalities in AML occurring in about a<br />
third of patients particularly those with diploid cytogenetics<br />
<strong>and</strong> acute promyelocytic leukemia. Available evidence suggests<br />
that these molecular lesions confer a shorter diseasefree<br />
survival <strong>and</strong> overall survival in patients with intermediate-risk<br />
cytogenetics. As a result, there is substantial interest<br />
in inhibition of the FLT3 kibase as a therapeutic target <strong>and</strong><br />
several promising inhibitors that target this tyrosine kinase<br />
<strong>are</strong> in clinical development.<br />
Several reported trials of these kinase inhibitors as a single<br />
agent <strong>and</strong> incombination with traditional cytotoxic<br />
agents have clearly demonstrated their activity. However,<br />
future trials involving perhaps more potent <strong>are</strong> likely to shed<br />
further insights on the relevance of FLT3 kinase as a target,<br />
the population most likely to derive benefit, the most appropriate<br />
agents for combination, <strong>and</strong> the clinical <strong>and</strong> biological<br />
correlates predicting a benefit.<br />
OP11 Allogeneic SCT for AML – when to treat<br />
OP12 Allogeneic SCT with reduced intensity<br />
conditioning for AML<br />
Didier Blaise, Unité de Transplantation et de Thérapie<br />
Cellulaire (UTTC), département d’hématologie, Institut<br />
Paoli-Calmettes, Marseille <strong>and</strong> Université de la<br />
Méditerranée, Marseille, France.<br />
Allogeneic stem cell transplantation (allo-SCT) is the<br />
treatment exerting the most efficient antileukemic effect in<br />
acute myeloblastic leukemia (AML). In selected subset of<br />
patients, this conducts into a survival benefit as comp<strong>are</strong>d to<br />
chemotherapy strategies. However, the oldest patients can<br />
r<strong>are</strong>ly benefit from intensive treatment including st<strong>and</strong>ard<br />
myeloablative allo-SCT because of an unacceptable high<br />
risk of procedure-related toxicity. This point is especially<br />
critical when considering AML patients in first CR (CR1).<br />
Finally, most of the patients lack a human lymphocyte antigen<br />
(HLA)-identical donor further precluding an allo-SCT<br />
strategy.<br />
The development of the so-called non-ablative, or reduced-intensity<br />
conditioning (RIC) regimens appears to decrease<br />
allo-SCT-related toxicities, as promising results have<br />
already been reported in different series of patients with<br />
various hematological malignancies. In contrast to st<strong>and</strong>ard-dosed<br />
myeloablative allo-SCT, <strong>and</strong> although long term<br />
follow-up is still needed in many studies, RIC allo-SCT is<br />
relatively well tolerated by patients with high-risk clinical<br />
features such as advanced age or associated co-morbidities.<br />
Nevertheless, toxicity might represent only one face of the<br />
problem, since AML encompasses a group of chemo-sensitive<br />
diseases, raising concerns that significant reduction of<br />
the intensity of the st<strong>and</strong>ard conditioning regimens may<br />
negatively impact long-term leukemic control. This concern<br />
might be particularly app<strong>are</strong>nt in patients with high-risk<br />
leukemic features. Indeed, the importance of dose intensity<br />
has been already shown in myeloablative allo-SCT. However,<br />
the beneficial effect of more intensive conditioning<br />
that is associated with a reduced risk for relapse was offset<br />
by an increased transplant-related toxicity. The latter figures<br />
may be even more complex since the relative benefit of myeloablation<br />
as part of the conditioning regimen, may also<br />
depend on patient <strong>and</strong> disease status at time of allo-SCT<br />
(e.g. CR1 vs. beyond CR1 or advanced disease). Thus, investigators<br />
<strong>are</strong> currently faced with a dilemma on how to<br />
optimize the potential role of RIC allo-SCT in patients with<br />
AML, while delivering minimal myeloablation <strong>and</strong> maximizing<br />
allogeneic immunotherapy. To add to this debate we<br />
will review present knowledge on reduced intensity regimen<br />
approach in AML <strong>and</strong> report our experience.<br />
OP13 Novel drugs for AML<br />
Hagop Kantarjian, Department of Leukemia, U.T. M.D.<br />
Anderson Cancer Center, Houston, TX, USA [see SA01]<br />
OP14 Molecular Pathogenesis of Myelodysplastic<br />
Syndromes<br />
Omar Abdel-Wahab, Alan Shih, Ross L. Levine, Leukemia<br />
Service, Department of Medicine, Human Oncology <strong>and</strong><br />
Pathogenesis Program, Memorial Sloan Kettering Cancer<br />
Center<br />
Myelodysplastic syndromes represent one of the most<br />
common myeloid malignancies, <strong>and</strong> <strong>are</strong> associated with poor<br />
outcome overall due to progressive cytopenias/bone marrow<br />
failure <strong>and</strong> progression to acute myeloid leukemia. Importantly,<br />
clinical <strong>and</strong> cytogenetic parameters have been<br />
used to improve prognostication for MDS patients, however<br />
little insight into the molecular pathogenesis of MDS<br />
had been elucidated until recently when a series of c<strong>and</strong>idate<br />
gene <strong>and</strong> whole genome studies have identified recurrent<br />
somatic mutations in MDS patients including TET2,<br />
ASXL1, DNMT3A, EZH2, <strong>and</strong> TP53 mutations. Importantly,<br />
a subset of these genes including ASXL1, EZH2, <strong>and</strong><br />
TP53 have been associated with poor outcome, <strong>and</strong> recent<br />
studies have shown that these mutations can be used to supplement<br />
the IPSS <strong>and</strong> improve prognostication in MDS.<br />
These data will be reviewed.<br />
In addition recent functional studies have begun to elucidate<br />
how these disease alleles contribute to MDS pathogenesis.<br />
Specifically, the TET family of proteins have been<br />
shown to place a hydroxyl mark on methylated DNA <strong>and</strong><br />
lead to DNA demethylation. We have shown that TET2 mutations<br />
leads to loss of DNA hydroxymethylation <strong>and</strong> a hypermethylation<br />
phenotype in leukemia patients. In addition,<br />
in vitro <strong>and</strong> in vivo studies show that TET2 loss leads to<br />
impaired hematopoietic differentiation, increased stem cell<br />
self-renewal, <strong>and</strong> myeloid transformation in vivo. These<br />
data will be presented in detail.<br />
Finally, more recent studies have revealed a role of mutations<br />
in chromatin modifying enzymes in MDS pathogenesis,<br />
including ASXL1 <strong>and</strong> EZH2 mutations. The effects of<br />
these mutations on chromatin state, gene expression, <strong>and</strong><br />
hematopoietic function have begun to be elucidated, sug-<br />
23
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
gesting mutations in chromatin modifying enzymes coopt<br />
the epigenetic state of hematopoietic stem/progenitor cells<br />
to contribute to transformation. Data from recent in vitro<br />
<strong>and</strong> in vivo studies including novel MDS models will be<br />
presented in detail.<br />
OP15 Risk models in MDS<br />
David Steensma, Dana-Farber Cancer Institute, Harvard<br />
Medical School, Boston, MA, USA<br />
In recent years, investigators have proposed several novel<br />
risk models for the purpose of forecasting the clinical course<br />
of patients with myelodysplastic syndromes (MDS). The<br />
most widely used MDS prognostic system in clinical practice<br />
continues to be the 4-strata 1997 International Prognostic<br />
Scoring System (IPSS), but clinicians have recognized<br />
for many years that the IPSS has a number of critical limitations.<br />
These limitations include unsatisfactory applicability<br />
of the IPSS to a variety of clinical situations such as secondary,<br />
therapy-related MDS or previously treated patients;<br />
lack of sensitivity to the degree of patients’ peripheral blood<br />
cytopenias, especially severe thrombocytopenia; excessive<br />
emphasis on elevated marrow blast proportion comp<strong>are</strong>d to<br />
high-risk cytogenetics; a restricted number of included<br />
karyotypes; <strong>and</strong> failure to account for either comorbid conditions,<br />
or newer biomarkers of demonstrated prognostic<br />
value such as the presence of high-grade marrow fibrosis or<br />
elevated serum ferritin level. Collectively, these limitations<br />
make the original IPSS a less accurate <strong>and</strong> helpful tool than<br />
it might otherwise be, <strong>and</strong> have prompted other investigators<br />
to derive <strong>and</strong> propose newer risk stratification tools.<br />
The 5-strata Word Health Organization (WHO) classification-based<br />
Prognostic Scoring System (WPSS), proposed<br />
by Malcovati <strong>and</strong> colleagues initially in 2007 <strong>and</strong> since<br />
modified to include marrow fibrosis, attempted to improve<br />
on the IPSS by including transfusion dependence as well as<br />
bringing the prognostic classification in line with the WHO<br />
Classification of Tumors of Haematopoietic <strong>and</strong> Lymphoid<br />
tissues as updated in 2001 <strong>and</strong> again in 2008. In 2008, Kantarjian<br />
<strong>and</strong> colleagues from the MD Anderson Cancer Center<br />
proposed a 4-strata generalized risk model for patients<br />
with MDS that is both sensitive to the degree of cytopenias<br />
<strong>and</strong> emphasizes the importance of high risk karyotype,<br />
which several analyses have suggested is a more powerful<br />
marker of a negative outcome than increased marrow myeloblast<br />
proportion. A review of 1,503 Mayo Clinic patients<br />
comparing the 1997 IPSS, the WPSS, <strong>and</strong> the MD Anderson<br />
Cancer Center general risk model found that while all 3<br />
prognostic systems were useful, the MD Anderson classification<br />
scoring system accurately classified the broadest<br />
range of patients <strong>and</strong> also achieved the greatest separation<br />
between lower risk <strong>and</strong> higher risk groups.<br />
In May 2011, Greenberg discussed a revised/updated version<br />
of the IPSS, IPSS-R, at the 11th MDS Foundation International<br />
Symposium in Edinburgh, Scotl<strong>and</strong>. The IPSS-<br />
R includes a much broader range of karyotypes than the<br />
initial IPSS (based on the German-Austrian consortium data<br />
24<br />
of Haase <strong>and</strong> colleagues), has 5 stratification groups instead<br />
of 4, <strong>and</strong> rebalances the relative risk of cytogenetic abnormalities<br />
comp<strong>are</strong>d to marrow blast proportion, as well as<br />
introducing a graduated system for cytopenias that allows at<br />
least some sensitivity to the degree of cytopenia rather than<br />
just the number of cytopenias. Work on extending <strong>and</strong> validating<br />
the IPSS-R is ongoing.<br />
In addition to inclusion of comorbidities <strong>and</strong> other patient<br />
features, new disease-associated biomarkers that might be<br />
incorporated in future versions of the IPSS include results<br />
of flow cytometric panels, array-based measurement of loss<br />
of heterozygosity <strong>and</strong> gene copy number, <strong>and</strong> assessment<br />
specific molecular abnormalities. The MDS-associated somatic<br />
gene mutation l<strong>and</strong>scape continues to exp<strong>and</strong>, <strong>and</strong><br />
none of the existing risk models incorporates mutational<br />
analysis. For example, Bejar <strong>and</strong> colleagues in the Benjamin<br />
Ebert laboratory in Boston assessed 439 samples from<br />
patients with MDS stratified using the IPSS, <strong>and</strong> found that<br />
mutations in EZH2, ASXL1, TP53, or RUNX1 all conferred<br />
an IPSS-independent adverse prognosis in terms of overall<br />
survival. None of the other mutations tested – ETV6, CBL,<br />
NRAS/KRAS, IDH1/2, TET2, NPM1, or JAK2 – had an<br />
IPSS-independent effect on survival. Since the publication<br />
of Bejar’s paper in the New Engl<strong>and</strong> Journal of Medicine,<br />
the Washington University in St. Louis group have described<br />
DNMT3A mutations, which <strong>are</strong> associated with a strikingly<br />
adverse negative IPSS- <strong>and</strong> karyotype-independent prognostic<br />
effect, both in MDS <strong>and</strong> in acute myeloid leukemia.<br />
Finally, somatic SF3B1 mutations, recently described in<br />
MDS by the Cancer Genome Project of the Wellcome Trust<br />
Sanger Institute – represent a class of mutation that appears<br />
to be particularly strongly associated with MDS subtype refractory<br />
anemia with ring sideroblasts <strong>and</strong> associated with<br />
lower-risk disease. Incorporation of these <strong>and</strong> other novel<br />
prognostic markers will continue to require revision of risk<br />
stratification schemes in the years to come.<br />
OP16 Iron Chelation Therapy in MDS<br />
Luca Malcovati, Department of Hematology Oncology,<br />
S. Matteo Hospital Foundation, University of Pavia<br />
Medical School, Pavia, Italy<br />
Anemia is the most frequent peripheral cytopenia observed<br />
in myelodysplastic syndromes (MDS), <strong>and</strong> is an established<br />
negative prognostic factor in patients with MDS.<br />
Most patients with MDS eventually become dependent on<br />
regular red cell transfusions.The onset of a transfusion-dependency<br />
is associated with a worsening of survival <strong>and</strong> an<br />
increased risk of progression into acute myeloid leukemia. 1<br />
Transfusion-dependent patients invariably develop secondary<br />
iron overload. Transfusion iron is primarily taken up<br />
by the reticuloendothelial cells, but later redistributed to p<strong>are</strong>nchymal<br />
cells. This process is modulated by several factors,<br />
including ineffective erythropoiesis through suppression<br />
of hepcidin production. P<strong>are</strong>nchymal iron overload<br />
from transfusions is responsible for morbidity <strong>and</strong> mortality<br />
in patients with thalassemia major, but clinical consequences<br />
have been reported also in patients with MDS.
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
The reference method for determining body iron stores is<br />
the assessment of hepatic iron concentration. Although percutaneous<br />
liver biopsy is difficult to implement in MDS because<br />
of neutropenia <strong>and</strong> thrombocytopenia, data have been<br />
reported in these patients. Schafer <strong>and</strong> coworkers demonstrated<br />
an increased liver iron concentration with signs of<br />
portal fibrosis in a high proportion of transfusion-dependent<br />
adults patients with refractory <strong>and</strong> sideroblastic anemia. 2<br />
In MDS patients, body iron status is routinely assessed by<br />
serum ferritin; although its level can be affected by inflammation<br />
or liver disease, sequential measurements were proven<br />
to be of value in monitoring iron overload. In transfusion-dependent<br />
MDS patients retrospective studies showed<br />
that elevated serum ferritin was associated with worse survival,<br />
3 <strong>and</strong> poor outcome after allogeneic hematopoietic<br />
stem cell transplantation. 4<br />
Magnetic resonance imaging T2* provides a non-invasive<br />
method for detecting <strong>and</strong> quantifying both liver <strong>and</strong><br />
myocardial iron overload. Preliminary studies adopting this<br />
approach showed both hepatic <strong>and</strong> myocardial iron accumulation<br />
can be observed in heavily transfused MDS patients.<br />
5<br />
According to the available evidence- <strong>and</strong> consensus-based<br />
guidelines, patients with refractory anemia with ring<br />
sideroblasts or other forms of refractory anemia, in whom<br />
long-term transfusion therapy is likely, <strong>are</strong> recognized as<br />
the best c<strong>and</strong>idates to receive iron chelation therapy. In addition,<br />
patients who <strong>are</strong> c<strong>and</strong>idates for allogeneic stem cell<br />
transplantation may also benefit from chelation therapy,<br />
since iron overload is associated with increased transplantrelated<br />
mortality. 6,7<br />
In conclusion, the available evidence allows to identify<br />
subsets of MDS patients that at risk of developing p<strong>are</strong>nchymal<br />
iron overload <strong>and</strong> might benefit from iron chelation<br />
therapy. Nevertheless, a more accurate information on the<br />
impact of iron-mediated organ damage on the outcome of<br />
patients with MDS is warranted in order to support clinical<br />
decision with evidence-based criteria.<br />
R E F E R E N C E S<br />
1. Cazzola M, Malcovati L. Myelodysplastic syndromes-coping with ineffective<br />
hematopoiesis. N Engl J Med 2005;352(6):536–8.<br />
2. Schafer AI, Cheron RG, Dluhy R, et al. Clinical consequences of acquired<br />
transfusional iron overload in adults. N Engl J Med 1981;304<br />
(6):319–24.<br />
3. Malcovati L, Della Porta M, Pascutto C, et al. Prognostic factors <strong>and</strong> life<br />
expectancy in myelodysplastic syndromes classified according to WHO<br />
criteria. A basis for clinical decision-making. J Clin Oncol 2005;23:<br />
7594–603.<br />
4. Arm<strong>and</strong> P, Kim HT, Cutler CS, et al. Prognostic impact of elevated pretransplant<br />
serum ferritin in patients undergoing myeloablative stem cell<br />
transplantation. Blood 2007;109(10)4586–8.<br />
5. Di Tucci AA, Matta G, Deplano S, et al. Myocardial iron overload assessment<br />
by T2* magnetic resonance imaging in adult transfusion dependent<br />
patients with acquired anemias. Haematologica 2008;93(9):<br />
1385–8.<br />
6. Aless<strong>and</strong>rino EP, Amadori S, Barosi G, et al. Evidence- <strong>and</strong> consensusbased<br />
practice guidelines for the therapy of primary myelodysplastic<br />
syndromes. A statement from the Italian Society of Hematology. Haematologica<br />
2002;87(12):1286–306.<br />
7. Bowen D, Culligan D, Jowitt S, et al. Guidelines for the diagnosis <strong>and</strong><br />
therapy of adult myelodysplastic syndromes. Br J Haematol 2003;120<br />
(2):187–200.<br />
OP17 Progress with epigenetic therapy<br />
in MDS<br />
Pierre Wijermans, Haga Hospital, The Hague,<br />
The Netherl<strong>and</strong>s<br />
Epigenetic therapy with demethylating agents for intermediate<br />
<strong>and</strong> high risk MDS was developed over the last 10<br />
years. We now know that up to almost 50% of the patients<br />
can reach a response when treated properly. Many problems<br />
in the treatment of these patients however <strong>are</strong> not solved yet<br />
as for instance who should be treated, what is the most efficient<br />
drug, what is the best dosing scheme <strong>and</strong> how long<br />
should we give therapy in case of response.<br />
There <strong>are</strong> some answer to give on the basis of new information<br />
that <strong>are</strong> relevant to the treating physicians.<br />
Who should be treated?<br />
The Italian study with Azacytidine in low risk en intermediate<br />
risk patients confirmed earlier 5-aza-2-deoxycytidine<br />
(Decitabine) experience that treating some of these patients<br />
is helpful. Longer duration of the treatment with probably<br />
also maintenance in case of good response seems appropriate.<br />
Also some of the more high risk patients especially with<br />
adversed cytogenetic abnormalities might be good c<strong>and</strong>idates.<br />
The first results come available that also some of AML<br />
patients may benefit.<br />
Which drugs should we use<br />
Azacytidine <strong>and</strong> Decitabine probably do differ in their effect<br />
on the tumor cell therefore combination therapy seems<br />
an interesting option.<br />
HDAC inhibitors <strong>are</strong> used in multiple phase II trials <strong>and</strong><br />
although potentially very interesting have not showed major<br />
clinical inpact in the treatment of MDS patients yet. However<br />
combination therapy is an option based upon the working<br />
mechanism of the two drugs.<br />
Which dosing scheme<br />
Alternative more convenient dosing schemes with lower<br />
dose both for Azacytidine <strong>and</strong> Decitabine <strong>are</strong> presented.<br />
Some of them <strong>are</strong> using lower doses. How low can we go<br />
with the dose? Prelininary results of studies to intracellular<br />
drug levels revealed that an intra-individual metabolism<br />
might important.<br />
How long should we treat<br />
Complete cure of the MDS is with epigenetic therapy not<br />
possible. We know that often soon after stopping (even in de<br />
cases of a CR) the disease will relapse. Individual experience<br />
of physicians showed us that long term maintenance<br />
treatment might a good option.<br />
The option to treat fit patients with a donor with an allotransplantation<br />
after reaching a CR with epigenetic therapy<br />
has been explored with some success.<br />
25
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
OP18 Hematopoietic cell transplantation<br />
for MDS: New developments<br />
Theo J.M. de Witte, Department of Tumor Immunology,<br />
Radboud University Medical Centre, Nijmegen,<br />
The Netherl<strong>and</strong>s<br />
The spectrum of myelodysplastic syndromes (MDS) varies<br />
from an indolent course over several years to a rapid<br />
progression to acute myeloid leukemia (AML) 1 . MDS classification<br />
systems have been modified recently, leading to<br />
the WHO classifications <strong>and</strong> WHO-based prognostic scoring<br />
system (WPSS) 2, 3 . The new classifications have improved<br />
the accuracy of prognosis by incorporating the impact<br />
of cytogenetic characteristics <strong>and</strong> transfusion dependency.<br />
WHO classifications <strong>and</strong> WPSS showed prognostic<br />
relevance after allo-SCT 4 . According to WPSS criteria, low<br />
risk patients have the highest overall survival rate (80%) <strong>and</strong><br />
the lowest relapse probability (9%) 5 years after transpalntation<br />
5 , but most patients with these low risk criteria do not<br />
require treatment with allo-SCT.<br />
Currently, the most effective curative treatment is allogeneic<br />
stem cell transplantation (alloSCT), with long-term<br />
survival rates between 25% <strong>and</strong> 70%. However, treatmentrelated<br />
mortality continues to be a limiting factor 6 . The most<br />
important factors influencing outcome after alloSCT <strong>are</strong> not<br />
recipient age or intensity of conditioning, but disease stage<br />
at the time of transplantation 7 .<br />
Several large studies in de-novo AML have assessed the<br />
role of allogeneic SCT by a donor versus no donor comparison<br />
8–10 . In these studies the advantage of the presence of<br />
a histocompatible sibling donor was mainly restricted to patients<br />
younger than 40 years. In the MDS Criant study the<br />
average age was considerably higher than 40 years <strong>and</strong> only<br />
28% (38/135) of the patients who reached CR <strong>and</strong> ≤55 years<br />
old, were younger than 40 years 11 . In the Criant study only<br />
patients with unfavorable or intermediate cytogenetic characteristics<br />
appe<strong>are</strong>d to benefit from allogeneic stem cell<br />
transplantation 11 . Whether patients with advanced stages<br />
of MDS should receive remission-induction chemotherapy<br />
prior to the transplant conditioning remains a point for discussion<br />
11 . Retrospective analyses showed conflicting data.<br />
Interpretation of the data is hampered by various selection<br />
biases in the two treatment approaches <strong>and</strong> by lacking details<br />
about the administered chemotherapy prior to the transplant<br />
conditioning 6,12 . The Criant study shows that the great<br />
majority of patients with an identified donor received the<br />
transplant (94%). The 4-year DFS rate of the donor-group<br />
of 46% is encouraging comp<strong>are</strong>d to large registry data. 13<br />
In conclusion: these data suggest that allogeneic SCT<br />
may be the treatment of choice for the young patients (age<br />
≤55 years) with MDS, characterized by poor risk or intermediate<br />
risk cytogenetics, who have a histocompatible donor.<br />
For patients lacking an HLA-compatible sibling donor,<br />
the outcome with autologous SCT or chemotherapy may be<br />
good alternatives for MDS patients with good-risk cytogenetic<br />
characteristics. Until now, no study has proven superiority<br />
of autologous SCT comp<strong>are</strong>d to intensive chemotherapy<br />
11 .<br />
26<br />
Reduced intensity conditioning regimens (RIC) for alloSCT<br />
in MDS has dramatically exp<strong>and</strong>ed the scope of allografting<br />
to many previously ineligible older patients, or<br />
patients with multiple co-morbidities. The heterogeneity<br />
amongst conditioning regimens between centers is considerable,<br />
but usually the procedure appears to be associated<br />
with durable hematopoietic engraftment amongst both sibling<br />
<strong>and</strong> unrelated HLA-matched donor allografts, together<br />
with an acceptable level of transplant-related mortality. The<br />
question whether RIC regimens result in better outcome<br />
when comp<strong>are</strong>d to marrow ablative conditioning has been<br />
addressed in several studies. EBMT performed a retrospective<br />
study of 836 patients with MDS undergoing allogeneic<br />
HSCT with HLA matched siblings, comparing 215 patients<br />
receiving reduced intensity conditioning with 621 patients<br />
receiving st<strong>and</strong>ard myeloablative conditioning (SMC). Patients<br />
receiving RIC were older (age > 50 years in 73% RIC<br />
vs. 28% in SMC, P
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
iron absorption <strong>and</strong> increased iron toxicity. Infections occur<br />
frequently in patients with AML <strong>and</strong> MDS, especially after<br />
during <strong>and</strong> after intensive antileukemic therapy. Infections<br />
<strong>are</strong> associated with increased levels of cytokines, such as<br />
IL6, which also blocks Hepcidin production <strong>and</strong> increased<br />
iron absorption in the gut with its associated iron toxicity.<br />
Finally, every unit of erythrocytes adds 200 mg of iron to<br />
the total iron store of 5 gm in an individual of 75 kg, Several<br />
studies 16 indicate that pre-conditioning ferritin levels<br />
<strong>are</strong> associated with post-transplant complications, such as<br />
mucositis, bacteremia, <strong>and</strong> fever episodes 4, 18 . This association<br />
was app<strong>are</strong>nt in autologous 19 , but more importantly in<br />
the large retrospective analysis performed by the Dana Farber<br />
Institute Group on 543 recipients of allogeneic HSCT 20 .<br />
This study showed a strong association between pretransplantation<br />
serum ferritin level <strong>and</strong> a lower overall survival,<br />
especially in patients with MDS <strong>and</strong> acute leukemia (AL) 20 .<br />
Strikingly, the median ferritin level in this group was 930<br />
mg/l. The percentage of patients with elevated ferritin levels<br />
varied greatly from 25% in chronic myeloid leukemia<br />
(CML) to 70% in lymphoma, 81% in MDS <strong>and</strong> 97% in AL.<br />
The question is what to do to prevent this iron overload<br />
related toxicity? The approach should be multifactorial because<br />
iron overload <strong>and</strong> toxicity cannot be solely contributed<br />
to the number of transfused units of erythrocytes 21 . In<br />
a postmortem study of 10 patients who died early after<br />
HSCT 21 the iron content was in the range of hemachromatosis<br />
patients while the average number of transfusions given<br />
from diagnosis to death was only 48 units. In the pretransplant<br />
period vigorous iron chelation may be important, but<br />
prospective studies should prove a survival benefit. During<br />
the transplant period anti-oxidant therapy, including various<br />
iron chelators, glutamine or the angiotensin-converting enzyme<br />
(ACE)-inhibitor Captopril may be considered, but<br />
clinical experience is limited to anecdotal observations 16 .<br />
During the conditioning <strong>and</strong> the early post-transplant period,<br />
innocuous glutathione-depleting agents like acetaminophen<br />
should be avoided 16 . Finally, in the post-transplant<br />
period phlebotomy, sometimes combined with erythropoietin,<br />
has been successfully applied after HSCT in thalassemic<br />
patients. For those patients who cannot be phlebotomized<br />
iron chelation can be considered as well.<br />
In conclusion: iron toxicity is likely to be an underestimated<br />
cause of HSCT treatment-related mortality. We need<br />
to know more on the pathogenesis, the diagnosis <strong>and</strong> the<br />
monitoring of iron induced organ damage. Prevention of<br />
iron-induced toxicity will require a multidisciplinary approach<br />
of biochemists, pathologists, transfusionists <strong>and</strong> clinicians.<br />
It is clear we do need well-designed prospective<br />
studies both with interventions prior to HSCT <strong>and</strong> after<br />
HSCT.<br />
Several new drugs have now been approved for the treatment<br />
of MDS. The question often arises, especially in older<br />
patients, whether patients should be treated with those (less<br />
toxic) drugs <strong>and</strong> be transplanted only if they do not or no<br />
longer respond or should undergo HSCT at the time of optimum<br />
response. In addition, these new treatment modalities<br />
may be used to reduce more efficiently the MDS clone prior<br />
to the HSCT conditioning. Weighing the pros <strong>and</strong> cons in<br />
view of the potential post-HSCT complications, especially<br />
GVHD, provides a challenging task. GVHD, particularly in<br />
its chronic form, occurs in 50%–60% of patients. Ongoing<br />
trials <strong>are</strong> directed at optimizing pre-HSCT therapy, conditioning<br />
<strong>and</strong> GVHD prophylactic regimens to minimize toxicity<br />
while maintaining a potent cytotoxic effect with low<br />
GVHD incidence. These efforts include various approaches<br />
of pre HSCT therapy, incorporation of ATG, use of antibody-conjugated<br />
radioisotopes <strong>and</strong> post- HSCT administration<br />
of chemotherapy, primarily hypomethylating agents.<br />
R E F E R E N C E S<br />
1. Bennett JM, Catovsky D, Daniel MT et al. Proposals for the classification<br />
of the myelodysplastic syndromes. Br J Haematol 1982;51(2):<br />
189–199.<br />
2. Malcovati L, Porta MG, Pascutto C et al. Prognostic factors <strong>and</strong> life<br />
expectancy in myelodysplastic syndromes classified according to WHO<br />
criteria: a basis for clinical decision making. J Clin Oncol 2005;23<br />
(30):7594–7603.<br />
3. Malcovati L, Germing U, Kuendgen A et al. Time-dependent prognostic<br />
scoring system for predicting survival <strong>and</strong> leukemic evolution in<br />
myelodysplastic syndromes. J Clin Oncol 2007;25(23):3503–3510.<br />
4. Aless<strong>and</strong>rino EP, la Porta MG, Bacigalupo A et al. Prognostic impact<br />
of pre-transplantation transfusion history <strong>and</strong> secondary iron overload<br />
in patients with myelodysplastic syndrome undergoing allogeneic stem<br />
cell transplantation: a GITMO study. Haematologica 2010;95(3):<br />
476–484.<br />
5. Aless<strong>and</strong>rino EP, la Porta MG, Bacigalupo A et al. WHO classification<br />
<strong>and</strong> WPSS predict posttransplantation outcome in patients with myelodysplastic<br />
syndrome: a study from the Gruppo Italiano Trapianto di<br />
Midollo Osseo (GITMO). Blood 2008;112(3):895–902.<br />
6. de Witte T, Hermans J, Vossen J et al. Haematopoietic stem cell transplantation<br />
for patients with myelo-dysplastic syndromes <strong>and</strong> secondary<br />
acute myeloid leukaemias: a report on behalf of the Chronic Leukaemia<br />
Working Party of the European Group for Blood <strong>and</strong> Marrow Transplantation<br />
(EBMT). Br J Haematol 2000;110(3):620–630.<br />
7. Lim Z, Br<strong>and</strong> R, Martino R et al. Allogeneic hematopoietic stem-cell<br />
transplantation for patients 50 years or older with myelodysplastic syndromes<br />
or secondary acute myeloid leukemia. J Clin Oncol 2010;28(3):<br />
405–411.<br />
8. Suciu S, M<strong>and</strong>elli F, de Witte T et al. Allogeneic comp<strong>are</strong>d with autologous<br />
stem cell transplantation in the treatment of patients younger than<br />
46 years with acute myeloid leukemia (AML) in first complete remission<br />
(CR1): an intention-to-treat analysis of the EORTC/GIME-<br />
MAAML-10 trial. Blood 2003;102(4):1232–1240.<br />
9. Cornelissen JJ, van Putten WL, Verdonck LF et al. Results of a HOV-<br />
ON/SAKK donor versus no-donor analysis of myeloablative HLAidentical<br />
sibling stem cell transplantation in first remission acute myeloid<br />
leukemia in young <strong>and</strong> middle-aged adults: benefits for whom?<br />
Blood 2007;109(9):3658–3666.<br />
10. Burnett AK, Wheatley K, Goldstone AH et al. The value of allogeneic<br />
bone marrow transplant in patients with acute myeloid leukaemia at<br />
differing risk of relapse: results of the UK MRC AML 10 trial. Br J<br />
Haematol 2002;118(2):385–400.<br />
11. de Witte T, Hagemeijer A, Suciu S et al. Value of allogeneic versus autologous<br />
stem cell transplantation <strong>and</strong> chemotherapy in patients with<br />
myelodysplastic syndromes <strong>and</strong> secondary acute myeloid leukemia.<br />
Final results of a prospective r<strong>and</strong>omized European Intergroup Trial.<br />
Haematologica 2010;95(10):1754–1761.<br />
12. Nakai K, K<strong>and</strong>a Y, Fukuhara S et al. Value of chemotherapy before allogeneic<br />
hematopoietic stem cell transplantation from an HLA-identical<br />
sibling donor for myelodysplastic syndrome. Leukemia 2005;19(3):<br />
396–401.<br />
13. Sierra J, Perez WS, Rozman C et al. Bone marrow transplantation from<br />
HLA-identical siblings as treatment for myelodysplasia. Blood 2002;<br />
100(6):1997–2004.<br />
14. Martino R, Iacobelli S, Br<strong>and</strong> R et al. Retrospective comparison of reduced-intensity<br />
conditioning <strong>and</strong> conventional high-dose conditioning<br />
for allogeneic hematopoietic stem cell transplantation using HLA-identical<br />
sibling donors in myelodysplastic syndromes. Blood 2006;108<br />
(3):836–846.<br />
27
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
15. Sorror ML, Maris MB, Storb R et al. Hematopoietic cell transplantation<br />
(HCT)-specific comorbidity index: a new tool for risk assessment before<br />
allogeneic HCT. Blood 2005;106(8):2912–2919.<br />
16. Evens AM, Mehta J, Gordon LI. Rust <strong>and</strong> corrosion in hematopoietic<br />
stem cell transplantation: the problem of iron <strong>and</strong> oxidative stress.<br />
Bone Marrow Transplant 2004;34(7):561–571.<br />
17. Tanno T, Bhanu NV, Oneal PA et al. High levels of GDF15 in thalassemia<br />
suppress expression of the iron regulatory protein hepcidin. Nat<br />
Med 2007;13(9):1096–1101.<br />
18. Pullarkat V. Objectives of iron chelation therapy in myelodysplastic syndromes:<br />
more than meets the eye? Blood 2009;114(26):5251–5255.<br />
19. Altes A, Ruiz A, Martinez C et al. The relationship between iron<br />
overload <strong>and</strong> clinical characteristics in a Spanish cohort of 100 C282Y<br />
homozygous hemochromatosis patients. Ann Hematol 2007;86(11):<br />
831–835.<br />
20. Arm<strong>and</strong> P, Kim HT, Cutler CS et al. Prognostic impact of elevated pretransplantation<br />
serum ferritin in patients undergoing myeloablative<br />
stem cell transplantation. Blood 2007;109(10):4586–4588.<br />
21. Strasser SI, Kowdley KV, Sale GE, McDonald GB. Iron overload in<br />
bone marrow transplant recipients. Bone Marrow Transplant 1998;22<br />
(2):167–173.<br />
OP19 Treatment Options for Myelodysplastic<br />
Syndromes<br />
Elias Jabbour, Guillermo Garcia-Manero, Hagop<br />
Kantarjian, Department of Leukemia, The University of<br />
Texas M.D. Anderson Cancer Center, Houston, Texas<br />
Abstract: Myelodysplastic syndromes <strong>are</strong> a group of<br />
heterogeneous hematopoietic stem cell disorders characterized<br />
by peripheral blood cytopenias <strong>and</strong> a risk of transformation<br />
to acute myeloid leukemia. Until recently, treatment<br />
of MDS predominately consisted of supportive c<strong>are</strong> measures.<br />
However, three agents for the treatment of MDS have<br />
recently been approved: lenalidomide, decitabine <strong>and</strong> azacitidine.<br />
These agents have dramatically improved the outcomes<br />
for patients with MDS. To date, azacitidine is the<br />
only agent that has demonstrated a survival advantage when<br />
comp<strong>are</strong>d to conventional c<strong>are</strong>. Novel agents <strong>and</strong> combination<br />
regimens including lenalidomide, decitabine <strong>and</strong> azacitidine<br />
<strong>are</strong> being explored in an effort to further improve<br />
patient outcomes.<br />
Introduction<br />
Myelodysplastic syndromes (MDS) <strong>are</strong> a heterogeneous<br />
group of clonal hematopoietic stem cell disorders that impair<br />
normal hematopoiesis, resulting in a variable number<br />
of cytopenias <strong>and</strong> a potential to evolve into acute myeloid<br />
leukemia (AML). 1 With a median age at diagnosis around<br />
70 years, MDS typically affects the elderly. 1,2 Hence, there<br />
is much morbidity <strong>and</strong> mortality associated with this patient<br />
population, as patients frequently suffer from complications<br />
due to cytopenias as well as other comorbidities. The two<br />
systems used for classifying MDS <strong>are</strong> the French American<br />
<strong>and</strong> British (FAB) criteria <strong>and</strong> the more recently revised<br />
World Health Organization (WHO) classification system. A<br />
third system, the International Prognostic Scoring System<br />
(IPSS) can predict survival based on percentage of bone<br />
marrow blasts, karyotype, <strong>and</strong> number of peripheral blood<br />
cytopenias3 <strong>and</strong> is the most widely used prognostic tool for<br />
assisting with treatment decisions.<br />
For many years, supportive c<strong>are</strong> with blood products (red<br />
blood cell (RBC) <strong>and</strong> platelet transfusions), hematopoietic<br />
28<br />
growth factors, <strong>and</strong> antibiotics remained the only treatment<br />
modality for MDS patients, until the development of three<br />
novel agents that may alter the natural history of this disease.<br />
Within the past decade, the United States (U.S.) Food<br />
<strong>and</strong> Drug Administration (FDA) has approved an immunomodulatory<br />
agent, lenalidomide (Revlimid, Celgene) <strong>and</strong><br />
two hypomethylating agents, decitabine (Dacogen, Eisai,<br />
Inc.) <strong>and</strong> azacitidine (Vidaza, Celgene) for the treatment<br />
of patients with MDS. In simple practice, therapy is tailored<br />
to IPSS score with an emphasis on supportive c<strong>are</strong> therapies<br />
or lenalidomide for lower-risk patients (IPSS low-or intermediate<br />
[int]-1) <strong>and</strong> more intensive therapies such as conventional<br />
chemotherapy, allogeneic hematopoietic stem cell<br />
transplant (HST) <strong>and</strong> clinical trials, as well as hypomethylating<br />
agents, for patients with higher-risk disease (IPSS int-<br />
2 or high) or lower-risk patients with progressive disease. 3<br />
Treatment of Lower-risk MDS<br />
Supportive C<strong>are</strong><br />
Initial clinical management of lower-risk MDS patients<br />
with symptomatic anemia includes the use of erythropoiesis<br />
stimulating agents (ESA), such as epoetin alpha (Epogen,<br />
Amgen; Procrit,Ortho Biotech) or darbepoetin alfa (Aranesp,<br />
Amgen). ESAs have been shown to reduce RBC<br />
transfusion needs in MDS patients <strong>and</strong> when given with<br />
granulocyte colony-stimulating factor (G-CSF), ESAs have<br />
been shown to confer a survival advantage. 4 The likelihood<br />
of response to ESAs has been correlated with RBC transfusion<br />
needs <strong>and</strong> serum erythropoietin levels. Patients with<br />
low transfusion requirements (500 mU/mL <strong>are</strong> least likely to respond to ESAs. 5,6 Demonstrated<br />
in a recent prospective, r<strong>and</strong>omized study by the<br />
<strong>East</strong>ern Cooperative Oncology Group (ECOG), patients<br />
with low-risk MDS <strong>and</strong> low serum EPO levels experienced<br />
higher erythroid response rates when given ESAs with or<br />
without G-CSF comp<strong>are</strong>d to patients with high-risk disease.<br />
7<br />
Immunosuppressive therapy (IST)<br />
A subset of MDS patients with bone marrow failure responds<br />
to IST, which suggests that an immune-mediated<br />
pathogenesis is responsible for the cytopenias. In these patients<br />
with hypocellular bone marrows, IST with antithymocyte<br />
globulin (ATG), cyclosporine or both can be utilized.<br />
In patients with MDS, ATG alone has been shown to decrease<br />
red blood cell transfusion requirements as well as<br />
improve neutropenia <strong>and</strong> thrombocytopenia. 8 Likewise,<br />
long term outcomes in low risk MDS patients have shown<br />
higher response rates with ATG <strong>and</strong> cyclosporine (54%)<br />
than ATG alone (29%)(P=0.004). 9 Factors that have been<br />
shown to favor response to ATG include age, 8–10 HLA-DR15<br />
positivity, 8–10 <strong>and</strong> shorter duration of red blood cell transfusion<br />
requirements. 8,9 In general, patients will respond to IST<br />
within 3 to 4 months <strong>and</strong> will remain clinically stable for<br />
years, but many eventually relapse with return of cytopeni-
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
as. Recently, a phase I/II pilot study demonstrated alemtuzumab,<br />
an anti-CD52 monoclonal antibody, to produce durable<br />
responses in patients with intermediate-risk MDS who<br />
fit criteria to respond to IST. Ninety-seven percent of int-1<br />
risk patients <strong>and</strong> 57% of int-2 patients responded to alemtuzumab<br />
by 3 months, which was superior to response rates<br />
reported with ATG alone 9 . Furthermore, at 12 months follow-up,<br />
56% of responding patients had normal blood<br />
counts <strong>and</strong> 78% of patients were transfusion independent. 11<br />
Immunomodulating Therapy (IMID)<br />
Lenalidomide<br />
Lenalidomide was FDA approved in 2005 for the treatment<br />
of patients with transfusion-dependent anemia due to<br />
low- <strong>and</strong> int-1 risk MDS associated with deletion 5q karyotype<br />
(del(5q)). The approval of lenalidomide was based on<br />
two phase II studies demonstrating a high frequency of erythroid<br />
responses in patients with an isolated del(5q) or<br />
del(5q) with other abnormalities. 12,13 The majority of patients<br />
in these studies were IPSS low- or int-1 risk patients<br />
with transfusion-dependent anemia. The majority of patients<br />
achieved a hematologic response (reduced transfusion<br />
needs) <strong>and</strong> became transfusion independent. Of note, responses<br />
occurred despite karyotype complexity <strong>and</strong> patients<br />
with thrombocytopenia at baseline were less likely to respond<br />
to lenalidomide comp<strong>are</strong>d to patients with platelets<br />
>100,000 per cubic milliliter at baseline. Furthermore, a<br />
majority of patients had cytogenetic improvement, <strong>and</strong> 45%<br />
had a complete cytogenetic response. Hence, these responses<br />
illustrate lenalidomide’s effect on the biology of the disease<br />
by reversing the cytogenetic abnormalities associated<br />
with the 5q13 deletion. 13 Following these studies, Raza et al<br />
evaluated the safety <strong>and</strong> efficacy of lenalidomide in 214 patients<br />
with transfusion-dependent anemia due to lower-risk<br />
MDS without del(5q). Hematologic responses were lower<br />
than those observed in patients with del(5q), but the rate of<br />
transfusion independence was 26% <strong>and</strong> the median duration<br />
of transfusion independence was 41 weeks. 14 Lenalidomide<br />
demonstrated a potential benefit for low risk patients without<br />
del(5q) who remain transfusion dependent after supportive<br />
c<strong>are</strong> measures or for patients who <strong>are</strong> not c<strong>and</strong>idates<br />
for ESAs or more intensive therapy. Although lenalidomide<br />
is generally well tolerated, it induces significant cytopenias<br />
resulting in dose reduction or interruption in a majority of<br />
patients.<br />
Treatment of Higher-risk MDS<br />
Hypomethylating Agents<br />
Azacitidine <strong>and</strong> Decitabine<br />
Azacitidine <strong>and</strong> decitabine <strong>are</strong> both hypomethylating<br />
agents that irreversibly inhibit DNA methyltransferase, resulting<br />
in progressive loss of methylation <strong>and</strong> reactivation<br />
of tumor suppressor genes. Azacitidine was the first DNA<br />
methyltransferase inhibitor approved by the U.S. FDA in<br />
2004 for the treatment of all FAB subtypes of MDS. This<br />
approval was based on the results of three CALGB studies<br />
which evaluated the efficacy <strong>and</strong> safety of azacitidine 75<br />
mg/m2 IV or SQ x 7 days every 28 days in MDS patients. A<br />
pooled analysis of the CALGB trials (8421, 8921, <strong>and</strong> 9221)<br />
reported overall response rates (ORR) between 40 <strong>and</strong> 47%<br />
(CR 10–17%, PR 1%, HI 23–36%) for azacitidine <strong>and</strong> 17%<br />
(HI only) for BSC by IWG 2000 criteria 15 . 16<br />
Subsequently, the AZA-001 trial established an improved<br />
overall survival in patients with higher-risk MDS. In this<br />
phase III trial, 358 patients with IPSS int-2 or high-risk<br />
MDS were r<strong>and</strong>omized to receive azacitidine (75 mg/m 2 SQ<br />
daily x 7 days, every 28 days) or conventional c<strong>are</strong> (BSC,<br />
low-dose cytarabine, or intensive chemotherapy). The overall<br />
survival was significantly longer with azacitidine comp<strong>are</strong>d<br />
to conventional c<strong>are</strong> (24.5 vs. 15 months, HR 0.58;<br />
95% CI 0.43–0.77, p=0.0001) <strong>and</strong> was present regardless of<br />
MDS subtype <strong>and</strong> IPSS subgroup. The median time to AML<br />
transformation was reduced with azacitidine comp<strong>are</strong>d to<br />
conventional c<strong>are</strong> (17.8 vs. 11.5 months; HR 0.5; 95% CI<br />
0.35–0.7, p
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
mg/m 2 IV x 5 days every 4 weeks. By modified IWG criteria<br />
21 , the ORR was 51% <strong>and</strong> the median survival was 19.4<br />
months. Patients received a median of five cycles of treatment<br />
<strong>and</strong> 82% of the responses were seen by the second<br />
cycle. 22 Furthermore, the efficacy of low-dose decitabine<br />
<strong>and</strong> intensive chemotherapy was comp<strong>are</strong>d in a historical<br />
comparison of patients with higher-risk MDS at the MD<br />
Anderson Cancer Center. This study showed a similar CR<br />
rate, but significantly lower 6-week <strong>and</strong> 3-month mortality<br />
rates <strong>and</strong> improved survival with decitabine. 23<br />
Patients require several courses of azacitidine <strong>and</strong> decitabine<br />
(3–6 cycles) before demonstrating a response, so<br />
drug- <strong>and</strong> disease-induced myelosuppression can be common<br />
during this time period. Therefore, treatment should<br />
continue with both agents for a minimum of 3–4 cycles before<br />
declaring therapy a failure. Although azacitidine is an<br />
outpatient regimen, it is complicated by a 7- consecutive<br />
day regimen, necessitating weekend administration. More<br />
convenient regimens (i.e. 5 day, 5 days followed by 2 additional<br />
weekdays) have been explored in predominately lower-risk<br />
patients <strong>and</strong> response rates appear similar among the<br />
three regimens. 24,25 However, it is not certain that these regimens<br />
will lead to a survival advantage in higher-risk MDS<br />
patients.<br />
Stem Cell Transplant<br />
The only potential curative option for MDS is allogeneic<br />
stem cell transplant (HSCT), but is restricted to patients<br />
with a donor <strong>and</strong> those free from co-morbidities that may<br />
preclude them from this option. For patients older than 55<br />
years, the mortality rate is approximately 38%. For patients<br />
that <strong>are</strong> eligible for HSCT, the timing of transplantation is<br />
important. Published data identifying the optimal timing of<br />
HSCT is scant. However, a retrospective analysis of patients<br />
younger than 60 years of age who received a myeloablative<br />
conditioning regimen from a sibling donor transplant suggests<br />
that survival is better for low- <strong>and</strong> int-1 risk patients<br />
receiving a transplant at the time of disease progression<br />
rather than at diagnosis. Outcomes for int-2 <strong>and</strong> high-risk<br />
patients <strong>are</strong> better when transplantation is done as early as<br />
possible. 26 Therefore, donor screening for younger patients<br />
should begin as soon as possible regardless of the IPSS<br />
score at diagnosis. This sheds some light on the timing for<br />
younger patients. For elderly patients, reduced intensity<br />
transplants may be an option.<br />
Conclusion<br />
Patients with MDS <strong>are</strong> predominately elderly <strong>and</strong> have<br />
multiple comorbidities that preclude them of curative therapies.<br />
For many years, supportive c<strong>are</strong> measures remained<br />
the only treatment modality for MDS patients, until the development<br />
of three novel agents that may alter the biology<br />
of this disease. The recent development of three FDA-approved<br />
agents, lenalidomide, azacitidine <strong>and</strong> decitabine,<br />
have dramatically changed the MDS l<strong>and</strong>scape. Lenalidomide<br />
is remarkably effective in lower-risk patients, producing<br />
complete transfusion independence in the majority of<br />
del(5q) <strong>and</strong> some non-del(5q) patients. The hypomethylating<br />
agents, azacitidine <strong>and</strong> decitabine, <strong>are</strong> effective in the<br />
30<br />
setting of higher-risk MDS patients, producing responses in<br />
nearly half the treated patients. Comp<strong>are</strong>d to conventional<br />
c<strong>are</strong> regimens, azacitidine has significantly improved the<br />
median survival of higher-risk patients. Despite these therapeutic<br />
advances, the responses in higher-risk patients <strong>are</strong><br />
not durable, making the search for other novel agents necessary.<br />
R E F E R E N C E S<br />
1. Heaney M, Golde D. Myelodysplasia. N Engl J Med 1999;340:<br />
1649–60.<br />
2. Sekeres MA, Schoonen WM, Kantarjian H, et al. Characteristics of US<br />
patients with myelodysplastic syndromes: results of six cross-sectional<br />
physician surveys. J Natl Cancer Inst 2008;100:1542–51.<br />
3. Greenberg P, Cox C, LeBeau MM, et al. International scoring system<br />
for evaluating prognosis in myelodysplastic syndromes. Blood 1997;<br />
89:2079–88.<br />
4. Jadersten M, Malcovati L, Dybedal I, et al. Erythropoietin <strong>and</strong> granulocyte-colony<br />
stimulating factor treatment associated with improved<br />
survival in myelodysplastic syndrome. J Clin Oncol 2008;26:3607–13.<br />
5. Hellstrom-Lindberg E. Efficacy of erythropoietin in the myelodysplastic<br />
syndromes: a meta-analysis of 205 patients from 17 studies. Brit J<br />
Haemat 1995;89:67–71.<br />
6. Hellstrom-Lindberg E, Gulbr<strong>and</strong>sen N, Lindberg G, et al. A validated<br />
decision model for treating the anaemia of myelodysplastic syndromes<br />
with erythropoietin + granulocyte colony-stimulating factor: significant<br />
effects on quality of life. Br J Haematol 2003;120:1037–46.<br />
7. Greenburg PL, Sun Z, Miller KB, et al. Treatment of myelodysplastic<br />
syndrome patients with erythropoietin with or without granulocyte<br />
colony-stimulating factor: results of a prospective r<strong>and</strong>omized phase 3<br />
trial by <strong>East</strong>ern Cooperative Oncology Group (E1996). Blood 2009;<br />
114:2393–2400.<br />
8. Molldrem JJ, Leifer E, Bahceci E, et al. Antithymocyte globulin for<br />
treatment of the bone marrow failure associated with myelodysplastic<br />
syndromes, Ann Intern Med, 2002;137:156–63.<br />
9. Slo<strong>and</strong> EM, Wu CO, Greenberg P, et al. Factors affecting response <strong>and</strong><br />
survival in patients with myelodysplasia treated with immunosuppressive<br />
therapy. J Clinical Oncol 2008;26:2505–11.<br />
10. Saunthararajah Y, Nakamura R, Wesley R, et al. A simple method to<br />
predict response to immunosuppressive therapy in patients with myelodysplastic<br />
syndrome. Blood 2003;102:3025–7.<br />
11. Slo<strong>and</strong> EM, Olnes MJ, Shenoy A, et al. Alemtuzumab treatment of intermediate-1<br />
myelodysplasia patients is associated with sustained improvement<br />
in blood counts <strong>and</strong> cytogenetic remissions. J Clin Oncol<br />
2010;28:5166–73.<br />
12. List A, Kurtin S, Roe DJ, et al. Efficacy of lenalidomide in myelodysplastic<br />
syndromes. N Engl J Med 2005;352: 549–57.<br />
13. List A, Dewald G, Bennett J, et al. Lenalidomide in the myelodysplastic<br />
syndrome with chromosome 5q deletion. New Engl J Med 2006;355:<br />
1456–65.<br />
14. Raza A, Reeves JA, Feldman EJ, et al. Phase 2 study of lenalidomide in<br />
transfusion-dependent, low-risk, <strong>and</strong> intermediate-1- risk myelodysplastic<br />
syndromes with karyotypes other than deletion 5q. Blood 2008;<br />
111:86–93.<br />
15. Cheson BD, Bennett JM, Kantarjian H, et al. Report of an international<br />
working group to st<strong>and</strong>ardize response criteria for myelodysplastic<br />
syndromes. Blood 2000;96:3671–4.<br />
16. Silverman LR, McKenzie DR, Peterson BL, et al. Further analysis of<br />
trials with azacitidine in patients with myelodysplastic syndrome: studies<br />
8421, 8921, <strong>and</strong> 9221 by the Cancer <strong>and</strong> Leukemia Group B. J Clin<br />
Oncol 2006;24:3895–3903.<br />
17. Fenaux P, Mufti GJ, Hellstrom-Lindberg E, et al. Efficacy of azacitidine<br />
comp<strong>are</strong>d with that of conventional c<strong>are</strong> regimens in the treatment<br />
of higher-risk myelodysplastic syndromes: a r<strong>and</strong>omized, open-label,<br />
phase III study. Lancet Oncol 2009;10:223–32.<br />
18. Kantarjian H, Issa JP, Rosenfeld CS, et al. Decitabine improves patient<br />
outcomes in myelodysplastic syndromes: results of a phase III r<strong>and</strong>omized<br />
study. Cancer 2006;106:1794–803.<br />
19. WijerMans P, Suciu S, Liliana Baila L, et al. Low dose decitabine versus<br />
best supportive c<strong>are</strong> in elderly patients with intermediate or high<br />
risk MDS not eligible for intensive chemotherapy: final results of the
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
r<strong>and</strong>omized phase III study (06011) of the EORTC Leukemia <strong>and</strong> German<br />
MDS Study Groups. Blood 2008;112: abstract 226.<br />
20. Kantarjian H, Oki Y, Garcia-Manero G, et al. Results of a r<strong>and</strong>omized<br />
study of 3 schedules of low-dose decitabine in higher-risk myelodysplastic<br />
syndrome <strong>and</strong> chronic myelomonocytic leukemia. Blood 2007;<br />
109:52–7.<br />
21. Cheson BD, Greenberg PL, Bennett JM, et al. Clinical application <strong>and</strong><br />
proposal for modification of the International Working Group (IWG)<br />
response criteria in myelodysplasia. Blood 2006;108:419–25.<br />
22. Steensma DP, Baer MR, Slack JL, et al. Multicenter study of decitabine<br />
administered daily for 5 days every 4 weeks to adults with myelodysplastic<br />
syndromes: the alternative dosing for outpatient treatment<br />
(ADOPT) trial. J Clin Oncol 2009;27: 3842–8.<br />
23. Kantarjian HM, O’Brien S, Huang X, et al. Survival advantage with<br />
decitabine versus intensive chemotherapy in patients with higher risk<br />
myelodysplastic syndrome: comparison with historical experience.<br />
Cancer 2007;109:1133–7.<br />
24. Lyons RM, Cosgriff TM, Modi SS, et al. Hematologic response to three<br />
alternative dosing schedules of azacitidine in patients with myelodysplastic<br />
syndromes. J Clin Oncol 2009; 27:1850–6.<br />
25. Martin MG, Walgren RA, Procknow E, et al. A phase II study of 5-day<br />
intravenous azacitidine in patients with myelodysplastic syndromes.<br />
Am J Hematol 2009;84: 560–4.<br />
26. Cutler CS, Lee SJ, Greenberg P, et al. A decision analysis of allogeneic<br />
bone marrow transplantation for the myelodysplastic syndromes: delayed<br />
transplantation for low-risk myelodysplasia is associated with<br />
improved outcome. Blood 2004;104:579–85.<br />
OP20 Pathophysiology of MPNs <strong>and</strong> role of JAK2<br />
mutations<br />
Richard A Van Etten, Molecular Oncology Research<br />
Institute & Division of Hematology/Oncology, Tufts<br />
Medical Center, Boston, MA, USA<br />
Since the discovery of the somatic JAK2 V617F mutation in<br />
myeloproliferative neoplasms (MPNs) in 2005, there have<br />
been dramatic advances in our underst<strong>and</strong>ing of the molecular<br />
pathogenesis of the non-CML MPNs. We now appreciate<br />
that JAK2 mutations (either JAK2 V617F or mutations in<br />
exon 12 of JAK2) <strong>are</strong> found in virtually all patients with<br />
polycythemia vera, <strong>and</strong> JAK2 mutation testing has become<br />
a central part of the diagnostic evaluation of patients with<br />
suspected MPN. Yet, there <strong>are</strong> still significant gaps in our<br />
knowledge <strong>and</strong> several central questions that remain unanswered.<br />
One unresolved issue is how one mutation<br />
(JAK2 V617F ) can cause distinct MPN phenotypes (PV, ET,<br />
<strong>and</strong> PMF) in different patients. A partial answer to this question<br />
has been provided by transgenic <strong>and</strong> retroviral mouse<br />
models wherein the JAK2 V617F kinase is expressed in mouse<br />
hematopoietic cells. These models lend experimental support<br />
for the concept that expression of JAK2 V617F at levels<br />
similar to or higher than endogenous JAK2 causes erythrocytosis<br />
whereas lower expression favors thrombocytosis,<br />
but several variables, including origin of JAK2 <strong>and</strong> mouse<br />
strain, confound the picture. Contributions from other somatic<br />
mutations <strong>and</strong> possible germline disease-modifying<br />
alleles <strong>are</strong> other potential mechanisms for phenotypic heterogeneity.<br />
Another question is whether there <strong>are</strong> cooperating<br />
mutations that complement or precede the acquisition of<br />
a JAK2 mutation. Several lines of evidence point to the existence<br />
of one or more predisposing mutations in MPNs:<br />
families with occurrence of several different MPNs in multiple<br />
members, patients (mainly ET) with clonal hematopoiesis<br />
whose JAK2 V617F allele burden is less than 50%,<br />
JAK2 V617F patients with other somatic mutations (eg, del20q)<br />
in JAK2 +/+ cells, <strong>and</strong> JAK2 V617F patients who progress to<br />
AML where the blasts lack the JAK2 V617F mutation. C<strong>and</strong>idate<br />
gene <strong>and</strong> genome-wide SNP analyses have identified<br />
correlations with disease phenotype <strong>and</strong> discovered a remarkable<br />
association of an intronic JAK2 allele (rs10974944 or<br />
46/1) that significantly predisposes carriers to develop<br />
JAK2 V617F –positive MPN, where the mutation arises preferentially<br />
on the same JAK2 gene as the SNP. The mechanism<br />
(»hypermutability« vs »fertile ground«) through which this<br />
occurs is unclear, but the same haplotype predisposes to<br />
MPL mutations in PMF. Recent studies have also identified<br />
somatic mutations that can occur in concert with JAK2/<br />
MPL mutations: TET2 loss-of-function mutations in 10%,<br />
ASXL1 mutations in 8–10%, IDH1/2 mutations in 3–5%,<br />
<strong>and</strong> EZH2 mutations in 10–15% of MPN patients. The same<br />
mutations can be found in MDS <strong>and</strong> AML patients, indicating<br />
that these alleles can be associated with other myeloid<br />
neoplasms. Clonal analysis of malignant hematopoietic<br />
colonies demonstrates that these mutations can either precede<br />
or develop after a JAK2 mutation; in some cases<br />
(TET2, IDH1/2) they occur most commonly at time of progression<br />
to AML. Emerging functional data <strong>and</strong> genetic<br />
studies in mice suggest these mutations affect the epigenetic<br />
state of the leukemic cells. Results from ongoing genomic<br />
deep sequencing of MPN patient genomes <strong>are</strong> expected to<br />
shed additional light on the pathogenesis of JAK2 V617F –negative<br />
MPN. Finally, the question remains as to the overall<br />
utility of JAK2 as a target for therapy in the MPNs. Clinical<br />
results with small molecule JAK2 inhibitors (summarized<br />
by Dr. Verstovsek in this Symposium) demonstrate that all<br />
six of the inhibitors in clinical trials <strong>are</strong> effective at reducing<br />
spleen size, reversing elevated proinflammatory cytokines,<br />
<strong>and</strong> improving quality of life <strong>and</strong> performance status in<br />
MPN patients, independent of JAK2 mutation status. However,<br />
the effects of these agents on JAK2 allele burden, myelofibrosis,<br />
cytopenias <strong>and</strong> transfusion requirements, thrombohemorrhagic<br />
complications, <strong>and</strong> risk of progression to<br />
AML in MPN <strong>are</strong> less clear. There appears to be a fundamental<br />
difference between JAK2 <strong>and</strong> ABL1 as therapeutic<br />
targets in MPN <strong>and</strong> CML, respectively. Recent translational<br />
research has begun to identify some of the mechanisms involved,<br />
including Epo-dependent sensitivity of malignant<br />
JAK2 V617F –positive hematopoietic progenitors to JAK2 inhibitors,<br />
<strong>and</strong> a possible compensatory role of other JAK<br />
family members.<br />
OP21 JAK2 inhibitors<br />
Srdjan Verstovsek, MD Anderson Cancer Center, Leukemia<br />
Department, Houston, Texas, USA<br />
Myelofibrosis: Myelofibrosis (MF) is a Philadelphia chromosome-negative<br />
myeloproliferative neoplasm (MPN) of<br />
the bone marrow. This life-threatening disease is characterized<br />
by splenomegaly <strong>and</strong> burdensome symptoms, including<br />
fatigue, night sweats, pruritus, abdominal pain, <strong>and</strong><br />
cachexia. 1 The annual incidence of MF is about 1.0 per<br />
100,000 population, <strong>and</strong> patients have a median life expectancy<br />
of 2 to 11 years due to complications of progressive<br />
31
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
splenomegaly, hepatomegaly with liver failure, portal hypertension,<br />
gastrointestinal bleeding, pulmonary hypertension,<br />
infections, <strong>and</strong> malnutrition. 3 Allogeneic stem cell<br />
transplantation (alloSCT) offers the only potentially cure<br />
for MF, but is associated with a high rate of transplant-related<br />
mortality. 4 Other treatments for MF provide only temporary<br />
<strong>and</strong>/or suboptimal relief of constitutional symptoms,<br />
anemia, <strong>and</strong> splenomegaly, <strong>and</strong> do not generally change the<br />
natural progression of the disease.<br />
JAK2 as a Therapeutic Target in MF: Dysregulation of<br />
the JAK2-STAT pathway is a central pathogenic component<br />
in MF. Some clinical features of MF (anemia, splenomegaly,<br />
risk of transformation to acute myeloid leukemia) have<br />
been related to JAK2 V617F mutation or allele burden; 5–7 however,<br />
the gain-of-function JAK2 V617F mutation is found in<br />
only about 50% of MF patients. Other mutations that result<br />
in activation of JAK-STAT signaling have been detected,<br />
including mutations in exon 12 of the JAK2 gene 8 <strong>and</strong> the<br />
MPL515 mutation in the thrombopoietin receptor. 9<br />
JAK2 Inhibitors in MF: The initial reports of the JAK2 V617F<br />
mutation in MPNs led to the development of ruxolitinib as<br />
the first potent, selective, oral JAK1 <strong>and</strong> JAK2 inhibitor for<br />
clinical use in MF patients. Currently, there <strong>are</strong> several<br />
JAK2 inhibitors in development. Ruxolitinib is currently the<br />
only JAK inhibitor to complete phase III trials in MF.<br />
The safety <strong>and</strong> efficacy of ruxolitinib were evaluated in a<br />
phase I/II study in 153 high- or intermediate-risk patients<br />
with primary MF, post-polycythemia vera (PV) MF, or postessential<br />
thrombocythemia (ET) MF. The median duration<br />
of follow-up was 14.7 months. 11 Phase I results established<br />
25 mg twice daily as the maximum tolerated dose (MTD),<br />
with thrombocytopenia as the dose-limiting toxicity (DLT).<br />
Phase II data established an optimized dose of 15 mg twice<br />
daily (10 mg twice daily if platelets were 100–200 x 10 9 /L)<br />
with monthly dose escalations up to 25 mg twice daily (if no<br />
response <strong>and</strong> no toxicity were observed). Approximately<br />
half of the patients achieved a ≥ 50% reduction in splenomegaly<br />
by palpation. Magnetic resonance imaging (MRI)<br />
confirmed reductions in spleen size. A 50% reduction in<br />
spleen size by palpation was consistent with a 35% reduction<br />
in volume by MRI. In addition, ruxolitinib improved<br />
debilitating MF-related symptoms, including fatigue, night<br />
sweats, <strong>and</strong> pruritus as assessed by the Myelofibrosis Symptom<br />
Assessment Form (MFSAF). 12 Among biomolecular<br />
parameters associated with disease activity, there was a reduction<br />
in plasma levels of proinflammatory cytokines (IL-<br />
6, TNF-α), an increase in plasma levels of leptin <strong>and</strong> erythropoietin,<br />
<strong>and</strong> a dose- <strong>and</strong> time-dependent reduction in constitutively<br />
phosphorylated STAT3 <strong>and</strong>/or STAT5.<br />
COMFORT-I is a r<strong>and</strong>omized, double-blind, placebocontrolled<br />
phase III trial of ruxolitinib in patients with MF. 13<br />
The primary endpoint was the proportion of patients achieving<br />
a ≥ 35% reduction in spleen volume at 24 weeks of<br />
treatment as assessed by MRI. The study met this endpoint:<br />
41.9% of patients had a ≥ 35% reduction in spleen volume<br />
versus 0.7% in the placebo group (P
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
has been confirmed by long term analysis of a subgroup of<br />
the study group who have now been followed up to 91<br />
months (4). Earlier studies had shown safety <strong>and</strong> efficacy of<br />
anagrelide in younger patients (5,6). Meanwhile, long term<br />
data from registries also covering older patients in Austria<br />
(7), Spain (8), Czech Republic (9) or Germany (10) confirm<br />
that anagrelide is well tolerated <strong>and</strong> effective in reducing<br />
platelets to target levels in patients with ET. Addressing the<br />
special issue of cardiovascular adverse events a recent Italian<br />
study has demonstrated a low impact of this concern (11). In<br />
some patients deterioration of renal function is observed under<br />
long term anagrelide treatment: in such patients comedication<br />
or evidence for transformation into myelofibrosis<br />
have to be checked since CMPN can cause glomerulopathy<br />
(12). Progression of bone marrow fibrosis (which is not present<br />
in patients diagnosed according to the WHO classification)<br />
cannot be halted with anagrelide (13).<br />
Taken together, anagrelide is a valuable drug for the treatment<br />
of patients with ET.<br />
R E F E R E N C E S<br />
1. Tefferi A. Polycythemia vera <strong>and</strong> essential thrombocythemia: 2011 update<br />
on diagnosis, risk stratification <strong>and</strong> management. Amer J Hematol<br />
2011;86:293–301.<br />
2. Petrides PE. Anagrelide: What was new in 2005 <strong>and</strong> 2006? Sem Thrombosis<br />
Research 2006;32:399–408.<br />
3. Petrides PE et al. ANAHYDRET: A European multicenter prospective<br />
phase 3 study: Noninferiority of anagrelide comp<strong>are</strong>d to hydroxyurea<br />
in newly WHO diagnosed ET patients.Haematologica 2009;94:440.<br />
4. Gisslinger H et al., in preparation.<br />
5. Storen EC, Tefferi A. Long term use of anagrelide in young patients<br />
with essential thrombocythemia. Blood 2001;97:863–866.<br />
6. Mazzucconi MG et al. A long term study of young patients with essential<br />
thrombocythemia treated with anagrelide. Haematologica 2004;<br />
89:1306–1313.<br />
7. Steurer M et al. Longterm experience with anagrelide (Thromboreductin®)<br />
in the treatment of essential thrombocythemia: data from an international<br />
regsitry. Blood, ASH abstract 2010;32828.<br />
8. Giralt M et al. Retrospective analysis of the efficacy <strong>and</strong> tolerability of<br />
anagrelide in patients with essential thrombocythemia: Spanish registry<br />
of essential thrombocythemia. Med Clin (Barc) 2009;133:86–90.<br />
9. Penka P et al. Essential thrombocythemia <strong>and</strong> other myeloproliferative<br />
disorders treated with thromboreductin: a report from the data base registry.<br />
Vnitr Lek 2010;56:503–512.<br />
10. Petrides PE, Siegel P. Unpublished.<br />
11. Gugliotta L et al. Low impact of cardiovascular adverse events on<br />
anagrelide treatment discontinuation in a cohort of 232 patients with<br />
essential thrombocythemia. Leukemia Research 2011, online.<br />
12. Siad SM et al. Myeloproliferative neoplasms cause glomerulopathy.<br />
Kidney Int 2011, online.<br />
13. Hultdin M et al. Progression of bone marrow fibrosis in patients with<br />
essential thrombocythemia <strong>and</strong> polycythemia vera during anagrelide<br />
treatment. Med Oncol 2007;24:63–70.<br />
OP23 Treatment of Polycythemia Vera<br />
With Interferon<br />
Richard T. Silver, Weill Cornell Medical College, USA<br />
Certain diseases deserve intense medical scrutiny because<br />
the abnormalities encountered stimulate investigation,<br />
which greatly enhance our underst<strong>and</strong>ing of physiologic<br />
mechanisms. The myeloproliferative disorders, including<br />
polycythemia vera (PV), fall into this category. Two recent<br />
major advances have been made in PV: the discovery of the<br />
JAK2 V617F mutation which is useful for diagnosis <strong>and</strong> as a<br />
marker for treatment effect, <strong>and</strong> the use of interferons as a<br />
therapeutic modality.<br />
Although hydroxyurea remains the most commonly used<br />
cytoreductive treatment for PV, limitations of its use have<br />
not received adequate attention. These include its leukemogenic<br />
effect after 10–15 years of use, development of squamous<br />
cell carcinoma of the skin, skin ulcers, <strong>and</strong> other<br />
forms of oral, hepatic <strong>and</strong> renal toxicity. For the younger<br />
patient, hydroxyurea is not appropriate because of its effect<br />
on embryogenesis.<br />
The use of recombinant interferon (rIFN) as a therapeutic<br />
measure has led to significant improvement in the treatment<br />
of all myeloprolifetrative diseases in the past 20 years, <strong>and</strong><br />
especially polycythemia vera. This has been based on appreciation<br />
that a low dose of rIFN used over a prolonged<br />
period may have a significant therapeutic effect. In our presentation,<br />
we will review some of the salient features pertaining<br />
to clinical use of interferon in PV.<br />
Of the two types of interferon, type I (which includes alpha<br />
<strong>and</strong> beta interferon) <strong>and</strong> type II (which includes gamma<br />
interferon), it is alpha interferon which is primarily used in<br />
hematologic practice. Interferon has a wide range of effects<br />
of interest to the hematologist: It augments the functional<br />
activity of T-cells, macrophages, <strong>and</strong> natural killer cells; it<br />
induces dendritic differentiation; it promotes apoptosis of a<br />
variety of tumor cell types; it suppresses the ability of normal<br />
hematopoietic progenitor cells to form colonies in vitro;<br />
it may stimulate dormant hematopoietic cells to cycle, thus<br />
making them more susceptible to the effect of chemotherapeutic<br />
agents. Interferon also inhibits erythroid progenitors<br />
<strong>and</strong> erythroid burst-forming units in vitro <strong>and</strong> produces<br />
morphologic <strong>and</strong> biochemical changes in megakaryocytes<br />
including megakaryocytic proliferation <strong>and</strong> thrombopoeitin-induced<br />
TPO receptor signaling. Interferon alpha antagonizes<br />
platelet derived growth factor. These reasons provide<br />
a physiologic basis for its use in PV.<br />
Two general types of interferons have been clinically<br />
used. In the past, the largest experience has been with interferon<br />
alpha 2b, but more recently with pegylated interferon<br />
alpha 2a (Peg A). More than 350 patients with PV have been<br />
reported with interferon, the largest number (55) treated<br />
with interferon (rIFN) alpha-2b by Silver. 1 Reduction in<br />
phlebotomy rate occurred in 100% of patients <strong>and</strong> freedom<br />
from phlebotomy in 96%. 1 Kiladjian reported on the effects<br />
of Peg A in 37 patients also with a 100% reduction in phlebotomy<br />
rate <strong>and</strong> 97% freedom from phlebotomy. 2 Qualitative<br />
side effects in general have been the same with either<br />
type of interferon – i.e. headache, malaise, fever, chills, fatigue,<br />
myalgia being the most common but less severe with<br />
Peg A than with rIFNα2b. With Peg A, significant reduction<br />
in JAK2 V617F median allele burden at 24 months has been reported<br />
by Kiladjian (45% to 5%) 2 <strong>and</strong> by Quintás-Cardama<br />
(64% to 12%) 3 but not by Silver who reported that hematologic<br />
response, both complete <strong>and</strong> partial, did not correlate<br />
with the molecular response with either Peg A or rIFNα2b<br />
treated patients. 4 However, drop out rates for the three investigations<br />
related to toxicity were 24%, 10%, <strong>and</strong> 6% respectively.<br />
2,3 Thus, it remains to be determined whether or<br />
33
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
not over the long-term there will be significant difference in<br />
the course of disease between a higher discontinuation rate<br />
<strong>and</strong> a lower JAK2 V617F burden comp<strong>are</strong>d to lower discontinuation<br />
rate <strong>and</strong> a higher molecular burden.<br />
In the interferon trials reported by both Silver <strong>and</strong> Kiladjian,<br />
there was a striking decrease in the number of CNS<br />
vascular events comp<strong>are</strong>d to other published data. Whether<br />
this represents a stricter attention to hematocrit levels as<br />
practiced by both the French <strong>and</strong> American groups or some<br />
unique biologic effect of interferon remains to be determined.<br />
Noteworthy <strong>are</strong> two international trials of the Myeloproliferative<br />
Disease Research Consortium with PEG-interferon<br />
alpha 2a which will open soon. One study comp<strong>are</strong>s Peg<br />
A to hydroxyurea in high risk PV <strong>and</strong> ET patients. The other<br />
uses Peg A as a salvage therapy for PV <strong>and</strong> ET in patients<br />
resistant or intolerant to hydroxyurea. Hopefully, these studies<br />
will provide answers to some of the questions raised in<br />
this presentation.<br />
R E F E R E N C E S<br />
1. Silver RT. Long-term effects of the treatment of polycythemia vera with<br />
recombinant interferon-alpha. Cancer 2006;107:451–458.<br />
2. Kiladjian JJ, Cassinat B, Chevret S, Turlure P, Cambier N, Roussel M, et<br />
al. Pegylated interferon-alfa-2a induces complete hematologic <strong>and</strong> molecular<br />
responses with low toxicity in polycythemia vera. Blood 2008;<br />
112:3065–3072.<br />
3. Quintas-Cardama A, Kantarjian H, Manshouri T, Manshouri T, Luthra<br />
R, Estrov Z, et al. Pegylated interferon alfa-2a yields high rates of hematologic<br />
<strong>and</strong> molecular response in patients with advanced essential<br />
thrombocythemia <strong>and</strong> polycythemia vera. J Clin Oncol. 2009;27:5418–<br />
5424.<br />
4. Silver RT, V<strong>and</strong>ris K, Wang YL, Adriano F, Jones AV, Christos PJ, et al.<br />
JAK2(V617F) allele burden in polycythemia vera correlates with grade<br />
of myelofibrosis, but is not substantially affected by therapy. Leuk Res<br />
2011;35:177–182.<br />
OP24 Allogeneic Hematopoietic Stem Cell<br />
Transplantation for Myelofi brosis<br />
Nicolaus Kröger, Department of Stem Cell<br />
Transplantation, University Hospital Hamburg-Eppendorf,<br />
Hamburg, Germany<br />
Hematopoietic stem cell transplantation offers a curative<br />
therapy for patients with myelofibrosis. Due to toxicity, allografting<br />
following myeloablative regimens is mainly applicable<br />
to young patients. Two larger studies reported a 1<br />
year non-relapse mortality of 27% <strong>and</strong> 31%, resulting in a 5<br />
year estimated survival of 47% <strong>and</strong> 58%. (Guardiola et al.<br />
1999 <strong>and</strong> Deeg et al. 2003). The major risk factors in the<br />
myeloablative studies were advanced age, advanced disease<br />
status according to Lille-score, <strong>and</strong> mismatched unrelated<br />
donors.<br />
With the introduction of dose-reduced conditioning using<br />
busulfan or melphalan with fludarabin, transplantation became<br />
tolerable also in older patients. Improvement in management<br />
of transplant-related complications as well as increasing<br />
numbers of volunteer stem cell donors lead to an<br />
increased use of alternative donors. In the so far largest prospective<br />
multicenter study of the Chronic Leukemia Working<br />
Party of the European Group for Blood <strong>and</strong> Marrow<br />
34<br />
Transplantation (EBMT)103 patients were included <strong>and</strong><br />
transplanted after a dose reduced conditioning consisting of<br />
busulfan (10mg/kg) /fludarabin <strong>and</strong> in vivo T-cell depletion<br />
with ATG. All but 2 patients showed leukocyte <strong>and</strong> platelets<br />
engraftment, <strong>and</strong> the cumulative incidence of TRM at 1 year<br />
was 16% which was significantly higher with HLA-mismatched<br />
donors. At 3 years, the cumulative incidence of<br />
relapse was 22% <strong>and</strong> significantly influenced by the risk<br />
status according to Lille. After a median follow up of 33<br />
months (range, 12–76), five-year estimated OS <strong>and</strong> DFS<br />
was 67% <strong>and</strong> 51% respectively. In the multivariate analysis,<br />
age>55 years <strong>and</strong> HLA-mismatched transplantation significantly<br />
predicted inferior overall survival (Kröger et al.<br />
2009).<br />
At the histomorphological level, a complete or near complete<br />
resolution of bone marrow fibrosis resolution was seen<br />
in 59% of patients by day 100, 90% by day 180, <strong>and</strong> 100%<br />
by one year post-AHSCT<br />
Considering the sufficient evidence available that even in<br />
the case of massive splenomegaly donor cells engraftment<br />
<strong>and</strong> full donor chimerism <strong>are</strong> achievable, together with the<br />
significant risks associated with splenectomy pre-transplant<br />
such as surgical risk, delayed immunreconstitution after<br />
AHSCT <strong>and</strong> possibly the reported increased relapse, splenectomy<br />
is not generally recommended in transplant-eligible<br />
patients.<br />
Through the discovery of new disease specific mutations,<br />
such as JAK2V617F or MPL, close monitoring of residual<br />
disease became feasible in many patients <strong>and</strong> can be used a<br />
guide for adoptive immunotherapy such as donor lymphocyte<br />
infusion (Achalby et al 2010) achieving of new transplant-derived<br />
models to estimate risk status <strong>and</strong> possible<br />
outcome in every individual patient <strong>and</strong> help in therapy decision<br />
<strong>and</strong> determine optimal timing of stem cell transplantation.<br />
Such a tool may optimally include not only clinicomorphological<br />
characteristics but also other potentially relevant<br />
factors such as cytogenetics <strong>and</strong> novel molecular<br />
markers.<br />
R E F E R E N C E S<br />
1. Alchalby H, Badbaran A, Zabelina T et al. (2010) Impact of JAK2V617F<br />
mutation status, allele burden, <strong>and</strong> clearance after allogeneic stem cell<br />
transplantation for myelofibrosis. Blood 116:3572–3581.<br />
2. Deeg HJ, Gooley TA, Flowers ME et al. (2003) Allogeneic hematopoietic<br />
stem cell transplantation for myelofibrosis. Blood 102:3912–3918.<br />
3. Guardiola P, Anderson JE, B<strong>and</strong>ini GW et al. (1999) Allogeneic stem<br />
cell transplantation for agnogenic myeloid metaplasia: a European<br />
Group for Blood <strong>and</strong> Marrow Transplantation, Societe Francaise de<br />
Greffe de Moelle, Gruppo Italiano per il Trapianto del Midollo Osseo,<br />
<strong>and</strong> Fred Hutchinson Cancer Research Center Collaborative Study.<br />
Blood 93:2831–2838.<br />
4. Kröger N, Alchalby H, Klyuchnikov E (2009a) et al. JAK2-V617F-triggered<br />
preemptive <strong>and</strong> salvage adoptive immunotherapy with donor-lymphocyte<br />
infusion in patients with myelofibrosis after allogeneic stem<br />
cell transplantation. Blood 113:1866–1868.<br />
5. Kröger N, Holler E, Kobbe G et al. (2009 b) Allogeneic stem cell transplantation<br />
after reduced-intensity conditioning in patients with myelofibrosis:<br />
a prospective, multicenter study of the Chronic Leukemia Working<br />
Party of the European Group for Blood <strong>and</strong> Marrow Transplantation<br />
(EBMT). Blood 114:5264–5270.<br />
6. Kröger N, Badbaran A, Holler E et al. (2007 a) Monitoring of the JAK2-<br />
V617F mutation by highly sensitive quantitative real-time PCR after allogeneic<br />
stem cell transplantation in patients with myelofibrosis. Blood<br />
109:1316–1321.
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
OP25 Jumping 1q Translocations <strong>are</strong> Clonal<br />
Markers of Myeloid Malignancies<br />
Associated with Transformation to AML<br />
Vesna Najfeld, J. Tripodi, A. Scalise, L. Silverman, R.T.<br />
Silver, S. Fruchtman, R. Hoffman, Tumor Cytogenetics<br />
Laboratory, Departments of Pathology <strong>and</strong> Medicine, The<br />
Myeloproliferative Disorders Program, The Tisch Cancer<br />
Institute, The Mount Sinai School of Medicine, New York,<br />
NY, Department of Med., Cornell-Weill School of<br />
Medicine, New York, USA<br />
Jumping translocations (JT) <strong>are</strong> r<strong>are</strong> cytogenetic phenomenon<br />
resulting from a part of one chromosome translocating<br />
to several recipient chromosomes, creating multiple<br />
related clones within a single patient. Due to their rarity in<br />
myeloid malignancies it is uncertain whether this abnormality<br />
contributes to disease progression. We retrospectively<br />
investigated 1qJT in 23 patients with myeloproliferative neoplasm<br />
(MPN) <strong>and</strong> myelodysplastic syndrome (MDS) who<br />
were evaluated in the Tumor Cytogenetics Laboratory at the<br />
Mount Sinai School of Medicine between 1984 <strong>and</strong> 2009.<br />
Diagnoses were made according to the World Health Organization<br />
classification criteria. Table1 outlines the characteristics<br />
of the 23 patients with 1qJT. Among 512 studied<br />
patients with MPN (polycythemia vera [PV]=361, primary<br />
myelofibrosis [PMF]=151), 3 (PV=2, PMF=1) were identified<br />
who had 1qJT at diagnosis.<br />
Table 1. Characteristics of 23 patients with Jumping 1q translocations<br />
MPN<br />
No. (%)<br />
MDS<br />
No. (%)<br />
Baseline Analysis<br />
Patients 7 16<br />
Patients with 1qJT 3 5<br />
Normal Karyotype 0 (0) 8 (50)<br />
Abnormal Karyotype 7 (100) 8 (50)<br />
Transformation to AML<br />
Sequential Analysis<br />
2 (29) 4 (25)<br />
Patients 5* 12**<br />
Specimens 24 101<br />
Normal Karyotype 0 (0) 7 (67)<br />
Transformation to AML 4 10<br />
Mean Time from 1qJT to AML in Months (Range) 8 (0–16) 9 (0–42)<br />
Mean Follow up in Months (Range) 65 (2–132) 34 (8–78)<br />
Mean Time (Months) to develop 1qJT (Range) 47 (0–109) 21 (0–58)<br />
* One patient (#3) had 1qJT at diagnosis <strong>and</strong> had one follow-up study<br />
** One patient (#20) had 1qJT at diagnosis <strong>and</strong> 4 sequential studies up to 18<br />
months after the intial study<br />
Additionally four of 165 (PV=96, PMF=69) patients with<br />
MPN-acquired 1qJT over a period of 11 years (the overall<br />
incidence was 1.3% or 4.2% among cytogenetically abnormal).<br />
The mean follow up of the five patients was 65 months<br />
<strong>and</strong> the mean time from diagnosis to the development of<br />
1qJT was 47 months. Four of these five patients transformed<br />
to acute myeloid leukemia (AML) within 8 months of acquiring<br />
1qJT. Patient 6 is particularly informative, he ini-<br />
tially had i(9)(p10) but developed a der(6)t(1;6)(q21;q27)<br />
subclone in two of 18 cells after 6 years. Over time the subclone<br />
involved 100% of cells. The patient was treated solely<br />
with interferon. The most recent analysis revealed 1qJT to<br />
chromosomes 6, 7, Y as well as dup(1)(q21). The initial cytogenetic<br />
analysis of 16 patients with MDS/AML revealed a<br />
normal karyotype in 8 patients <strong>and</strong> an abnormal karyotype<br />
in the other eight patients. Out of 532 studied between 1986<br />
<strong>and</strong> 2009 we identified five patients who had 1qJT at diagnosis.<br />
Four of these five patients presented at the time of<br />
transformation of MDS to AML <strong>and</strong> the fifth patient was<br />
studied after autologous stem cell transplantation. Follow<br />
up studies revealed 11 patients developed 1qJT (the overall<br />
incidence was 3%, or 6% among cytogenetically abnormal).<br />
The mean time to develop 1qJT was 34 months. Among<br />
eight patients with an initial normal karyotype the average<br />
time to acquire 1qJT was 27 months. Once 1qJT were documented<br />
they persisted for an average 9 months in 14 of<br />
(88%) before evolving into AML. Our data do not provide<br />
any common pattern as to the role of the partner chromosomes<br />
in 1qJT. However, 81% of recipient breakpoints<br />
were localized in pericentric regions while the remaining<br />
19% were telomeric fusions. The presence of 1qJT at diagnosis<br />
or the subsequent acquisition of 1qJT appears to be<br />
associated with imminent transformation to AML in patients<br />
with MPN <strong>and</strong> MDS after an average of 8 <strong>and</strong> 9<br />
months, respectively. Once acquired, the prognosis tended<br />
to be dependent on a copy number of 1q indicating that<br />
1qJT was associated with both disease progression <strong>and</strong> poor<br />
prognosis.This work was supported in part by the grant P01<br />
CA1 108671 from the National Institutes of Health.<br />
OP26 Prognostic Tools in CML<br />
Rudiger Hehlmann, Universität Heidelberg, Germany<br />
Prognosis of CML has improved due to the availability of<br />
several new first-line treatment options (optimized imatinib,<br />
2 nd generation TKI first-line). Prediction of prognosis in<br />
CML is currently estimated by criteria at diagnosis <strong>and</strong> by<br />
response to treatment.<br />
At diagnosis, Sokal <strong>and</strong> EUTO scores have been commonly<br />
used for prognostic prediction in the pre-imatinib<br />
era. Since imatinib has changed the natural course of the<br />
disease, a new score (EUTOS score) has been developed<br />
from imatinib treated patients which uses only two variables<br />
(spleen size <strong>and</strong> percentage of basophils in the peripheral<br />
blood) <strong>and</strong> separates a high from a low risk group. The<br />
EUTOS score has a predictive value which is about 1. 4<br />
times more powerful than that of the Sokal score (Hasford<br />
et al, Blood prepublished May 2, 2011).<br />
Under therapy, the gold st<strong>and</strong>ard for prognostic prediction<br />
has been complete cytogenetic remission (CCR). Recently<br />
also major molecular remission (MMR) at 12 months<br />
after start of treatment has been associated with better<br />
survival (Hehlmann et al., JCO 29: 1634–1642, 2011).<br />
MMR is a prerequisite for complete molecular remission<br />
which is considered a necessary step on the path to cure <strong>and</strong><br />
for discontinuation of imatinib. Molecular analysis can be<br />
35
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
performed with peripheral blood <strong>and</strong> avoids bone marrow<br />
puncture.<br />
A further advance in prognostic prediction is early molecular<br />
response at the 10% level (international scale, IS)<br />
after 3 months of treatment (Hanfstein et al., Blood 116,<br />
2010, ASH, abstr. 360). Patients with a BCR-ABL level less<br />
than 10% (IS) after 3 months have a significantly better progression<br />
free survival (96% vs. 83% after 8 years).<br />
It is concluded that molecular analyses performed by harmonized<br />
laboratories with st<strong>and</strong>ardized methods might replace<br />
cytogenetics as the new method of choice for prognostic<br />
prediction at least partially in the future (Müller at al.,<br />
Leukemia 23: 1957–1963, 2009).<br />
OP27 Imatinib, still the best fi rst line therapy?<br />
David Marin, Department of Hematology, Imperial College<br />
London, London, United Kingdom<br />
R<strong>are</strong>ly in the history of medicine has any new drug constituted<br />
such a radical advance in the therapy of a particular<br />
disease as has imatinib for chronic myeloid leukemia<br />
(CML). Imatinib has been the st<strong>and</strong>ard front line therapy for<br />
CML for nearly 10 years <strong>and</strong> although it may still be too<br />
early to appreciate the full extent to which imatinib improves<br />
the survival of CML patients. However at 5 years<br />
more than one third of the patients have ab<strong>and</strong>oned the medication<br />
on account of side effects, lack of efficacy or progression.<br />
Furthermore, imatinib may soon be displaced as<br />
front line therapy by nilotinib, dasatinib or bosutinib. Small<br />
phase II studies using nilotinib or dasatinib as initial therapy<br />
in CML patients have shown that these drugs induce very<br />
deep responses in the majority of patients with virtually nobody<br />
failing to achieve complete cytogenetic response.<br />
Three large phase III studies comparing nilotinib, dasatinib<br />
<strong>and</strong> bosutinib with imatinib <strong>are</strong> ongoing with very promising<br />
early results. It is likely that at least two of these drugs<br />
will prove to be superior to imatinib; if that is the case, it<br />
will be difficult to decide what the initial therapy for CML<br />
patients should be as the there <strong>are</strong> no ongoing studies comparing<br />
the three new drugs between each other.<br />
OP28 Outcome of Treatment of CML with 2 nd<br />
Generation Tyrosine Kinase Inhibitors<br />
After Imatinib Failure<br />
Elias Jabbour, Jorge Cortes, Hagop Kantarjian,<br />
Department of Leukemia, The University of Texas MD<br />
Anderson Cancer Center, Houston, Texas<br />
Abstract: Although imatinib revolutionized the management<br />
of chronic myeloid leukemia (CML), recent data indicate<br />
a transformation in the treatment approach likely in the<br />
near future. For patients who fail with st<strong>and</strong>ard-dose imatinib<br />
therapy, imatinib dose escalation is a second-line option.<br />
However, high-dose imatinib is not an appropriate approach<br />
for patients experiencing drug toxicity, <strong>and</strong> there<br />
remain questions over the durability of responses achieved<br />
with this strategy. Alternative second-line options include<br />
36<br />
the newer tyrosine kinase inhibitors (TKIs) like dasatinib<br />
<strong>and</strong> nilotinib. A substantial amount of long-term data for<br />
these agents is available. Although both <strong>are</strong> potent <strong>and</strong> specific<br />
BCR-ABL TKIs, dasatinib <strong>and</strong> nilotinib exhibit unique<br />
pharmacological profiles <strong>and</strong> response patterns relative to<br />
different patient characteristics, such as disease stage <strong>and</strong><br />
BCR-ABL mutational status. The superiority of second<br />
generation TKIs over imatinib in newly diagnosed disease<br />
has been recognized as well. They induce high <strong>and</strong> rapid<br />
rates of cytogenetic <strong>and</strong> molecular response, with less progression<br />
to advanced forms of disease in comparison with<br />
imatinib. Several investigational agents specific for those<br />
patients with the T315I mutation remain under evaluation.<br />
The future of CML therapy may include early use of these<br />
potent agents to help more patients achieve molecular remission<br />
<strong>and</strong> potentially be a path to a CML cure.<br />
Introduction<br />
Chronic myelogenous leukemia (CML) is a myeloproliferative<br />
neoplasm with an incidence of 1–2 cases per 100,000<br />
adults, with increasing incidence with age <strong>and</strong> a slight male<br />
predominance of 1.3:1. Thirty percent of patients <strong>are</strong> 60<br />
years old or older, with the median age at presentation being<br />
45–50 years old1 . The pathogenesis of CML involves a specific<br />
genetic abnormality involving the fusion of the Abelson<br />
murine leukemia (ABL) gene on chromosome 9 with<br />
the breakpoint cluster region (BCR) gene on chromosome<br />
222 . In 95% of cases, this fusion is the result of a balanced<br />
translocation between chromosomes 9 <strong>and</strong> 22 [t(9;22)(q34;<br />
q11)], termed the Philadelphia chromosome3,4 . The remaining<br />
5% of cases <strong>are</strong> a result of other genetic abnormalities<br />
that result in the fusion of these same genes4 . The resultant<br />
BCR-ABL fusion protein contains the constitutively active<br />
tyrosine kinase region of ABL that produces a proliferative<br />
signal that regulates growth <strong>and</strong> replication through downstream<br />
pathways such as RAS5 , RAF6 , JUN kinase7 , MYC8 ,<br />
<strong>and</strong> STAT 9–11 . This contributes to leukemogenesis by creating<br />
a cytokine-independent cell cycle with aberrant apoptotic<br />
signals in response to cytokine withdrawal2 .<br />
The causal role played by BCR-ABL in leukemogenesis,<br />
specifically as it relates to CML, has led to the development<br />
of tyrosine kinase inhibitors (TKIs) <strong>and</strong> represents the bulk<br />
of pharmaceutical research performed in this <strong>are</strong>na within<br />
the last decade. TKIs mitigate the oncogenic activity of the<br />
BCR-ABL protein through competitive inhibition at the<br />
ATP-binding site, leading to the inhibition of phosphorylation<br />
of proteins involved in BCR-ABL mediated intracellular<br />
signal transduction, <strong>and</strong> thereby causing the arrest of<br />
growth <strong>and</strong> apoptosis in CML cells12–14 .<br />
Imatinib mesylate (Gleevec; Novartis Pharmaceuticals<br />
Corporation, NJ, USA) was the first of these drugs to receive<br />
the approval by the United States Food <strong>and</strong> Drug Administration<br />
(FDA) in 2001 for the treatment of patients<br />
with CML-CP at a dose of 400 mg/day; as well as for advanced<br />
phase (CML-AP) <strong>and</strong> blast phase (CML-BP) diease<br />
at a higher dose of 600 mg/day15–17 . The advent of imatinib<br />
revolutionized the treatment of CML <strong>and</strong> represented improved<br />
outcome over the previously well established gold<br />
st<strong>and</strong>ard of interferon-alpha (IFN-a) based treatments18 . As
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
a result, patients with CML in the chronic phase (CML-CP)<br />
can expect a lifespan of approximately 25 years <strong>and</strong> even<br />
beyond, transforming CML from a disease which was once<br />
fatal, with a 40% 7-year survival to one that is chronic, with<br />
a 90% 7-year survival.<br />
Outcome with imatinib<br />
The l<strong>and</strong>mark phase III IRIS trial (International R<strong>and</strong>omized<br />
Study of Interferon versus STI571) was the first to<br />
clearly demonstrate the superiority of imatinib treatment in<br />
CML-CP as comp<strong>are</strong>d to IFN-a. Complete cytogenetic response<br />
(CCyR) rates were increased in the imatinib group<br />
over the IFN group (68% vs. 7% at 12 months; <strong>and</strong> 76.2%<br />
vs. 14.5% at 18 months) 19,20 . Imatinib produced durable<br />
CCyR with rates of 87% <strong>and</strong> 85% at 5 years <strong>and</strong> 8 years<br />
respectively21,22 . Major molecular response (MMR) rates,<br />
defined as a 3 log reduction in BCR-ABL transcripts19 , or<br />
BCR-ABL:control gene ratio of 0.10 or less23 , were also improved<br />
(39% vs. 2% at 12 months; p
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
of patients who appear to have rising levels of BCR-ABL<br />
transcripts while maintaining a cytogenetic response. This<br />
may indicate an increased risk for development of mutations<br />
or failure to therapy, however, this value should be<br />
considered with caution. It is inherently variable due to the<br />
fact that it is an international normalized ratio, <strong>and</strong> there is<br />
significant variability in values reported from different laboratories.<br />
Thus, a small increase in BCR-ABL transcript<br />
levels does not necessarily indicate treatment failure or loss<br />
of response. This is supported by the 3-year follow up of the<br />
IRIS trial in which CCyR, regardless of MMR, was associated<br />
with improved OS 25 . If a patient who has previously<br />
achieved a MMR is noted to have a 1 log, or 5 fold increase<br />
in BCR-ABL transcripts, the value should be repeated <strong>and</strong><br />
confirmed in 1–3 months to evaluate for loss of cytogenetic<br />
response. Patient compliance should be evaluated in both<br />
cases, <strong>and</strong> mutation analysis should be considered if the patient<br />
has been identified as having a suboptimal response<br />
within the first year of therapy or has had a loss of response<br />
at any time 29 .<br />
Resistance to imatinib<br />
Despite the success of imatinib, a substantial proportion,<br />
33%, of patients have been shown to be resistant to therapy30,31<br />
. This resistance can be classified into two types: primary<br />
<strong>and</strong> secondary. Failure to achieve any of the ELN outlined<br />
criteria for response in accordance with the duration of<br />
therapy is considered primarily resistant; those who have<br />
previously achieved <strong>and</strong> subsequently lost their response in<br />
accordance with those guidelines <strong>are</strong> considered secondarily<br />
resistant18,29,30 . Primary resistance can be further divided<br />
into primary hematologic resistance, which occurs in 2%–<br />
4% of cases who fail to normalize peripheral counts; or primary<br />
cytogenetic resistance, which is more common <strong>and</strong><br />
occurs in approximately 15%–25% of patients who fail to<br />
reduce their Ph+ cells to 35% or fewer of those sampled32 .<br />
Causal factors in imatinib resistance can be classified as<br />
either BCR-ABL dependent, or BCR-ABL independent.<br />
Point mutations <strong>are</strong> the most well-characterized BCR-ABL<br />
dependent factors <strong>and</strong> <strong>are</strong> responsible for 35–75% of cases<br />
of resistance30,33–38 . A key component to imatinib resistance<br />
centers around its ability to bind only to the closed, or inactive,<br />
conformation of the ABL kinase, <strong>and</strong> requires a very<br />
specific structural arrangement for entry <strong>and</strong> binding. Point<br />
mutations can cause steric hindrance as well as elimination<br />
of critical molecules required for hydrogen bonding between<br />
imatinib <strong>and</strong> ABL kinase, thus mitigating imatinib’s<br />
efficacy30,38–40 . Examples of such mutations include T315I,<br />
Y253H, <strong>and</strong> F255K, among others38 .<br />
BCR-ABL independent mechanisms of resistance include<br />
amplification of the ABL kinase oncogene in response<br />
to high plasma imatinib levels30,41–44 ; increased efflux of the<br />
drug by increased expression of P-glycoprotein (Pgp) efflux<br />
pumps30,45–47 ; decreased drug uptake secondary to decreased<br />
expression of the drug uptake transporter, hOCT130,48–51 ;<br />
cytoplasmic sequestration of imatinib by increased serum<br />
protein alfa1-acid glycoprotein (AGP) which binds imatinib<br />
<strong>and</strong> impairs subsequent binding to ABL kinase30,52,53,54 ;<br />
low serum drug concentration30 ; <strong>and</strong> alternative signaling<br />
38<br />
pathway activation, including Ras/Raf/MEK kinase, STAT,<br />
Erk2, <strong>and</strong> SFK phosphorylation of BCR-ABL, all of which<br />
decrease susceptibility to imatinib 30 .<br />
Adherence is another BCR-ABL independent factor that<br />
has been shown to affect outcome. Rates of daily imatinib<br />
adherence have been estimated to range from 75% to<br />
90% 55–57 with higher adherence rates correlated to improved<br />
outcome. In one study of 87 patients with CML-CP treated<br />
with imatinib 400 mg daily, adherence was shown to correlate<br />
with MMR <strong>and</strong> CMR at 6 years. An adherence rate of<br />
90% or less resulted in MMR in only 28.4% as comp<strong>are</strong>d to<br />
94.5% in patients with greater than 90% adherence rates<br />
(P
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
In another study assessing 84 patients over 61 months<br />
with failure to st<strong>and</strong>ard-dose imatinib, doses were escalated<br />
to 600–800 mg daily. In 21 patients with hematologic failure,<br />
48% achieved a CHR, with only 14% achieving a cytogenetic<br />
response. In 63 patients with cytogenetic failure,<br />
75% responded with CCyR. Two <strong>and</strong> 3-year EFS rates were<br />
57% <strong>and</strong> 47%, respectively; with OS rates of 84% <strong>and</strong> 76%,<br />
respectively 59 . Thus, while dose escalation after failure of<br />
st<strong>and</strong>ard-dose imatinib is an important <strong>and</strong> viable treatment<br />
option, it is likely to be effective only in the subset of patients<br />
with previous cytogenetic responses <strong>and</strong> is not indicated<br />
for patients with intolerance to the drug. Thus, clinical<br />
consideration should be given to 2 nd generation TKIs.<br />
Second generation tyrosine kinase inhibitors<br />
[Table2]<br />
Dasatinib<br />
Dasatinib was approved by the US FDA in 2006 for the<br />
2nd line treatment of CML-CP, -AP, -BP, <strong>and</strong> Philadelphiapositive<br />
acute lymphoblastic leukemia [Ph (+) ALL] with<br />
resistance or intolerance to prior therapy with imatinib60,61 .<br />
Dasatinib is 325 times more potent than imatinib38,62 . Unlike<br />
imatinib, dasatinib binds to both the active <strong>and</strong> inactive<br />
forms of BCR-ABL30 .<br />
Several studies have shown that dasatinib is highly effective<br />
in CML-CP In the START-C trial, an international, multicenter,<br />
phase II trial assessing 387 patients with CML-CP<br />
who had demonstrated imatinib intolerance (n= 99) or resistance<br />
(n=288), patients were treated with dasatinib at an<br />
initial dose of 70 mg BID. Twenty four-month follow-up<br />
data showed overall rates of CyR 62%, CCyR 53%, CHR<br />
91%, <strong>and</strong> MMR 47%. Two-year PFS was 80% <strong>and</strong> OS was<br />
94%. Adverse events included grade 3 neutropenia (50%),<br />
grade 3 thromboyctopenia (49%), <strong>and</strong> grade 3 pleural effusions<br />
(9%). Nine percent of all adverse events were considered<br />
»severe62 .« In another study assessed the efficacy of<br />
dasatinib in 445 imatinib-resistant or intolerant patients<br />
with CML-CP (n=186), CML-AP (n=107), CML-myeloid<br />
blast crisis (n=74), CML-lymphoid blast crisis (n=42), or<br />
Ph (+) ALL (n=36). Dasatinib produced MCyR rates of<br />
45% <strong>and</strong> CCyR rates of 33% in patients with CML-CP, <strong>and</strong><br />
major hematologic response rates in advanced stages of disease,<br />
including 59% in CML-AP; 39% in CML myeloid<br />
blast crisis; 31% in lymphoid blast crisis; <strong>and</strong> 42% in Ph (+)<br />
ALL 61 .<br />
The dose optimization study CA180034 r<strong>and</strong>omized 622<br />
patients with imatinib resistant or intolerant CML-CP to 4<br />
dasatinib treatment arms, including 100 mg daily, 50 mg<br />
BID, 140 mg daily, <strong>and</strong> 70 mg BID. Dasatinib dosed at 100<br />
mg daily produced similar CyR <strong>and</strong> PFS rates as other dosing<br />
schedules, with significantly fewer occurrences of grade<br />
3–4 neutropenia, thrombocytopenia, anemia, <strong>and</strong> pleural effusions.<br />
There were also fewer treatment interruptions, reductions,<br />
<strong>and</strong> discontinuations at 100 mg daily as comp<strong>are</strong>d<br />
to the other treatment groups 63 .<br />
Further evaluation of dasatinib therapy in imatinib-resistant<br />
patients with mutations by meta-analysis of 3 dasatinib<br />
studies, including the START-C, START-R, <strong>and</strong> CA180-034<br />
dose optimization study, revealed that rates of response with<br />
dasatinib <strong>are</strong> favorable in a variety of genetic mutations including<br />
E255K/V (CCyR 38%), L248V (CCyR 40%), <strong>and</strong><br />
G250E (CCyR 33%). CCyR rates were lower in F317L(7%),<br />
Q252H (17%), L384M(0%), <strong>and</strong> V299L (0%). Patients with<br />
T315I mutations did not respond to dasatinib 64 .<br />
Dasatinib has also been evaluated in patients with imatinib-resistant<br />
or intolerant CML-AP. One study assessed<br />
174 such patients treated with dasatinib 70 mg BID. Major<br />
hematologic response rates were 64%, CHR rates were<br />
45%; MCyR rates were 39% <strong>and</strong> CCyRrates were 32%.<br />
PFS at 12 months was 66% <strong>and</strong> OS was 82%. Adverse<br />
events included grade 3–4 thrombocytopenia (82%), neutropenia<br />
(76%), <strong>and</strong> diarrhea (52%, grade 3 or 4 in 8%) 65 .<br />
Appropriate dosing in CML-AP was evaluated in another<br />
study, in which 317 patients were r<strong>and</strong>omized to receive dasatinib<br />
at 140 mg daily or 70 mg BID. The results at 2 years<br />
after initiation of treatment demonstrated similar efficancy<br />
in rates of hematologic <strong>and</strong> cytogenetic responses, as well<br />
as in PFS <strong>and</strong> OS rates. Dasatinib 140 mg once daily did<br />
demonstrate an improved safety profile with statistically<br />
Table 2. Response to second generation tyrosine kinase inhibitors (dasatinib, nilotinib <strong>and</strong> bosutinib) in patients who <strong>are</strong> imatinib-resistant or intolerant<br />
in chronic phase, accelerated phase <strong>and</strong> blast phase<br />
Response<br />
Dasatinib<br />
Percent Response<br />
Nilotinib Bosutinib<br />
CP<br />
N=387<br />
AP<br />
n=174<br />
MyBP<br />
n=109<br />
LyBP<br />
n=48<br />
CP<br />
n=321<br />
AP<br />
N=137<br />
MyBP<br />
N=105<br />
LyBP<br />
N=31<br />
CP N=146<br />
AP<br />
N=51<br />
BP<br />
N=38<br />
Median follow-up (mo) 15 14 12+ 12+ 24 9 3 3 7 6 3<br />
% Resistant to imatinib 74 93 91 88 70 80 82 82 69 NR* NR*<br />
% Hematologic Response – 79 50 40 94 56 22 19 85 54 36<br />
CHR 91 45 27 29 76 31 11 13 81 54 36<br />
NEL – 19 7 6 – 12 1 0 – 0 0<br />
% Cytogenetic Response NR 44 36 52 NR NR NR NR – NR NR<br />
Complete 49 32 26 46 46 20 29 32 34 27 35<br />
Partial 11 7 7 6 15 12 10 16 13 20 18<br />
% Survival (at 12 months) 96 (15) 82 (12) 50 (12) 50 (5) 87 (24) 67 (24) 42 (12) 42 (12) 98 (12) 60 (12) 50 (10)<br />
Legend: CP: chronic phase; AP: accelerated phase; MyBP: myeloid blast phase; LyBP: lymphoid blast phase, mo: months; CHR: complete hematologic response;<br />
NEL: no evidence of leukemia<br />
39
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
fewer patients experiencing pleural effusions (20% vs. 39%;<br />
P
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
results show achievement of an 85% CHR rate, 28% CyR<br />
rate, 15% MCyR rate, 15% MMR rate, <strong>and</strong> 57% reduction<br />
in the T315I clone. OS was not met in this group of patients.<br />
In CML-AP, 37.5% showed hematologic response with OS<br />
of 18.8 months. In CML-BP, hematologic response was<br />
demonstrated in 30% with OS of 1.8 months 78 .<br />
An update combining both of the above study populations<br />
was presented at ASH 2010. Thirty six of the 93 chronic<br />
phase patients had been treated previously with 3 or more<br />
TKIs. Over a median followup of 7.5 months, 27/36 (75%)<br />
achieved or maintained a CHR <strong>and</strong> 7 (19%) achieved a<br />
major CyR (4 complete <strong>and</strong> 3 partial) with omacetaxine,<br />
with a median duration of at least 4 months. These findings<br />
support the further investigation of this agent in patients<br />
failing other TKI therapy 79 . Grade 3 to 4 hematologic adverse<br />
events included thrombocytopenia (65%), neutropenia<br />
(48%), <strong>and</strong> anemia (40%), febrile neutropenia (12%),<br />
bone marrow failure (12%), pancytopenia (7%) <strong>and</strong> febrile<br />
bone marrow aplasia (6%). Grade 3 to 4 nonhematologic<br />
adverse events included fatigue (6%). Grade 1–2 adverse<br />
events included diarrhea, fatigue, nausea, vomiting, fever,<br />
headache, <strong>and</strong> asthenia 77,78,79 .<br />
Predictors of outcome<br />
The primary goal of therapy for patients with CML is still<br />
achievement of CCyR. Those who achieve this goal, have a<br />
low probability of eventually progressing. Achieving a major<br />
molecular response is desirable as it further improves the<br />
long-term outcome, but patients who have a CCyR <strong>are</strong> not<br />
considered to have failure to imatinib if they do not have a<br />
major molecular response. This is because the difference in<br />
EFS probability is small, although significant. The timing of<br />
this response is also important. Despite initial suggestions<br />
form the IRIS trial that a MMR at 12 months improved<br />
long-term outcome, comp<strong>are</strong>d to CCyR but no MMR, the<br />
8-year follow-up data has shown no difference in outcome<br />
using this hallmark. By 18 months, patients who have a<br />
CCyR <strong>and</strong> MMR have a better probability of EFS than those<br />
with CCyR but no MMR, but the difference is small (95%<br />
vs. 86%), <strong>and</strong> even smaller if considering only transformation<br />
to AP or BP or death as an event (99% vs 96%) 80 .<br />
The recommendations by the ELN have provided a clear<br />
framework for decision making <strong>and</strong> the significance of the<br />
definitions of failure <strong>and</strong> suboptimal response have been<br />
demonstrated in two independent series27,81 . Patients with<br />
suboptimal response to therapy have an inferior outcome,<br />
although the significance appears to be heterogeneous, with<br />
a more profound adverse prognostic effect for patients with<br />
suboptimal response to therapy at earlier time points (6<br />
months) <strong>and</strong> than at later time points (18 months). It is however<br />
reasonable to consider treatment modifications for patients<br />
who have a suboptimal response to therapy. Treatment<br />
guidelines recommend dose escalation of imatinib to 600 or<br />
800 mg/day in cases of suboptimal response38,70 . However, it<br />
should be acknowledged that there is minimal data available<br />
regarding the effectiveness of this approach58,59 . For patients<br />
with clear failure to imatinib therapy, the current approach<br />
is to change therapy to a second generation TKI, although<br />
ASCT is also an option following treatment failure17,82 .<br />
Clinical trial data have confirmed the efficacy of dasatinib<br />
<strong>and</strong> nilotinib in patients with imatinib resistance or intolerance<br />
<strong>and</strong> the superiority of dasatinib versus imatinib dose<br />
escalation following imatinib resistance 70,81,83 . It is possible<br />
that earlier treatment switch to second-line agents, i.e. after<br />
suboptimal response, could result in more favorable longterm<br />
outcomes than with dose-escalated imatinib, but there<br />
<strong>are</strong> currently no clinical data to support this hypothesis.<br />
In addition to efficacy outcomes, mutational data should<br />
be considered when selecting TKI therapy 84 . The BCR-ABL<br />
genotype can be used to guide treatment decisions since it is<br />
a prognostic factor for disease progression 84–86 . Patients with<br />
T315A/I, F317I/L, <strong>and</strong> V299L mutations do not appear to<br />
respond consistently to therapy with dasatinib 86–89 , whereas<br />
patients with the F359C/V substitution do benefit from dasatinib<br />
86 . In an analysis of 1043 patients who underwent<br />
mutational assessment in phase II/III studies in CP CML, 14<br />
patients had baseline F317L mutations, <strong>and</strong> just one patient<br />
had a baseline V299L mutation 89 . It was found that patients<br />
bearing F317L mutations achieved a high CHR rate (93%),<br />
but cytogenetic response rates (MCyR, 14%; CCyR, 7%)<br />
were lower than in patients without these mutations. Importantly,<br />
in patients treated with dasatinib, high response rates<br />
were obtained with the common imatinib-resistant mutations<br />
in Y253, E255 <strong>and</strong> E359 residues.<br />
Nilotinib resistance is associated with mutations in the<br />
T315, Y253, <strong>and</strong> E255 residues 84–86 . Indeed, recently it was<br />
shown that the presence of E255K/V, Y253H, or F359C/V<br />
mutations at baseline <strong>are</strong> independent predictors of worsened<br />
PFS in patients with CP CML 86 . Therefore, dasatinib<br />
therapy may be more appropriate for patients with these<br />
common mutations, whereas nilotinib may be better suited<br />
for those patients with F317L mutations 88 . Although both<br />
dasatinib <strong>and</strong> nilotinib <strong>are</strong> ineffective against T315I BCR-<br />
ABL 85 , this mutation is more likely to affect patients in<br />
the advanced phases of CML 85 . Patients with T315I may<br />
achieve favorable outcomes with therapies other than the<br />
available second-line TKIs, e.g AP24534, omacetaxine, <strong>and</strong><br />
others 90,91 .<br />
A recent study has explored factors that may predict response<br />
<strong>and</strong> outcome in patients with chronic-phase CML<br />
receiving dasatinib or nilotinib after failing imatinib 92,93 .<br />
The analysis included 123 patients in chronic phase post<br />
imatinib failure: 78 treated with dasatinib <strong>and</strong> 45 treated<br />
with nilotinib. Multivariate analysis for predictive factors<br />
was performed for event-free survival, overall survival, <strong>and</strong><br />
12-month major cytogenetic response (MCyR). Investigators<br />
found that event-free survival in response to a second<br />
TKI in CML depends on achieving a prior cytogenetic response<br />
to imatinib <strong>and</strong> on the patient’s performance status.<br />
In the study, patients with performance status ≥ 1 <strong>and</strong> no<br />
prior cytogenetic response to imatinib had a high likelihood<br />
of responding to a second TKI with poor event-free survival<br />
<strong>and</strong> overall survival. Patients with both risk factors had a<br />
24-month overall survival of only 40% comp<strong>are</strong>d with 95%<br />
for patients with neither risk factor. Therefore, patients with<br />
no previous cytogenetic response to imatinib should be offered<br />
additional treatment approaches including allogeneic<br />
stem cell transplantation <strong>and</strong> clinical trials. However, the<br />
41
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
achievement of MCyR with a second TKI by 12 months<br />
may compensate for the presence unfavorable baseline factors<br />
93 .<br />
Safety <strong>and</strong> tolerability <strong>are</strong> also important considerations<br />
in choosing a TKI. The potential impact of the drug’s AE<br />
profile on any of the patient’s preexisting conditions should<br />
be considered in choosing between second generation BCR-<br />
ABL inhibitors. Since pleural effusion is more common for<br />
patients receiving dasatinib therapy, patients with risk factors<br />
for pleural effusion such as a prior cardiac history,<br />
chronic obstructive pulmonary disease <strong>and</strong> hypertension <strong>are</strong><br />
at greater risk for developing these complications 67 . Risk<br />
factors for developing pleural effusions while taking dasatinib<br />
also include disease stage (BC > AP > CP), previous<br />
lung problems such as smoking or infections <strong>and</strong> those patients<br />
maintained on starting doses of dasatinib 94 .<br />
Blood glucose elevations have been observed in 11% of<br />
CML-CP, <strong>and</strong> 4% of CML-AP patients treated with nilotinib<br />
72,95 . While no CML-CP or CML-AP patients required<br />
dose adjustments, dose interruption or discontinued nilotinib<br />
therapy due to elevated blood glucose, preexisting hyperglycemia<br />
should be c<strong>are</strong>fully monitored to ensure that<br />
the condition is not exacerbated by nilotinib treatment. Prior<br />
severe pancreatitis may also be a concern on nilotinib therapy,<br />
<strong>and</strong> patients with a history should be closely monitored<br />
on nilotinib therapy.<br />
Cardiac events, including congestive heart failure, left<br />
ventricular dysfunction <strong>and</strong> QT prolongation have all been<br />
reported with dasatinib <strong>and</strong> nilotinib. Though they occurred<br />
in
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
also significantly improved the rates of CCyR <strong>and</strong> MMR at<br />
24 months. CCyR at 24 months was 87% with 400 mg twice<br />
daily nilotinib comp<strong>are</strong>d with 77% with imatinib (P =<br />
.0018). Likewise, MMR at 24 months was 59% with 400<br />
mg nilotinib vs 37% with imatinib (P < .0001). There were<br />
also significantly fewer progressions to advanced phase <strong>and</strong><br />
blast crisis with nilotinib. Based on these data, nilotinib has<br />
been approved for the frontline therapy of CML. The gap in<br />
efficacy in favor of nilotinib has persisted over time <strong>and</strong> it<br />
appears that nilotinib may improve both short-term <strong>and</strong><br />
long-term outcomes comp<strong>are</strong>d with imatinib 100 .<br />
In the ENESTnd trial, nilotinib was also shown to be safe<br />
<strong>and</strong> well-tolerated with no increase in side-effects comp<strong>are</strong>d<br />
with imatinib. By contrast, treatment-related gastrointestinal<br />
toxicity <strong>and</strong> fluid retention of all grades were more frequent<br />
with imatinib than they were in either nilotinib<br />
arm 100 .<br />
Dasatinib in the frontline setting [Table 4]<br />
Cortes et al at MD Anderson Cancer Center published a<br />
study in which 50 patients with newly diagnosed CML-CP<br />
were r<strong>and</strong>omized to dasatinib 100 mg once daily or 50 mg<br />
twice daily in the frontline setting. Median follow up was 24<br />
months. Of the 50 patients enrolled in the study, 49 (98%)<br />
attained a CCyR <strong>and</strong> 41 (82%) attained a MMR. Ninety<br />
four percent of patients attained CCyR by 6 months. There<br />
was no difference in response rate by treatment arm. The<br />
projected event-free survival rate at 24 months was 88%.<br />
Grade 3/ 4 hematologic toxicities included neutropenia <strong>and</strong><br />
thrombocytopenia, <strong>and</strong> occurred in 21% <strong>and</strong> 10% of patients,<br />
respectively. Nonhematologic toxicity was usually<br />
grade 1 to 2. There was no significant difference in toxicity<br />
between the two arms, <strong>and</strong> the actual median dose at 12<br />
months was 100 mg (range, 20 to 100 mg). These results<br />
lead to the conclusion that the management of CML-CP in<br />
the frontline setting with dasatinib is an effective approach,<br />
yielding high rates of CCyR <strong>and</strong> MMR101 .<br />
The DASISION trial, an international, multicenter, r<strong>and</strong>omized<br />
phase III trial on frontline dasatinib therapy, r<strong>and</strong>omized<br />
519 patients to receive dasatinib 100 mg once<br />
daily or imatinib 400 mg once daily. Findings from this trial<br />
were recently published102 . The current data presented at<br />
ASH 2010 represented an 18-month follow-up showing that<br />
dasatinib was superior to imatinib with respect to the primary<br />
endpoint, the rate of CCyR. The likelihood of achieving<br />
a CCyR at any time was higher with dasatinib vs imatinib<br />
(85% vs 80%; hazard ratio [HR] = 1.5; P < .0001) 103 .<br />
Table 4. Response rates with frontline dasatinib.<br />
Study<br />
Number of<br />
CCyR (%) MMR (%)<br />
patients<br />
PFS (%) OS (%)<br />
MDACC 50 98 82 – –<br />
DASISION 259 78 57<br />
94.9<br />
(18 months)<br />
96<br />
(18 months)<br />
S0325 123 82 59<br />
99<br />
(12 months)<br />
100<br />
(12 months)<br />
CCyR: complete cytogenetic response, MMR: major molecular response,<br />
PFS: progression free survival, OS: overall survival, MDACC: MD Anderson<br />
Cancer Center<br />
*cCCyR (confirmed complete cytogenetic response) is reported for DASI-<br />
SION study.<br />
In addition, the secondary endpoint, the rate of MMR,<br />
was also significantly improved with dasatinib comp<strong>are</strong>d<br />
with imatinib. The likelihood of achieving MMR at any<br />
time with dasatinib was significantly higher than with imatinib<br />
(57% vs 41%; HR = 1.8; P < .0001). Based on these<br />
data, dasatinib was approved by the US Food <strong>and</strong> Drug Administration<br />
as a st<strong>and</strong>ard of c<strong>are</strong> for CML patients. Dasatinib<br />
was also shown to be well tolerated, with low rates of<br />
grade 3/4 hematologic <strong>and</strong> nonhematologic toxicity, as well<br />
as a low rate of discontinuation due to adverse events although,<br />
pleural effusion occurred only in patients treated<br />
with dasatinib (in 12% of 258 patients, nearly all grade 1<br />
<strong>and</strong> 2) 102,103 .<br />
Another study by the Southwest Oncology Group (S0325)<br />
comp<strong>are</strong>d dasatinib 100 mg to imatinib 400 mg in newly<br />
diagnosed CML in chronic phase. The study showed that<br />
dasatinib was associated with greater MMR comp<strong>are</strong>d with<br />
imatinib at 12 months. However, the 12-month rates of complete<br />
hematologic response (CHR), CCyR, OS, or PFS were<br />
comparable between treatment groups. The lack of statistical<br />
significance in rates of CCyR was likely due to the fact<br />
that patients who were not evaluable were considered nonresponders<br />
104 .<br />
Bosutinib in the frontline setting<br />
The BELA trial, an international, mutlicenter, open-label<br />
phase III trial, comp<strong>are</strong>s bosutinib with imatinib in the<br />
frontline setting using CCyR as a primary endpoint <strong>and</strong><br />
MMR as a secondary endpoint105 . In this study, non-evaluable<br />
patients were considered non-responders. Consequently,<br />
bosutinib was associated with a similar rate of CCyR<br />
comp<strong>are</strong>d with imatinib at 12 months (70% vs 68%; P =<br />
.601), <strong>and</strong> the primary endpoint was not met. In evaluable<br />
patients only, bosutinib did induce a significantly higher<br />
rate of CCyR comp<strong>are</strong>d with imatinib (78% vs 68%; P =<br />
.026). In addition, there was a significantly higher MMR<br />
with bosutinib in both the intent-to-treat <strong>and</strong> evaluable populations<br />
(intent-to-treat patients: 39% vs 26%, P = .002;<br />
evaluable patients: 43% vs 27%, P < .001). More follow-up<br />
on these studies is needed to determine whether these responses<br />
<strong>are</strong> sustained <strong>and</strong> whether bosutinib is truly superior<br />
to imatinib.<br />
Conclusion<br />
The treatment of CML has progressed significantly since<br />
the approval of imatinib in 2001. With the advent of TKIs,<br />
the focus of the scientific community has shifted to the molecular<br />
management of disease, which has had a considerable<br />
impact on the approach to cancer treatment to date.<br />
Imatinib has transformed CML from an immediately lifethreatening<br />
disease to one that is treatable with daily oral<br />
medication that makes it possible to improve both overall<br />
survival <strong>and</strong> maintain quality of life. However, increasing<br />
incidence of imatinib-resistance <strong>and</strong> intolerance necessitates<br />
the development of alternative therapies. There is a<br />
substantial amount of data supporting the improvement in<br />
outcome in long term follow up of the 2nd generation TKIs,<br />
nilotinib <strong>and</strong> dasatinib. Improving outcome in the frontline<br />
setting should be the direction of further scientific research,<br />
43
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
including the implementation of 2 nd generation TKIs as<br />
frontline therapy.<br />
Despite extraordinary progress, a true cure for CML is<br />
not generally achieved by Abl kinase inhibitors. TKIs <strong>are</strong><br />
potent inhibitors of Bcr-Abl kinases (among others), resulting<br />
in rapid reduction of the majority of cells carrying the<br />
Ph chromosomal marker. However, suppression of Abldriven<br />
hematopoiesis may be insufficient to eradicate quiescent<br />
stem cells. Studies assessing the combination of TKIs<br />
with promising agents <strong>are</strong> ongoing. These combinations include<br />
TKI <strong>and</strong> hedgehog inhibitors, omacetaxine, vaccines,<br />
<strong>and</strong> hypomethylatings agents. If successful, this strategy<br />
could lead to a safe <strong>and</strong> permanent discontinuation of therapy<br />
in patients with a good response. The impact of using<br />
more potent agents in the frontline setting on the potential to<br />
discontinue TKI therapy remains to be determined. The future<br />
of CML therapy may include early use of these potent<br />
agents, perhaps in combination with new molecules, to help<br />
more patients achieve CMR, which could lead to therapy<br />
discontinuation <strong>and</strong> cure.<br />
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superiority of nilotinib versus imatinib in patients with newly diagnosed<br />
chronic myeloid leukemia in chronic phase (CML-CP).<br />
Blood (Annual abstract )Abstract 207<br />
101. Cortes JE, Jones D, O’Brien S, et al. Results of dasatinib therapy in<br />
patients with early chronic-phase chronic myeloid leukemia. J Clin<br />
Oncol 28:398–404.2010.<br />
102. Kantarjian H, Shah NP, Hochhaus A, et al. Dasatinib versus imatinib<br />
in newly diagnosed chronic-phase chronic myeloid leukemia. N Engl<br />
J Med. 2010;362:2260–2270.<br />
103. Shah N, Kantarjian HM, Hochhaus A, et al. Dasatinib versus imatinib<br />
in patients with newly diagnosed chronic myeloid leukemia in chronic<br />
phase (CML-CP) in the DASISION trial: 18-month follow-up. Program<br />
<strong>and</strong> abstracts of the 52nd American Society of Hematology Annual<br />
Meeting <strong>and</strong> Exposition; December 4–7, 2010; Orl<strong>and</strong>o, Florida.<br />
Abstract 206.<br />
104. Jerald P. Radich, Kenneth J. Kopecky, <strong>and</strong> Suzanne Kamel-Reid, et al.<br />
A R<strong>and</strong>omized Phase II Trial of Dasatinib 100 Mg Vs Imatinib 400<br />
Mg In Newly Diagnosed Chronic Myeloid Leukemia In Chronic<br />
Phase (CML-CP): The S0325 Intergroup Trial. Blood (ASH Annual<br />
Meeting Abstracts), Nov 2010; 116: LBA-6.<br />
105. Gambacorti-Passerini C, Kim DW, Kantarjian HM, et al. An ongoing<br />
phase 3 study of bosutinib (SKI-606) versus imatinib in patients with<br />
newly diagnosed chronic phase chronic myeloid leukemia. Program<br />
<strong>and</strong> abstracts of the 52nd American Society of Hematology Annual<br />
Meeting <strong>and</strong> Exposition; December 4–7, 2010; Orl<strong>and</strong>o, Florida. Abstract<br />
208.<br />
OP29 Second line TKI – the best fi rst line therapy?<br />
Gianantonio Rosti, (Italy)<br />
Abstract not submitted.<br />
OP30 How to monitor CML therapy<br />
Elias Jabbour, Department of Leukemia, The University<br />
of Texas M. D. Anderson Cancer Center, Houston, Texas,<br />
USA [see OP28]<br />
OP31 Stem cell transplants for chronic phase<br />
CML<br />
OP32 Pathophysiology of Myeloma<br />
Christoph J. Heuck, University of Arkansas for Medical<br />
Sciences, Myeloma Institute for Research <strong>and</strong> Therapy,<br />
Little Rock, AR, USA<br />
Muchof the recent progress in the treatment of multiple<br />
myeloma has been attributed to the introduction of several<br />
novel agents which, when combined with st<strong>and</strong>ard cytotoxic<br />
agents <strong>and</strong> each other, have imparted a high frequency of<br />
clinical responses. We have previously reported on the superior<br />
survival outcomes in Total Therapy 3A (TT3A), with<br />
added bortezomib (Bz), comp<strong>are</strong>d with Total Therapy 2<br />
(TT2),which r<strong>and</strong>omized patients to a control arm or an ex-
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
perimental thalidomide arm of a multi-agent chemotherapy<br />
<strong>and</strong> t<strong>and</strong>em autograft-supported high-dose melphalan program.<br />
The major advance with TT3A was observed in the<br />
85% of patients presenting with gene expression profiling<br />
(GEP)-defined low-risk myeloma <strong>and</strong>. As part of TT3A,<br />
pharmacogenomic investigations of Bz, using GEP analysis<br />
pre- <strong>and</strong> post-48 hr test-dosing, were performed in an attempt<br />
to further delineate low- versus high-risk disease.<br />
Pharmacogenomic investigations after test-dose applications<br />
of Bz have revealed that high expression levels of proteasome<br />
genes <strong>are</strong> linked to inferior prognosis in both of our<br />
TT3 protocols. The GEP80 model discriminated outcomes<br />
whether applied to post-Bz or baseline samples. These findings,<br />
observed in TT3A, were validated in TT3B <strong>and</strong> also<br />
applied to both arms of TT2 (control <strong>and</strong> thalidomide).<br />
Employing post-Bz <strong>and</strong> baseline samples in TT3, the<br />
GEP80 model provided segregation of high-risk subsets of<br />
9% <strong>and</strong> 3%, respectively, in the GEP70 low-risk group <strong>and</strong><br />
low-risk subsets of 41% <strong>and</strong> 55%, respectively, in the<br />
GEP70 high-risk setting. In TT2, the GEP80 model failed to<br />
discern a low-risk subset among the patients with GEP70<br />
high-risk disease, <strong>and</strong> the GEP80 model discriminated only<br />
one patient with high-risk status among those identified to<br />
have GEP70 low-risk disease.<br />
We found a significant upregulation in the expression of<br />
proteasome genes following a 48-hour Bz test dose. PSMD4<br />
was only one of three genes common to both GEP70 <strong>and</strong><br />
GEP80 models. PSMD4 <strong>and</strong> other proteasome genes were<br />
uniquely upregulated by Bz but not by dexamethasone, immunomodulatory<br />
agents, <strong>and</strong> melphalan. Prognostically,<br />
GEP80(BL)-defined high-risk status was the sole genetic<br />
parameter that survived multivariate PFS <strong>and</strong> OS models,<br />
along with low albumin <strong>and</strong> high LDH, although all the<br />
other st<strong>and</strong>ard <strong>and</strong> both cytogenetic <strong>and</strong> molecular genetic<br />
variables also contributed when examined alone.<br />
We have previously reported that both the copy number<br />
<strong>and</strong> the percentage of cells with amp1q21 invariably increase<br />
when comparing samples obtained at diagnosis <strong>and</strong><br />
at relapse. Genes residing on chromosome 1q21 contribute<br />
critically to the high-risk designation in the GEP70 model.<br />
Consistent with this, we have noted that the GEP70 score<br />
inevitably increases at relapse <strong>and</strong> a shift from low to high<br />
risk imparts a significantly shorter post-relapse survival.<br />
OP33 Bortezomib in the Treatment of Multiple<br />
Myeloma<br />
Joan Bladé, Institut of Hematology <strong>and</strong> Oncology,<br />
Department of Hematology Hospital Clinic, Barcelona,<br />
Spain<br />
Bortezomib is a first-in-class selective proteasome inhibitor<br />
approved for the treatment of relapsed <strong>and</strong> refractory<br />
multiple myeloma (MM) as well as in first-line therapy in<br />
combination with melphalan <strong>and</strong> prednisone (MPV) for patients<br />
not eligible for high-dose therapy/autologous stem<br />
cell transplantation (ASCT). In vitro, bortezomib induces<br />
apoptosis of myeloma cells <strong>and</strong> inhibits cell adhesion within<br />
the bone marrow microenvironment. Preclinical <strong>and</strong> clinical<br />
data have shown that bortezomib enhances sensitivity <strong>and</strong><br />
can reverse resistance to st<strong>and</strong>ard therapeutic agents used<br />
in MM.<br />
The first phase II trial of bortezomib (SUMMIT) in patients<br />
with MM who had received at least 3 lines of therapy<br />
showed an overall response rate of 35% including 10% of<br />
CR or nCR. The second pivotal phase II trial (CREST), also<br />
performed in patients with relapsed/refractory myeloma<br />
showed that a reduced dose of 1 mg/m 2 instead of the usual<br />
dose of 1.3 mg/m 2 induced a response rate of 33% with<br />
lower toxicity. A r<strong>and</strong>omized trial comparing bortezomib<br />
versus high-dose dexamethasone (APEX) showed that bortezomib<br />
was superior in RR, PFS <strong>and</strong> OS. A large phase 3<br />
trial of bortezomib plus pegylated liposomal doxorubicin<br />
versus bortezomib alone resulted in a significantly superior<br />
CR plus VGPR rate, PFS <strong>and</strong> OS in favour of the combination.<br />
The subcutaneous administration of bortezomib has<br />
shown similar efficacy with less peripheral neuropathy than<br />
the i.v. formulation. Bortezomib can be effective in patients<br />
with extramedullary disease <strong>and</strong> can partially overcome the<br />
poor prognosis of high-risk cytogenetics. Patients who have<br />
responded to bortezomib with no significant peripheral neuropathy<br />
<strong>and</strong> have been for longer than 6 months off therapy<br />
should be re-treated with the same drug.<br />
In a large phase III (VISTA) trial of newly diagnosed patients<br />
non-eligible for ASCT the association of melphalanprednisone-bortezomib<br />
(MPV) was superior to MP in RR<br />
(71 vs. 36%), CR rate (30 vs. 4%), PFS (median, 24 vs.<br />
16%) <strong>and</strong> OS (82.6 vs. 69.5%). For patients with renal failure<br />
the best initial treatment regimen seems to be the association<br />
of bortezomib/dexamethasone with or without doxorubicin.<br />
In patients eligible for ASCT, the induction with<br />
botezomib/dexamethasone results in pre-transplant RR of<br />
65% including 12% of immunofixation negative CR. The<br />
RR post-transplant is about 90% with 33% CR. The addition<br />
of a third drug, either doxorubicin (PAD, VDD) or thalidomide<br />
(VTD), results in an increased pre-transplant CR<br />
rate from 20 to 35% <strong>and</strong> a post-transplant CR up to 50%. In<br />
consequence, a pre-transplant induction regimen should today<br />
include bortezomib <strong>and</strong> dexamethasone plus a third<br />
agent, preferably an IMiD or a doxorubicin formulation.<br />
It has been shown for the first time outside of the allogeneic<br />
setting, that 18% of patients in at least VGPR after<br />
ASCT achieved molecular remission by qualitative <strong>and</strong><br />
quantitative PCR with intensification therapy with VTD. In<br />
addition, post-transplant intensification with bortezomib<br />
alone significantly improved the CR rate. Finally, encouraging<br />
results with bortezomib maintenance in the ASCT <strong>and</strong><br />
non-transplant setting <strong>are</strong> being reported <strong>and</strong> the possible<br />
efficacy of maintenance with bortezomib is studies in a<br />
number of ongoing clinical trials<br />
OP34 IMIDs in Myeloma<br />
Robert Peter Gale, Haematology Section, Division of<br />
Experimental Medicine, Department of Medicine, Imperial<br />
College, London, UK <strong>and</strong> Celgene Corp, Summit, NJ, USA<br />
The pathophysiology of multiple myeloma is complex.<br />
The initiating event is a mutational event in a B-cell. However,<br />
there <strong>are</strong> important additional mechanisms including:<br />
47
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
(1) additional mutational events within the myeloma clone;<br />
(2) aberrancies of the bone marrow micro-environment; (3)<br />
abnormalities of cytokines <strong>and</strong> hematopoietic growth factors;<br />
<strong>and</strong> (4) immune-deficiency. For several decades myeloma-therapy<br />
focused predominately on control of the myeloma<br />
clone by cytotoxic DNA-alkylating drugs (like melphalan<br />
<strong>and</strong> cyclophosphamide) <strong>and</strong> by drugs directly toxic<br />
to B-cells (like dexamethasone). Recently, new classes of<br />
anti-myeloma drugs were developed including proteosomeinhibitors<br />
(like bortezomib) <strong>and</strong> so-called immune-modulating<br />
drugs (IMiDs) (like thalidomide, lenalidomide <strong>and</strong><br />
pomalidomide). My talk focus on the mechanism(s) of action<br />
of IMiDs in myeloma <strong>and</strong> clinical efficacy.<br />
IMiDs <strong>are</strong> effective anti-myeloma drugs. Their mechanisms<br />
of action <strong>are</strong> diverse <strong>and</strong> complex. They also differ<br />
for different IMiDs. In general, IMiDs act on 4 targets in<br />
myeloma: (1) direct cytotoxicity; (2) immune-modulation;<br />
(3) effects on the bone marrow micro-environment; <strong>and</strong> (4)<br />
modulation of cytokines <strong>and</strong> hematopoietic growth factors.<br />
Exactly how IMiDs mediate these effects <strong>are</strong> complex. For<br />
example, IMiDS cause cell-cycle arrest by increasing P21,<br />
ERG1 <strong>and</strong> P15 expression, altering expression of cancer<br />
suppressor genes CDK2 <strong>and</strong> RB1, decreasing interferon<br />
regulatory factor-4 (IRF4), increasing caspase-3,-8 <strong>and</strong> -9<br />
expression <strong>and</strong> apoptosis <strong>and</strong> by decrease expression of tumour<br />
necrosis factor-alpha (TNFα). There <strong>are</strong> also stimulating<br />
effects on T- <strong>and</strong> NKT-cells. These mechanisms will be<br />
discussed in detail.<br />
Substantial data support the important clinical activity of<br />
IMiDs, alone or with other anti-myeloma drugs (like dexamethasone),<br />
in myeloma-therapy. R<strong>and</strong>omized clinical trials<br />
support the effectiveness of thalidomide <strong>and</strong> lenalidoime<br />
in persons with newly-diagnosed <strong>and</strong> with advanced myeloma.<br />
Interestingly, lenalidomide also prevents myelom<strong>are</strong>lapse<br />
in recipients of high-dose therapy <strong>and</strong> hematopoietic<br />
cell autotransplants. Pomalidomide, the newest IMiD, is active<br />
in persons failing therapy with thalidomide <strong>and</strong> lenalidomide.<br />
These data suggest different proportions of anti-myeloma<br />
mechanisms of action <strong>and</strong> support sequencing of <strong>and</strong><br />
combinations of IMiDs in myeloma-therapy.<br />
OP35 Curing Multiple myeloma – the facts behind<br />
the claim<br />
Bart Barlogie, Alan Mitchell, John D Shaughnessy Jr,<br />
<strong>and</strong> John Crowley, Myeloma Institute for Research <strong>and</strong><br />
Therapy, University of Arkansas for Medical Sciences,<br />
Little Rock, AR; <strong>and</strong> Cancer Research And Biostatistics,<br />
Seattle, WA<br />
Our Total Therapy (TT) approach for newly diagnosed<br />
multiple myeloma (MM) was initiated in 1989 with the<br />
stated goal of attempting MM cure by applying all known<br />
MM-active agents up-front in order to overcome the genomic<br />
chaos present in the majority of patients. We <strong>are</strong> reporting<br />
on updates of TT1 (n=231), TT2 r<strong>and</strong>omizing 668<br />
patients between a control an thalidomide arm, <strong>and</strong> TT3 that<br />
incorporated bortezomib up-front together with thalidomide<br />
<strong>and</strong> applying VTD in maintenance (n=303). With median<br />
follow-up times of 17.8 years in TT1, 9.4 years in TT2 <strong>and</strong><br />
48<br />
6.1 years in TT3, patients alive at last contact include 44,<br />
321, 214, respectively, of whom 24, 208, 194 remain progression-free<br />
including 15, 156,149 in continuous complete<br />
remission (CR). According to an exponential/plateau model,<br />
significant cure fractions (CF) were estimated from overall<br />
survival (OS), progression-free survival (PFS) <strong>and</strong> CR duration<br />
(CRD) as 14.6%, 10.1% <strong>and</strong> 14.1% in TT1; 19.9%,<br />
15.6% <strong>and</strong> 32.2% in TT2’s control arm; 22.5%, 24.7% <strong>and</strong><br />
40.3% in TT2’s thalidomide arm; <strong>and</strong> 61.6%, 58.2% <strong>and</strong><br />
77.2% in TT3. Data will be presented on age- <strong>and</strong> genderadjusted<br />
comparisons of overall survival (OS) with the general<br />
population along with the independent baseline features<br />
linked to 5-yr PFS <strong>and</strong> CRD estimates, also in the context of<br />
gene expression profiling (GEP), available in subsets of<br />
TT2 <strong>and</strong> TT3 trials. Collectively our results support the conclusion<br />
of curability in principle through increasing survival<br />
plateaus especially for GEP-defined low-risk MM reaching<br />
post-CR CF estimates of >80% in TT3 but also 33% in<br />
high-risk MM treated with TT3.<br />
OP36 Adult ALL treatment approach for B-ALL<br />
Dieter Hoelzer, University of Frankfurt, Germany<br />
Therapy of Burkitt leukemia (WHO classification 2008,<br />
also mature B-ALL or L3 ALL) with conventional chemotherapy<br />
resulted in an extremely overall survival of less then<br />
10% in all published studies.<br />
Short intensive sequential therapy<br />
Improvement in outcome of Burkitt lymphoma/ leukemia<br />
was first obtained in paediatric protocols e.g. (CODOX-M,<br />
BFM, LMB). Important treatment elements were high-dose<br />
fractionated alkylating agents, metabolites, high-dose Meth-
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
otrexate <strong>and</strong> high-dose Ara-C. When such protocols (e.g.<br />
CODOX-M/IVAC, GMALL-B-NHL, Hyper-CVAD) were<br />
applied in adult B-ALL <strong>and</strong> Burkitt-NHL, the CR rate increased<br />
up to 80%, <strong>and</strong> the overall survival to 50–60%. Further<br />
intensification, e.g. in HDMTX-dose, did not improve<br />
results.<br />
Stem cell transplantation<br />
Autologous stem cell transplantation was considered as<br />
an alternative option in Burkitt lymphoma/ leukemia. Survival<br />
rates in retrospective analysis <strong>and</strong> prospective studies<br />
ranged from 30–60%. A substantial proportion of patients<br />
was not included because of CNS/ BM involvement or rapid<br />
progress. Allogeneic transplant resulted in an overall survival<br />
of 25–30%, most patients had high risk features or far<br />
advanced disease. It was concluded that the allogeneic HCT<br />
may exert a graft-versus-leukemia effect. Overall those SCT<br />
results were not superior to those obtained with short intensive<br />
sequential chemotherapy.<br />
Immunochemotherapy<br />
Burkitt-NHL/ leukemia cells express in >85% CD20.<br />
Therefore some adult studies included the anti-CD20 monoclonal<br />
antibody (MoAb) Rituximab. The response rate increased<br />
<strong>and</strong> overall survival rate improved to 80–90% in<br />
Burkitt lymphoma, in some studies somewhat inferior for<br />
Burkitt leukemia.<br />
Burkitt-NHL in HIV<br />
20–40% of all NHL in HIV+ patients <strong>are</strong> Burkitt NHL.<br />
When the short intensive treatment regimen were applied to<br />
those patients, outcome was clearly superior to CHOP. CR<br />
of approx. 60–70% <strong>and</strong> an overall survival rate of 50% were<br />
achieved when the patients received an additional intensive<br />
antiviral therapy (HAART).<br />
In a recent attempt HIV+ Burkitt NHL patients received<br />
also the MoAb Rituximab in addition to the intensive chemotherapy<br />
<strong>and</strong> – despite the risk of increased immunosuppression<br />
– the survival was improved to >60%.<br />
Prognostic factors<br />
With the improvement in outcome, it is not clear which<br />
adverse prognostic factors for Burkitt-NHL/ BL remain.<br />
Achievement of CR <strong>and</strong> probably stage of disease, but most<br />
likely the double-hit lymphomas with a MYC/8q24 translocation<br />
in combination with another recurrent translocation,<br />
mainly t(14;18) with BCL2-IGH fusion <strong>are</strong> associated with<br />
an unfavourable prognosis. For those patients an early SCT<br />
might be indicated.<br />
Future directions<br />
A new strong adverse prognostic risk factor in Burkitt<br />
leukemia is MRD, but is most unlikely relevant for Burkitt-<br />
NHL.<br />
For the remaining small fraction of non-responding or<br />
relapsed patients it is difficult to find promising approaches,<br />
this could be novel drugs including new antibodies, with the<br />
aim to reduce the tumor load before a SCT.<br />
Realising the r<strong>are</strong>ness of the disease, joined efforts in<br />
ALL study groups to identify risk populations <strong>and</strong> new promising<br />
approaches should be considered.<br />
OP37 T-ALL – Current Treatment<br />
Stefan Faderl, Department of Leukemia, The University of<br />
Texas MD Anderson Cancer Center Texas, USA [see SA01]<br />
Patients with T ALL constitute about 25% of all adult<br />
patients with ALL. The median age at diagnosis is about 30<br />
years <strong>and</strong> it is seen more commonly in males. Not infrequently<br />
do patients with T ALL present with high white<br />
blood cell (WBC) counts <strong>and</strong> an anterior mediastinal mass<br />
which may reach bulky proportions. Immunophenotyping<br />
by flow cytometry is an essential part of the diagnostic work<br />
up to confirm the diagnosis of an acute leukemia, assign the<br />
correct lineage, an define the stage of maturation of the blast<br />
cell population. Based on expression of various CD markers<br />
T cell blasts <strong>are</strong> divided into early, cortical (thymic) <strong>and</strong><br />
meduallary (mature) subtypes. The most T cell lineage specific<br />
marker is expression of surface CD3 (sCD3). This<br />
marker is typically positive in the medullary type, negative<br />
in the early stages <strong>and</strong> ambiguously expressed in the cortical<br />
subtypes. Although less specific but of sufficient sensitivity,<br />
CD1a is expressed in the cortical stages of T ALL but<br />
not in early <strong>and</strong> medullary subtypes.<br />
The prognosis of T ALL was poor in the past but has<br />
improved substantially over recent decades <strong>and</strong> nowadays<br />
surpasses that of patients with the more common precursor<br />
B cell ALL. This evolution is due to changes in treatment<br />
design <strong>and</strong> in particular based on 1) increased intensity; <strong>and</strong><br />
2) addition of other active drugs (eg, cytarabine, cyclophosphamide,<br />
asparaginase). For example, whereas long-term<br />
disease-free survival (DFS) was about 35% with conventional<br />
Non-Hodgkin’s lymphoma (NHL) regimens, it increased<br />
to about 50% when applying NHL regimens for<br />
high-grade lymphomas <strong>and</strong> around 55% when using ALL<br />
protocols. 1<br />
An example for a current high-intensity ALL program is<br />
Hyper-CVAD. 2 Hyper-CVAD consists of 8 intensive induction<br />
/consolidation cycles where hyper-CVAD (hyperfractionated<br />
cyclophosphamide, doxorubicin, vincristine, dexamethasone)<br />
alternates with high-dose methotrexate <strong>and</strong> cytarabine.<br />
This is followed by up to 32 months of the so<br />
called POMP maintenance (vincristine, methotrexate, mercaptopurine,<br />
prednisone). Central nervous system (CNS)<br />
prophylaxis consists of intrathecal therapy with cytarabine<br />
<strong>and</strong> methotrexate for a maximum of 8 injections. The experience<br />
of patients with lymphoblastic lymphoma (T cell lineage<br />
in 79% of the patients) was recently published. Fortynine<br />
patients were included with a median age of 31 years<br />
(range 17 to 59). The complete remission rate was 96% <strong>and</strong><br />
5-year survival 68%. Fourteen of the patients who achieved<br />
CR relapsed at a median of 13 months. The joint study of<br />
the MRC UKALL XII/ECOG E2993 trial included 356 patients<br />
with T ALL with a median age of 29 years. 3 Patients<br />
received 2 induction phases (daunorubicin, vincristine, asparaginase,<br />
prednisone, methotrexate in phase 1 followed<br />
by cyclophosphamide, cytarabine, mercaptopurine, <strong>and</strong> methotrexate<br />
in phase 2). Patients were then either assigned to<br />
an allogeneic stem cell transplant (SCT) arm (if they had an<br />
HLA-compatible donor <strong>and</strong> were younger than 50 years) or<br />
r<strong>and</strong>omized between either an autologous SCT or chemo-<br />
49
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
therapy (if they were at least 50 years old <strong>and</strong> had no donor).<br />
Prior to their assigned or r<strong>and</strong>omized treatment every patient<br />
received high-dose methotrexate <strong>and</strong> asparaginase.<br />
The complete remission rate was 94%; older patients (over<br />
age 50 years) had a significantly lower remission probability<br />
of 79%. The median 5-year survival probability was 48%<br />
with significant differences based on age (38% for patients<br />
over age 35), WBC (41% for patients with a WBC of<br />
>100,000/mcl), immunophenotype (patients who expressed<br />
CD13 <strong>and</strong> lacked CD1a expression did worse), <strong>and</strong> karyotype<br />
(19% with complex karyotypes).<br />
The German ALL Study Group (GMALL) evaluated outcome<br />
of patients with T ALL based on immunophenotype:<br />
early (sCD3 negative, CD1a negative), thymic (CD1a positive),<br />
<strong>and</strong> mature/medullary (sCD3 positive). 4 Three different<br />
studies included a total of 744 patients. Study GMALL<br />
05/93 included 239 patients who all received multiagent<br />
chemotherapy without provisions for SCT in first remission.<br />
Studies GMALL 06/99 <strong>and</strong> 07/03 consisted of 505<br />
patients. In these latter two studies patients received an intensified<br />
treatment (pegaspargase, high-dose methotrexate)<br />
<strong>and</strong> patients with early, mature <strong>and</strong> high-risk thymic T ALL<br />
received SCT in first CR. Outcome was most favorable for<br />
patients with thymic ALL where 10-year survival exceeded<br />
60% with chemotherapy alone. Results were worst for patients<br />
with early <strong>and</strong> mature T-ALL if they received chemotherapy<br />
but were significantly better if these patients received<br />
an allogeneic SCT in first remission.<br />
Novel approaches aim to include additional drugs. In a<br />
study by the MD Anderson group Hyper-CVAD is being<br />
combined with nelarabine. Patients receive Hyper-CVAD as<br />
detailed above. Prior to the POMP maintenance they receive<br />
two cycles of nelarabine followed by one further cycle of<br />
nelarabine later during the maintenance. Interim results<br />
have recently been presented. 5 Of 23 patient with a median<br />
age of 38 years (rate 21 to 76), the CR rate was 96%. With a<br />
median follow up of 14 months, median overall <strong>and</strong> DFS<br />
have not been reached. The survival probability at 3 years<br />
was 65%. These data <strong>are</strong> in keeping with those reported by<br />
other groups before. Longer follow up will be necessary to<br />
determine the benefit if any of the addition of nelarabine<br />
<strong>and</strong> in what sequence.<br />
In summary, modern <strong>and</strong> intensive multiagent chemotherapy<br />
regimens achieve remissions in most patients <strong>and</strong><br />
long-term DFS in about 50 to 60%. New markers of prognosis<br />
(immunophenotype, genotype) <strong>are</strong> valid in determining<br />
whether or not further intensification (SCT) in first remission<br />
can improve outcome. Other markers (eg, mutations of<br />
NOTCH1 or detection of the NUP214-ABL1 fusion gene)<br />
<strong>are</strong> being explored as basis for applying targeted treatment<br />
approaches (gamma secretase inhibitors in the former <strong>and</strong><br />
tyrosine kinase inhibitors in the latter example). New drugs<br />
<strong>and</strong> combinations such as with nelarabine provide further<br />
means to exp<strong>and</strong> therapeutic options in the future.<br />
R E F E R E N C E S<br />
1. Cortelazzo S, Ponozoni M, Ferreri AJM, Hoelzer D. Lymphoblastic<br />
lymphoma. Cri Rev Oncol/Hematol 2011 [epub]<br />
2. Thomas DA, O’Brien S, Cortes J, et al. Outcome with the hyper-CVAD<br />
regimens in lymhoblastic lymphoma. Blood 2004;104:1624–1630.<br />
50<br />
3. Marks DI, Paietta EM, Moorman AV, et al. T-cell acute lymphoblastic<br />
leukemia in adults: clinical features, immunophenotype, cytogenetics,<br />
<strong>and</strong> outcome from the large r<strong>and</strong>omized prospective trial (UKALL XII/<br />
ECOG E2993). Blood 2009;114:5136–5145.<br />
4. Hoelzer D, Thiel E, Arnold R, et al. Successful subtype oriented treatment<br />
strategies in adult T-ALL; Results of 744 patients treated in three<br />
consecutive GMALL Studies. Blood 2009;114:abs 324.<br />
5. Al-Ameri A, Thomas DA, Rav<strong>and</strong>i F, et al. Hyper-CVAD plus nelarabine<br />
in the treatment of newly diagnosed patients with T cell acute lymphoblastic<br />
leukemia/ lymphoblastic lymphoma (T-ALL/LL). J Clin Oncol<br />
2011;29:432S.<br />
OP38 Young adult with ALL – how to treat<br />
Jean-Pierre Marie, Stéphanie Haïat, Anne Vekhoff<br />
& Ollivier Legr<strong>and</strong>, Department of Hematology, Saint-<br />
Antoine Hospital & Université Pierre et Marie Curie,<br />
Paris, EORTC Leukemia Group<br />
Survival for adult with ALL is lower than in children,<br />
mainly due to the relapse rate. A pressing question is whether<br />
the age-related differences in outcome <strong>are</strong> predicated by<br />
the disease per see or whether they result from a different<br />
approach to, or tolerance of, therapy. Boissel et al. (1) comp<strong>are</strong>d<br />
the outcome of adolescents (15–20 years) with ALL<br />
treated in France in either the pediatric FRALLE 93 or the<br />
adult LALA-94 clinical trials. With a median follow up of<br />
about 3.5 years, the CR rate (94% vs. 83%), event free survival<br />
(EFS) at 5 years (67% vs.41%), <strong>and</strong> the DFS for the<br />
CR patients (72% vs. 49%) were far superior in the pediatric<br />
group <strong>and</strong> multivariate analysis confirmed the independent<br />
effect of the treatment trial on outcome. The major differences<br />
between the pediatric or adult approach were the actually<br />
given dosages of asparaginase, corticosteroids <strong>and</strong> vinca-alkaloids.<br />
Another difference was the strict discipline<br />
with which the treatment courses were administered by the<br />
pediatricians comp<strong>are</strong>d to the flexibility of the internists.<br />
Analyses with similar outcome have been reported by comparing<br />
ALL patients aged 15 till 21 years treated in different<br />
countries (2,7). The recent GRAALL-2003 study suggests<br />
that pediatric-inspired therapy markedly improves the outcome<br />
in adult patients with ALL, at least until the age of 45<br />
(8). We recently tested the feasibility of a pediatric regimen<br />
(FRALLE 2000) (9) in 40 adult ALL patients (age 16–57<br />
years), <strong>and</strong> comp<strong>are</strong>d the results to the EORTC ALL4 trial<br />
(10). Median follow-up of alive patients was 1596 days for<br />
patients treated in pediatric protocol <strong>and</strong> 1552 days for patients<br />
treated in ALL4 protocol (p=NS). DFS <strong>and</strong> OS were<br />
63%±9%, <strong>and</strong> 70%±7%, <strong>and</strong> were significantly longer in<br />
patients under 40yo (86%±7% versus 30%±15%, p=0.003<br />
[DFS] <strong>and</strong> 86%±7.8% vs 49%±12%, p=0.01 [OS], respectively)<br />
or cortico/chemo-sensitive (71%±9% versus 36%±<br />
15%, p=0.01 [DFS] <strong>and</strong> 86%±7%, versus 28%±13%, p=<br />
0.0004 [OS]) than in other patients.<br />
Ten patients had undetectable minimal residual disease<br />
(MRD) <strong>and</strong> none of them experienced relapse. Grade 3 – 4<br />
toxicities included a considerable number of severe infections,<br />
liver function abnormalities, unexpected peripheral<br />
neuropathies, osteonecrosis <strong>and</strong> denutrition. These toxicities<br />
increased with age. The adherence discipline with respect<br />
to time-lines of the treatment schedules was successful<br />
in approximately 50% of the limited number of patients
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
studied so far. Similar experience was observed in the HO-<br />
VON-70 study, which included 54 patients aged 18 to 39<br />
years. Overall, it was concluded that results appe<strong>are</strong>d very<br />
encouraging, but that side effects necessitated prolongation<br />
of the induction/consolidation/ intensification phase in a<br />
considerable number of patients <strong>and</strong> that the protocol<br />
seemed too intensive for older patients. The threshold, in<br />
our experience but also in the GRAALL <strong>and</strong> the HOVON is<br />
40 yo.<br />
In conclusion, adolescents but also »young« adults (
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
ond generation ABL TK inhibitors. This provides the rationale<br />
for the administration of TKI after SCT, although the<br />
exact modalities, e.g. type of TKI, dose, starting timepoint<br />
<strong>and</strong> duration of treatment remain to be resolved.<br />
The importance of mutations in clinical resistance to<br />
available TKI has promoted the search for novel inhibitors,<br />
active particularly against the T315I gatekeeper mutation.<br />
Interesting immunologic approaches <strong>are</strong> based on recently<br />
developed bispecific T-cell-engager (BiTE) antibodies<br />
that transiently engage cytotoxic T-cells for lysis of selected<br />
target cells. The bispecific antibody construct called blinatumomab<br />
links T cells with CD19-expressing target cells,<br />
resulting in a non-restricted cytotoxic T-cell response <strong>and</strong><br />
T-cell activation. Preliminary results indicate that treatment<br />
with blinatumomab is able to convert MRD positive ALL<br />
into an MRD negative status, <strong>and</strong> that this is well tolerated.<br />
Current efforts also involve the optimisation of molecular<br />
techniques to quantitate minimal residual disease <strong>and</strong> identify<br />
resistance mechanisms. Optimal treatment results necessitate<br />
the integration of all available therapeutic <strong>and</strong> molecular<br />
diagnostic approaches into predefined, long-term<br />
strategies that take into account both patient <strong>and</strong> disease<br />
characteristics.<br />
OP40 MRD – criteria for postremission therapy<br />
Deborah Thomas, (USA)<br />
52<br />
Abstract not submitted.<br />
OP41 Allogeneic stem cell transplantation for<br />
adult ALL: st<strong>and</strong>ard vs. Reduced-intensity<br />
conditioning<br />
Mohamad Mohty, Hematology Dpt., University-Hopsital<br />
of Nantes, Centre de Recherche en Cancerologie de<br />
Nantes-Angers (CRCNA), INSERM U892, F-44093<br />
Nantes, France<br />
Acute lymphoblastic leukemia (ALL) accounts for approximately<br />
15 to 20% of all adult acute leukemias. Despite<br />
the fact that 80 to 90% of adult patients with ALL succeed<br />
in achieving complete remission (CR), most of them will<br />
relapse <strong>and</strong> die of their disease. Among adults with ALL,<br />
long-term leukemia-free survival (LFS) rates of 30 to 40%<br />
have been obtained with the use of chemotherapy, as comp<strong>are</strong>d<br />
with 45 to 75% with the use of conventional myeloablative<br />
conditioning (MAC) allogeneic stem cell transplantation<br />
(allo-SCT). The latter favorable effect is likely due to a<br />
reduced risk of relapse, especially in those patients in first<br />
CR. However, non-relapse mortality (NRM) may counterbalance<br />
that favorable overall outcome observed after MAC<br />
allo-SCT in those elderly patients <strong>and</strong>/or in patients with<br />
comorbidities. Thus, the use of reduced intensity conditioning<br />
(RIC) prior to allo-SCT may offer hitherto unavailable<br />
opportunities to obtain a graft-vs.-leukemia effect without<br />
the toxicities of intense preparative regimens. However, one<br />
must acknowledge that the role of allo-SCT in adult ALL is<br />
still controversial. In addition, ALL encompasses a group of<br />
chemosensitive diseases, raising concerns that significant<br />
reduction of the intensity of the preparative regimen prior to<br />
allo-SCT may have a negative impact on long-term leukemic<br />
control as it has been already shown in other settings.<br />
Also, very few data is available analyzing RIC allo-SCT for<br />
patients with ALL.<br />
This report will discuss the available research evidence in<br />
this field with a special focus on comparative studies which<br />
assessed the outcomes of adult patients with ALL who underwent<br />
allo-SCT, <strong>and</strong> were analyzed according to the type<br />
of conditioning received prior to allo-SCT (RIC vs. MAC).<br />
OP42 Autologous SCT for ALL – stil a chalange<br />
Sebastian Giebel, Department of Bone Marrow<br />
Transplantation, Maria Sklodowska-Curie Memorial<br />
Cancer Centre <strong>and</strong> Institute of Oncology, Gliwice Branch,<br />
Gliwice, Pol<strong>and</strong><br />
First-line therapy of adults with Ph-negative acute lymphoblastic<br />
leukemia (ALL) consists of remission induction<br />
followed by intensive consolidation. Further treatment usually<br />
depends on the presence of risk factors. Conventional<br />
risk factors include initial tumor burden, age, immunophenotype,<br />
karyotype, <strong>and</strong> time to achieve complete remission<br />
(CR). In recent years, a number of studies demonstrated a<br />
strong prognostic value of the status of minimal residual<br />
disease (MRD) measured after induction <strong>and</strong> consolidation.<br />
1–3 According to some authors MRD together with cytogenetics<br />
may be sufficient for risk stratification. 4,5 Patients<br />
allocated to st<strong>and</strong>ard risk (SR) group used to be treated with<br />
long-term maintenance chemotherapy while those with high<br />
risk (HR) features <strong>are</strong> usually offered allogeneic stem cell<br />
transplantation (alloSCT).<br />
The role of autologous SCT (autoSCT) in adults with<br />
ALL has not been clearly defined. In the 1990ies a series of<br />
studies have been conducted to evaluate whether high-dose<br />
therapy followed by autoHSCT may improve the outcome<br />
of HR patients lacking an HLA-identical sibling comp<strong>are</strong>d<br />
to conventional-dose post-consolidation chemotherapy. 6–9<br />
In the EORTC ALL3 study results of autoHSCT <strong>and</strong> maintenance<br />
treatment appe<strong>are</strong>d superimposable. 6 In the PETH-<br />
EMA ALL93 study no significant difference between the<br />
transplantation <strong>and</strong> chemotherapy arm could be demonstrated,<br />
however, there was some tendency in favor of conventional-dose<br />
treatment (disease-free survival, DFS, 44% vs.<br />
35% at 5 years). 7 In contrast, results of the LALA-94 suggested<br />
some advantage of autoHSCT (DFS 25% vs. 13% at<br />
5 years) although the difference was not statistically significant.<br />
8 A pooled analysis of three subsequent trials by the<br />
French group (LALA-85/87/94) showed that autoHSCT may<br />
contribute to decreased risk of relapse comp<strong>are</strong>d to conventional-dose<br />
chemotherapy (66% vs. 78%, p=0.05) with mno<br />
significant impact on survival. 10 Altogether, the above cited<br />
studies did not provide clear evidence for neither the superiority<br />
nor inferiority of autoHSCT over the maintenance.<br />
In the largest so far MRC UKALLXII/ECOG 2993 study<br />
investigators tested if autoHSCT may be administered instead<br />
of consolidation + maintenance for patients lacking an<br />
HLA-identical sibling, irrespective of the presence of risk<br />
factors. 9 The overall survival was significantly worse in the
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
autoHSCT comp<strong>are</strong>d to chemotherapy arm (46% vs. 37% at<br />
5 years, p=0.03) leading to conclusion that early autoHSCT<br />
cannot substitute consolidation. In addition the donor vs. no<br />
donor analysis revealed advantage of alloHSCT arm in SR<br />
patients. In HR group the non-relapse mortality was 39%<br />
among patients having a donor, overcoming advantage related<br />
to reduced risk of relapse.<br />
Disappointing results of prospective trials evaluating the<br />
role of autoHSCT led to a general tendency to ab<strong>and</strong>on this<br />
treatment option in adults with ALL. It must be stressed,<br />
however, that design of the studies could have been suboptimal.<br />
First of all, the trials have been conducted before the<br />
era of routine MRD assessment. Low tumor burden is prerequisite<br />
of successful autotransplantation as in other conditions<br />
the transplant material may be contaminated by residual<br />
leukemic blasts leading to their re-transplantation <strong>and</strong><br />
early relapse. Evaluation of MRD status in bone marrow<br />
reflecting the tumor load may therefore be crucial for selection<br />
of patients who could benefit from autoHSCT. Indeed,<br />
in a retrospective analysis by the European Working Group<br />
for Adult ALL, the MRD level was demonstrated the most<br />
important prognostic factor with DFS of 58% for patients<br />
with MRD
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
mia (CLL) cells. The availability of these antibodies is making<br />
a great impact in the treatment of CLL. Alemtuzumab, a<br />
chimeric monoclonal antibody that targets the CD52 surface<br />
antigen, was the first antibody approved for the treatment<br />
of patients with CLL. It induces responses in one-third<br />
of relapsed <strong>and</strong> refractory patients, <strong>and</strong> in more than 80% of<br />
the patients when used as initial therapy. Alemtuzumab has<br />
been used as single agent as well as in combination with the<br />
monoclonal antibody rituximab or with chemotherapy in<br />
combination with fludarabine, cyclophosphamide <strong>and</strong> alemtuzumab.<br />
Treatment with alemtuzumab is associated with a<br />
profound lymphocyte depletion <strong>and</strong> acquired immunosuppression;<br />
therefore, opportunistic infections <strong>are</strong> often increased<br />
following this therapy limiting its use. Rituximab,<br />
a chimeric monoclonal antibody against CD20 has been<br />
widely used in lymphoproliferative disorders. In CLL, rituximab<br />
has limited activity when used as single agent, but has<br />
significant synergism when used in combination with other<br />
monoclonal antibodies or chemotherapy. The addition of<br />
rituximab to the combination of fludarabine <strong>and</strong> cyclophosphamide<br />
has been shown to improve response rate <strong>and</strong> prolong<br />
survival in physically fit patients with CLL. Rituximab<br />
has also shown activity in combination with numerous chemotherapeutic<br />
agents such as bendamustine <strong>and</strong> pentostatin.<br />
More recently developed, ofatumumab, is a fully humanized<br />
anti-CD20 antibody with efficacy in patients whose<br />
disease is refractory to both fludarabine <strong>and</strong> alemtuzumab.<br />
Ofatumumab is currently undergoing evaluation in combination<br />
with chemotherapy <strong>and</strong> other biological agents. Other<br />
antibodies or related molecules currently in clinical trials<br />
include GA101, a type II anti-CD20 antibody, lumiliximab,<br />
an antibody targeting CD23, blinatumomab, a bi-specific<br />
single-chain antibody targeting CD19 <strong>and</strong> Tru-016 a small<br />
modular immunopharmaceutical (SMIP) targeting CD37.<br />
These monoclonal antibodies <strong>and</strong> related agents use diverse<br />
mechanisms of action, complement each other <strong>and</strong> when<br />
used in combinations have the potential to enhance the activity<br />
of chemotherapy <strong>and</strong> other biologic agents. Through<br />
the ongoing <strong>and</strong> future development of such combinations,<br />
effective therapeutic options for patients with CLL will continue<br />
to increase.<br />
OP47 New <strong>and</strong> old drugs in CLL – we can do<br />
better<br />
Peter Hillmen, (United Kingdom)<br />
54<br />
Abstract not submitted.<br />
OP48 SCT for CLL – when?<br />
Issa Khouri, Department of Stem Cell Transplantation<br />
<strong>and</strong> Cellular Therapy, The University of Texas MD<br />
Anderson Cancer Center, Houston, Texas, USA<br />
In the past decade, the paradigm for allogeneic stem cell<br />
transplantation (SCT) for chronic lymphocytic leukemia<br />
(CLL) has changed. Confidence in the power of the graftversus-leukemia<br />
effect has encouraged the use of transplan-<br />
tation after low-intensity, nonmyeloablative preparative<br />
regimens. This strategy has resulted in long-term remissions<br />
in a subset of patients with advanced CLL who develop resistance<br />
to conventional treatments. Nonmyeloablative SCT<br />
(NST) can overcome adverse prognostic factors such as the<br />
presence or absence of somatic mutations in the immunoglobulin<br />
heavy chain variable region, Zeta-chain-associated<br />
protein 70 kDa expression, <strong>and</strong> the presence of chromosomal<br />
aberrations, including 17p13.1 deletion. Recent studies<br />
suggested that patients’ hematopoietic SCT-comorbidity index,<br />
tumor bulk, age, <strong>and</strong> disease refractoriness were important<br />
determinants of survival. We review the results of<br />
NST in CLL, discuss the evolution of the new nonmyeloablative<br />
approaches, <strong>and</strong> make recommendations for when<br />
SCT should be considered in patients with CLL.<br />
OP49 Prognostic score for Hematopoietic Stem<br />
Cell Transplantation<br />
Alois Gratwohl, Hematology, Medical Faculty, University<br />
of Basel, Basel, Switzerl<strong>and</strong><br />
Hematopoietic stem cell transplantation (HSCT) has become<br />
the treatment of choice for many patients with a congenital<br />
or acquired severe disorder of the hematopoietic<br />
system. Despite marked improvements over time, HSCT remains<br />
inherently associated with morbidity <strong>and</strong> mortality.<br />
Prior to any decision to proceed with HSCT an assessment<br />
is warranted whether the potential benefits outweigh the<br />
risks of the procedure. Risk assessment is complex, requires<br />
specific skills <strong>and</strong> experience <strong>and</strong> includes risk of the disease<br />
<strong>and</strong> risk of HSCT. Risk of HSCT includes pre-, peri-<br />
<strong>and</strong> post transplant risk elements. Not all of them <strong>are</strong> known<br />
at the time of decision making, pretransplant elements <strong>are</strong>.<br />
The EBMT risk score provides a simple tool to assess instantly<br />
pre-transplant risks for an individual patient. Five<br />
factors, age of the patient (40 years 2 score points), stage of the disease (Early disease<br />
stage 0; intermediate disease stage 1; late stage disease 2<br />
score points), time from diagnosis to HSCT (1<br />
year 1 score point. Note: time interval diagnosis to HSCT<br />
does not apply for patients transplanted in 1 st CR, score is<br />
always 0), donor type (HLA-identical sibling as donor 0;<br />
other donor 1 score point) <strong>and</strong> donor recipient gender combination<br />
(»all other combinations« 0; »female donor for a<br />
male recipient« 1 score point) augment risk for an individual<br />
patient with increasing score from 0 as best to 7 as worst.<br />
Individual risks <strong>are</strong> additive! The score holds for all acquired<br />
hematological disorders, for allogeneic <strong>and</strong> autologous<br />
HSCT (for autologous HSCT consider only age, disease<br />
stage <strong>and</strong> time interval; hence score 0–5). The score is<br />
independent of the HSCT technology; eg, it is valid for st<strong>and</strong>ard<br />
or reduced intensity conditioning, for bone marrow,<br />
peripheral blood <strong>and</strong> cord blood transplants, for grafts with<br />
or without T cell depletion. Survival is uniformly worse for<br />
older patients, transplanted in more advanced disease stage<br />
after a long time interval with a mismatched donor than for<br />
younger patients, transplanted soon in early stage with a<br />
well matched donor. Additional factors such as performance
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
score, comorbidities, CMV serostatus or cytokine polymorphisms<br />
add to the risk <strong>and</strong> improve prediction. There impact<br />
differs for low or high risk patients. Optimal donor recipient<br />
gender combination or CMV serostatus improve outcome in<br />
otherwise low risk patients whereas a low performance<br />
score might be acceptable in low risk but detrimental in otherwise<br />
high risk patients. Such comparative assessment of<br />
disease risk <strong>and</strong> global pre-transplant risk can guide the decisions<br />
for individual patients between HSCT <strong>and</strong> a non<br />
transplant approach. The EBMT score forms the basis for a<br />
risk adapted individualized strategy which should replace<br />
the traditional »donor versus no donor« concept.<br />
OP50 Consideration in Choosing the Optimal<br />
Stem Cell Source<br />
Mary M. Horowitz, Division of Hematology <strong>and</strong> Oncology,<br />
Department of Medicine, Medical College of Wisconsin<br />
<strong>and</strong> Scientific Director, Center for International Blood<br />
<strong>and</strong> Marrow Transplantation (CIBMTR), USA<br />
Considerations in selecting the optimal cell source for allogeneic<br />
transplantation include donor relationship (related<br />
versus unrelated), donor-recipient HLA-matching. <strong>and</strong> cell<br />
source (bone marrow vs peripheral blood versus umbilical<br />
cord blood). HLA-identical siblings <strong>are</strong> generally accepted<br />
as the preferred donor unless donor co-morbidities preclude<br />
donation. Whether to use bone marrow or peripheral blood<br />
grafts from sibling donors depends, in part, on recipient factors.<br />
Although peripheral blood grafts <strong>are</strong> associated with<br />
higher risks of chronic graft-versus-host disease (GVHD),<br />
patients with advanced disease may benefit from the higher<br />
cell doses possible with such grafts. If an HLA-identical<br />
sibling is not available, a search for an unrelated adult volunteer<br />
donor may be done. Best results with unrelated donor<br />
transplantation <strong>are</strong> obtained when donor <strong>and</strong> recipient <strong>are</strong><br />
matched at high-resolution for HLA A, B, C, <strong>and</strong> DRB1. In<br />
the absence of a matched unrelated donor, a donor with a<br />
single mismatch at these loci may be used. In such situations,<br />
matching at low-expression alleles (DQ, DP, DRB3/<br />
4/5) may be beneficial. CIBMTR data suggest that bone<br />
marrow or peripheral blood grafts from unrelated donors<br />
result in similar survival rates but with more GVHD; a large<br />
r<strong>and</strong>omized trial of unrelated donor blood versus bone marrow<br />
grafts is in progress. Some data suggest that peripheral<br />
blood transplantation may be more permissive of HLA mismatching<br />
than bone marrow transplantation. If an adult unrelated<br />
donor is not available in a timely manner, umbilical<br />
cord blood mismatched at one or two loci may be used, with<br />
current data suggesting results similar to results with unrelated<br />
bone marrow or peripheral blood transplantation. The<br />
limiting factor in cord blood transplantation is cell dose,<br />
which may be circumvented by use of multiple units. The<br />
choice of an adult donor versus cord blood is influenced by<br />
graft factors such as HLA-match <strong>and</strong> cell dose but also by<br />
patient factors such as age, weight, type of disease <strong>and</strong> urgency<br />
of the clinical situation. Haploidentical peripheral<br />
blood or bone marrow transplantation may also be effective<br />
graft sources with a recent study suggesting results similar<br />
to cord blood transplantation. With an increasing array of<br />
graft source options, transplantation should be considered<br />
early in the disease course of patients with diseases potentially<br />
benefited by allografting to allow appropriate testing<br />
of potential donors <strong>and</strong> to avoid undue delay when transplantation<br />
becomes necessary. Decisions about when <strong>and</strong><br />
with which graft source to perform transplantation should<br />
be based on a several factors, including donor <strong>and</strong> graft<br />
characteristics but also patient age, performance status <strong>and</strong><br />
disease.<br />
OP51 Source of stem cells in the allogeneic<br />
transplant setting: bone marrow versus<br />
peripheral blood stem cells<br />
Mohamad Mohty, Hematology Dpt., University-Hopsital<br />
of Nantes, Centre de Recherche en Cancerologie de<br />
Nantes-Angers (CRCNA), INSERM U892, F-44093<br />
Nantes, France<br />
While peripheral blood stem cells (PBSC) <strong>are</strong> used almost<br />
exclusively in autologous transplantation, recent surveys<br />
indicate that PBSC <strong>are</strong> used in 50% to 70% of allogeneic<br />
stem-cell transplants. Thus, large variation in practice<br />
<strong>and</strong> considerable uncertainty exists with respect to the relative<br />
effects of allogeneic PBSC transplantation (PBSCT)<br />
versus bone marrow transplantation (BMT) on the outcomes<br />
of patients with hematologic malignancies. Indeed, the use<br />
of PBSCs for allogeneic transplantation is still not universally<br />
accepted. This is in part due to unresolved concerns<br />
about the long-term effects of growth factor treatment in<br />
healthy volunteers <strong>and</strong> data suggesting that this stem cell<br />
source is associated with more chronic graft-versus-host<br />
disease (cGVHD). Comp<strong>are</strong>d with BM, PBSC grafts contain<br />
significantly more total blood cells <strong>and</strong> more CD34+<br />
cells. However, the most striking difference is the 10-fold<br />
higher number of T cells in the PBSC graft. Other differences<br />
include a higher number of monocytes <strong>and</strong> the absence<br />
of mesenchymal stem cells.<br />
In order to address the question of PBSCT versus BMT,<br />
several r<strong>and</strong>omized controlled trials have been conducted.<br />
However, despite these well designed <strong>and</strong> executed clinical<br />
trials, taken individually, most of these trials were relatively<br />
small to draw definitive conclusions, <strong>and</strong> not surprisingly,<br />
substantial controversy still remains regarding the impact<br />
on mortality, disease control, <strong>and</strong> other important clinical<br />
outcomes in relation with the type of donor.<br />
This report will examine the differences in the outcomes<br />
between HLA–matched, related <strong>and</strong> unrelated allogeneic PB-<br />
SCT <strong>and</strong> BMT as therapy for hematologic malignancies.<br />
OP52 Conditioning for SCT – the impact<br />
of disease?!<br />
Dietger Niederwieser, (Germany)<br />
Abstract not submitted.<br />
55
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
OP53 Conditioning for SCT – the impact<br />
of disease?!<br />
John Barrett, Hematology Branch, National Heart,<br />
Lung <strong>and</strong> Blood Institute, National Institutes of Health.<br />
Bethesda, MD, USA<br />
Background<br />
Bone marrow stem cell transplantation for hematological<br />
malignancies was originally perceived as a necessary rescue<br />
from bone marrow failure following the definitive treatment<br />
of the malignant disease by high dose chemotherapy or radiation.<br />
The earliest clinical studies from the mid 1950s involved<br />
autologous bone marrow harvest, a single high dose<br />
infusion of an alkylating agent followed by bone marrow<br />
infusion rescue. Nevertheless, as early as 1956 Barnes <strong>and</strong><br />
Loutit demonstrated that in contradistinction to autologous<br />
marrow grafts an allogeneic bone marrow could confer a<br />
graft versus-leukemia (GVL) effect, albeit with an associated<br />
lethal graft-versus-host reaction (GVH) 1 . Despite this<br />
early recognition that the curative effect of a bone marrow<br />
allograft lay not only in the strength of the conditioning<br />
regimen but also in the alloreactivity of donor against recipient<br />
leukemia it was generally considered that the GVL<br />
effect was modest unless associated with such severe GVH<br />
disease that it would be impracticable to pursue ways to select<br />
<strong>and</strong> maximize GVL. In 1990 two papers changed our<br />
perception by demonstrating that the GVL effect made a<br />
major contribution to the curative effect of stem cell transplantation.<br />
The first – a study by Horowitz, from the International<br />
Bone Marrow Transplantation Registry revealed<br />
the significantly lower relapse risk in survivors who had developed<br />
acute <strong>and</strong> chronic GVHD with lowest relapse in<br />
those who experienced both complications2 . The second,<br />
from Kolb <strong>and</strong> colleagues, revealed the remarkable potential<br />
of infusions of donor lymphocytes to achieve stable<br />
cures of chronic myelogenous leuekemia (CML) relapsing<br />
after bone marrow transplantation3 . The new perception that<br />
GVL was a force to be recognized has underpinned the subsequent<br />
evolution of SCT strategies. Here I will discuss the<br />
interplay between the myelosuppression <strong>and</strong> immunosuppression<br />
of the conditioning regimen, the stem cell graft<br />
type, <strong>and</strong> post graft immunosuppression in the control of<br />
malignant disease. The impact of various transplant approaches<br />
on disease type <strong>and</strong> stage will then be considered<br />
with the aim of identifying the best transplant strategy for<br />
the individual patient.<br />
The multifunctional role of the conditioning regimen<br />
The agents used in conditioning regimens impact both<br />
the hematopoietic <strong>and</strong> immune system as well as causing<br />
off-target damage to other organ systems especially those<br />
showing rapid cell turnover such as the gastrointestinal<br />
tract. Figure 1 shows commonly used conditioning agents<br />
classified by the spectrum of their properties. However it<br />
should be noted that detailed characterization of the immunosuppressive<br />
properties of many agents such as busulfan,<br />
is lacking.<br />
Nevertheless we now have enough underst<strong>and</strong>ing of the<br />
relative actions of conditioning agents that regimens can be<br />
56<br />
Figure 1. Relative properties of common conditioning regimen agents<br />
designed according to their intensity <strong>and</strong> myeolsuppressive<br />
characteristics, as well as their ability to immunoablate.<br />
C<strong>are</strong>fully selected combinations can minimize the unwanted<br />
side effects. Currently used conditioning regimens <strong>are</strong><br />
classified as full intensity or reduced intensity which may or<br />
may not be myeloablative.<br />
Role of myelosuppressive intensity<br />
There <strong>are</strong> now many studies comparing reduced intensity<br />
<strong>and</strong> st<strong>and</strong>ard intensity regimens in specific malignancies.<br />
Myeloablative intensity can be measured by myeloid cell<br />
chimerism using CD15 as a marker. Lower intensity regimens<br />
allow host hematopoietic recovery before their ultimate<br />
rejection <strong>and</strong> replacement by donor myeloid cells<br />
when the donor immunity transcends that of the host. Predictably<br />
many studies show that relapse rates <strong>are</strong> higher in<br />
recipients of reduced intensity transplants while recipients<br />
of full intensity transplants <strong>are</strong> at greater risk of death from<br />
non-relapse complications.<br />
Role of immunosuppressive intensity<br />
In a completely immunoablated recipient with no T cell<br />
or NK cell function the SCT can rapidly engraft. Donor T<br />
cell chimerism, measured in the CD3 fraction of peripheral<br />
blood, reaches 100% by day 14 permitting the early establishment<br />
of GVL effects accompanied by a risk of early<br />
acute GVHD. The type of conditioning regimen affects the<br />
degree to which residual host cells persist <strong>and</strong> thus affects<br />
the pace of engraftment of the donor immune system.<br />
Towards the selection of the best conditioning regimen<br />
for the disease<br />
While it is broadly true that more intensive conditioning<br />
leads to greater antileukemic control as well as conferring<br />
greater immunosuppression <strong>and</strong> permitting early donor immune<br />
function, the relative merits of promoting GVL effects<br />
or relying on direct suppression of malignancy by<br />
chemoradiotherapy depend on the malignant disease in<br />
question. The current challenge is to vary the conditioning<br />
regimen to deliver the optimum conditions for cure for specific<br />
disease subtypes.
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
Diseases where GVT effects predominate<br />
The role of conditioning in promoting the GVT effect<br />
transcends any anti-malignancy effect in two situations; In<br />
solid tumors insensitive to chemotherapy such as renal cell<br />
cancer the role of the conditioning is to establish the donor<br />
immune system to initiate GVT activity. Fludarabine <strong>and</strong><br />
cyclophosphamide combinations function well in this regard<br />
achieving rapid donor T cell chimerism without myeolablation.<br />
Some hematological malignancies – CML,<br />
chronic lymphocytic leukemia (CLL), <strong>and</strong> some non-hodgkin<br />
lymphomas (NHL) <strong>are</strong> especially sensitive to GVL effects.<br />
NHL regimens that avoid excessive immunosuppression<br />
from conditioning using Campath (anti CD52) antibody<br />
have a significantly lower relapse rate. In CML prior<br />
to the imatinib era several studies began to explore the use<br />
of non-myeloablative regimens or reduced intensity regimens<br />
to achieve cure cure without complications from intensive<br />
treatment. These studies showed that without the<br />
contribution from some myelosuppression there was an increased<br />
risk of persistent disease. CLL appears to be particularly<br />
susceptible to GVL. As typically older patients<br />
with CLL require transplants there has been much progress<br />
in designing low intensity but effective regimens for such<br />
patients.<br />
Diseases requiring disease control as well as GVL/GVT<br />
Despite a GVL effect being demonstrable most hematological<br />
disorders (including myelodysplastic syndromes,<br />
acute leukemias <strong>and</strong> multiple myeloma) require myeloablation<br />
to maximize the chance of cure. The problem arises in<br />
this group that there is a trade-off between curative potential<br />
<strong>and</strong> risk of mortality from non-relapse causes. This has led<br />
to c<strong>are</strong>ful titration of the dose intensity of the conditioning<br />
especially in older or debilitated patients recognizing that<br />
relapse risk increases with reduction in intensity.<br />
Diseases without GVT<br />
It seems likely that some solid tumors, neuroblastoma,<br />
melanoma <strong>and</strong> breast cancer have minimal benefit from a<br />
GVT effect. While GVT effects have been described in<br />
breast cancer they appear to be in only a minority of patients.<br />
Despite the potential for immunotherapy in this disease<br />
allogeneic stem cell transplants for melanoma have not<br />
been promising. After immunoablative conditioning the disease<br />
appears to rapidly accelerate precluding any delayed<br />
benefit from the GVT effect.<br />
The future – disease control without excessive<br />
conditioning intensity<br />
Improvements in the present status of SCT for malignant<br />
disease await developments in two <strong>are</strong>as; (1) Augmentation<br />
of the GVT /GVL effect. Areas of investigation include<br />
ways to generate tumor-specific or minor antigen-specific<br />
CTL to prevent or treat relapse, use of tumor specific vaccines,<br />
<strong>and</strong> augmentation of NK mediated GVL through NK<br />
infusions <strong>and</strong> cytokines to boost NK function4,5 . Other promising<br />
approaches <strong>are</strong> the use of demethylating agents to<br />
upregulate presentation of cancer-testis antigens on malignant<br />
cells <strong>and</strong> the use of cytokines <strong>and</strong> immunostimulatory<br />
agents such as revlemid (upregulated CTL generation) 5 , <strong>and</strong><br />
bortezomib (upregulated TRAIL mediate killing) 6 .<br />
(2) Delivering focused antimalignant therapy: The introduction<br />
of »small molecules« – tyrosine kinase inhibitors<br />
(TkI), <strong>and</strong> targeted therapy of malignancy while efficacious<br />
as a st<strong>and</strong> alone treatment in CML may best be combined<br />
with SCT. In Ph+ ALL, TkI with SCT may improve the<br />
chances of disease-free survival 7 . Sirolimus appears to have<br />
a unique double therapeutic effect of controlling GVHD<br />
while having a direct anti-lymphoma effect 8 . Lastly the use<br />
of radio-isotopes to target the bone marrow may be a promising<br />
way to deliver high dose treatment to the <strong>are</strong>as where<br />
leukemia resides while avoiding general organ toxicity 9 .<br />
R E F E R E N C E S<br />
1. Barnes DW, Corp MJ, Loutit, JF, Neal FE. Treatment of murine leukaemia<br />
with X rays <strong>and</strong> homologous bone marrow; preliminary communication.<br />
Br Med J 1956;2(4993):626–7.<br />
2. Horowitz MM, Gale RP, Sondel PM, Goldman JM, Kersey J, Kolb HJ,<br />
Rimm AA, Ringdén O, Rozman C, Speck B, et al. Graft-versus-leukemia<br />
reactions after bone marrow transplantation. Blood 1990;75:555–62.<br />
3. Kolb HJ, Mittermüller J, Clemm C, Holler E, Ledderose G, Brehm G,<br />
Heim M, Wilmanns W Donor leukocyte transfusions for treatment of<br />
recurrent chronic myelogenous leukemia in marrow transplant patients.<br />
Blood 1990;76:2462–5.<br />
4. Barrett J, Rezvani K. Immunotherapy: Can we include vaccines with<br />
stem-cell transplantation? Nat Rev Clin Oncol 2009;6:503–5.<br />
5. Parmar S, Fern<strong>and</strong>ez-Vina M, de Lima M.Novel transplant strategies for<br />
generating graft-versus-leukemia effect in acute myeloid leukemia. Curr<br />
Opin Hematol 2011;18:98–104.<br />
6. Yong AS, Keyvanfar K, Hensel N, Eniafe R, Savani BN, Berg M, Lundqvist<br />
A, Adams S, Slo<strong>and</strong> EM, Goldman JM, Childs R, Barrett AJ.<br />
Primitive quiescent CD34+ cells in chronic myeloid leukemia <strong>are</strong> targeted<br />
by in vitro exp<strong>and</strong>ed natural killer cells, which <strong>are</strong> functionally<br />
enhanced by bortezomib. Blood 2009;113:875–82.<br />
7. Lee HJ, Thompson JE, Wang ES, Wetzler M. Philadelphia chromosomepositive<br />
acute lymphoblastic leukemia: current treatment <strong>and</strong> future perspectives.<br />
Cancer 2011;117:1583–94.<br />
8. Arm<strong>and</strong> P, Gannamaneni S, Kim HT, Cutler CS, Ho VT, Koreth J, Alyea<br />
EP, LaCasce AS, Jacobsen ED, Fisher DC, Brown JR, Canellos GP,<br />
Freedman AS, Soiffer RJ, Antin JH. Improved survival in lymphoma<br />
patients receiving sirolimus for graft-versus-host disease prophylaxis<br />
after allogeneic hematopoietic stem-cell transplantation with reducedintensity<br />
conditioning. J Clin Oncol 2008;26:5767–74.<br />
9. Pagel JM, Kenoyer AL, Bäck T, Hamlin DK, Wilbur DS, Fisher DR,<br />
Park SI, Frayo S, Axtman A, Orgun N, Orozco J, Shenoi J, Lin Y, Gopal<br />
AK, Green DJ, Appelbaum FR, Press OW. Anti-CD45 pretargeted radioimmunotherapy<br />
using bismuth-213: high rates of complete remission<br />
<strong>and</strong> long-term survival in a mouse myeloid leukemia xenograft model.<br />
Blood 2011;118:703–1.<br />
OP54 Infectious Complications of Stem Cell<br />
Transplantation<br />
Finn B. Petersen, Intermountain Blood <strong>and</strong> Marrow<br />
Transplant Program, Salt Lake City, Utah, USA<br />
Introduction<br />
Despite major advances in detecting, preventing <strong>and</strong> treating<br />
infections associated with any type of stem cell transplantation<br />
(SCT), non-relapse mortality after SCT r<strong>are</strong>ly<br />
occurs without a direct or indirect contribution from an infectious<br />
episode. Thus, by 2009, infections were reported as<br />
a primary cause of mortality in up to 8% of autologous, <strong>and</strong><br />
up to 20% of allogeneic SCT recipients1 . For this reason,<br />
ongoing focus on cost-effective means to detect, prevent<br />
57
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
<strong>and</strong> treat SCT associated infections need to remain a major<br />
focal point of SCT c<strong>are</strong>.<br />
Methods<br />
5 complementary approaches <strong>are</strong> commonly used by SCT<br />
clinicians to minimize the risk of morbidity <strong>and</strong> mortality<br />
from infectious diseases: 1) prophylactic modalities, 2) empiric<br />
modalities, 3) pre-emptive modalities, 4) therapeutic<br />
modalities, <strong>and</strong> 5) salvage modalities. Which modality will<br />
be most effective for a given situation or patient population<br />
for prophylaxis depends solely on the severity of infection<br />
to be prevented, the cost, <strong>and</strong> expected adverse events, for<br />
empiric therapy on signs or symptoms of infection vs. the<br />
inability of early detection, for pre-emptive therapy on the<br />
ability for early detection vs. available effective therapy, for<br />
therapy on having effective therapeutics available, <strong>and</strong> for<br />
salvage on having effective second line therapies available<br />
in case of primary treatment failure.<br />
Major Advances<br />
Since the beginning of clinical SCT, <strong>and</strong> the recognition<br />
of the high morbidity <strong>and</strong> mortality from infections in this<br />
patient population, infection prevention <strong>and</strong> control have<br />
been a main <strong>are</strong>a of clinical SCT research, already in the<br />
1970’s documenting the benefit of protective environments,<br />
prophylactic antimicrobials <strong>and</strong> rapid diagnosis of the most<br />
serious infections.<br />
The most significant advances over the past 25 years in<br />
reducing the impact <strong>and</strong> threat of infectious diseases in SCT<br />
<strong>are</strong> shown in table 1. However, these improvements have<br />
most often been used to exp<strong>and</strong> SCT treatments to older <strong>and</strong><br />
higher risk patients, or for permitting us of more potent immunesuppression<br />
with the SCT, for a net stable treatment<br />
related morbidity <strong>and</strong> mortality from infectious diseases<br />
over time.<br />
Future Directions<br />
Aside from continuing to refine <strong>and</strong> adapt the modalities<br />
listed in table 1 to the ever changing transplant <strong>and</strong> microbiological<br />
environments, future improvements in reducing<br />
the impact of infectious diseases associated with SCT may<br />
Table 1. Modalities to reduce the impact of infectious diseases in stem<br />
cell transplantation<br />
Modality<br />
Year<br />
Introduced<br />
Use<br />
Broad Spectrum Systemic Antibiotics 1986 P, E, PE, T, S<br />
Acyclovir 1983 P, E, PE, T<br />
Post-transplant Filgrastim 1989 P, E, PE<br />
Peripheral Blood Stem Cells 1990 P<br />
1st generation triazoles (fluconazol) 1990 P, E, PE, T<br />
Quinolone Prophylaxis during neutropenia 1991 P, T<br />
CMV Early Diagnosis / Treatment 1992 P, E, PE, T<br />
Lipid Compound Polyenes 1992 E, T, S<br />
Echinoc<strong>and</strong>ens / 2nd generation triazoles 2000 P, E, PE, T, S<br />
Pre-/post-transplant Palifermin 2005 P<br />
P=Prophylactic, E=Empiric, PE=pre-emptive, T=therapeutic, S=Salvage.<br />
Bolded letters designate primary use.<br />
58<br />
come from clinical adaptation of single nucleotide polymorphisms<br />
(SNPs) of toll-like receptor (TLR) or similar inflammatory<br />
response associated genes, potentially permitting an<br />
infectious disease risk allocations of patients based on specific<br />
infection response genotypes.<br />
Also, a better ability to promote earlier <strong>and</strong> more complete<br />
post-transplant immune reconstitution, <strong>and</strong> to be able<br />
to control antigen-discrepancies between donor <strong>and</strong> recipient<br />
without having to use infection facilitating immunosuppressive<br />
agents such as corticosteroids <strong>and</strong> tumor-necrosisfactor<br />
blockers, would promote infection control in SCT<br />
patients. Lastly, shifting all anti-infectious activities from<br />
empiric <strong>and</strong> therapeutic to prophylactic <strong>and</strong> pre-emptive use<br />
also would represent a significant step forward, but the realization<br />
of such a goal will depend on further development of<br />
sensitive <strong>and</strong> microbe specific early detection tests, of which<br />
only a few <strong>are</strong> available for clinical use today. Finally, in<br />
today’s strained budgetary environment, an ongoing weighing<br />
of the use of often expensive, but effective, infection<br />
prophylaxis modalities against the cost, both monetary <strong>and</strong><br />
human, of devastating <strong>and</strong> potentially fatal infections, is an<br />
absolute necessity.<br />
Of help to the transplant clinicians <strong>are</strong> an increasing body<br />
of evidence based guidelines published by specialty groups<br />
<strong>and</strong> societies, such as what the major national <strong>and</strong> international<br />
societies involved in SCT did in their most recent update<br />
of »Guidelines for preventing infectious complications<br />
among hematopoietic cell transplant recipients: a global<br />
perspective« in a special issue of Bone Marrow Transplantation<br />
published in 2009 1<br />
Conclusion<br />
While major improvements in detection, prevention <strong>and</strong><br />
therapy of SCT related infectious diseases have been significant<br />
over time, <strong>and</strong> permitted SCT of higher risk patients<br />
<strong>and</strong> using higher risk transplants, the microbiological, transplant,<br />
<strong>and</strong> regulatory fields <strong>are</strong> constantly evolving in unpredictable<br />
ways, presenting clinical stem cell transplant<br />
clinicians with ever new infectious disease challenges.<br />
R E F E R E N C E S<br />
1. M Tomblyn et al: »Guidelines for preventing infectious complications<br />
among hematopoietic cell transplant recipients: a global perspective«.<br />
Bone Marrow Transplantation 2009;44:453–526<br />
OP55 Old drug, new tricks in prevention of graftversus-host<br />
disease (GVHD): Development<br />
<strong>and</strong> clinical applicability of high-dose<br />
cyclophosphamide<br />
Leo Luznik, Division of Hematologic Malignancies;<br />
Department of Oncology, Sidney Kimmel Comprehensive<br />
Cancer Center at Johns Hopkins, Baltimore, MD. USA<br />
GVHD is a major complication of allogeneic hematopoietic<br />
stem cell transplantation (alloHSCT). The successful<br />
prevention of acute GVHD with CNIs <strong>and</strong> methotrexate<br />
(MTX) was developed in the 1980s <strong>and</strong> has revolutionized<br />
the field of alloHSCT; however, at least 50% of patients still
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
develop this complication.(1, 2) There is currently no successful<br />
strategy for the prevention of chronic GVHD, the<br />
most common cause of late morbidity <strong>and</strong> mortality. It affects<br />
over 50% of patients who would otherwise have been<br />
cured of their primary malignancy.(3) Mechanistically, immunosuppressive<br />
drugs given to control GVHD suppress<br />
alloimmunity by the nonspecific inhibition of alloreactive T<br />
cell activation, proliferation, <strong>and</strong> differentiation. By blocking<br />
T-cell activation, currently used agents in the GVHD<br />
prophylaxis regimens interfere with the apoptosis of the<br />
alloreactive T cells, causing global immunosuppression<br />
<strong>and</strong> a delay in the time for induction of transplantation<br />
tolerance. Of all the commonly used immunosuppressants,<br />
only MTX <strong>and</strong> cyclophosphamide (Cy) can induce the<br />
apoptosis of alloantigen-activated human T cells.(4) MTX,<br />
although active as a single agent for GVHD prevention, due<br />
to its intrinsic toxicity profile, it cannot be administered in<br />
higher doses critical for inducing the en masse alloreactive<br />
T-cell apoptosis. On the other h<strong>and</strong>, Cy can safely be administered<br />
in high-doses, which <strong>are</strong> required to eliminate alloreactive<br />
clones after alloHSCT because of its favorable safety<br />
profile, including lack of toxicity to the primitive hematopoietic<br />
stem cells.(5) Our recently published results suggest<br />
that high-dose Cy is sufficient as a single agent in the<br />
prevention of both acute <strong>and</strong> chronic GVHD after myeloablative<br />
conditioning <strong>and</strong> allografting using HLA-matched<br />
related <strong>and</strong> unrelated donors.(6) Patients transplanted using<br />
this strategy have a low incidence of infections <strong>and</strong>, despite<br />
the advanced disease stage, their survival is favorable, suggesting<br />
that this approach retains the graft-versus-leukemia<br />
(GVL) effect. Our group has been also exploring high dose,<br />
post-transplantation Cy as prophylaxis of GVHD after nonmyeloablative,<br />
HLA-haploidentical bone marrow transplantation,<br />
or mini-haploBMT.(7) Among 210 recipients of<br />
mini-haploBMT, 87% of patients have experienced sustained<br />
donor cell engraftment. The cumulative incidences of<br />
grades II-IV acute GVHD <strong>and</strong> chronic GVHD <strong>are</strong> 27% <strong>and</strong><br />
13%, respectively. Five-year cumulative incidence of nonrelapse<br />
mortality is 18% <strong>and</strong> actuarial overall survival <strong>and</strong><br />
event-free survivals <strong>are</strong> 35% <strong>and</strong> 27%, respectively. Recent<br />
multi-center phase II trial conducted by Blood <strong>and</strong> Marrow<br />
Transplant Clinical Trials Network confirmed the validity<br />
of posttransplant Cy in GVHD prevention across HLA-barriers.(8)<br />
Survival rates after posttransplant Cy-based minihaploBMT<br />
were comparable to survival rates in patients<br />
with high-risk hematologic malignancies who were transplanted<br />
with blood or marrow from HLA- matched unrelated<br />
donors after reduced conditioning. In conclusion, by<br />
taking advantage of the differential susceptibility of proliferating,<br />
alloreactive T cells over non-proliferating, non-alloreactive<br />
T cells to high dose Cy, this novel strategy provides<br />
a unique opportunity to optimize GvHD prophylaxis<br />
after HLA-matched alloBMT <strong>and</strong> increase the use of HLAmismatched<br />
donors. (9) (10)<br />
R E F E R E N C E S<br />
1. Appelbaum FR. Hematopoietic-cell transplantation at 50. N Engl J<br />
Med 2007;357:1472–1475.<br />
2. Storb R, Deeg HJ, Whitehead J, Appelbaum F, Beatty P, Bensinger W,<br />
Buckner CD, Clift R, Doney K, F<strong>are</strong>well V, et al. Methotrexate <strong>and</strong><br />
cyclosporine comp<strong>are</strong>d with cyclosporine alone for prophylaxis of<br />
acute graft versus host disease after marrow transplantation for leukemia.<br />
N Engl J Med 1986;314:729–735.<br />
3. Lee SJ. Have we made progress in the management of chronic graft-vshost<br />
disease? Best Pract Res Clin Haematol 23:529–535.<br />
4. Strauss G, Osen W, Debatin KM. Induction of apoptosis <strong>and</strong> modulation<br />
of activation <strong>and</strong> effector function in T cells by immunosuppressive<br />
drugs. Clin Exp Immunol 2002;128:255–266.<br />
5. Jones RJ, Barber JP, Vala MS, Collector MI, Kaufmann SH, Ludeman<br />
SM, Colvin OM, Hilton J. Assessment of aldehyde dehydrogenase in<br />
viable cells. Blood 1995;85:2742–2746.<br />
6. Luznik L, Bolanos-Meade J, Zahurak M, Chen AR, Smith BD, Brodsky<br />
R, Huff CA, Borrello I, Matsui W, Powell JD, Kasamon Y, Goodman<br />
SN, Hess A, Levitsky HI, Ambinder RF, Jones RJ, Fuchs EJ. High-dose<br />
cyclophosphamide as single-agent, short-course prophylaxis of graftversus-host<br />
disease. Blood 115:3224–3230.<br />
7. Luznik L, O’Donnell PV, Symons HJ, Chen AR, Leffell MS, Zahurak<br />
M, Gooley TA, Piantadosi S, Kaup M, Ambinder RF, Huff CA, Matsui<br />
W, Bolanos-Meade J, Borrello I, Powell JD, Harrington E, Warnock S,<br />
Flowers M, Brodsky RA, S<strong>and</strong>maier BM, Storb RF, Jones RJ, Fuchs<br />
EJ. HLA-haploidentical bone marrow transplantation for hematologic<br />
malignancies using nonmyeloablative conditioning <strong>and</strong> high-dose,<br />
posttransplantation cyclophosphamide. Biol Blood Marrow Transplant<br />
2008;14:641–650.<br />
8. Brunstein CG, Fuchs EJ, Carter SL, Karanes C, Costa LJ, Wu J, Devine<br />
SM, Wingard JR, Aljitawi OS, Cutler CS, Jagasia MH, Ballen KK,<br />
Eapen M, O’Donnell PV. Alternative donor transplantation after reduced<br />
intensity conditioning: results of parallel phase 2 trials using<br />
partially HLA-mismatched related bone marrow or unrelated double<br />
umbilical cord blood grafts. Blood 118:282–288.<br />
9. Luznik L, Fuchs EJ. High-dose, post-transplantation cyclophosphamide<br />
to promote graft-host tolerance after allogeneic hematopoietic<br />
stem cell transplantation. Immunol Res 47:65–77.<br />
10. Luznik L, Jones RJ, Fuchs EJ. High-dose cyclophosphamide for graftversus-host<br />
disease prevention. Curr Opin Hematol 17:493–499.<br />
OP56 Chronic Graft-versus-Host Disease<br />
– Anything New in Prevention <strong>and</strong><br />
Treatment?<br />
Steven Zivko Pavletic, National Cancer Institute,<br />
Bethesda, Maryl<strong>and</strong>, USA<br />
Chronic graft-versus-host disease (cGVHD) is the leading<br />
cause of non-relapse morbidity <strong>and</strong> mortality in survivors<br />
after allogeneic hematopoietic stem cell transplantation<br />
(HSCT), but is also associated with lower malignancy<br />
relapse rates. In 2005 an NIH Consensus Conference galvanized<br />
the cGVHD clinical research field by providing st<strong>and</strong>ardized<br />
definitions about diagnosis, staging, response criteria,<br />
data collection <strong>and</strong> conduct of clinical trials. These<br />
consensus documents set the stage for a number of prospective<br />
cohort studies in the United States <strong>and</strong> internationally<br />
which <strong>are</strong> currently in progress.<br />
In spite of effective measures available for preventing<br />
acute GVHD, until recently, there were no signs that similar<br />
preventive strategies could be developed for cGVHD. However,<br />
emerging data from cohort studies <strong>and</strong> clinical trials<br />
indicate <strong>are</strong>as where progress could be made. The key challenges<br />
for prevention in cGVHD <strong>are</strong> the lack of specificity<br />
of the current cGVHD therapies <strong>and</strong> our poor underst<strong>and</strong>ing<br />
of the graft-versus-malignancy effect (GVM) targets. There<br />
is a hope that ongoing studies which integrate in depth investigation<br />
of the cGVHD biology in conjunction with well<br />
annotated patient tissue samples will generate necessary information<br />
<strong>and</strong> lead towards the development of early tar-<br />
59
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
geted therapeutic interventions to prevent severe cGVHD.<br />
Parallel research is needed to identify precisely the GVM<br />
targets on the malignant cells or to integrate some of the<br />
newly emerging anti-cancer drugs in the cGVHD prevention<br />
<strong>and</strong> treatment algorithms. One of the strategies to develop<br />
better timing of cGVHD prevention is to identify<br />
markers of cGVHD activity that differentiate active disease<br />
manifestations from those that <strong>are</strong> caused by the irreversible<br />
damage.<br />
In the <strong>are</strong>a of front line therapy there have been several<br />
attempts to bring promising agents as first line in addition to<br />
steroids. None of these combinations have succeeded in improving<br />
symptoms of cGVHD <strong>and</strong> commonly have been associated<br />
with prohibitive side effects including increased<br />
relapse. Therefore 0.5–1.0 mg/kg/day of prednisone remains<br />
the st<strong>and</strong>ard front line systemic treatment for cGVHD.<br />
Unfortunately, about 50% of cGVHD patients fail steroids<br />
<strong>and</strong> need second line treatments. Currently there is no st<strong>and</strong>ard<br />
recommended second line therapy for cGVHD <strong>and</strong> the<br />
choice of agent is based on the patient <strong>and</strong> clinician preferences,<br />
prior treatment history <strong>and</strong> expected side effects profile.<br />
Agents which <strong>are</strong> most commonly used in steroid refractory<br />
cGVHD include extracorporeal photopheresis, mycophenolate,<br />
sirolimus, rituximab, pentostatin <strong>and</strong> imatinib.<br />
Currently st<strong>and</strong>ard second line therapy is a clinical trial if<br />
available. The treatment of the bronchiolitis obliterans syndrome<br />
(BOS) which is the lung manifestation of cGVHD<br />
poses a specific challenge to clinicians due to the high mortality<br />
<strong>and</strong> lack of effective treatments for this most devastating<br />
presentation of cGVHD. BOS is increasingly recognized<br />
as an <strong>are</strong>a for clinical research. In summary, although little<br />
progress in improving our ability to prevent or treat cGVHD<br />
can yet be decl<strong>are</strong>d, there <strong>are</strong> a number of promising basic<br />
research studies <strong>and</strong> clinical trials which suggest significant<br />
breakthroughs in the near future.<br />
OP57 Relapse after Allogeneic Hematopoietic<br />
Stem Cell Transplantation – The Necessity<br />
for New Strategies <strong>and</strong> Treatments<br />
Michael R. Bishop, Medical College of Wisconsin,<br />
Milwaukee, Wisconsin, USA<br />
Recurrence of disease is the leading cause of mortality<br />
after allogeneic hematopoietic stem cell transplantation (alloHSCT),<br />
whose efficacy is largely attributed to graft-versus-tumor<br />
(GVT) effects. There <strong>are</strong> several factors that <strong>are</strong><br />
responsible for the biologic resistance of malignancies to<br />
beneficial effects of alloHSCT including clonal evolution of<br />
cancer, drug <strong>and</strong> radiation resistance, cancer epigenetics,<br />
<strong>and</strong> possibly cancer stem cells. However, several other factors<br />
affect the occurrence <strong>and</strong> outcome of relapse, including<br />
conditioning regimen, type of allograft, <strong>and</strong> disease histology,<br />
status, <strong>and</strong> sensitivity to chemotherapy. Optimally strategies<br />
<strong>are</strong> needed to precisely balance immune responses to<br />
favor GVT without harmful graft-versus-host disease to protect<br />
against relapse <strong>and</strong> treat recurrent disease after HSCT.<br />
The outcomes of patients relapsing after an alloHSCT generally<br />
remain poor even with the use of donor lymphocytes<br />
infusions (DLI). Developing strategies to promptly identify<br />
60<br />
patients at risk for relapse after alloHSCT, while malignancy<br />
is in a more treatable stage, could decrease relapse rates<br />
after alloHSCT. Monitoring of minimal residual disease<br />
(MRD) post-transplant, through methods such as molecular<br />
genetics, tumor-specific molecular primers, fluorescein in<br />
situ hybridization, <strong>and</strong> multi-parameter flow cytometry,<br />
could lead to novel preemptive treatments of relapse. Studies<br />
<strong>are</strong> also needed to provide data with detail on disease<br />
status, prior treatments, biologic markers, <strong>and</strong> post-transplant<br />
events to identify patients at high risk for relapse. The<br />
development of strategies to intervene prior to florid relapse<br />
may include non-immunologic therapies, such as targeted<br />
preparative regimens <strong>and</strong> post-transplant drug therapy, as<br />
well as immunologic interventions, including graft <strong>and</strong> Tcell<br />
engineering, vaccination, <strong>and</strong> dendritic cell-based approaches.<br />
There is no st<strong>and</strong>ard approach to treating relapse<br />
after alloHSCT. Withdrawal of immune suppression <strong>and</strong><br />
DLI <strong>are</strong> commonly used for all diseases; however, the efficacy<br />
of DLI is quite variable depending on disease histology<br />
<strong>and</strong> state <strong>and</strong> has limited efficacy in the majority of hematologic<br />
malignancies. As such, there is a significant need for<br />
novel therapies, strategies, <strong>and</strong> well-designed, disease-specific<br />
trials for relapse following alloHSCT, particularly in<br />
patients for whom DLI is not an option. The 2009 National<br />
Cancer Institute International Workshop on the Biology,<br />
Prevention, <strong>and</strong> Treatment of Relapse after Allogeneic Hematopoietic<br />
Stem Cell Transplantation was convened to<br />
identify, prioritize, <strong>and</strong> coordinate future research activities<br />
related to relapse after alloHSCT. The Workshop suggested<br />
3 major initiatives for a coordinated research effort to address<br />
the problem of relapse after alloHSCT: (1) to establish<br />
multicenter correlative <strong>and</strong> clinical trial networks for basic/<br />
translational, epidemiologic, <strong>and</strong> clinical research; (2) to establish<br />
a network of biorepositories for the collection of<br />
samples before <strong>and</strong> after alloHSCT to aid in laboratory <strong>and</strong><br />
clinical studies; <strong>and</strong> (3) to further refine, implement, <strong>and</strong><br />
study the Workshop-proposed definitions for disease-specific<br />
response <strong>and</strong> relapse <strong>and</strong> recommendations for monitoring<br />
of MRD. These recommendations, in coordination<br />
with ongoing research initiatives <strong>and</strong> transplantation organizations,<br />
provide a research framework to rapidly <strong>and</strong> efficiently<br />
address the significant problem of relapse after alloHSCT.<br />
OP58 Design, conduct <strong>and</strong> analysis of clinical<br />
trials in acute leukemia: the keys of success<br />
Stefan Suciu, EORTC Headquaters, Brussels, Belgium<br />
Clinical trials <strong>are</strong> experiments performed in medical settings<br />
in order to determine maximum tolerated dose of a<br />
drug/regimen (phase I), its activity (phase II) or efficacy<br />
(phase III) in a given patient population. In order to shorten<br />
the drug development, phase I/II, or phase II/III, or even<br />
phase I/III trials may be set-up as well. Phase I <strong>and</strong> II trials<br />
require a limited number of patients, as their endpoints <strong>are</strong><br />
toxicity <strong>and</strong> activity (e.g. CR rate) respectively. In order to<br />
detect moderate treatment differences in term of efficacy,<br />
r<strong>and</strong>omized phase III trials require large numbers of patients<br />
<strong>and</strong> long follow-up. Such trials <strong>are</strong> sized according to a pri-
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
mary endpoint, generally overall survival, event-free survival,<br />
progression-free survival or disease-free survival (for<br />
patients who reached CR). Secondary endpoints contain remaining<br />
efficacy endpoints, CR rate, highest toxicity/adverse<br />
events observed during treatment courses, time to recovery<br />
<strong>and</strong>, if possible, quality-of-life evaluations. Longterm<br />
outcomes <strong>and</strong> toxicities, incidences of secondary tumors<br />
<strong>are</strong> evaluated as well, in case of potentially toxic or<br />
long lasting treatments (drugs, drug combinations, irradiations).<br />
A phase III trial may contain several r<strong>and</strong>omized questions.<br />
If no interactions between them <strong>are</strong> foreseen, such<br />
factorial designs represent an efficient way to use a patient<br />
population. To overcome possible interactions, 10–20% more<br />
patients should be added as comp<strong>are</strong>d to a classical one<br />
question trial.<br />
Acute leukemias, lymphoblastic (ALL) or myeloblastic<br />
(AML), <strong>are</strong> heterogeneous diseases. In AML distinct entities<br />
have been determined (e.g. APL, t(8;21)/inv(16), FLT3,<br />
etc). Age <strong>and</strong> performance status <strong>are</strong> important patient-factors<br />
to adjust treatment intensity. In the personalised treatment<br />
era, patient population available to enter into a phase<br />
III trial becomes quite limited, even within a large cooperative<br />
group. Intergroup trials should be set-up in order to<br />
reach adequate patient accrual. The leading group, in cooperation<br />
with a Company, should set-up the protocol, with<br />
the input of other interested groups. Agreements regarding<br />
submissions (e.g. protocol, SAE) to local regulatory authorities,<br />
data collection process, publication rules <strong>and</strong> authorship,<br />
etc should be set-up <strong>and</strong> applied.<br />
Phase III trial analyses should be done when mature efficacy<br />
data <strong>are</strong> available: final analysis, when the required<br />
number of events is reached, <strong>and</strong> interim looks, if specified<br />
in the protocol. Early stopping rules for efficacy <strong>and</strong>/or futility<br />
should be based on well defined statistical rules. In<br />
order to avoid any conflict of interest, only an Independent<br />
Data Monitoring committee (IDMC) should evaluate the interim<br />
results <strong>and</strong> provide adequate recommendations to the<br />
trialists. If there is sufficient evidence that the experimental<br />
treatment is superior to the st<strong>and</strong>ard one, or the treatment<br />
difference is already too low or goes in the wrong direction,<br />
one may draw early conclusions, <strong>and</strong>, if necessary, switch<br />
patients already entered in the trial, from one arm to another.<br />
Statistical analyses should be done in accordance to the trial<br />
design, using efficient statistical tests. If r<strong>and</strong>omization was<br />
stratified by some prognostic factors (e.g. age <strong>and</strong> WBC),<br />
statistical test (e.g. logrank test or Cox model) should be<br />
stratified/adjusted by these factors, in case a block-size/<br />
minimization method was used for r<strong>and</strong>omization. Such test<br />
will provide unbiased treatment difference estimate, having<br />
an increased efficiency as comp<strong>are</strong>d to the unstratified/unadjusted<br />
test. Adjustments by other important factors could<br />
be done. Interactions between some factors <strong>and</strong> treatment<br />
could be investigated as well, for detection of potential predictive<br />
factors for treatment efficacy.<br />
A successful trial requires a good idea, e.g. the assessment<br />
of a targeted drug to be used alone or in an already<br />
existing treatment scheme, in a »marker«-positive patient<br />
population, in whom the experimental treatment may be applied.<br />
The trial should be properly designed, preferentially<br />
be r<strong>and</strong>omized in order to avoid any systematic bias. Disease<br />
assessments should mirror as much as possible the<br />
usual clinical practice, <strong>and</strong> be scheduled <strong>and</strong> made evenly in<br />
the treatment groups. Efficient data collection regarding the<br />
main <strong>and</strong> secondary endpoints should be done. A good cooperation<br />
of clinical investigators should provide a fast recruitment.<br />
Interim <strong>and</strong> final analyses using proper statistical<br />
technique should be done on (relatively) mature data in order<br />
to be able drawing valid conclusions. In case of any<br />
safety concerns, in some trials (e.g. phase III, r<strong>and</strong>omized<br />
phase I/III), safety data should be monitored by an Independent<br />
Data Safety Monitoring Board (IDSMB), with no conflict<br />
of interest. This should meet regularly in order to provide<br />
adequate recommendations regarding the study conduct.<br />
OP59 Front line therapy for indolent B-cell<br />
lymphoma<br />
Nathan Fowler, Department of Lymphoma <strong>and</strong> Myeloma,<br />
MD Anderson Cancer Center, Houston, Texas, USA<br />
A number of treatment options exist for newly diagnosed<br />
patients with indolent non-Hodgkins lymphoma (iNHL).<br />
Several r<strong>and</strong>omized studies have demonstrated an improvement<br />
in both progression free survival (PFS) <strong>and</strong> overall<br />
survival (OS) with the addition of anti-CD20 directed monoclonal<br />
antibody (MAB) therapy into frontline combinations.<br />
Despite these developments, the majority of advanced<br />
stage patients still relapse with iNHL or undergo aggressive<br />
transformation, <strong>and</strong> improvements in frontline treatment <strong>are</strong><br />
needed. Although maintenance treatment with MABs <strong>and</strong><br />
consolidation with anti-CD20 radioconjugates results in<br />
prolongation of PFS, their effect on OS is unknown. Bendamustine<br />
has significant activity in iNHL, <strong>and</strong> recent r<strong>and</strong>omized<br />
studies suggest a potential role in untreated patients.<br />
Newer agents, such as the immumomodulatory agent<br />
lenalidomide, the proteasome inhibitor bortezomib, <strong>and</strong><br />
drugs targeting essential steps in the B-cell receptor pathway<br />
such as Bruton’s tyrosine kinase (BTK) <strong>and</strong> PI-3 kinase<br />
show promise. Studies <strong>are</strong> currently underway exploring the<br />
potential to incorporate these <strong>and</strong> other novel biologic<br />
agents into frontline treatment for iNHL.<br />
OP60 Rituximab maintenance treatment<br />
in indolent lymphoma<br />
Ofer Sphilberg, Inst. of Hematology, Davidoff Center,<br />
Beilinson Hospital & Tel-Aviv University, Israel<br />
Follicular lymphoma, which represents 15%–30% of newly<br />
diagnosed lymphomas, is an indolent lymphoma that is<br />
characterized by slow growth <strong>and</strong> a high initial response rate<br />
but relapsing <strong>and</strong> progressive disease. Most patients <strong>are</strong> diagnosed<br />
with advanced disease, that is, stage III or IV, <strong>and</strong> cannot<br />
be cured with currently available conventional therapies.<br />
New treatment modalities <strong>are</strong> therefore urgently needed.<br />
The chimeric monoclonal antibody rituximab targeted<br />
against CD20, a protein that is expressed on the surface of<br />
61
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
all mature B cells, is active in many B-cell lymphomas that<br />
express this molecule. Rituximab administered intravenously<br />
in combination with chemotherapy improves overall survival<br />
in patients with newly diagnosed <strong>and</strong> relapsed indolent<br />
lymphoma comp<strong>are</strong>d with chemotherapy alone.<br />
Rituximab maintenance therapy following successful induction<br />
has recently emerged as a highly effective treatment<br />
for follicular lymphoma. R<strong>and</strong>omized clinical trials as well<br />
as systematic review <strong>and</strong> meta-analysis, analyzing the impact<br />
of rituximab maintenance comp<strong>are</strong>d to observation<br />
alone have demonstrated a significantly better outcome in<br />
terms of progression-free survival in patients who received<br />
as first-line treatment single-agent rituximab, st<strong>and</strong>ard chemotherapy<br />
<strong>and</strong> recently also immuno-chemotherapy. In the<br />
setting of relapsed disease, rituximab maintenance has shown<br />
a significant benefit even in terms of overall survival.<br />
These data suggest that maintenance therapy with rituximab<br />
as four weekly infusions every 6 months or as a single<br />
infusion every 2–3 months, should be added to st<strong>and</strong>ard<br />
therapy for patients with follicular lymphoma after successful<br />
induction therapy.<br />
OP61 Risk adapted treatment for patients<br />
with B-DLBCL<br />
M<strong>are</strong>k Trneny, (Czech Republic)<br />
62<br />
Abstract not submitted.<br />
OP62 Treatment of peripheral T-Cell lymphomas<br />
Pier Luigi Zinzani, Institute of Hematology »Seràgnoli«,<br />
University of Bologna, Italy<br />
Up till recent years, no major therapeutic advances have<br />
been observed in peripheral T/NK-cell lymphomas (PTCL),<br />
with overall survival (OS) values for most of the systemic<br />
entities in the order of 25–35% at five years. Furthermore,<br />
there has been a rather consistent lack of PTCL-specific<br />
clinical trials, partly due to the rarity of this condition, <strong>and</strong><br />
partly to diagnostic difficulties <strong>and</strong> controversial views on<br />
whether immunophenotype-specific treatment strategies<br />
should be adopted. As a consequence of the REAL <strong>and</strong> the<br />
subsequent WHO classification of malignant lymphomas,<br />
present day diagnostic approaches identify PTCL entities<br />
based upon immunophenotype in association with clinical,<br />
morphological, <strong>and</strong> molecular genetic data. These advances<br />
have recently led to PTCL-specific clinical trials.<br />
Analogue to the treatment strategy applied in diffuse<br />
large B-cell lymphoma (DLBCL), combination chemotherapy<br />
with CHOP (cyclophosphamide, adriamycin, vincristine,<br />
prednisone) or CHOP-like variants has up till now been<br />
the most frequently used first line therapy also in PTCL.<br />
Given as st<strong>and</strong>ard schedule every three weeks, this approach<br />
does not seem to benefit more than 25–30% of the patients,<br />
while schedule intensification, e.g. shortening of the timeinterval<br />
between courses <strong>and</strong>/or addition of etoposide, has<br />
by some authors been reported to improve outcome. However,<br />
reported OS values have been varying, often depend-<br />
ing on the included number of prognostically more favourable<br />
cases belonging to the histological subtype anaplastic<br />
large cell lymphoma (ALCL), alk-positive.<br />
Based on small-scale observations on single-agent efficacy,<br />
gemcitabine has also been investigated in some PTCLspecific<br />
trials. Response rates were encouraging, but of relatively<br />
short duration.<br />
High-dose therapy with autologous stem cell transplant<br />
(HDT/ASCT) proved feasible in both relapsed/refractory<br />
<strong>and</strong> treatment-naïve PTCL. Overall results suggest a more<br />
favorable impact of this approach in first line as comp<strong>are</strong>d<br />
to salvage treatment. However, most data <strong>are</strong> of selected <strong>and</strong><br />
retrospective nature. At present, only a few PTCL-restricted<br />
phase II trials investigating HDT/ASCT as part of a firstline<br />
therapeutic approach have been reported. Of these only<br />
very few have a sufficient cohort-size to compensate for the<br />
heterogeneity of this disorder.<br />
Combinations of chemotherapy with T-cell specific monoclonal<br />
antibodies (MoAb) have shown high overall response<br />
rates (ORR) <strong>and</strong> <strong>are</strong> currently being investigated in<br />
ongoing clinical trials.<br />
Due to the rarity of T/NK-cell neoplasms, no PTCL-restricted<br />
phase III trials have yet been completed. However,<br />
the first international efforts have recently been launched.<br />
OP63 Therapy of Mantle cell Lymphoma<br />
Christian Geisler, Rigshospitalet, Copenhagen,<br />
Denmark<br />
The treatment of choice in younger, fit MCL patients is<br />
induction immunochemotherapy followed by high-dose<br />
therapy with autologous stem cell support. Phase-II data<br />
have strongly suggested that Ara-C containing immunochemotherapy<br />
is superior to R-CHOP, <strong>and</strong> this has now been<br />
confirmed by a r<strong>and</strong>omized trial by the European MCL Network.<br />
In elderly/frail patients, however, R-CHOP was superior<br />
to R – fludarabine + cyclophosphamide, possibly as the<br />
combined net effect of efficacy <strong>and</strong> tolerability. The combination<br />
of R-CHOP with rituximab maintenance has furher<br />
prolonged progression-free survival <strong>and</strong> may be the regimen<br />
of choice in elderly frail patients, but needs testing<br />
against R-AraC. The treatment goal in both settings is complete<br />
clinical <strong>and</strong> molecula remission.Targeted therapy with<br />
proteasome inhibitors, m-Tor inhibitors <strong>and</strong> other new compounds<br />
represents promising <strong>are</strong>as of development in firstline<br />
<strong>and</strong> salvage treatment.<br />
OP64 Is there a role of radioimmunotherapy<br />
in NHL<br />
OP65 Therapy for relapsed/refractory aggressive<br />
NHL<br />
Anas Younes, (USA)<br />
Abstract not submitted.
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
OP66 Alternative monoclonal antibodies<br />
for the treatment of NHL<br />
Luis Fayad, (USA)<br />
Abstract not submitted.<br />
OP67 Early favorable <strong>and</strong> unfavorable Hodgkin<br />
lymphoma in adults, st<strong>and</strong>ards <strong>and</strong><br />
directions<br />
Patrice Carde, Institut Gustave Roussy, Villejuif, France<br />
Few malignancies, if any, benefited a step-by-step improvement<br />
in tumor control <strong>and</strong> survival rates as early favorable<br />
<strong>and</strong> unfavorable Hodgkin lymphoma. Competition<br />
between Cooperative groups through to rigorous prospective<br />
r<strong>and</strong>omized phase III trials result in the current proposal<br />
of an optimal treatment balancing relapse <strong>and</strong> longterm<br />
risks. St<strong>and</strong>ard treatment consists in 2 to 3 cycles of<br />
ABVD followed by 20–30 Gy involved field radiation therapy<br />
(IFRT) in early favorable <strong>and</strong> in a minimum of 4 cycles<br />
<strong>and</strong> of 30 Gy in early unfavorable stages (E. Lugtenburg &<br />
A. Hagenbeek Treatment of Early Favorable HL chapt. 10,<br />
pp. 179 in Hodgkin Lymphoma -A. Engert <strong>and</strong> S.J. Horning<br />
(eds.) DOI: 10.1007/978-3-642-12780-9_11, © Springer-<br />
Verlag Berlin Heidelberg 2011; Raemaekers JJJ & Engert A<br />
Treatment of Early Unfavorable HL, chapt. 11, pp. 185–187<br />
ibid); These st<strong>and</strong>ards provide EFS/PFS/FFTF <strong>and</strong> OS rates<br />
of 93% <strong>and</strong> 97%, respectively for early favorable stages<br />
(GHSG HD-10) <strong>and</strong> of 91 an >97%, respectively for early<br />
unfavorable stages (GHSG HD-14); see Table 1.<br />
Taking into account the already very high level of the current<br />
results, the relatively short follow-up of 3–5 years for<br />
most of these studies <strong>and</strong>, unhappily, the rarity of late reports,<br />
due to the hard work <strong>and</strong> low reward from long-term<br />
updates, only dismal differences can be expected between<br />
treatment arms, even adequately powered, as in the HD-13<br />
GHSG study looking at the value of each of the individual<br />
ABVD components. For instance the maximal Progression<br />
free survival (PFS) differential seen among recent trials has<br />
been the 91 to 97% 3-year yield (p
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
Time-dependent covariates (markers, time-to-response,<br />
»quality« or »speed« of response) <strong>are</strong> particularly subject to<br />
flaws for 2 reasons: (1) they <strong>are</strong> highly treatment-dependent<br />
(2) as occasional brilliant predictors of response, they <strong>are</strong> -<br />
wrongly- expected to direct the treatment strategy, <strong>and</strong><br />
therefore improve global survival. Actually, even identification<br />
of a poor-faring group in no way means that a more<br />
adequate treatment is available for this precise group. The<br />
EORTC paved the way for such a strategy in advanced HL<br />
(Carde P. Early response to chemotherapy (CT) is a faithful<br />
surrogate independent predictive factor that can influence<br />
treatment strategy in Hodgkin’s Disease (HD). Proc. Fifth<br />
International Symposium on Hodgkin’s Lymphoma 22–25<br />
September 2001, Köln, Germany. Leukemia & Lymphoma<br />
42,suppl.2 :35,2001 (oral presentation, abst. # I-40)).<br />
FDG-PET scans better assess tumor burden than CT scans<br />
<strong>and</strong> functional imaging has been shown to predict outcome<br />
after combined modality therapy in early stage HL with a<br />
very high negative predictive value (Hutchings M, Loft A,<br />
Hansen M, et al: FDG PET after two cycles of chemotherapy<br />
predicts treatment failure <strong>and</strong> progression-free survival in<br />
Hodgkin lymphoma. Blood 107:52–59, 2006). FDG-PET,<br />
already known important in staging <strong>and</strong> treatment evaluation<br />
recently became fashionable to adapt the treatment, for less,<br />
or more...<br />
Calling for less treatment recently proved disappointing,<br />
according to the results of the H10 International/EORTC<br />
study, where deleting involved node irradiation (IN RT) in<br />
PET 2 negative patients (early favorable <strong>and</strong> unfavorable<br />
stages) resulted in lower PFS (XXXXXX). Other cooperative<br />
groups attempt not to duplicate these results.<br />
Calling for more treatment in early positive PET 2 patients<br />
<strong>and</strong> being successful is tricky, apart from the false positives,<br />
that in part depend upon the treatment; indeed, most patients<br />
with positive interim PET <strong>are</strong> cured, so that the positive predictive<br />
value in early stage has been exceeded 15% in a recent<br />
study (Sher DH, Mauch PM, Van Deen AAet al. Prognostic<br />
significance of mid- <strong>and</strong> post ABVD PET imaging in<br />
Hodgkin’s lymphoma: the importance of involved – field<br />
radiotherapy. Ann Oncol. 2009;20(11):1848–53). In this respect<br />
the result of the International/EORTC H10 trial is eagerly<br />
awaited for.<br />
TARGETED TREATMENT TO HODGKIN <strong>LYMPHOMA</strong><br />
TUMOR CELLS<br />
Targeted therapy to receptors <strong>and</strong> antigens expressed by<br />
the Hodgkin <strong>and</strong> Reed Sternberg cells (HRS), proves efficient,<br />
whether or not these <strong>are</strong> the ultimate tumor stem cells<br />
(A. Younes <strong>and</strong> A. Engert. New agents for patients with<br />
Hodgkin lymphoma. chapt. 20, pp. 283–294 in Hodgkin<br />
Lymphoma -A. Engert <strong>and</strong> S.J. Horning (eds.) DOI:<br />
10.1007/978-3-642-12780-9_11, © Springer-Verlag Berlin<br />
Heidelberg 2011). Since two decades, among the many c<strong>and</strong>idate-new<br />
drugs for HL, very few reached clinical practice,<br />
<strong>and</strong> none to first-line advanced HL. However, m-Tor inhibitors,<br />
histone deacetylases (HDAC) inhibitors, immunomodulators<br />
(lenalidomide), <strong>and</strong> anti-CD30 antibody drug conjugate<br />
brentuximab vedotin (SGN-35) demonstrate a significant<br />
activity in phase II studies.<br />
64<br />
Table 2. References of main large phase 2 <strong>and</strong> r<strong>and</strong>omized trials reported<br />
in localized HL<br />
4-drug regimens : ABVD (CMT)<br />
Favourable patients<br />
ABVD x2 + IF RT HD-7 Engert JCO 2007. (Engert et al. 3495-502)<br />
Unfavourable patients<br />
ABVD x4 + IF RT Milan Bonadonna JCO 2004.<br />
(Bonadonna et al. 2835-41)<br />
ABVD x6 + M RT H6 Carde JCO 1993. (Carde et al. 2258-72)<br />
ABVD x6 + IF RT H9U Fermé Blood ASH 2005. (Fermé et al. 813)<br />
Noordijk JCO 2005. (Noordijk et al. 6505)<br />
ABVD x4 + IF RT H9U Fermé Blood ASH 2005.(Fermé et al. 813)<br />
Noordijk JCO 2005. (Noordijk et al. 6505)<br />
ABVD x4 + IF RT H9U Fermé Blood ASH 2005.(Fermé et al. 813)<br />
Noordijk JCO 2005. (Noordijk et al. 6505)<br />
ABVD x 4 + IF RT HD-10 Engert NEJM 2010. (Engert et al.)<br />
ABVD x 2 + IF RT HD-10 Engert NEJM 2010. (Engert et al.)<br />
ABVD x4 + IF RT 20 or 30 Gy HD-11 Eich 2010 submitted. (Eich et al.)<br />
ABVD x4 + IF RT 30 Gy HD-14 Borchmann Blood ASH 2008<br />
ABVD x4 + IN RT & FDG-PET adapted) H10 EORTC André Blood<br />
ASH 2009<br />
response adapted strategies – based on FDG-PET imaging<br />
Favourable patients<br />
ABVD x2 & PET2 <strong>and</strong> adaptation H10F cf André ASH 2009.<br />
(Andre et al. 97)<br />
ABVD x2 & PET2 <strong>and</strong> adaptation HD-16 GHSG ongoing 2010<br />
Unfavourable patients<br />
ABVD x2 & PET2 <strong>and</strong> adaptation H10U André ASH 2009 (Andre et al. 97)<br />
escalated BEACOPP x2 + ABVD x 2 +IF/IN RT HD-17 GHSG project 2010<br />
SGN-35 demonstrates an activity/toxicity profile that<br />
may allow rapid upgrading to phase III trials, even in early<br />
stage disease (Younes A, Bartlett NL, Leonard JP et al.<br />
Brentuximab Vedotin (SGN-35) for Relapsed CD30-Positive<br />
Lymphomas. N Engl J Med 2010; 363:1812–1821November<br />
4, 2010). The Italian, French <strong>and</strong> EORTC groups<br />
may seize a unique opportunity launch a phase III trial<br />
(H12) to assess the benefit of this new drugs in a large number<br />
of early stage unfavorable patients. The purpose is to<br />
comp<strong>are</strong> SGN-35 + AVD (=EXP) with ABVD alone (=STD),<br />
both followed by 30 Gy RT. Population is early stage unfavorable<br />
Hodgkin disease. There would be a phase 2 trial<br />
followed by a phase 3 trial.<br />
TREATMENT STRATEGY FOR HL TENDS TO BE<br />
DIRECTED TO ITHE INDIVIDUAL PATIENT<br />
Unlike »targeted« treatments for certain types of solid<br />
tumors such as colon (KRAS) or lung (EGFR) carcinomas,<br />
or hematological conditions (chronic myeloid leukemia),<br />
where treatment is based on individual patient’s tumor characteristics,<br />
HL strategy remains individually blind. However<br />
biological approaches develop <strong>and</strong> may comfort the huge<br />
knowledge that a 40 year experience could accumulate in<br />
terms of conventional treatment <strong>and</strong> late effects, a unique<br />
situation in onco-hematology.<br />
OP68 21st Century Radiation treatments<br />
in Hodgkin lymphoma<br />
Theodore Girinsky on behalf of the EORTC Lymphoma<br />
Group, Institut Gustave Roussy, Villejuif, France<br />
Background. The occurrence of late complications due<br />
to old concepts <strong>and</strong> techniques forced the radiation oncolo-
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
gy community to evolve. Nowadays modern radiotherapy<br />
allows radiation to be delivered almost »surgically.«<br />
Radiation therapy is now always used in combination<br />
with chemotherapy. This combination allows the implementation<br />
of »mini radiotherapy« in which radiation doses <strong>and</strong><br />
fields <strong>are</strong> reduced to a minimum <strong>and</strong> precisely implemented<br />
using sophisticated radiation delivery techniques.<br />
Radiation doses can now be reduced to 20–30 Gy, as<br />
demonstrated by the German Hodgkin Study Group. Radiation<br />
fields have become smaller <strong>and</strong> more precise as a result<br />
of the involved node radiotherapy concept developed a decade<br />
ago by the EORTC group. Tremendous progress in<br />
imaging technology such as CT/PET allow an increasingly<br />
accurate identification of initially involved lymph nodes. In<br />
our experience with 141 patients, FDG-PET depicted undetected<br />
LNs in 70% of the patients. Sophisticated radiation<br />
delivery such as IMRT or the deep inspiration breath hold<br />
technique allow precise implementation of these »surgical<br />
fields« with good results. In our study of 50 patients with<br />
localized Hodgkin lymphoma, 5-year progression-free survival<br />
<strong>and</strong> overall survival were 92% <strong>and</strong> 94% respectively.<br />
Conclusions. Sophisticated <strong>and</strong> precise radiation treatments<br />
combined with chemotherapy should allow excellent<br />
cure <strong>and</strong> quality of life in patients with Hodgkin lymphoma.<br />
OP69 Improving Outcome in High Risk Hodgkin’s<br />
lymphoma<br />
Andreas Engert, University Hospital of Cologne, Köln,<br />
Germany<br />
Hodgkin lymphoma has become one of the best-curable<br />
malignancies with tumor-free survival rates in excess of<br />
80%. However, the prognosis for high-risk advanced stage<br />
patients or those with relapsed or refractory disease still<br />
needs improving. To this end, the German Hodgkin Study<br />
Group (GHSG) has developed a more dose intense regimen,<br />
BEACOPP, which demonstrated superiority of our old st<strong>and</strong>ard<br />
of c<strong>are</strong> in a prospectively r<strong>and</strong>omized trial (HD9). The<br />
ten-years update of this study indicates significant differences<br />
in terms of tumor control (18%) <strong>and</strong> overall survival<br />
(11%) between the old st<strong>and</strong>ard (8xCOPP/ABVD) <strong>and</strong> 8<br />
cycles of BEAOPP escalated (Engert et al, JCO, 2009). The<br />
follow-up study, HD12 suggested that radiotherapy (RT)<br />
might not be needed in all patients. This was proven by our<br />
HD15 study in which only PET-positive patients having residual<br />
disease of at least 2,5 cm after chemotherapy received<br />
additional RT.<br />
In order to further reduce toxicity of treatment <strong>and</strong> increase<br />
efficacy, numerous new drugs <strong>are</strong> currently being<br />
developed for HL. The most promising is SGN-35 (Brentuximab<br />
Vedotin) which has shown 75% responses in the<br />
pivotal phase II study. This <strong>and</strong> other new approaches will<br />
be discussed.<br />
OP70 What is the role of PET in Hodgkin’s<br />
lymphoma<br />
Martin Hutchings, Departments of Hematology <strong>and</strong><br />
Oncology, Rigshospitalet, Copenhagen University<br />
Hospital, Denmark<br />
Combined computed tomography <strong>and</strong> positron emission<br />
tomography with 18F-fluorodeoxyglucose (FDG-PET/CT)<br />
has become a cornerstone imaging method in the management<br />
of malignant lymphoma, particularly in the management<br />
of Hodgkin lymphoma. FDG-PET/CT provides an<br />
improved staging accuracy, with higher sensitivity than conventional<br />
imaging methods including CT. The FDG uptake<br />
in Hodgkin lymphoma masses decreases rapidly after initiation<br />
of therapy in well responding patients, <strong>and</strong> this makes<br />
early interim FDG-PET/CT the strongest available predictor<br />
of treatment response <strong>and</strong> prognosis. A negative posttreatment<br />
FDG-PET/CT is highly predictive of long-term<br />
disease-free survival, <strong>and</strong> this has led to the incorporation of<br />
FDG-PET/CT into the revised response criteria for malignant<br />
lymphoma. This presentation will critically address the<br />
value of FDG-PET in Hodgkin lymphoma, including shortcomings<br />
of the available scientific evidence <strong>and</strong> common<br />
problems <strong>and</strong> pitfalls when FDG-PET/CT is used in the<br />
daily clinic <strong>and</strong> in clinical trials. The potential value of<br />
FDG-PET/CT in the follow-up setting, <strong>and</strong> in the management<br />
of relapsed Hodgkin lymphoma will be discussed.<br />
OP71 Treatment of Relapsed/Refractory<br />
Hodgkin’s lymphoma<br />
Igor Aurer, Division of Hematology, Department of<br />
Medicine, Clinical Hospital Center <strong>and</strong> School of<br />
Medicine, University of Zagreb, Croatia<br />
Hodgkin’s lymphoma (HL) is one of the most curable<br />
forms of cancer. Depending on stage <strong>and</strong> prognostic factors<br />
between 60% <strong>and</strong> 95% of patients <strong>are</strong> cured with st<strong>and</strong>ard<br />
front-line therapy. Therefore, about 25% of patients will, at<br />
some point in the course of their disease, need salvage treatment.<br />
Best results in patients below 60–65 (70) years of age in<br />
1 st relapse without significant comorbidities <strong>are</strong> achieved<br />
with intensive salvage regimens followed by autologous<br />
stem cell transplantation (ASCT) with or without consolidative<br />
radiotherapy. Long-term outcome of this approach is<br />
quite favorable, with disease-free survival rates of about<br />
60%. Although a substantial proportion of patients respond<br />
to alternative front-line chemotherapy regimens, such as<br />
COPP, the advantage of ASCT to chemotherapy alone has<br />
been proven in r<strong>and</strong>omized trials. DHAP is the most frequently<br />
used <strong>and</strong> studied second-line chemotherapy regimen.<br />
In a recently published r<strong>and</strong>omized trial, 2 cycles of<br />
DHAP followed by BEAM conditioning <strong>and</strong> ASCT were<br />
less toxic <strong>and</strong> at least as effective as 2 cycles of DHAP,<br />
high-dose single agent chemotherapy, BEAM <strong>and</strong> ASCT.<br />
Based on these data, 2 cycles of chemotherapy prior to<br />
ASCT <strong>are</strong> considered st<strong>and</strong>ard. There <strong>are</strong> no r<strong>and</strong>omized<br />
trials comparing DHAP with other regimens such as ICE,<br />
65
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
HDIM or IGEV, <strong>and</strong> the results of published phase II trials<br />
<strong>are</strong> similar. Therefore, no recommendations regarding the<br />
choice of intensive salvage regimens can be made at present.<br />
The outlook of refractory patients (i.e. those that progress<br />
during or relapse within 3 months after the end of frontline<br />
treatment) is substantially worse. Only about 30% of<br />
them <strong>are</strong> cured with this approach. For both, refractory or<br />
relapsing patients, response to second line treatment is the<br />
most important prognostic factor. ASCT is ineffective in<br />
progressing patients <strong>and</strong> only about 20% of patients with<br />
stable disease benefit from the procedure.<br />
There <strong>are</strong> no r<strong>and</strong>omized trials on the role of radiotherapy<br />
(RT) in this setting but most centers use it either before or<br />
after ASCT. The radiation fields vary, some irradiate only<br />
<strong>are</strong>as that were not in CR (by PET or CT) after ASCT, some<br />
those that were not in remission after salvage chemotherapy<br />
<strong>and</strong> some all <strong>are</strong>as involved at relapse.<br />
Patients who <strong>are</strong> not c<strong>and</strong>idates for ASCT with a localized<br />
relapse in a previously unirradiated <strong>are</strong>a can be effectively<br />
treated with salvage radiotherapy.<br />
About 40–50% of patients fail second-line treatment. For<br />
them the st<strong>and</strong>ard approach used to be chemotherapy, either<br />
with different drug combinations or single-agents, such as<br />
vinblastine or gemcitabine, <strong>and</strong> the judicious use of radiotherapy.<br />
Average survival of such patients is more than 1<br />
year, bearing witness to the chemo- <strong>and</strong> radiosensitivity of<br />
HL. This approach is probably going to change very soon,<br />
because very promising results have been reported with<br />
brentuximab-vedotin (also known as SGN-35) an anti-CD30<br />
monoclonal antibody linked to a cytotoxic agent with antitubullary<br />
activity. Other new agents that <strong>are</strong> being tested in<br />
this setting include histone-deacetylase inhibitors, lenalidomide<br />
<strong>and</strong> m-TOR inhibitors. Finally, the role of allogeneic<br />
stem-cell transplantation remains unclear. While long-term<br />
disease free survival can be achieved with reduced intensity<br />
conditioning in about 40% of patients responding to salvage<br />
chemotherapy, treatment-related mortality <strong>and</strong> morbidity<br />
remains a significant problem <strong>and</strong> comparative trials still<br />
have to show which population of patients will benefit from<br />
this approach.<br />
OP72 Allogeneic SCT for Hodkin’s lymphoma<br />
Ana Sureda, Haematology Department, Addenbrooke’s<br />
Hospital, Cambridge, UK<br />
Myeloablative conditioning <strong>and</strong> allo-SCT<br />
in Hodgkin’s lymphoma<br />
The first reports on allogeneic stem cell transplantation<br />
(allo-SCT) in patients with HL appe<strong>are</strong>d in the mid eighties<br />
[1, 2]. Two larger registry-based studies published in 1996<br />
gave disappointing results. Gajewski et al analyzed 100 HL<br />
patients allografted from HLA-identical siblings <strong>and</strong> reported<br />
to the International Bone Marrow Transplant Registry<br />
(IBMTR) [3]. The 3-year-rates for OS, DFS, <strong>and</strong> the probability<br />
of relapse were 21%, 15%, <strong>and</strong> 65%, respectively.<br />
The major problems after transplantation were persistent or<br />
recurrent disease or respiratory complications, which accounted<br />
for 35% to 51% of deaths. A case-matched analysis<br />
66<br />
including 45 allografts <strong>and</strong> 45 autografts reported to the<br />
EBMT was performed by Milpied et al [4]. They did not<br />
find significant differences in actuarial probabilities of OS,<br />
PFS, <strong>and</strong> relapse rates between allo-SCT <strong>and</strong> ASCT (25%,<br />
15%, 61% vs. 37%, 24%, 61%, respectively). The actuarial<br />
TRM at 4 years was significantly higher for allografts than<br />
for autografts (48% vs 27%, p=0.04). Acute GvHD ≥ grade<br />
II was associated with a significantly lower risk of relapse,<br />
but also with a lower survival rate.<br />
A number of reports confirmed the registry data: allo-<br />
SCT resulted in lower relapse rates but significantly higher<br />
toxicity with no improvement over ASCT when PFS or OS<br />
were considered [5–7]. Although the poor results after myeloablative<br />
conditioning could at least partly be explained<br />
by the very poor-risk features of many individuals included<br />
in these early studies, the high procedure-related morbidity<br />
<strong>and</strong> mortality prevented the widespread use of allo-SCT.<br />
Reduced intensity conditioning <strong>and</strong> allo-SCT<br />
in Hodgkin’s lymphoma<br />
The largest cohort of patients treated with RIC/allo-SCT<br />
in HL was recently reported by the LWP of the EBMT [8]<br />
(n=285). Median time from diagnosis to allo-SCT was 41 (4<br />
– 332) months. Patients had received an average of four<br />
lines of prior therapy (1 – 8) <strong>and</strong> 288 patients (77%) had<br />
failed one or two ASCT. At the time of allo-SCT, 47 patients<br />
(17%) were in CR, 123 patients (43%) had chemosensitive<br />
disease <strong>and</strong> 115 patients (40%) had chemoresistant disease<br />
or untested relapse. One hundred <strong>and</strong> seventy two patients<br />
(63%) were allografted from a matched sibling donor<br />
(MRD), 94 (33%) from a matched unrelated donor (MUD),<br />
<strong>and</strong> 19 from a mismatched donor (7%). Grade II-IV acute<br />
GvHD (aGVHD) was reported in 27% of patients, chronic<br />
GvHD (cGVHD) in 40% of patients at risk. The 100-day<br />
TRM was 12% but increased to 20% at 12 months, <strong>and</strong> to<br />
22% at three years. The development of chronic GVHD was<br />
associated with a higher TRM <strong>and</strong> a trend to a lower relapse<br />
rate. In a l<strong>and</strong>mark analysis the development of either acute<br />
or chronic GVHD by 9 months post transplant was associated<br />
with a significantly lower relapse rate.<br />
The MD Anderson Cancer Center updated their experience<br />
[9] in 58 patients with relapsed or refractory HL who<br />
underwent a RIC/allo-SCT from a MRD (n=25) or a MUD<br />
(n=33). Forty-eight (83%) patients had received a prior<br />
ASCT. Disease status at RIC/allo-SCT was sensitive relapse<br />
(n=30) or refractory relapse (n=28). The conditioning regimen<br />
employed was fludarabine (125–130 mg/m2 over 4–5<br />
days), melphalan (140 mg/m2 IV over 2 days) (FM) <strong>and</strong> antithymocyte<br />
globulin (thymoglobulin 6 mg/kg over 3 days)<br />
was added for the 14 most recent MUD transplants. Cumulative<br />
100-day <strong>and</strong> 2-year TRM were 7% <strong>and</strong> 15%, respectively.<br />
The cumulative incidence (CI) of grade II-IV acute<br />
GVHD was 28%. The CI of chronic GVHD at any time was<br />
74%. Fourteen patients (24%) received a total of 25 (range<br />
1–5) donor leukocyte infusions (DLIs) for disease progression/relapse.<br />
Five of them (35%) received CT as well, <strong>and</strong><br />
nine (64%) developed acute GVHD after the DLI. Projected<br />
2-year OS <strong>and</strong> PFS were 64% <strong>and</strong> 32%, with 2-year projected<br />
disease progression at 55%. There was no statistically
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
significant difference between MRD <strong>and</strong> MUD transplants<br />
with regard to OS, PFS <strong>and</strong> disease progression. There was<br />
a trend for the response status prior to allo-SCT to favorably<br />
impact PFS (p=0.07) <strong>and</strong> disease progression (p=0.049),<br />
but not OS (p=0.4). Partial responders <strong>and</strong> patients with<br />
stable/ refractory disease f<strong>are</strong>d similarly with regards to OS<br />
<strong>and</strong> PFS.<br />
Forty patients with relapsed or refractory HL treated with<br />
the combination of fludarabine (150 mg/m 2 ) <strong>and</strong> melphalan<br />
(140 mg/m 2 ) have recently been presented by the Spanish<br />
group [10]. GvHD prophylaxis consisted of cyclosporine A<br />
(CsA) <strong>and</strong> methotrexate (MTX). Twenty-one patients (53%)<br />
had received >2 lines of CT, 23 patients (58%) had been irradiated,<br />
<strong>and</strong> 29 patients (73%) had failed a previous ASCT.<br />
Twenty patients were allografted in resistant relapse <strong>and</strong> 38<br />
patients received hematopoietic cells from a MRD. Oneyear<br />
TRM was 25%. Acute GvHD developed in 18 patients<br />
(45%) <strong>and</strong> cGvHD in 17 (45%) of the 31 evaluable patients.<br />
Extensive cGvHD was associated with a trend to a lower<br />
relapse rate (71% vs 44% at 24 months, p=0.07). The response<br />
rate three months after RIC/allo-SCT was 67%.<br />
Eleven patients received donor lymphocyte infusions (DLIs)<br />
for relapse or persistent disease. Six patients (54%) responded.<br />
OS <strong>and</strong> PFS were 48% <strong>and</strong> 32% at 2 years, respectively.<br />
Refractoriness to CT was the only adverse prognostic<br />
factor for both OS <strong>and</strong> PFS.<br />
Investigators from Seattle reported their results in relapsed<br />
/ refractory HL patients [11]. Thirty-eight patients<br />
had a MRD, 24 a MUD <strong>and</strong> 28 a HLA-haploidentical related<br />
donor. The patients received 2 Gy total body irradiation<br />
(TBI) alone (n=17) or in combination with fludarabine<br />
(90 mg/m 2 ) <strong>and</strong> immunosuppression consisted of micophenolate<br />
mofetil (MMF) <strong>and</strong> CsA. All patients were heavily<br />
pre-treated with a median of five prior regimens administered.<br />
92% of the patients had failed a previous ASCT. Prior<br />
to RIC/allo-SCT 22 patients were in CR, 30 in PR, 9 had<br />
relapsed disease, <strong>and</strong> 29 had refractory disease. The overall<br />
incidence of grade II-IV aGvHD was 50%. The incidence of<br />
extensive cGvHD was 55% at 1 year. TRM was significantly<br />
lower in those patients being allografted from a HLAhaploidentical<br />
donor. Relapse risk was also lower in haploidentical<br />
recipients.<br />
Peggs et al explored the effects of in vivo T-cell depletion<br />
with alemtuzumab followed by fludarabine (150 mg/m 2 )<br />
<strong>and</strong> melphalan (140 mg/m 2 ) in multiply relapsed patients;<br />
90% of them had failed a previous autograft [12]. At transplant,<br />
8 patients were in CR, 25 patients were in PR, one<br />
patient was in untested relapse, <strong>and</strong> 15 patients had refractory<br />
disease. Thirty-one patients were allografted from a<br />
MRD <strong>and</strong> 18 from MUDs. All patients engrafted, grade II-<br />
IV aGvHD occurred in 16% of patients, 14% developed<br />
cGvHD before DLIs. Nineteen patients received DLIs for<br />
progression (n=16) or mixed chimerism (n=3). Nine patients<br />
(56%) showed a response, which was significantly associated<br />
with, acute <strong>and</strong>/or extensive chronic GvHD. Nonrelapse<br />
mortality was 16% at 730 days. Projected 4-year OS<br />
<strong>and</strong> PFS were 56% <strong>and</strong> 39%, respectively.<br />
Finally, the final results of a multicenter phase II prospective<br />
study on the role of RIC/Allo-SCT were presented at<br />
ASH2010 [13]. 92 HL patients with an HLA identical sib-<br />
ling or a MUD were treated with 2 courses of salvage chemotherapy.<br />
Seventy-eight patients (85%) who showed at<br />
least stable disease were eligible to receive a RIC/Allo-SCT;<br />
all 14 patients with chemorefractory disease died from progressive<br />
lymphoma. Most allografted patients had failed a<br />
prior autologous transplantation (86%); 50 patients were allografted<br />
with chemosensitive <strong>and</strong> 28 with resistant disease;<br />
MUDs were used in 23 patients. Fludarabine (150 mg/m 2<br />
iv) <strong>and</strong> melphalan (140 mg/m 2 iv) were used as conditioning<br />
regimen <strong>and</strong> cyclosporine A plus methotrexate as graft-versus-host<br />
disease prophylaxis. Non-relapse mortality was<br />
8% at 100-days <strong>and</strong> 15% at 1-year. Relapse was the major<br />
cause of failure. PFS was 48% at 1-year <strong>and</strong> 24% at 4-years.<br />
Chronic GVHD was associated with a lower relapse incidence<br />
<strong>and</strong> a better PFS (figure 3). Patients allografted in CR<br />
had a significantly better outcome. OS was 71% at 1-year<br />
<strong>and</strong> 43% at 4-years.<br />
No definitive information is available with respect to the<br />
best conditioning protocol or the impact of T-cell depletion<br />
in this setting. If one accepts that attempting an effective<br />
graft-versus-HL reaction may require several months, preventing<br />
early progression by administering a vigorous conditioning<br />
regimen remains an essential goal still to accomplish.<br />
In this sense, the combination of a more intensive<br />
preparative regimen, the BEAM protocol together with a<br />
profound T-cell depletion with alemtuzumab as aGVHD<br />
prophylaxis has demonstrated to be associated with sustained<br />
donor engraftment, a high response rate, minimal<br />
toxicity (NRM 7.6%) <strong>and</strong> a low incidence of GVHD [14].<br />
The two analyses presented by the Lymphoma WP of the<br />
EBMT also strengthen this argument.<br />
Comparison of myeloablative <strong>and</strong> reduced-intensity<br />
conditioning prior to allo-SCT in relapsed <strong>and</strong><br />
refractory Hodgkin’s lymphoma<br />
The LWP has performed the only analysis reported so far<br />
which comp<strong>are</strong>s outcomes after reduced-intensity or myeloablative<br />
conditioning in patients with HL [15]. Ninetyseven<br />
patients with HL were allografted after RIC <strong>and</strong> 93<br />
patients were allografted after a conventional regimen. A<br />
previous ASCT was more frequent in the RIC/allo-SCT<br />
group (59% vs 41%, p=0.03) as was the use of peripheral<br />
blood stem cells (82% vs 56% p
Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
HL effect comes from two main sources: the demonstration<br />
that the development of acute or chronic GVHD after allo-<br />
SCT is associated to a lower relapse rate <strong>and</strong> the clinical<br />
information coming from DLIs. Relapse rate is significantly<br />
lower in those patients developing GVHD after transplantation.<br />
This fact was already indicated by single center analysis<br />
including low number of patients [9,140, 12, 13] but also<br />
by larger retrospective analyses such as those performed by<br />
the Lymphoma WP of the EBMT. The development of either<br />
acute or chronic GVHD by 9 months after transplant<br />
was associated with a lower relapse rate in Robinson’s analysis<br />
[8]. The development of acute GVHD alone did not<br />
reduce the relapse rate but was associated with a significantly<br />
higher TRM <strong>and</strong> a lower PFS <strong>and</strong> OS. In contrast,<br />
the development of chronic GVHD alone was associated<br />
with a trend to lower relapse rate, a significantly higher<br />
TRM but had no impact on OS or PFS. In the comparative<br />
analysis between conventional allo-SCT <strong>and</strong> RIC/allo-SCT<br />
the development of chronic GVHD after transplantation<br />
significantly reduced relapse rate after transplant <strong>and</strong> improved<br />
PFS in those patients presenting with this complication<br />
[15].<br />
The most direct evidence for a graft versus malignancy<br />
effect comes from observations relating to disease responses<br />
to DLIs. Peggs et al have previously reported clinical responses<br />
in 9 of 16 patients receiving DLIs for measurable<br />
disease post RIC/allo-SCT [12]. Other small series have reported<br />
response rates of 44–54% following DLI administration<br />
[9, 10]. In Robinson’s analysis [8] many DLIs were<br />
administered following adjunctive therapy but disease responses<br />
were reported in 30% of patients receiving DLI<br />
alone. Patients responding to DLIs had a higher incidence<br />
of GVHD post DLI than those not responding. These data<br />
confirm the presence of a clinically effective graft versus<br />
Hodgkin’s effect. However, the efficacy of DLIs is likely to<br />
depend upon the bulk of disease at the time of administration<br />
<strong>and</strong> the optimal use of DLI requires further refinement.<br />
Preemptive, dose escalating or PET scan guided strategies<br />
may improve the overall efficacy of DLIs [16, 17].<br />
How to improve the results of allo-SCT?<br />
Relapse rate is the major cause of failure for those patients<br />
with relapsed / refractory HL being considered c<strong>and</strong>idates<br />
for such an approach. There <strong>are</strong> several possible ways<br />
to address this issue: better patient selection <strong>and</strong> chemosensitivity<br />
of the tumour. Disease status at the time of allo-SCT<br />
is the most important prognostic factor for the long-term<br />
outcome of this procedure. Only those patients in CR or<br />
very good PR should be considered adequate c<strong>and</strong>idates for<br />
an allo-SCT at least with the current protocols. In this sense,<br />
new salvage strategies to try to put patients into a better response<br />
should be sought. Pre-transplant PET does not seem<br />
to have a prognostic impact on either OS or PFS after allo-<br />
SCT but PET was able to diagnose relapse after allo-SCT<br />
earlier than conventional computed tomography [16, 18]. In<br />
this sense, the role of PET should be further explored in this<br />
setting.<br />
Modulation of the intensity of the conditioning regimen<br />
can also result in lower relapse rate after allo-SCT. Low-<br />
68<br />
dose TBI containing regimens seem to be associated to a<br />
high relapse rate in the RIC-allo setting [8, 15]. New drugs<br />
with potential antitumoral activity in front of HL but with a<br />
safe profile <strong>are</strong> being currently tested by different groups.<br />
The intensity of conditioning regimen can be eventually<br />
augmented without significantly modifying Non-Relapse<br />
Mortality (NRM) taking into consideration the population<br />
of patients that <strong>are</strong> considered c<strong>and</strong>idates for an allo-SCT<br />
<strong>and</strong> the fact that GVL effect is not as potent as in low-grade<br />
lymphoproliferative disorders.<br />
Finally, the »so called« maintenance strategy currently<br />
being explored in the ASCT setting can also be analyzed in<br />
the allogeneic one.<br />
R E F E R E N C E S<br />
1. Appelbaum FR, Sullivan KM, Thomas ED, et al. Allogeneic marrow<br />
transplantation in the treatment of MOPP-resistant Hodgkin’s disease.<br />
J Clin Oncol 1985;3:1490–1494.<br />
2. Phillips GL, Reece DE, Barnett MJ, et al. Allogeneic marrow transplantation<br />
for re fractory Hodgkin’ disease. J Clin Oncol 1989;7:1039–<br />
1045.<br />
3. Gajewski JL, Phillips GL, Sobocinski KA, et al. Bone marrow transplants<br />
from HLA-identical siblings in advanced Hodgkin’s disease. J<br />
Clin Oncol 1996;14:572–578.<br />
4. Milpied N, Fielding AK, Pearce RM, Ernst P, Goldstone AH. Allogeneic<br />
bone marrow transplant is not better than autologous transplant for<br />
patients with relapsed Hodgkin’s disease. J Clin Oncol. 1996;14:1291–<br />
1296.<br />
5. Anderson JE, Litzow MR, Appelbaum FR, et al. Allogeneic, syngeneic,<br />
<strong>and</strong> autolo gous marrow transplantation for Hodgkin’s disease: The 21year<br />
Seattle Experience. J Clin Oncol 1993;11:2342–2350.<br />
6. Jones RJ, Ambinder RF, Piantadosi S, Santos GW. Evidence of a graftversus-lymphoma<br />
effect associated with allogeneic bone marrow transplantation.<br />
Blood 1991;77:649–653.<br />
7. Akpek G, Ambinder RF, Piantadosi S, Abrams RA, Brodsky RA, Vogelsang<br />
GB, et al. Long-term results of blood <strong>and</strong> marrow transplantation<br />
for Hodgkin’s disease. J Clin Oncol 2001;19:4314–4321.<br />
8. Robinson S, Sureda A, Canals C, et al. Reduced intensity allogeneic<br />
stem cell transplantation for Hodgkin’s lymphoma: Identification of<br />
prognostic factors predicting outcome. Haematol 2008;94:230–238.<br />
9. Anderlini P, Saliba R, Acholonu S, Okoroji GJ, Donato M, Giralt S, et<br />
al. Reduced-intensity allogeneic stem cell transplantation in relapsed<br />
<strong>and</strong> refractory Hodgkin’s disease: low transplant-related mortality <strong>and</strong><br />
impact of intensity of conditioning regimen. Bone Marrow Transplant<br />
2005;35:943–951.<br />
10. Alv<strong>are</strong>z I, Sureda A, Caballero MD, et al. Non-myeloablative stem cell<br />
transplantation is an effective therapy for refractory or relapsed Hodgkin’s<br />
lymphoma: Results of a Spanish prospective cooperative protocol.<br />
Biol Blood Marrow Transplant 2006;12:172–183.<br />
11. Burroughs LM, O’Donnell PV, S<strong>and</strong>maier BM, et al. Comparison of<br />
outcomes of HLA-matched related, unrelated, or HLA-haploidentical<br />
related hematopoietic cell transplantation following nonmyeloablative<br />
conditioning for relapsed or refractory Hodgkin lymphoma. Biol Blood<br />
Marrow Transplantation 2008;14:1279–1287.<br />
12. Peggs KS, Hunter A, Chopra R, et al. Clinical evidence of a graft-versus-Hodgkin’s-lymphoma<br />
effect after reduced-intensity allogeneic<br />
transplantation. Lancet 2005;365:1934–1941.<br />
13. Sureda A, Canals C, Arranz R, et al. Allogeneic stem cell transplantation<br />
after reduced-intensity conditioning in patients with relapsed or<br />
refractory Hodgkin’s lymphoma: results of the HDR-Allo Study, a prospective<br />
clinical trial by the Grupo Español de Linfomas/Trasplante de<br />
Médula Ósea (GEL/TAMO) <strong>and</strong> the Lymphoma Working Party of the<br />
European Group for Blood <strong>and</strong> Marrow Transplantation. Leukemia<br />
(submitted).<br />
14. Faulkner RD, Craddock C, Byrne JL, et al. BEAM-alemtuzumab reduced-intensity<br />
allogeneic stem cell transplantation for lymphoproliferative<br />
diseases: GVHD, toxicity, <strong>and</strong> survival in 65 patients. Blood<br />
2004;103:428–434.
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations<br />
15. Sureda A, Robinson S, Çanals C, et al Reduced-intensity conditioning<br />
comp<strong>are</strong>d with conventional allogeneic stem-cell transplantation in relapsed<br />
or refractory Hodgkin’s lymphoma: an analysis from the Lymphoma<br />
Working Party of the European Group for Blood <strong>and</strong> Marrow<br />
Transplantation. J Clin Oncol 2008;26:455–462.<br />
16. Peggs KS, Thomson KJ, Hart DP et al. Dose-escalated donor lymphocyte<br />
infusions following reduced intensity transplantation: toxicity,<br />
chimerism, <strong>and</strong> disease responses. Blood 2004;103:1548–1556.<br />
17. Hart DP, Avivi I, Thomson KJ, et al. Use of 18 F-FDG positron emission<br />
tomography following allogeneic transplantation to guide adoptive immunotherapy<br />
with donor lymphocyte infusions. Br J Haematol 2005;<br />
128:824–829.<br />
18. Lambert JR, Bomanju JB, Pegas KS, et al. Prognostic role of PET scanning<br />
before <strong>and</strong> alter reduced-intensity allogeneic stem cell transplantation<br />
for lymphoma. Blood 2010;115:2763–2768.<br />
OP73 New Drugs in the treatment of Hodkin’s<br />
lymphoma<br />
Anas Younes, (USA)<br />
Abstract not submitted.<br />
69
Meet the Professor<br />
MP01 Chronic myeloid leukemia<br />
Martin Mistrik, Dept. of Hematology <strong>and</strong> Transfusiology,<br />
University Hospital Bratislava, Slovakia<br />
Introduction<br />
Chronic myeloid leukemia (CML) was first described in<br />
the nineteenth century, but treatment with arsenicals <strong>and</strong> radiotherapy<br />
was unsatisfactory. In the 1950s busulfan <strong>and</strong><br />
hydroxycarbamid were introduced, <strong>and</strong> the disease control<br />
has improved. Significant progress brought discovery of the<br />
Philadelphia (Ph) chromosome (4), that results from a t(9;22)<br />
translocation <strong>and</strong> that leukemia originates from a single hematopoietic<br />
»stem cell« with BCR-ABL fusion gene (2; 3).<br />
In the 1980s interferon-alpha replaced chemotherapeuticals<br />
<strong>and</strong> induced in some patients Ph-chromosome negativity.<br />
Between 1980 <strong>and</strong> 2000, allogeneic stem cell transplantation<br />
(allo-SCT) was initial treatment for younger patients<br />
with HLA-matched donors. In the last decade, the introduction<br />
of imatinib (imatinib mesylate, IM), the Abl tyrosine<br />
kinase inhibitor (TKI), has dramatically changed CML therapeutic<br />
strategy (1). The annual number of SCT for CML<br />
has fallen markedly <strong>and</strong> according to the latest ELN recommendations<br />
from 2009 most hematologists today recommend<br />
initial treatment with IM. IM has transformed CML<br />
from an invariably fatal disease in its natural evolution to a<br />
chronic illness, like hypertension, diabetes, or AIDS if patients<br />
comply with daily oral therapy. Although CML is a<br />
relatively r<strong>are</strong> malignancy, effective treatment has significantly<br />
enlarged population of patients, increased its prevalence<br />
<strong>and</strong> raised new problems of management.<br />
What is important at diagnosis?<br />
At first spleen size (by palpation cm bellow costal margin<br />
at maximal inspirium) has to be recorded, <strong>and</strong> complete <strong>and</strong><br />
differential blood count, bone marrow aspiration <strong>and</strong> conventional<br />
cytogenetics performed. In case of Ph-negative<br />
karyotype FISH <strong>and</strong> PCR for BCR-ABL is m<strong>and</strong>atory. HLA<br />
typing of siblings should be done in every patient fit for<br />
allo-SCT.<br />
What <strong>are</strong> the next steps at diagnosis?<br />
1. disease phase assessment according to<br />
blasts (chronic phase: < 10% in peripheral blood<br />
<strong>and</strong>/ or nucleated bone marrow cells; accelerated<br />
phase: 10 – 19%; blastic phase: ≥ 20%)<br />
basophils (chronic phase: < 20% in peripheral blood;<br />
accelerated phase: ≥ 20%)<br />
platelet count (accelerated phase: persistent thrombocytopenia<br />
< 100 x 109 /l)<br />
spleen size (accelerated phase: increasing spleen<br />
size)<br />
cytogenetics (accelerated phase: evidence of clonal<br />
evolution)<br />
2. Risk score assessment (5)(www.roc.se/sokal.asp) –<br />
Sokal risk: low < 0,8; intermediate 0,8 – 1,2 <strong>and</strong> high<br />
> 1,2:<br />
Age (years)<br />
Myeloblasts in blood (%)<br />
Platelets (x 10 9 /l)<br />
Spleen size (cm)<br />
What is the first line treatment?<br />
Leukocytosis has to be controlled with hydroxyurea, addition<br />
of allopurinol is important as well. Low risk patients<br />
should start treatment with IM, intermediate <strong>and</strong> high risk<br />
patients could profit from upfront second generation TKI<br />
therapy. The treatment goal is achievement of major molecular<br />
response (it means 3 log bcr/abl reduction, or bcr/abl<br />
Meet the Professor Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
In summary, there is a lot one can get right or wrong at<br />
diagnosis. The majority or all patients who present with de<br />
novo CML should if possible receive initial treatment with<br />
TKI (imatinib, nilotinib or dasatinib). Monitoring blood<br />
counts, cytogenetics <strong>and</strong> quantitative PCR <strong>are</strong> used according<br />
to the level of response. Allo-SCT can be considered<br />
according to the TKI effectivity. For non chronic phase<br />
CML patients TKI ± chemotherapy followed by allo-SCT is<br />
the treatment of first choice.<br />
R E F E R E N C E S<br />
1. Druker BJ, Talpaz M, Resta DJ, et al. Efficacy <strong>and</strong> safety of a specific<br />
inhibitor of the BCR-ABL tyrosine kinase in chronic myeloid leukemia.<br />
New Engl J Med 2001;344:1031–1037<br />
2. Geary CG. The story of chronic myeloid leukaemia. Br J Haematol<br />
2000;110:2–11<br />
3. Goldman JM, Daley GQ. Chronic myeloid leukemia: a brief history. In:<br />
Melo JV, Goldman JM, editors. Myeloproliferative Disorders. New<br />
York, NY: Springer; 2007. p. 10–13<br />
4. Nowell PC, Hungerford DA. A minute chromosome in human granulocytic<br />
leukemia. Science 1960;132:1497<br />
5. Sokal JE, Baccarani M, Russo D, et al. Staging <strong>and</strong> prognosis in chronic<br />
myelogenous leukemia. Semin Hematol 1988;25:49–61<br />
MP02 Essential (primary) Thrombocythemia<br />
Petro E. Petrides, Hematology Oncology Center <strong>and</strong><br />
Ludwig-Maximilians-University Medical School Munich,<br />
Germany<br />
This seminar will cover all relevant aspects of essential<br />
(primary) thrombocythemia (ET). Starting with the precise<br />
histological diagnosis of ET, which is based on the current<br />
WHO-classification <strong>and</strong> the discussion of differential diagnosis<br />
from reactive thrombocythemia, it continues with the<br />
novel molecular markers JAK2 V617F <strong>and</strong> MPL which <strong>are</strong><br />
present in 50 or 5% resp.of all ET patients.<br />
Next, platelet production <strong>and</strong> function under normal <strong>and</strong><br />
pathological (ET) circumstances <strong>are</strong> outlined.<br />
From the limited data on epidemiology (since ET is an<br />
orphan disease), the question of life expectancy is discussed.<br />
Then signs <strong>and</strong> symptoms of ET patients <strong>are</strong> outlined.<br />
which <strong>are</strong> caused by microcirculatory, thrombotic or hemorrhagic<br />
events.<br />
When ET has been diagnosed by histological <strong>and</strong> molecular<br />
markers, a staging procedure should be performed:<br />
this includes a differential blood smear, serum electrolytes<br />
(with the occurrence of pseudohyperkalemia), uric acid, renal<br />
<strong>and</strong> hepatic values as well as cholesterol (HDL <strong>and</strong><br />
LDL) <strong>and</strong> triglycerides.<br />
Clinical investigation should include a physical examination,<br />
an ultrasound of the spleen (in three dimensions with<br />
volume determination), Doppler ultrasound of the carotid<br />
arteries (plaque formation, intima media thickness) <strong>and</strong> an<br />
exercise electrocardiogram.<br />
Goal of therapeutic interventions is primary <strong>and</strong> secondary<br />
prevention of disease associated complications. At the<br />
moment therapeutical recommendations <strong>are</strong> based upon<br />
age, thrombosis <strong>and</strong> platelet counts. A more comprehensive<br />
approach includes life style (physical activities, smoking,<br />
72<br />
diet, biological age), additional thrombophilic risk factors<br />
(through appropriate testing) <strong>and</strong> how well the patient is informed<br />
about the disease <strong>and</strong> its potential complications.<br />
Basic therapy includes »wait <strong>and</strong> see« or platelet antiaggregatory<br />
treatment with aspirin although only retrospective<br />
data confirm the validity of the latter approach. For cytoreduction<br />
three substances <strong>are</strong> nowadays in use: anagrelide,<br />
hydroxyurea <strong>and</strong> pegylated interferon-alpha with different<br />
mechanisms of action. Only three r<strong>and</strong>omized clinical trials<br />
testing hydroxyurea <strong>and</strong>/or anagrelide (Bergamo/Vicenza,<br />
PT1 <strong>and</strong> Anahydret) have been carried out. Long term efficacy<br />
<strong>and</strong> adverse effect data <strong>are</strong> available only for anagrelide<br />
from post marketing registries from different countries. Pros<br />
<strong>and</strong> cons of the three therapeutical regimens will be discussed.<br />
In addition, novel approaches such as telomerase<br />
inhibitors will be outlined.<br />
Treatment of aged people (up to 96 years), children or<br />
during pregnancy pose additional chalenges.<br />
Case examples for the questions addressed will be given<br />
from daily practise.<br />
MP03 Acute myeloid leukemia<br />
Boris Labar, Division of Hematology, Department of<br />
Medicine, Clinical Hospital Center <strong>and</strong> School of<br />
Medicine, University of Zagreb, Croatia<br />
Classification of acute myeloid leukemia<br />
The current WHO classification is using morphology, immunophenotyping,<br />
cytogenetic <strong>and</strong> molecular genetic abnormalities<br />
to delineate entities of AML with a different<br />
prognostic significance (1). The WHO classification of AML<br />
is given in Table 1. A number of recurrent genetic abnormalities<br />
<strong>are</strong> sufficiently defined to be recognized as entities<br />
of AML.<br />
Moreover some of new genetic abnormalities, mutation<br />
of NPM1 gene <strong>and</strong> CEBPA gene <strong>are</strong> also added to classification<br />
(2, 3). These mutations <strong>are</strong> associated with good prognosis.<br />
FLT3 mutations (4) <strong>are</strong> not defined as a separate entity<br />
but there <strong>are</strong> sufficient data that these mutations have<br />
the prognostic impact. The entity of AML with myelodysplasia<br />
related changes is practically based on the morphological<br />
specific changes, i.e. morphological dysplastic changes<br />
in ≥50% of ≥2 cell lineages in bone marrow. In this<br />
group <strong>are</strong> patients with previous myelodysplastic syndrome<br />
(MDS) or myelodysplastic/myeloproliferative neoplasm<br />
(MDS/MPN) who evolve to AML with marrow or blood<br />
blast counts ≥20%, or if they have myelodysplasia related<br />
cytogenetic abnormality (see Table 1.) (5). Therapy related<br />
myeloid neoplasm (6) is high risk AML <strong>and</strong> should be treated<br />
with intensive chemotherapy <strong>and</strong> allogeneic SCT.<br />
A previous FAB classification is recognized in WHO<br />
classification ss the entity acute myeloid leukemia, not otherwise<br />
specified. In this subgroup one can find the morphologic<br />
separation of AML according to the immaturity of<br />
leukemic cells as well as according to the hematopoietic lineage<br />
involved. This subtype of AML is reserved for the patients<br />
without the known cytogenetic or molecular genetic
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Meet the Professor<br />
Table 1. Acute myeloid leukemia <strong>and</strong> related precursor neoplasm, <strong>and</strong><br />
acute leukemia of ambiguous lineage (WHO 2008) (1)<br />
Acute myeloid leukemia with recurrent genetic abnormalities<br />
– AML with t(8;21)(q22;q22); RUNX1-RUNX1T1<br />
– AML with inv(16)(p13.1;q22) or t(16;16)(p13.1;q22); CBFB-MYH11<br />
– APL with t(15;17)(q22;q12); PML-RARA*<br />
– AML with t(9;11)(p22;q23); MLLT3-MLL**<br />
– AML with t(6;9)(p23:q34); DEK-NUP214<br />
– AML with inv(3)(q21;q26.2) or t(3;3)(q21;q25.2); RPN1-EVI1<br />
– AML (megakaryoblastic) with t(1;22)(p13;q13); RBM15-MKL1<br />
– Provisional entity: AML with mutated NPM1<br />
– Provisional entity: AML with mutated CEBPA<br />
Acute myeloid leukemia with myelodysplasia related changes †<br />
Therapy related myeloid neoplasm ‡<br />
Acute myeloid leukemia, not otherwise specified (NOS)<br />
– Acute myeloid leukemia with minimal differentiation<br />
– Acute myeloid leukemia without maturation<br />
– Acute myeloid leukemia with maturation<br />
– Acute myelomonocytic leukemia<br />
– Acute monoblastic/monocytic leukemia<br />
– Acute erythroid leukemia<br />
Pure erythroid leukemia<br />
Erythroleukemia, erythroid/myeloid<br />
– Acute megakaryoblastic leukemia<br />
– Acute basophilic leukemia<br />
– Acute panmyelosis with myelofibrosis (syn.: acute myelofibrosis; acute<br />
myelosclerosis)<br />
Myeloid sarcoma (syn.: extramedullary myeloid tumor; granulocytic<br />
sarcoma, chloroma)<br />
Myeloid proliferation related to Down syndrome<br />
– Transient abnormal myelopoiesis (syn.: transient myeloproliferative<br />
disorder)<br />
– Myeloid leukemia associated with Down syndrome<br />
Blastic plasmacytoid dendritic cell neoplasm<br />
Acute leukemias of ambiguous lineage<br />
– Acute undifferentiated leukemia<br />
– Mixed phenotype acute leukemia with t(9;22)(q34;q11.2); BCR-ABL1 §<br />
– Mixed phenotype acute leukemia with t(v;11q23); MLL rearranged<br />
– Mixed phenotype acute leukemia, B/myeloid, NOS<br />
– Mixed phenotype acute leukemia, T/myeloid, NOS<br />
– Provisional entity: Natural killer (NK) cell lymphoblastic leukemia/<br />
lymphoma<br />
* Other recurring translocations involving RARA should be reported accordingly<br />
e.g. AML with t(1;17)(q23;q12)/ZBTB16-RARA; AML with t(11;17)<br />
(q13;q12); NUMA1-RARA; AML with T(5;17)(q35;q12); NPM1-RARA; or<br />
AML with STAT5B-RARA (the later have normal chromosome 17 on conventional<br />
cytogenetics)<br />
** Other translocations involving MLL should be reported accordingly: e.g.<br />
AML with t(6;11)(q27;q23); MLLT4-MLL; AML with t(11;19)(q23;p13.3);<br />
MLL-MLLT1; AML with t(11;19)(q23;p13.1); MLL-ELL; AML with t(10;11)<br />
(p12;q23); MLLT10-MLL.<br />
† >20% blood or marrow blasts <strong>and</strong> any of the following previous history of<br />
myelodysplastic syndrome (MDS) or myelodysplastic/myeloproliferative<br />
neoplasm (MDS/MPN): myelodysplasia-related cytogenetic abnormality (see<br />
below); multilineage dysplasia; <strong>and</strong> absence of both prior cytotoxic therapies<br />
for unrelated disease <strong>and</strong> aforementioned recurring genetic abnormalities;<br />
cytogenetic abnormalities sufficient to diagnose AML with myelodysplasi<strong>are</strong>lated<br />
changes <strong>are</strong>:<br />
– Complex karyotype (defined as 3 or more chromosomal abnormalities)<br />
– Unbalanced changes: -7 or del(7q); -5 or del(5q); i(17q) or t(17p); -13 or<br />
del(13q); del(11q); del(12p) or t(12p); del(9q); idic(X)(q13)<br />
– Balanced changes: t(11;16)(q23;p13.3); t(3;21)(q26;q22.1);<br />
t(1;3)(p36.3;q21.1); t(2;11)(p21;q23); t(5;12)(q33;p12); t(5;7)(q33;p13);<br />
t(5;10)(q33;q21); t(3;5)(q25;q34).<br />
‡ Cytotoxic agents implicated in therapy related hematologic neoplasm: alkylating<br />
agents; ionizing radiation therapy; topoisomerase II inhibitors; others.<br />
§ BCR-ABL1 positive leukemia may present as mixed phenotype leukemia,<br />
but should be treated as BCR-ABL1 positive acute lymphoblastic leukemia.<br />
abnormalities. In some of them, there <strong>are</strong> markers associated<br />
with prognostic significance.<br />
The r<strong>are</strong> forms of AML <strong>and</strong> acute leukemia of ambiguous<br />
lineage recognized in WHO classification <strong>are</strong> also associated<br />
with poor prognosis. The other WHO AML entities <strong>are</strong><br />
rather r<strong>are</strong> disorders <strong>and</strong> will not be discussed in detail.<br />
Prognosis of AML<br />
Patient’s related prognostic factors<br />
Age, co-morbidities, performance status <strong>and</strong> genetic variation<br />
in drug metabolism <strong>are</strong> the main prognostic factors<br />
related to patients with AML. Increasing age is important<br />
independent adverse prognostic factor (7). Currently all patients<br />
under the age of 60 <strong>are</strong> c<strong>and</strong>idate to receive st<strong>and</strong>ard<br />
intensive chemotherapy <strong>and</strong> according to prognostic factors<br />
stem cell transplantation or intensive chemotherapy as postremission<br />
therapy. It has to be stressed that age as a factor<br />
is not only dependent on so-called »calendar age«. Recently<br />
many older patients in a good clinical status have been successfully<br />
treated with intensive chemotherapy. Even more,<br />
stem cell transplantation with reduced intensity conditioning<br />
could be offered to older patients with reasonable toxicity<br />
<strong>and</strong> treatment related mortality (TRM) (8). So to define<br />
the treatment approach it is important to evaluate <strong>and</strong> to determine<br />
co-morbidities before any therapy. Many different<br />
comorbidity scores have been proposed to outline patients<br />
who <strong>are</strong> the c<strong>and</strong>idate for intensive therapy (9). It is very<br />
popular especially in older group of patients to differentiate<br />
»fit« from »unfit« or »frail« patients.<br />
Co-morbidity scoring is currently still under the investigation<br />
in many Cooperative groups. In younger patients comorbidity<br />
score is »defined« as inclusion/exclusion criteria.<br />
That means patients with e.g. »unacceptable« renal, cardial<br />
or hepatic abnormalities <strong>are</strong> not included into the study. By<br />
such approach at least 20–30% of younger patients <strong>are</strong> excluded<br />
from the treatment in the clinical trials. On the other<br />
h<strong>and</strong>s in older group more than 50% of patients <strong>are</strong> also<br />
excluded from the clinical trials. So, these patients have not<br />
been reported in any results?! Because of that it would be<br />
important to propose comorbidity score for all AML patients<br />
<strong>and</strong> to evaluate how many of the patients <strong>are</strong> able to<br />
receive st<strong>and</strong>ard therapy <strong>and</strong> stem cell transplantation, how<br />
many of them <strong>are</strong> c<strong>and</strong>idate for low-intensity treatment <strong>and</strong><br />
supportive c<strong>are</strong>. It is important to have the prospective data<br />
for the patients treated in the Centers of CELG. This will<br />
give us the real situation concerning the treatment applicability<br />
in the Central <strong>and</strong> <strong>East</strong>ern Europe.<br />
Many trials showed a better outcome for patients less than<br />
45 years of age comp<strong>are</strong>d to the group of patients from 45 to<br />
60 years of age. Nonetheless most of the cooperative groups<br />
for adult AML <strong>are</strong> including patients from 18 to 60 years of<br />
age as younger ones. They received intensive chemotherapy<br />
<strong>and</strong> stem cell transplantation with st<strong>and</strong>ard conditioning. Reduced<br />
intensive conditioning has been predominantly used in<br />
patients older than 50 years of age because of lower toxicity.<br />
Older group of patients <strong>are</strong> those with age >60. The comorbidity<br />
scoring treatment approaches mentioned before has<br />
been used practically only for older patients.<br />
Disease related prognostic factors<br />
According to AML working party of European Leukemia<br />
Net several important <strong>and</strong> independent prognostic factors<br />
have been recognized as white blood cell counts, existence<br />
of prior MDS or AML with MDS feature, previous cytotoxic<br />
therapy for another malignancy, <strong>and</strong> cytogenetic <strong>and</strong><br />
molecular abnormalities in leukemic cells (10). The signifi-<br />
73
Meet the Professor Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
cance of prognostic factors is dependent on the therapy<br />
given to a patient. The genetic abnormalities according to<br />
prognostic impact <strong>are</strong> given in Table 2.<br />
Therapy of AML<br />
In acute leukemia still the first goal of the treatment is<br />
to induce good control of the leukemia (i.e. complete remission)<br />
<strong>and</strong> after that to maintain the control of leukemia<br />
or to cure it. The first part of therapy is induction therapy<br />
by which we induce remission of leukemia. In the second<br />
one so-called postremission therapy our goal is to maintain<br />
the remission state or by intensive treatment approach<br />
to cure the leukemia.<br />
74<br />
Table 2. Prognostic impact of genetic abnormalities (10)<br />
Genetic group Subsets<br />
Favorable t(8;21)(q22;q22); RUNX1-RUNX1T1<br />
inv(16)(p13.1q22) or t(16;16)(p13.1;q22); CBFB-MYH11<br />
Mutated NPM1 without FLT3-ITD (normal karyotype)<br />
Mutated CEBPA (normal karyotype)<br />
Intermediate I Mutated NPM1 <strong>and</strong> FLT3-ITD (normal karyotype)<br />
Wild-type NPM1 <strong>and</strong> FLT3-ITD (normal karyotype)<br />
Wild-type NPM1 without FLT3-ITD (normal karyotype)<br />
Intermediate II t(9;11)(p22;q23); MLLT3-MLL<br />
Cytogenetic abnormalities not classified as favorable<br />
or adverse<br />
Adverse inv(3)(q21q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1<br />
t(6;9)(p23;q34); DEK-NUP214<br />
t(v;11)(v;q23); MLL rearranged<br />
-5 or del(5q); -7; abnl(17p); complex karyotype<br />
Remission-Induction Therapy<br />
Combination chemotherapy is the primary treatment<br />
modality for patients with AML. Options for induction<br />
chemotherapy include st<strong>and</strong>ard or high dose cytarabine in<br />
combination with an anthracycline. Approximately half of<br />
patients will require a second induction cycle to obtain a<br />
complete remission. A combination of an anthracycline<br />
such as daunorubicin for three days <strong>and</strong> »st<strong>and</strong>ard« dose<br />
cytarabine for 7 days should be recommended (11). High<br />
dose of cytarabine may increase the complete remission<br />
rate in patients less than 60 years of age. It does so at the<br />
cost of increased toxicity. Treatment-related mortality, the<br />
rate of early relapse, <strong>and</strong> overall survival <strong>are</strong> not clearly<br />
improved (12).<br />
At present, there is no conclusive evidence to recommend<br />
one »7+3« regimen over another. Depending on<br />
dose, schedule, <strong>and</strong> patient selection criteria, they have<br />
similar response rates <strong>and</strong> sh<strong>are</strong> common toxicities such<br />
as severe degrees of myelosuppression with moderate mucositis,<br />
<strong>and</strong> diarrhea. Idarubicin or mitoxantrone could be<br />
used instead of daunorubicine with a similar outcome.<br />
The best induction chemotherapy for older patients with<br />
AML remains to be identified. Intensive chemotherapy may<br />
be appropriate for selected patients with low or intermediate<br />
risk disease in whom the complete remission (CR) rate<br />
can be as high as 70 to 80 percent. With this approach, median<br />
survival is approximately eight months, but 9 to 12<br />
percent of patients will be alive at five years. Although pilot<br />
studies have used more intensive initial chemotherapy, a<br />
reasonable st<strong>and</strong>ard regimen for many older patients who<br />
<strong>are</strong> medically fit is seven days of continuous infusion cytarabine<br />
plus three days of daunorubicin (13).<br />
In general, the choice of anthracycline (eg, daunorubicin,<br />
mitoxantrone, or idarubicin) does not appear to affect<br />
overall outcome. However, higher doses of anthracyclines<br />
may result in superior rates of complete remission without<br />
an app<strong>are</strong>nt increase in toxicity.<br />
So, for most older adults with favorable or intermediate<br />
risk AML <strong>and</strong> an ECOG performance status of two or less<br />
<strong>and</strong> few comorbidities, we recommend remission induction<br />
treatment with a combination of daunorubicin for<br />
three days <strong>and</strong> »st<strong>and</strong>ard« dose cytarabine for seven days<br />
rather than other chemotherapy regimens or supportive<br />
c<strong>are</strong> alone.<br />
While not curative, many Centers consider low-dose<br />
cytarabine to be the st<strong>and</strong>ard against which other treatments<br />
for AML in the older patient should be evaluated. A<br />
number of trials have investigated the use of low-dose cytarabine<br />
in older subjects with AML, both for induction<br />
<strong>and</strong> later for maintenance of remission. Although the number<br />
of complete remissions was greater with intensive<br />
chemotherapy, the early death rate was also higher. As a<br />
result, there were no differences in survival or remission<br />
duration between the patients receiving more intensive<br />
therapy <strong>and</strong> patients on low-dose cytarabine (14).<br />
Postremission therapy<br />
Post-remission therapy in acute myeloid leukemia remains<br />
problematic <strong>and</strong> controversial. It has been demonstrated<br />
that younger patients can maintain longer complete<br />
remissions (CR) with aggressive post-remission therapies<br />
after induction treatment: allogeneic autologous stem cell<br />
transplantation, or intensive chemotherapy. Still there is<br />
no evidence that auto-SCT is superior in terms of overall<br />
survival to intensive chemotherapy (15). Data clearly<br />
show that patients with unfavorable risk disease <strong>are</strong> more<br />
often addressed to allo-SCT <strong>and</strong> patients with low-risk<br />
disease receive more often intensive consolidation chemotherapy<br />
(16). At the moment most of AML patients generally<br />
receive allo-SCT on the basis of donor availability<br />
(the so called »genetic r<strong>and</strong>omization«). In the recent year<br />
allo-SCT with reduced intensity conditioning have been<br />
successfully performed for the treatment of older AML<br />
patients (8).<br />
R E F E R E N C E S<br />
1. Vardiman JW et al. Blood 2009;114:937–951.<br />
2. Döhner K et al. Blood 2005;106:3740–3746.<br />
3. Schlenk RF et al. N Engl J Med 2008;358(18):1909–1918.<br />
4. Gale RE et al. Blood 2008;111:2776–2784.<br />
5. Mufti GJ et al. Haematologica 2008;93:1712–7.<br />
6. Godley LA, Larson RA. Semin Oncol 2008;35:418–429.<br />
7. Juliusson G et al. Blood 2009;113:4179–4187.<br />
8. Blaise D et al. Exp Hematol 2010;38:1241–50.<br />
9. Sorror ML et al. Blood 2005;106:2912:2919<br />
10. Döhner H et al. Blood 2010;115:453–474<br />
11. Kolitz JE. Br J Haematol 2006;134:555.<br />
12. Weick JK et al. Blood 1996;88:2841.<br />
13. Martin MG, Abboud CN. Blood Rev 2008;22:311–20.<br />
14. Zwierzina H et al. Leukemia 2005;19:1929–33.<br />
15. Cassileth PA et al. Blood 1992;79:1924.<br />
16. Cornelissen JJ et al. Blood 2007;109:3658.
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Meet the Professor<br />
MP04 Allogeneic Stem cell transplantation<br />
for hematological malignancies – current<br />
approach <strong>and</strong> future trends<br />
Boris Labar, Division of Hematology, Department of<br />
Medicine University Hospital Center Zagreb <strong>and</strong> School of<br />
Medicine, University of Zagreb, Croatia<br />
At the beginning of the second decade of 21 st century, 40<br />
years after first clinical use of allogeneic stem cell transplantation<br />
(SCT) for hematological malignancies I searched<br />
through the PUBMED to find out what is the current scientific<br />
interest in the field of stem cell transplantation. For this<br />
purpose I analyzed 300 recent publications (mostly 2011).<br />
In these publications 10% of them <strong>are</strong> committed to SCT in<br />
hematological malignancies. Most of them dealing with the<br />
reports of unusual sources of stem cells predominantly cord<br />
blood mesenchimal stem cells. Some reports <strong>are</strong> showing<br />
the results of transplants with reduced intensity conditioning.<br />
Late complications <strong>and</strong> never ending story how to induce<br />
GvL effect without GvHD <strong>are</strong> also reported. Contrary<br />
to that the majority of publication describe current results of<br />
stem cell treatment in regenerative medicine, chronic disease<br />
<strong>and</strong> autoimmune diseases, as well as in many non-hematological<br />
tumors. Logical conclusion after this very preliminary<br />
survey could be: The era of allogeneic SCT for<br />
hematological malignancies from the scientific point of<br />
view is finishing?! We solved(?) the most questions as how<br />
<strong>and</strong> when to perform SCT. We know the efficacy <strong>and</strong> limitation<br />
of SCT for hematological malignancies(?!). It seems<br />
much more interesting to study the trans-differentiation <strong>and</strong><br />
immunomodulatory capacity of stem cells comp<strong>are</strong>d to the<br />
investigation how to improve the outcome of allografting in<br />
hematological malignancies. I am not going to say that there<br />
is no interest for these approaches but it may be that scientific<br />
interest is really decreasing. Moreover targeting treatment<br />
approach as in CML with TKI, seems to be more attractive<br />
for the future investigation.<br />
On the other h<strong>and</strong> in every day clinical medicine transplant<br />
is very efficient therapy for leukemia <strong>and</strong> lymphoma.<br />
For high risk patients transplant is until now the only curable<br />
therapy. The outcome is improving every decade. Still<br />
this could be a st<strong>and</strong>ard therapy for many years from now.<br />
In many transitional countries SCT is not yet a routine treatment<br />
approach. To support this let me sh<strong>are</strong> with you some<br />
recent data from the Center(s) in transitional country(ies).<br />
Incidence of stem cell transplant is increasing every year<br />
especially for acute leukemia. The reasons for that could be:<br />
SCT is the most efficient treatment options for acute leukemia<br />
<strong>and</strong> MDS (1,2);<br />
By using more efficient supportive therapy transplant related<br />
toxicity <strong>and</strong> mortality is decreasing. This make SCT<br />
more popular (3).<br />
Less intensive conditioning is associated with lower early<br />
mortality. By this approach transplant could be offer an<br />
older patient group, i.e. 50 to 60 years of age. In well developed<br />
countries many centers treated patients older than 60<br />
years of age (4, 5) (Fig. 1.).<br />
The results of transplants with match unrelated donor<br />
(MUD) according to HLA-typing with high resolution (10/10<br />
or 9/10) is similar to the results of transplants with sibling<br />
Figure 1. Incidence of SCT according to st<strong>and</strong>ard <strong>and</strong> RIC conditioning<br />
at Zagreb Center<br />
Figure 2. The incidence of SCT according to sibling <strong>and</strong> MUD donor in<br />
Zagreb Center<br />
compatible donor; this clearly increase the number of SCT<br />
with MUD donor (6, 7) (Fig. 2.)<br />
In the recent year use of cord blood (two cord blood) <strong>are</strong><br />
feasible approach for adult patients (8).<br />
Transplant should be performed in almost all hematological<br />
malignancies. But the approach when to perform transplants<br />
depends on many factors. The high toxicity <strong>and</strong> mortality<br />
<strong>are</strong> the major determinants to perform allotransplant<br />
in early phase of the disease when the antitumor efficacy is<br />
the best. Transplant related mortality with st<strong>and</strong>ard conditioning<br />
depending on patient’s age range from 20% to 50%<br />
(9, 10).<br />
The main causes of death <strong>are</strong> given In Fig. 3.<br />
Figure 3. Causes of death in 1 st 100 days following allogeneic transplant<br />
in Zagreb Center.<br />
75
Meet the Professor Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
For the diseases with the high prediction of progression<br />
or relapse (acute leukemia <strong>and</strong> myelodysplastic syndrome)<br />
after st<strong>and</strong>ard therapy allotransplant should be perform immediately.<br />
Indolent hematological malignancies or tumors<br />
with effective <strong>and</strong> less toxic therapy (lymphoma, CLL, multiple<br />
myeloma <strong>and</strong> CML) should be treated in more advanced<br />
phase of disease, when other treatment options<br />
failed. In such situation it is crucial to define evidence based<br />
medicine criteria i.e. criteria that allografting have a benefit<br />
comp<strong>are</strong>d with the other treatment options.<br />
The transplant outcome is also influenced by the availability<br />
of compatible donor, the source of stem cells, the<br />
intensity of conditioning, the incidence <strong>and</strong> severioty of<br />
early <strong>and</strong> late complications after allografting as GvHD <strong>and</strong><br />
infections. This will be also presenting during the session.<br />
R E F E R E N C E S<br />
1. Serventi-Seiwerth R et al. Acta Med Croatica 2009;63:205–8.<br />
2. Oosterveld M et al. Leukemia 2003;17:859–68.<br />
3. Vicente D et al. Bone Marrow Transplant 2007;40:349–54.<br />
4. Luger SM et al. Bone Marrow Transplant 2011; in press.<br />
5. Servais S et al. Transfus Apher Sci 2011;44:205–10.<br />
6. Ciurea SO et al. Biol Blood Marrow Transplant 2011;17:923–9<br />
7. Schlenk RF et al. J Clin Oncol 2010;28:4492–9.<br />
8. Brunstein CG et al. Blood 2010;116:4693–9.<br />
9. Remberger M et al. Biol Blood Marrow Transplant 2011; in press.<br />
10. Gupta T et al. Hematol Oncol Stem Cell Ther 2011;4:17–29.<br />
MP05 Acute lymphoblastic leukemia<br />
Deborah Thomas, (USA)<br />
76<br />
Abstract not submitted.<br />
MP06 Myelodysplastic Syndromes (MDS)<br />
Petra Muus, Theo de Witte, Dept Hematology, Radboud<br />
University Nijmegen, Medical Centre, The Netherl<strong>and</strong>s<br />
General characteristics of MDS<br />
Myelodysplastic syndromes (MDS) <strong>are</strong> a heterogeneous<br />
group of disorders affecting the normal differentiation of<br />
hematopoietic cells. Clinical manifestations of MDS overlap<br />
with aplastic anemia (AA), paroxysmal nocturnal hemoglobinuria<br />
(PNH), acute myeloid leukemia (AML) <strong>and</strong> myeloproliferative<br />
syndromes (MPS). Differential diagnosis<br />
can be challenging. Most experts do agree that the majority<br />
of MDS clones arise at the level of a pluripotent hematopoietic<br />
stem cell.<br />
All types of MDS sh<strong>are</strong> dysplastic features in one or all<br />
of the myeloid, megakaryocytic, <strong>and</strong>/or erythroid lineages,<br />
frequently resulting in cytopenias of the affected lineages<br />
(thresholds: Hb 10g/dL, absolute neutrophil count
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Meet the Professor<br />
The differential diagnosis of pancytopenia <strong>and</strong> a hypocellular<br />
bone marrow with or without relative erythroid hyperplasia<br />
is particularly challenging. The patient may have hypoplastic<br />
MDS. But it is important to know that PNH may<br />
have a similar presentation, particularly with a concomitant<br />
viral disease. Alternatively in the presence or absence of a<br />
small PNH clone the diagnosis may be aplastic anemia<br />
(AA). Hypoplastic MDS is relatively r<strong>are</strong>. Hemolytic PNH<br />
may develop from AA (AA-PNH) or r<strong>are</strong>ly out of what first<br />
appe<strong>are</strong>d to be MDS (MDS-PNH) 9 . In all cases it is important<br />
to follow the patient c<strong>are</strong>fully <strong>and</strong> repeat diagnostics in<br />
time.<br />
Treatment of MDS<br />
Treatment of MDS is as diverse as its clinical manifestations.<br />
For elderly <strong>and</strong> low risk patients supportive treatment<br />
is most commonly consisting of transfusions with erythrocytes<br />
<strong>and</strong>/or platelets. Patients with ineffective hematopoiesis<br />
generally have low intracellular levels of folic acid <strong>and</strong><br />
may profit from folic acid suppletion. Early iron chelation<br />
therapy seems important to prevent iron overload <strong>and</strong> toxicity.<br />
Growth factors (ESA’s with <strong>and</strong> without G-CSF) influencing<br />
cytopenias have a place in lower risk MDS. International<br />
guidelines suggest that patients who <strong>are</strong> either erythrocyte<br />
transfusion dependent or have low epo levels <strong>are</strong><br />
c<strong>and</strong>idates for ESA’s. G-CSF may be synergistic to ESA’s in<br />
MDS10 . Fase I studies for Romiplostim in patients with<br />
MDS <strong>and</strong> low platelet counts were promising11 <strong>and</strong> a r<strong>and</strong>omized<br />
placebo controlled phase II study is presently being<br />
analyzed. Differentiation inducing agents <strong>and</strong> low-dose<br />
chemotherapy <strong>are</strong> currently not often used anymore.<br />
An important development in recent years is Lenalidomide<br />
in lower risk MDS with 5q-. A r<strong>and</strong>omized placebo<br />
controlled study demonstrated the effectivity of the agent12 .<br />
Registration of Lenalidomide in Europe is waiting safety<br />
reports, with regards to a potentially increased incidence of<br />
AML. Studies investigating the role of lenalidomide in low<br />
risk MDS without 5q abnormalities <strong>are</strong> ongoing.<br />
Hypomethylating agents <strong>are</strong> effective in intermediate <strong>and</strong><br />
high risk (IPSS) MDS. Patients on Vidaza had a better survival<br />
than those receiving st<strong>and</strong>ard c<strong>are</strong>13 . In an almost comparable<br />
group of patients decitabine demonstrated activity<br />
as well14 . In Europe only Vidaza is approved. Currently the<br />
drug needs to be injected sc for 7 consecutive days every 28<br />
days which is quite a burden for the patient. Of note: in<br />
cases were stable disease is achieved vidaza cannot be stopped.<br />
The only accepted curative treatment for MDS is an allogeneic<br />
stem cell transplantation (alloSCT) alone or after<br />
remission induction with high-dose chemotherapy. Various<br />
studies showed a 4-year survival between 20 <strong>and</strong> 30% of<br />
treated high-risk patients. This treatment is available to only<br />
a limited number of patients because of the lack of suitable<br />
donors <strong>and</strong> the intensity of the procedure, which is in many<br />
cases incompatible with the age of the patient. Development<br />
of other transplant modalities (matched unrelated donors,<br />
non-myeloablative conditioning) have rendered alloSCT<br />
accessible to more MDS patients. Hypomethylating agents<br />
may prove sufficient <strong>and</strong> relative non-toxic cytoreductive<br />
therapy before alloSCT.<br />
As an alternative intensive remission induction, followed<br />
by intensive consolidation chemotherapy alone can be considered.<br />
Some patients responded well to intensive chemotherapy<br />
followed by autologous stem cell transplantation 15 .<br />
MDS patients may have prolonged hypoplasia following intensive<br />
chemotherapy.<br />
MDS classification, prognostic characterization plus well<br />
defined response criteria <strong>are</strong> helping advance treatment options<br />
for patients with MDS 16 .<br />
R E F E R E N C E S<br />
1. Harris NL, Jaffe ES, Diebold J, Fl<strong>and</strong>rin G, Muller-Hermelink HK,<br />
Vardiman J, Lister TA, Bloomfield CD. The World Health Organization<br />
classification of neoplastic diseases of the hematopoietic <strong>and</strong> lymphoid<br />
tissues. Report of the Clinical Advisory Committee meeting,<br />
Airlie House, Virginia, November, 1997. Ann Oncol 1999;10:1419–32.<br />
2. Bennett JM, Catovsky D, Daniel MT, Fl<strong>and</strong>rin G, Galton DA, Gralnick<br />
HR, Sultan C. Proposals for the classification of the myelodysplastic<br />
syndromes. Br J Haematol 1982;51:189–99.<br />
3. Greenberg P, Cox C, LeBeau MM, Fenaux P, Morel P, Sanz G, Sanz M,<br />
Vallespi T, Hamblin T, Oscier D, Ohyashiki K, Toyama K, Aul C, Mufti<br />
G, Bennett J. International scoring system for evaluating prognosis in<br />
myelodysplastic syndromes. Blood 1997;89:2079–88.<br />
4. Greenberg PL, Sanz GF, Sanz MA. Prognostic scoring systems for risk<br />
assessment in myelodysplastic syndromes. Forum (Genova) 1999;9:<br />
17–31.<br />
5. Malcovati L, Germing U, Kuendgen A et al. Time-dependent Prognostic<br />
Scoring System for Predicting Survival <strong>and</strong> Leukemic Evolution in<br />
MDS. J CLin Oncol 2007;25:3503–3510.<br />
6. Aul C, Giagounidis A, Germing U. Epidemiological features of myelodysplastic<br />
syndromes: results from regional cancer surveys <strong>and</strong> hospital-based<br />
statistics. Int J Hematol 2001;73:405–10.<br />
7. Cogle R, Craig BJ, Rollison DE <strong>and</strong> List AF. Incidence of MDS using<br />
a novel claims-based algorithm: high number of uncaptured cases by<br />
cancer registries. Blood 2011;117:7121–7125.<br />
8. Madkaikar M, Gupta M, Jijina F, Ghosh K.Paroxysmal nocturnal haemoglobinuria:<br />
diagnostic tests, advantages, & limitations. Eur J Haematol<br />
2009;83(6):503–11.<br />
9. Li Y, Li X, Ge M, Shi J, Qian L, Zheng Y, Wang J. Long-term follow-up<br />
of clonal evolutions in 802 aplastic anemia patients: a single-center experience.<br />
Ann Hematol 2011;90:529–37.<br />
10. Jadersten M, Montgomery SM, Dybedal I et al. Longterm outcome of<br />
treatment of anemia in MDS with Erythropoietin <strong>and</strong> G-CSF. Blood<br />
2005;106:803–811.<br />
11. Kantarjian H, Fenaux P, Sekeres MA, Becker PS, Boruchov A, Bowen<br />
D, Hellstrom-Lindberg E, Larson RA, Lyons RM, Muus P, Shammo J,<br />
Siegel R, Hu K, Franklin J, Berger DP Safety <strong>and</strong> efficacy of romiplostim<br />
in patients with lower-risk myelodysplastic syndrome <strong>and</strong> thrombocytopenia.<br />
J Clin Oncol 2010;20;28(3):437–44.<br />
12. Fenaux P, Giagounidis A, Selleslag D, Beyne-Rauzy O, Mufti G, Mittelman<br />
M, Muus P, Te Boekhorst P, Sanz G, Del Cañizo C, Guerci-Bresler<br />
A, Nilsson L, Platzbecker U, Lübbert M, Quesnel B, Cazzola M,<br />
Ganser A, Bowen D Dr, Schlegelberger B, Aul C, Knight R, Francis J,<br />
Fu T, Hellström-Lindberg E. A r<strong>and</strong>omized phase 3 study of lenalidomide<br />
vs placebo in RBC transfusion-dependent patients with Low-/Intermediate-1-risk<br />
MDS with del5q. Blood. 2011 Jul 13. [Epub ahead of<br />
print].<br />
13. Fenaux P, Mufti GJ, Hellstrom-Lindberg E, Santini V, Finelli C, Giagounidis<br />
A, Schoch R, Gattermann N, Sanz G, List A, Gore SD, Seymour<br />
JF, Bennett JM, Byrd J, Backstrom J, Zimmerman L, McKenzie<br />
D, Beach C, Silverman LR; International Vidaza High-Risk MDS Survival<br />
Study Group. Efficacy of azacitidine comp<strong>are</strong>d with that of conventional<br />
c<strong>are</strong> regimens in the treatment of higher-risk myelodysplastic<br />
syndromes: a r<strong>and</strong>omised, open-label, phase III study. Lancet Oncol<br />
2009;10:223–32.<br />
14. Lübbert M, Suciu S, Baila L, Rüter BH, Platzbecker U, Giagounidis A,<br />
Selleslag D, Labar B, Germing U, Salih HR, Beeldens F, Muus P,<br />
Pflüger KH, Coens C, Hagemeijer A, Eckart Schaefer H, Ganser A, Aul<br />
77
Meet the Professor Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
C, de Witte T, Wijermans PW. Low-dose decitabine versus best supportive<br />
c<strong>are</strong> in elderly patients with intermediate- or high-risk myelodysplastic<br />
syndrome (MDS) ineligible for intensive chemotherapy: final<br />
results of the r<strong>and</strong>omized phase III study of the European Organisation<br />
for Research <strong>and</strong> Treatment of Cancer Leukemia Group <strong>and</strong> the<br />
German MDS Study Group. J Clin Oncol 2011;29(15):1987–96.<br />
15. de Witte T, Suciu S, Verhoef G, Labar B, Archimbaud E, Aul C, Selleslag<br />
D, Ferrant A, Wijermans P, M<strong>and</strong>elli F, Amadori S, Jehn U, Muus<br />
P, Boogaerts M, Zittoun R, Gratwohl A, Zwierzina H, Hagemeijer A,<br />
Willemze R: Intensive chemotherapy followed by allogeneic or autologous<br />
stem cell transplantation for patients with myelodysplastic syndromes<br />
(MDSs) <strong>and</strong> acute myeloid leukemia following MDS. Blood<br />
2001;98:2326–31.<br />
16. Greenberg P. Current therapeutic approaches for patients with MDS.<br />
Brit J of Haematology 2010;150:131–143.<br />
MP07 Diagnostic <strong>and</strong> therapeutic challanges<br />
in B – Chronic lymphocytic leukemia<br />
(B-CLL)<br />
Branimir Jaksic, Department of Medicine, University<br />
Hospital Merkur <strong>and</strong> School of Medicine, University of<br />
Zagreb, Croatia.<br />
In this session we will address the frequent challenges in<br />
the management of B-CLL. Some of the recent major clinical<br />
research advancements in the diagnostics <strong>and</strong> clinical<br />
therapeutic trials have put a new perspective on the actual<br />
nature of the disorder <strong>and</strong> helped to modify conceptual <strong>and</strong><br />
practical clinical approaches. Therefore we will address<br />
challenges referring to the diagnostics first, followed by the<br />
therapy, <strong>and</strong> finally discuss some of the typical scenarios<br />
from the practical clinical point of view.<br />
Diagnostics. Diagnostic criteria have recently been both<br />
simplified <strong>and</strong> made more specific. Thus, only a peripheral<br />
blood sample is required for the diagnosis, but at the same<br />
time the morphology supplemented by flow cytometry defined<br />
immune phenotype has become m<strong>and</strong>atory. In clinical<br />
practice this opened the problem in a definition of required<br />
panel of monoclonal antibodies <strong>and</strong> required level of their<br />
expression to distinguish between »typical« B-CLL <strong>and</strong><br />
»atypical or B-CLL variant(s)« as far as immune phenotype<br />
is concerned. Moreover, the concept of variants may encompass<br />
more clinical variability, such as distinct patterns<br />
of the tumor mass distribution <strong>and</strong> similar.<br />
The simple clinical <strong>and</strong> hematological parameters <strong>are</strong><br />
also commonly used for the evolution monitoring. We have<br />
been using for many years the Total Tumor Mass Scoring<br />
System (TTM) that is exclusively disease related. It proved<br />
to be very useful for both monitoring of the disease evolution<br />
<strong>and</strong> its response to the treatment independently of toxicities.<br />
Perhaps, the addition of more cellular <strong>and</strong> humoral<br />
immunological new parameters <strong>and</strong>/or infection related<br />
triggers may improve prediction of disease evolution.<br />
The comorbidity evaluation is important prerequisite for<br />
sound clinical decisions. As a rule, more effective treatments<br />
<strong>are</strong> at the same time associated with more toxicities<br />
as shown in the recently published trials. The overall clinical<br />
benefit should be c<strong>are</strong>fully balanced taking into account<br />
expected effect <strong>and</strong> expected tolerance. Thus, this part of<br />
the diagnostic process aimed to predict tolerance should<br />
never be neglected. The cumulative illness rating scales <strong>are</strong><br />
78<br />
helpful (CIRS-G is widely used for CLL) both in clinical<br />
trials <strong>and</strong> routine practice.<br />
The prognostic factors <strong>are</strong> individual variables that <strong>are</strong><br />
associated with prognosis. The prognosis is usually measured<br />
by the length of survival. The clinical usefulness of a<br />
given prognostic factor is related to the strength of its independent<br />
prognostic power. In addition to help prognostication,<br />
the prognostic analyses represent a powerful research<br />
tool to evaluate both biological <strong>and</strong> clinical relevance of a<br />
given variable. It is important to note that prognostic factors<br />
may be classified into (1) disease related, (2) patient related<br />
(B-CLL unrelated) <strong>and</strong> (3) intermediate group that may be<br />
in variable extent both disease <strong>and</strong> patient related. The distinction<br />
is important since disease related <strong>and</strong> patient related<br />
factors have different clinical meanings. The c<strong>are</strong>ful clinical<br />
evaluation is particularly important in the intermediate<br />
group, to classify a prognostic factor according to underlying<br />
cause. For example the presence of anemia or elevation<br />
of serum beta -2-microglobulin may be present due to disease<br />
itself or to disease unrelated condition, <strong>and</strong> consequently<br />
may have different impact on clinical decision on<br />
starting therapy<br />
The prognostic indices <strong>are</strong> composite scales that comprise<br />
several individual variables. The variables <strong>are</strong> chosen<br />
by their mutually independent prognostic power(s), <strong>and</strong> <strong>are</strong><br />
therefore excellent predictors of prognosis. However, if<br />
combining prognostic factors related to disease with those<br />
unrelated to the disease (which is a very common situation)<br />
they may have limited clinical impact. While a bad prognosis<br />
due to presence of the factors related to the disease warrants<br />
more aggressive treatment, patient related prognostic<br />
factors as for example advanced age may have clinically opposite<br />
indication. Failure to recognize this concept may<br />
have deleterious clinical repercussions.<br />
Therapy. There <strong>are</strong> two important basic questions for<br />
clinical practice: (1) When to treat? <strong>and</strong> (2) How to treat?<br />
Both questions <strong>are</strong> interrelated <strong>and</strong> depend mostly on the<br />
achievable aims of therapy definition. Based on the clinical<br />
trials results performed in 1980s that showed no advantage<br />
of early institution of therapy, it is today recommended in<br />
most of guidelines to refrain therapy until indication of active<br />
disease present. Although this is the common clinical<br />
practice, it is somehow problematic conceptually. Namely,<br />
this policy has resulted in a watch <strong>and</strong> wait practice for variable<br />
period of time, but once the indication to start therapy<br />
is adopted, there is a shift in goal, with a tendency to apply<br />
the most effective treatment aiming molecular response, or<br />
in other words, the eradication of the disease. This is in contrast<br />
to general paradigm in oncology that effective treatment<br />
should be applied with no delay. Thus, in current B-<br />
CLL clinical practice we often wait until the full blown<br />
disease to try to eradicate it. If we really believe in eradication<br />
potential of the given antineoplastic therapy (as may be<br />
the case according to the latest reports), this therapy should<br />
definitely be tried earlier in the course of the disease.<br />
As far as to define achievable aims of therapy, there is<br />
little doubt that the best would be to achieve eradication of<br />
the disease resulting in cure. The eradication will also mean<br />
to document molecular remission up to the sensitivity of<br />
available techniques. Also, this approach may be effective
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Meet the Professor<br />
in preventing emergence of therapy resistant, usually more<br />
malignant clones of the disease in contrast to the low intensity<br />
treatment that may favor emergence of resistance. However,<br />
this conceptually sound approach may not be feasible,<br />
because more effective treatment is usually more toxic. For<br />
this reason the aim should be balanced with expected tolerance,<br />
<strong>and</strong> if appropriate, by defining less ambitious aims<br />
such as major clinical remission or minor remission or stable<br />
disease. To achieve targeted aim the least toxic therapies<br />
should be chosen. This approach is a variant of »toxicity<br />
tailored therapy« taking into account comorbidity <strong>and</strong> other<br />
patient related factors, which all requires high level of clinical<br />
expertise.<br />
These general principles should be applied with caution<br />
on individual patients, particularly because an individual<br />
response <strong>and</strong> tolerance may vary considerably <strong>and</strong> they <strong>are</strong><br />
difficult to anticipate with certainty. Therefore therapy should<br />
be interactive <strong>and</strong> should be modified according to the<br />
achieved results. If necessary the goals should be reset. It is<br />
logical to start with the goal set as high as possible in accordance<br />
with the available data <strong>and</strong> clinical judgment, <strong>and</strong><br />
later proceed pending on the documented response <strong>and</strong> tolerance.<br />
Note that supportive c<strong>are</strong> is of the utmost importance,<br />
<strong>and</strong> therefore should be always delivered at the highest possible<br />
level.<br />
Clinical practice typical scenarios. Although the diagnostics<br />
<strong>and</strong> particularly therapy should be individualized in<br />
order to conform to the above principles <strong>and</strong> concepts, several<br />
clinical examples of the frequent clinical situations will<br />
be discussed, to illustrate the important challenges that <strong>are</strong><br />
present in the B-CLL management.<br />
MP08 Myelofi brosis<br />
Srdjan Verstovsek, MD Anderson Cancer Center, Leukemia<br />
Department, Houston, Texas, USA<br />
Myelofibrosis (MF) is a myeloproliferative neoplasm<br />
(MPN) characterized by abnormal proliferation of megakaryocytes,<br />
fi brosis of the bone marrow (BM), osteosclerosis,<br />
extramedullary hematopoiesis (EMH), <strong>and</strong> progressive<br />
BM failure with an increased risk of progression to acute<br />
myeloid leukemia (AML). MF was known by other names<br />
in the past, including chronic idiopathic MF, agnogenic<br />
myeloid metaplasia, <strong>and</strong> MF with myeloid metaplasia. MF<br />
is part of the classic Philadelphia chromosome–negative<br />
MPNs alongside polycythemia vera (PV) <strong>and</strong> essential<br />
thrombocythemia (ET). MF can occur as a primary disorder<br />
(PMF) or secondary to other MPNs, mainly PV (post-PV<br />
MF) <strong>and</strong> ET (post-ET MF). MF is a r<strong>are</strong> disease, with an<br />
incidence rate estimated at 1.46 cases/100,000 persons/year.<br />
Median age at diagnosis is 67 years, <strong>and</strong> both sexes <strong>are</strong><br />
equally affected. The prognosis of patients with MF is quite<br />
variable, as some patients can have a very indolent disorder<br />
with prolonged survival, whereas in other cases, the disease<br />
follows an aggressive course. Median survival of patients<br />
with MF is in the range of 69 months, <strong>and</strong> survival at 5 <strong>and</strong><br />
10 years is decreased 40% <strong>and</strong> 60%, respectively, comp<strong>are</strong>d<br />
with age <strong>and</strong> sex-matched controls. Major causes of death<br />
include transformation to acute leukemia, progressive BM<br />
failure due to MF, thrombotic <strong>and</strong> cardiovascular complications,<br />
<strong>and</strong> portal hypertension. The pathogenesis of MF is<br />
still unknown. Great advances in our underst<strong>and</strong>ing of the<br />
pathogenesis of this disorder were made with the discovery<br />
of mutations involved in cytokine receptor signaling pathways<br />
(JAK2V617F <strong>and</strong> MPLW515K/L). First-degree relatives<br />
of patients with MF <strong>and</strong> PV/ET have a 5- to 7-fold increased<br />
risk of developing MPNs, suggesting a strong genetic<br />
component in the susceptibility to this disease. Indeed,<br />
a specific single nucleotide polymorphism of the JAK2 gene<br />
(rs10974944) has been associated with an increased risk of<br />
developing JAK2V617F positive MPNs. Treatment of MF<br />
is suboptimal <strong>and</strong> palliative in nature, mainly directed toward<br />
alleviation of symptoms due to cytopenias or splenomegaly.<br />
In the past decade, several new drugs have been<br />
introduced for the treatment of patients with MF, <strong>and</strong> it is<br />
expected that the outcomes for these patients will soon improve<br />
as new compounds become available.<br />
MP09 Non-Hodgkin’s lymphoma<br />
Igor Aurer, Department of Medicine, Clinical Hospital<br />
Center <strong>and</strong> School of Medicine, University of Zagreb,<br />
Croatia<br />
New treatment modalities <strong>and</strong> new lymphoma classifications<br />
have substantially increased the number of different<br />
scenarios a physician could be facing when seeing patients<br />
with non-Hodgkin lymphomas (NHL). While good evidence<br />
exists for early treatment phases in patients with the<br />
more frequent NHL types, the same is not true for advanced<br />
disease, elderly <strong>and</strong> patients with significant comorbidities<br />
<strong>and</strong> r<strong>are</strong> NHL types.<br />
During this session I will review treatment st<strong>and</strong>ards <strong>and</strong><br />
recommendations for different types of NHL in different<br />
patient populations. Attendees will be urged to present problems<br />
they <strong>are</strong> or have been facing <strong>and</strong> discuss treatment options<br />
with the audience.<br />
Specific problems we will address include:<br />
1) Diffuse large-B cell lymphoma in elderly <strong>and</strong> patients<br />
with limited cardiac function<br />
2) Burkitt’s lymphoma<br />
3) Relapsing / refractory mantle-cell lymphoma<br />
4) Nodal non-follicular indolent lymphoma<br />
5) Extranodal marginal zone lymphoma<br />
6) Localized nodal indolent lymphomas<br />
7) Peripheral T-cell lymphomas<br />
MP10 Multiple Myeloma<br />
Damir Nemet, Division of Hematology, Department of<br />
Medicine, Clinical Hospital Centre Zagreb <strong>and</strong> School of<br />
Medicine, University of Zagreb, Zagreb, Croatia<br />
Multiple myeloma (MM) is a malignant hematological<br />
disease characterized by the accumulation of clonal plasma<br />
cells in bone marrow, presence of monoclonal protein in the<br />
blood <strong>and</strong>/or urine, destructive bone disease, hypercalce-<br />
79
Meet the Professor Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
mia, renal failure, <strong>and</strong> hematologic dysfunction. MM accounts<br />
for about 13% of all hematological neoplastic disease<br />
<strong>and</strong> 1% of all cancers. The annual age-adjusted incidence<br />
is 4,0–5,6 cases per 100.000 persons. The median age<br />
of patients at the time of diagnosis is about 65–70 years.<br />
In the marrow, MM cells interact with stromal components<br />
<strong>and</strong> other cells in the microenvironment to receive<br />
growth <strong>and</strong> survival factors <strong>and</strong> to modulate their environment<br />
inducing pathological phenomena, such as neovascularisation<br />
(angiogenesis <strong>and</strong> vasculogenesis) <strong>and</strong> bone disruption<br />
(osteoclastogenesis). Almost all patients with MM<br />
evolve from a premalignant condition known as monoclonal<br />
gammapathy of undetermined significance (MGUS). Smoldering<br />
myeloma (SMM) is an intermediate asymptomatic<br />
advanced stage which much more probability of progression<br />
to symptomatic disease. There is no need for treatment<br />
of smoldering MM until progression to active, symptomatic<br />
disease. The most important is to assess risk of progression<br />
in individual patient.<br />
Major clinical manifestations of MM <strong>are</strong> osteolytic bone<br />
lesions, anemia, hypercalcemia, renal failure, <strong>and</strong> an increased<br />
risk of infections. Extramedullary plasmacytomas<br />
<strong>and</strong> extramedullary expansion of lesions originated in the<br />
bone can be observed.<br />
The diagnosis of MM requires ≥10% of clonal BM plasma<br />
cells or a biopsy proven plasmacytoma, presence of serum<br />
<strong>and</strong>/or urinary monoclonal protein (true non-secretory<br />
myeloma is r<strong>are</strong>), <strong>and</strong> evidence of end organ damage known<br />
as CRAB: hypercalcemia, renal impairment, anemia, <strong>and</strong><br />
bone lesions. Several staging systems have been built to<br />
separate patients into various risk groups with different outcomes.<br />
The International Staging System (ISS) is now<br />
widely used; it is highly prognostic but presents some limitations.<br />
ISS separates patients into three groups based on<br />
beta-2-microglobulin <strong>and</strong> serum albumin concentrations<br />
with significant difference in survival. However, chromosomal<br />
abnormalities like del 13 on karyotyping, t(4;14),<br />
t(14;16), del 17p <strong>and</strong> 1q gains significantly impact outcome<br />
<strong>and</strong> some prognostic models <strong>are</strong> based solely on the presence<br />
of chromosomal changes.<br />
Treatment options have traditionally included corticosteroids,<br />
alkylating or other cytotoxic agents, <strong>and</strong> the use of<br />
high-dose chemotherapy followed by autologous stem cell<br />
transplantation (ASCT). Recent advances include use of<br />
novel immunomodulatory drugs thalidomide <strong>and</strong> lenalidomide,<br />
<strong>and</strong> proteasome inhibitor bortzomib. Despite these<br />
advances, most of the patients <strong>are</strong> not cured <strong>and</strong> ultimately<br />
develop chemotherapy-refractory disease.<br />
With the use of ASCT <strong>and</strong> after emergence of novel<br />
agents overall survival in MM has improved significantly in<br />
the last two decades. ASCT is a st<strong>and</strong>ard treatment approach<br />
80<br />
for younger (≥65 or even 70 years old) patients, therefore at<br />
initial treatment considerations MM patients <strong>are</strong> generally<br />
divided in »transplant eligible« <strong>and</strong> »transplant ineligible«<br />
group. Clinical trials so far have shown that high-dose therapy<br />
<strong>and</strong> ASCT improves response rates, disease-free survival<br />
(DSF), <strong>and</strong> overall survival (OS) in symptomatic patients<br />
with MM. More than half of MM patients <strong>are</strong> not eligible<br />
for high-dose therapy including elderly patients <strong>and</strong><br />
those with comorbidities. Recent results indicate significant<br />
improvement by adding novel drugs to st<strong>and</strong>ard therapy. AlloSCT<br />
with myeloablative or reduced intensity conditioning<br />
(RIC) is still investigational in myeloma <strong>and</strong> not widely accepted<br />
primarily due to still high transplant related mortality<br />
<strong>and</strong> high GvHD rates.<br />
Post-transplant strategies could be defined as »consolidation«<br />
(short term drug therapy, usually 3–6 months of duration)<br />
or »maintenance« (prolonged low dose drug therapy).<br />
At present it is unclear what strategies <strong>are</strong> effective, do these<br />
strategies prolong OS, do all patients should receive consolidation/maintenance,<br />
<strong>and</strong>, if not, who should receive<br />
such therapy.<br />
Almost all patients with MM eventually relapse. Options<br />
for further therapy include alkylating agents, corticosteroids,<br />
thalidomide, lenalidomide, bortezomib or liposomal<br />
doxorubicin in various combinations. The choice of treatment<br />
depends on several factors including drugs used as<br />
initial therapy, the degree <strong>and</strong> duration of response to previous<br />
therapy, type of relapse/progression (aggressive relapse<br />
or more indolent relapse), <strong>and</strong> previous toxicity. Pomalidomide,<br />
a new immunomodulatory drug <strong>and</strong> carfilzomib, a<br />
novel proteasome inhibitor, have significant activity in relapsed<br />
<strong>and</strong> refractory MM. Beside this, promising agents<br />
<strong>are</strong> histone deacetylase inhibitors vorinostat <strong>and</strong> panobiostat<br />
<strong>and</strong> potent anti-CS-1 antibody elotuzumab. Results of<br />
phase II studies with bendamustin <strong>are</strong> encouraging.<br />
Supportive therapy is an important part of whole strategy<br />
of myeloma treatment. Bisphosphonates, especially nitrogen-containing<br />
compounds (pamidronate, zoledronic acid)<br />
<strong>are</strong> potent inhibitors of bone resorption. They reduce skeletal<br />
complications in MM patients. RANKL inhibition by<br />
monoclonal antibody denosumab show promising results in<br />
clinical studies. Patients with MM <strong>are</strong> at high risk of developing<br />
infections. Appropriate prophylaxis is therefore m<strong>and</strong>atory<br />
during myeloma treatment. Renal failure is an important<br />
complication of myeloma. Symptomatic c<strong>are</strong> (appropriate<br />
hydration, urine alkalization, avoidance of nephrotoxic<br />
therapy <strong>and</strong> bisphosphonates) <strong>are</strong> important as well<br />
as immediate anti-myeloma treatment. Bortezomib is probably<br />
the best choice in patients with renal impairment due to<br />
his fast anti-myeloma activity, influence on inflammatory<br />
response, <strong>and</strong> no need for dose reduction.
State of the Art II.<br />
SA02 Diagnostic <strong>and</strong> Treatment Approach for<br />
Acute Myeloblastic Leukemia – Report from<br />
Central <strong>and</strong> <strong>East</strong>ern European Leukemia<br />
Group (CELG)<br />
Boris Labar 1 , Agnieszka Wierzbovska 2 , Georgi Mihaylov 3 ,<br />
Andreaa Moicean 4 , Dragica Tomin 5 , Zita Borbenyi 6 ,<br />
K<strong>are</strong>l Indrak 7 , Lidija Cevreska 8 , Martin Mistrik 9 ,<br />
W<strong>and</strong>a Knopinska-Posluszny 10 , Vildan Bijedic 11 .<br />
1 Division of Hematology, Department of Medicine,<br />
University Hospital Center <strong>and</strong> School of Medicine<br />
University of Zagreb, Croatia; 2 Department of<br />
Hematology, Medical University of Lodz, Copernicus<br />
Memorial Hospital, Lodz, Pol<strong>and</strong>; 3 Queen Joanna<br />
University Hospital, Sofia, Bulgaria; 4 Fundeni Clinical<br />
Institute, Second Department of Hematology, Buch<strong>are</strong>st,<br />
Romania; 5 Clinic of Hematology, Clinical Center Serbia,<br />
Belgrade, Serbia; 6 Second Department of Medicine,<br />
University Medical School of Szeged,<br />
Hungary; 7 Department of Hemato-Oncology, University<br />
Hospital Olomouc <strong>and</strong> Faculty of Medicine <strong>and</strong> Dentistry,<br />
Palacky University Olomouc, Czech Republic;<br />
8 Department of Hematology, Medical Faculty, Skopje,<br />
Republic of Macedonia; 9 Department of Hematology <strong>and</strong><br />
Transfusiology, University Hospital, Bratislava, Slovakia;<br />
10 Department of Clinical Biochemistry, University Medical<br />
School, Gdańsk, Pol<strong>and</strong>; 11 Department of Hematology,<br />
KCU, Sarajevo, Bosnia <strong>and</strong> Herzegovina.<br />
Abstract: Central <strong>and</strong> <strong>East</strong>ern Leukemia Cooperative<br />
Group (CELG) perform retrospective analysis of diagnostic<br />
<strong>and</strong> treatment possibilities for acute myeloblastic leukemia<br />
(AML). The results of the questionnaire for acute myeloblastic<br />
leukemia (AML) <strong>are</strong> presented.<br />
In a retrospective manner using the Questionnaire we analyzed<br />
in 26 centers of 10 countries the diagnostic <strong>and</strong> treatment<br />
possibilities for AML.<br />
In 10 countries more than 880 patients with AML have<br />
been treated per year. Most of the countries have the st<strong>and</strong>ard<br />
diagnostic tools. In some countries there <strong>are</strong> no facilities<br />
for cytogenetic <strong>and</strong> cryopreservation. Induction <strong>and</strong><br />
consolidation chemotherapy is cytarabine based in combination<br />
with anthracycline. The number of transplants is low<br />
due to insufficient number of transplant centers. In four<br />
countries patients <strong>are</strong> treated in rooms with two or more<br />
beds.<br />
The number of patients is sufficient for the future prospective<br />
clinical trials. Concerning the diagnostic tools,<br />
st<strong>and</strong>ard approach has been routinely performing in all centers.<br />
Therapy approach is cytarabine based in combination<br />
with anthracycline. Stem cell transplantation is performing<br />
in majority of Centers but still the number of transplants is<br />
low. The level of supportive c<strong>are</strong> differs from country to<br />
country <strong>and</strong> one of the priorities of CELG group is to st<strong>and</strong>ardize<br />
the diagnostic <strong>and</strong> treatment approaches. This is a<br />
prerequisite for the future clinical trials.<br />
Introduction<br />
In 2009 the 13 representatives of Central <strong>and</strong> <strong>East</strong>ern European<br />
countries founded the new group named Central <strong>and</strong><br />
<strong>East</strong>ern European Cooperative Leukemia Group (CELG).<br />
During the several meetings two main goals of the group<br />
activity were defined: 1. to design the prospective clinical<br />
trials for treatment of hematological malignancies <strong>and</strong> 2. To<br />
propose the guidelines <strong>and</strong> st<strong>and</strong>ards of diagnosis <strong>and</strong> treatment.<br />
One of the first activities of CELG group was to perform<br />
retrospective analysis dealing with the diagnostic <strong>and</strong> treatment<br />
possibilities for acute myeloblastic leukemia (AML).<br />
The results of the questionnaire for AML <strong>are</strong> presented.<br />
Methods<br />
Participating countries <strong>and</strong> centers:<br />
Twenty-six Centers from 10 countries respond the Questionnaire<br />
(Fig.1).<br />
Figure 1. Number of Centers from participating countries<br />
Questionnaire:<br />
The Questionnaire was create to get the answer about the<br />
AML diagnostic <strong>and</strong> treatment approach in Central <strong>and</strong><br />
<strong>East</strong>ern European countries. The questionnaire consists of<br />
three parts:<br />
Part one give the answers about the participating countries,<br />
number of Centers in each country, <strong>and</strong> number of patients<br />
treated per year.<br />
Part two is dealing with diagnostic possibilities for AML:<br />
morphology/cytochemistry, immunophenotyping, cytogenetic/molecular<br />
genetics, biobanking, HLA typing, microbiology.<br />
Part three is treatment part for AML: Induction therapy,<br />
postremission therapy (intensive chemotherapy, maintenance<br />
chemotherapy, autologous <strong>and</strong> allogeneic stem cell transplantation),<br />
supportive c<strong>are</strong> (infection prevention, growth<br />
factors, transfusion support).<br />
81
State of the Art Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
Statistical analysis<br />
Descriptive methods 1 have been used to present the obtained<br />
data from Questionnaire.<br />
Results<br />
Number of patients treated in CELG Centers.<br />
In 26 Centers from 10 countries (Fig 2.) 881 patients with<br />
AML have been treated during a period of 1 year.<br />
Figure 2. Number of patients with AML treated per year according to<br />
participating countries<br />
Most Centers were treated more than 20 patients per year;<br />
but in 4 of them less than 10 patients received therapy for<br />
AML. More than 60% of treated patients were younger than<br />
60 years of age (Fig. 3).<br />
Figure 3. Age of treated patients with AML according to participating<br />
countries<br />
Diagnosis of AML<br />
The majority of Centers <strong>are</strong> able to perform the st<strong>and</strong>ard<br />
diagnostic tools for acute leukemia as cytomorphology, cytochemistry<br />
<strong>and</strong> multiparameter (≥ 3 color) flow cytometry,<br />
as well as qualitative PCR (Fig. 4.).<br />
In one country there is no cytogenetic laboratory. Centers<br />
in 4 countries have no facilities for cryopreservation (Fig.<br />
5.) <strong>and</strong> they <strong>are</strong> not able to store the samples of peripheral<br />
blood <strong>and</strong> marrow. In 6 countries galactommanan test <strong>are</strong><br />
routinely performing for diagnosis of fungal infection (Fig<br />
5.). Comorbidity prognostic index2 has been used as a treatment<br />
predictor in 8 countries, especially in older patients.<br />
82<br />
Legends: BMA – bone marrow aspiration, Biopsy – bone marrow biopsy;<br />
Cytochem – cytochmistry; FC/+3 – fl ow cytometry using 3color;<br />
Genome – Genome molecular assays<br />
Figure 4. St<strong>and</strong>ard diagnostic facilities in centers of participating countries.<br />
Legend: Cryopres. – Cryopreservation<br />
Figure 5. Biobanking, cryopreservation, HLA-typing <strong>and</strong> infection diagnostic<br />
possibilities in centers of participating countries.<br />
Treatment of AML<br />
For patient younger than 60 years of age cytarabine based<br />
chemotherapy was the main regimen (Fig. 6.). For induction<br />
therapy »3+7« regimen 3 is the most frequently used treatment.<br />
For consolidation combination of intermediate dose<br />
of cytarabine in combination with anthracycline 4 is the most<br />
popular treatment option. Some centers treated AML according<br />
to EORTC protocol 5 . They added etopozide to anthracycline<br />
<strong>and</strong> cytarabine for induction therapy. Polish<br />
Centers have been using their own protocol, combination of<br />
cytarabine, cladribine <strong>and</strong> anthracycline 6,7 .<br />
Legend: EORTC – European Organization for Research <strong>and</strong> Treatment of<br />
Cancer; PALG – Polish Acute Leukemia Group; IntAraC – Intermediate<br />
dose of cytarabine<br />
Figure 6. Induction <strong>and</strong> postremission chemotherapy for patients 18 to<br />
60 years of age
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) State of the Art<br />
For older fit patients most of the CELG centers have been<br />
using 3+7 protocol (Fig 7.) For frail patients low dose cytarabine<br />
or symptomatic therapy has been the most frequent<br />
treatment approach (Fig. 7.).<br />
Legend: 3+7 – (daunoblastin 3 days + cytarabine 7 days); 2+5 (daunoblastin 2<br />
days + cytarabine 5 days); MICE – mitoxantrone, cytarabine, etoposide;<br />
Ara-C based – cytarabine based; LD-Ara-C – Low dose cytarabine;<br />
ASCT – Autologous stem cell transplantation; Hydrea – hydroxyurea<br />
Figure 7. Induction <strong>and</strong> postremission chemotherapy for patients older<br />
than 60 years of age<br />
Out of 667 patients eligible for transplantation, 194 of<br />
them (28%) received stem cells in post-consolidation period;<br />
15% were treated with allogeneic stem cell transplantation<br />
while 13% of patients received autologous stem cell<br />
(Fig. 8.).<br />
Legend: Allo-SCT – allogeneic Stem cell transplantation;<br />
Auto-SCT – autologous stem cell transplantation<br />
Figure 8. Number of patients treated with allogeneic <strong>and</strong> autologous<br />
stem cell transplantation<br />
Concerning the source of stem cells in autologous group<br />
most of the patients received stem cells from peripheral<br />
blood (97%). In allogeneic group in ¾ of patients stem cells<br />
were from peripheral blood, while in ¼ of them marrow was<br />
the source of stem cells. Two patients received stem cells<br />
from cord blood (Fig 9.).<br />
Allogeneic stem cell transplantation is not a st<strong>and</strong>ard<br />
treatment options in two countries. Therapy with match unrelated<br />
donor as well as conditioning with reduced intensity<br />
is still not available in two countries (Fig 10.).<br />
Legend: Allo-SCT – allogeneic Stem cell transplantation;<br />
Auto-SCT – autologous stem cell transplantation<br />
Figure 9. Source for stem cells<br />
Legend: Allo-SCT – allogeneic stem cell transplantation; MUD – Match<br />
unrelated donor; RIC – reduced intensity conditioning<br />
Figure 10. Availability of allogeneic stem cell transplantation, transplantation<br />
with unrelated donor <strong>and</strong> transplantation with reduced intensity<br />
conditioning<br />
Concerning the supportive c<strong>are</strong> 6 countries (four of them<br />
with laminar air-flow) <strong>are</strong> treated AML patients in 1-bed<br />
room, according to the principles of reverse isolation, while<br />
in 4 countries patients <strong>are</strong> caring in two or more than 2-bed<br />
rooms (Fig. 11.) Laminar air-flow unites <strong>are</strong> used exclusively<br />
for allogeneic transplantation.<br />
Legend: LAF – laminar air-fl ow<br />
Figure 11. St<strong>and</strong>ard of c<strong>are</strong> of the neutropenic patients<br />
Quinolones <strong>and</strong> fluconazole <strong>are</strong> the principal antimicrobial<br />
<strong>and</strong> antifungal drugs for bacterial <strong>and</strong> fungal infection<br />
prophylaxis respectively. All centers have the possibilities<br />
for platelet <strong>and</strong> red blood cell transfusion support although<br />
the criteria for transfusion differ from center to center.<br />
83
State of the Art Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
Discussion<br />
Most of the Centers in the Central <strong>and</strong> <strong>East</strong>ern European<br />
countries <strong>are</strong> well experienced centers for the diagnosis <strong>and</strong><br />
treatment of AML. In most of them the number of patient is<br />
sufficient to get all the necessary skills for AML diagnosis<br />
<strong>and</strong> treatment. But still some centers <strong>are</strong> treating small number<br />
of patients. In view of the current diagnostic <strong>and</strong> treatment<br />
approach especially the need for new molecular genome<br />
technique <strong>and</strong> transplantation together with the targeted<br />
therapy it is not rational to develop the center with a<br />
small number of patients. The cost of proper c<strong>are</strong> <strong>and</strong> treatment<br />
is too high for such a small number of patients. The<br />
recommendation is to treat not less than 30 patients per<br />
year.<br />
The total number of patients treated in 10 countries is<br />
quite sufficient to design <strong>and</strong> conduct prospective clinical<br />
trial. Another very important information coming from the<br />
data is age of the patients treated. Most of the patients (60–<br />
70%) <strong>are</strong> younger than 60 years of age. The median age of<br />
AML patients is 658 . This means that many patients did not<br />
reach these centers, <strong>and</strong> they <strong>are</strong> treated in the local hospitals.<br />
St<strong>and</strong>ard diagnostic facilities <strong>are</strong> sufficient in most centers<br />
for AML. Cytomorphology, immunophenotyping, cytogenetic<br />
<strong>and</strong> molecular technique is m<strong>and</strong>atory according to<br />
ELN criteria9 . The questionnaire delineated that most of the<br />
centers <strong>are</strong> able to perform these st<strong>and</strong>ard diagnostic tools.<br />
In one country cytogenetic is not performing routinely. According<br />
to WHO classification for myeloid neoplasm10 cytogenetic<br />
is important prognostic factor for AML <strong>and</strong> should<br />
be the part of st<strong>and</strong>ard diagnostic test. In the recent years we<br />
<strong>are</strong> faced with the detection of many new genetic alterations<br />
with prognostic impact11–15 . This represents a new diagnostic<br />
challenge for many centers, especially for four countries<br />
without the cryopreservation facilities. The centers in these<br />
countries have no possibilities to keep the samples for the<br />
more dem<strong>and</strong>ing test in AML. The recommendation is to<br />
organize referent laboratory for cryopreservation in a reasonable<br />
period of time.<br />
Induction <strong>and</strong> consolidation therapy <strong>are</strong> cytarabine-based<br />
in combination with anthracycline. The well known regime<br />
»3+7« is the most popular one. Still there is no data showing<br />
better treatment protocol for induction therapy3,16–18 . In elderly,<br />
treatment depends on co-morbidities. Fit elderly patients<br />
received less intensive chemotherapy comp<strong>are</strong>d to<br />
young patients, who predominantly received »3+7 regimen«.<br />
Frail patients have been treated with low-dose cytarabine<br />
or supportive c<strong>are</strong>19 .<br />
Only the minority of younger patients underwent stem<br />
cell transplantation. About 15% of them have been allografted,<br />
<strong>and</strong> 13% received their own marrow as postremission<br />
therapy. The reasons that might explain the small number<br />
of transplanted patients <strong>are</strong> insufficient facilities for<br />
transplants or low number of patients eligible for transplants.<br />
The questionnaire data shows that in some countries<br />
there <strong>are</strong> no sufficient facilities for allografting. At the moment<br />
the centers in two countries <strong>are</strong> not able to perform<br />
allogeneic transplants. In four countries allografting from<br />
matched unrelated donor (MUD) (20) was not performing.<br />
84<br />
In addition total body irradiation (TBI) for conditioning <strong>and</strong><br />
reduced intensity conditioning 21,22 have not been performing<br />
in 3 <strong>and</strong> 4 countries respectively. .<br />
Patient c<strong>are</strong> is not on the expected level for immunocompromised<br />
<strong>and</strong> neutropenic patients. In centers of 4 countries<br />
acute leukemia <strong>are</strong> treating in the room of two or more beds.<br />
It is m<strong>and</strong>atory to state that intensive chemotherapy <strong>and</strong><br />
stem cell transplantation could be performed only in the<br />
centers with 1-bed room.<br />
Conclusions<br />
The questionnaire revealed important data concerning the<br />
diagnosis <strong>and</strong> treatment of AML in centers of Central <strong>and</strong><br />
<strong>East</strong>ern Europe. A large number of patients have been currently<br />
treated in these centers. The number of patients is<br />
quite enough for the future prospective clinical trials. Concerning<br />
the diagnostic tools, st<strong>and</strong>ard approach has been<br />
performing routinely in most centers. Therapy approach is<br />
cytarabine based in combination with anthracycline. Stem<br />
cell transplantation is performing in the majority of Centers<br />
but still the number of transplants is low. The level of st<strong>and</strong>ard<br />
<strong>and</strong> supportive c<strong>are</strong> differs from country to country <strong>and</strong><br />
one of the priorities of CELG group is to st<strong>and</strong>ardize the<br />
diagnostic <strong>and</strong> treatment approaches. This is a prerequisite<br />
for the future clinical trials.<br />
R E F E R E N C E S<br />
1. Dawson B, Trapp RG, ur. Basic & Clinical biostatistics. LangeMedical<br />
Books/ McGraw-Hill 2001; 211–221.<br />
2. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of<br />
classifying prognostic comorbidity in longitudinal studies: development<br />
<strong>and</strong> validation. J Chronic Dis 1987;40:373–383.<br />
3. Löwenberg B, Pabst T, Vellenga E, van Putten W, Schouten HC, Graux<br />
C, et al. Dutch-Belgian Cooperative Trial Group for Hemato-Oncology<br />
(HOVON) <strong>and</strong> Swiss Group for Clinical Cancer Research (SAKK)<br />
Collaborative Group. Cytarabine dose for acute myeloid leukemia. N<br />
Engl J Med 2011; 364:1027–36.<br />
4. Ofran Y, Rowe JM. Induction <strong>and</strong> postremission strategies in acute myeloid<br />
leukemia: what is new? Curr Opin Hematol 2011; 18:83–8.<br />
5. M<strong>and</strong>elli F, Vignetti M, Suciu S, Stasi R, Petti MC, Meloni G, et al.<br />
Daunorubicin versus mitoxantrone versus idarubicin as induction <strong>and</strong><br />
consolidation chemotherapy for adults with acute myeloid leukemia:<br />
the EORTC <strong>and</strong> GIMEMA Groups Study AML-10. J Clin Oncol 2009;<br />
27:5397–403.<br />
6. Holowiecki J, Grosicki S, Robak T, Kyrcz-Krzemien S, Giebel S, Hellmann<br />
A, et al. Polish Adult Leukemia Group (PALG). Addition of<br />
cladribine to daunorubicin <strong>and</strong> cytarabine increases complete remission<br />
rate after a single course of induction treatment in acute myeloid<br />
leukemia. Multicenter, phase III study. Leukemia 2004; 18:989–97.<br />
7. Robak T, Wierzbowska A. Current <strong>and</strong> emerging therapies for acute<br />
myeloid leukemia. Clin Ther 2009; 2:2349–70.<br />
8. Yamamoto JF, Goodman MT. Patterns of leukemia incidence in the<br />
United States by subtype <strong>and</strong> demographic characteristics, 1997–2002.<br />
Cancer Causes Control 2008; 19:379–90.<br />
9. Döhner H, Estey EH, Amadori S, Appelbaum FR, Büchner T, Burnett<br />
AK, et al. Diagnosis <strong>and</strong> management of acute myeloid leukemia in<br />
adults: recommendations from an international expert panel, on behalf<br />
of the European LeukemiaNet. Blood 2010;115:453–474.<br />
10. Vardiman JW, Thiele J, Arber DA, Brunning RD, Borowitz MJ, Porwit<br />
A, et al. The 2008 revision of the WHO Classification of Myeloid<br />
Neoplasms <strong>and</strong> Acute Leukemia: rationale <strong>and</strong> important changes.<br />
Blood 2009;114(5):937–951.<br />
11. Grimwade D. The clinical significance of cytogenetic abnormalities in<br />
acute myeloid leukaemia. Best Pract Res Clin Haematol 2001;14:<br />
497–529.
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12. Gillil<strong>and</strong> DG, Griffin JD. Role of FLT3 in leukemia. Curr Opin Hematol<br />
2002;9(4):274–81.<br />
13. Schlenk RF, Döhner K, Krauter J, Fröhling S, Corbacioglu A, Bullinger<br />
L, et al. Mutations <strong>and</strong> treatment outcome in cytogenetically normal<br />
acute myeloid leukemia. N Engl J Med 2008;358(18):1909–1918.<br />
14. Green CL, Koo KK, Hills RK, Burnett AK, Linch DC, Gale RE. Prognostic<br />
significance of CEBPA mutations in a large cohort of younger<br />
adult patients with acute myeloid leukemia: impact of double CEBPA<br />
mutations <strong>and</strong> the interaction with FLT3 <strong>and</strong> NPM1 mutations. J Clin<br />
Oncol 2010 ; 28:2739–47.<br />
15. Marchesi F, Annibali O, Cerchiara E, Tirindelli MC, Avvisati G. Cytogenetic<br />
abnormalities in adult non-promyelocytic acute myeloid leukemia:<br />
A concise review. Crit Rev Oncol Hematol. 2010 Epub ahead of<br />
print.<br />
16. Estey E, Döhner H. Acute myeloid leukaemia. Lancet. 2006;368(9550):<br />
1894–1907.<br />
17. Kolitz, JE. Current therapeutic strategies for acute myeloid leukaemia.<br />
Br J Haematol 2006; 134:555.<br />
18. Fern<strong>and</strong>ez HF, Rowe JM. Induction therapy in acute myeloid leukemia:<br />
intensifying <strong>and</strong> targeting the approach. Curr Opin Hematol 2010;17:<br />
79–84.<br />
19. Estey E. Acute myeloid leukemia <strong>and</strong> myelodysplastic syndromes in<br />
older patients. J Clin Oncol 2007; 25:1908–1915.<br />
20. Schlenk RF, Döhner K, Mack S, Stoppel M, Király F, Götze K, et al.<br />
Prospective evaluation of allogeneic hematopoietic stem-cell transplantation<br />
from matched related <strong>and</strong> matched unrelated donors in younger<br />
adults with high-risk acute myeloid leukemia: German-Austrian trial<br />
AMLHD98A. J Clin Oncol 2010; 28:4642–8.<br />
21. Blaise D, Farnault L, Faucher C, Marchetti N, Fürst S, El Cheikh J et al.<br />
Reduced-intensity conditioning with Fludarabin, oral Busulfan, <strong>and</strong><br />
thymoglobulin allows long-term disease control <strong>and</strong> low transplant-related<br />
mortality in patients with hematological malignancies. Exp Hematol<br />
2010; 38:1241–50.<br />
22. Luger SM, Ringdén O, Zhang MJ, Pérez WS, Bishop MR,et al. Similar<br />
outcomes using myeloablative vs reduced-intensity allogeneic transplant<br />
preparative regimens for AML or MDS. Bone Marrow Transplant.<br />
2011 in press.<br />
85
Poster Presentations<br />
PP01 Rapamycin enhances dimethyl sulfoxidemediated<br />
growth arrest in human<br />
myelogenous leukemia cells<br />
Lalic H, Lukinovic-Skudar V, Banfic H, Visnjic D.<br />
Department pt of Physiology & CIBR, School of Medicine,<br />
University of Zagreb<br />
Aim: The pharmacological inhibitors of phosphoinositide<br />
3-kinase (PI3K)/Akt/mammalian target of rapamycin<br />
(mTOR) pathway have been proposed in the treatment of<br />
leukemia based on their antiproliferative effects, but their<br />
possible role in differentiation therapy is less explored. Rapamycin,<br />
an mTOR-inhibitor, has been recently reported to<br />
potentiate all-trans retinoic acid-mediated differentiation of<br />
HL-60 <strong>and</strong> NB4 cell lines along granulocytic pathway, <strong>and</strong><br />
monocytic differentiation of U937 cells induced by vitamin<br />
D3. Dimethyl sulfoxide (DMSO) is a potent inducer of<br />
granulocytic differentiation of myeloid cell lines <strong>and</strong> erythroid<br />
differentiation of K562 cells. The aim of the present<br />
study was to test for the possible synergistic effects of rapamycin<br />
<strong>and</strong> DMSO on growth arrest <strong>and</strong> differentiaton of<br />
human myelogenous leukemia cells.<br />
Materials <strong>and</strong> methods: Myeloblastic (AML-M2) HL-<br />
-60, promyelocytic (AML-M3) NB4, monocytic (AML-<br />
-M5) U937, immature (AML-M6) KG-1, <strong>and</strong> erythro-megakaryocytic<br />
K562 cell lines were maintained in exponential<br />
growth <strong>and</strong> differentiated in the presence of DMSO (0.6 or<br />
1.25%). The number of viable cells was quantified using a<br />
hemocytometer <strong>and</strong> trypan blue exclusion. The expression<br />
of differentiation markers <strong>and</strong> the cell cycle distribution of<br />
propidium iodide-labeled cells were determined by FACS<br />
analyses. Cell morphology was evaluated on May-Grunwald-Giemsa-stained<br />
cytospin preparations. The level of<br />
phosphorylated (Thr389) <strong>and</strong> total p70 S6 Kinase (p70<br />
S6K) in total cell lysates was determined by <strong>West</strong>ern blot<br />
analysis.<br />
Results: <strong>West</strong>ern blot analysis demonstrated that the incubation<br />
of leukemia cells in the presence of 20 nM rapamycin<br />
for 20 min completely reduced the level of Thr389phosphorylated<br />
p70 S6K, which is one of the principle<br />
downstream targets of activated mTOR. When applied at<br />
the same dose for 96 h, rapamycin alone exerted minimal<br />
antiproliferative effects; significant decrease in the number<br />
of viable cells was observed in rapamycin-treated HL-60<br />
<strong>and</strong> KG-1 cells. The presence of 1.25% DMSO for 96 h<br />
significantly inhibited the growth of all cell lines tested, <strong>and</strong><br />
the combination of rapamycin <strong>and</strong> DMSO inhibited the<br />
number of viable cells significantly more than either agent<br />
alone. FACS analysis of propidium iodide-labeled cells revealed<br />
a synergistic effect of rapamycin <strong>and</strong> DMSO on cell<br />
cycle arrest in G0/G1 phase.<br />
Conclusion: Rapamycin potentiates growth-inhibitory<br />
effects of DMSO in the established acute myeloid leukemia<br />
lines. These results suggest that mTOR inhibitors may have<br />
beneficial effects in combination with differentiation agents<br />
in therapy of AML<br />
PP02 Ikaros transcription factors expression<br />
in cell differentiation<br />
Antica M 1 , Paradzik M 1 , Matulic M 2 , Batinic D 3 , Labar B 3 .<br />
1 Division of Molecular Biology, Ru|er Bo{kovi} Institute,<br />
Zagreb, 2 Department of Molecular Biology, Faculty of<br />
Science, Zagreb, 3 University Hospital Center <strong>and</strong> School of<br />
Medicine, University of Zagreb Croatia.<br />
Ikaros family transcription factors <strong>are</strong> involved in lymphocyte<br />
differentiation <strong>and</strong> have a critical role at specific<br />
check points of the haemopoietic pathway. However, how<br />
developmentaly regulated changes <strong>are</strong> reflected in gene expression<br />
programs of lymphocyte differentiation is not well<br />
understood. We study the mechanisms <strong>and</strong> predisposition<br />
for leukemia development by analysing genes involved in<br />
hematopoietic differentiation. Gene targeting studies show<br />
that major players in the commitment of hematopoietic progenitors<br />
<strong>are</strong> Ikaros family transcription factors, <strong>and</strong> inappropriate<br />
expression of these genes might be involved in<br />
leukemogenesis. Accordingly, we analyzed the differential<br />
expression of Ikaros transcription factors <strong>and</strong> their splicing<br />
variants in the most frequent leukemia types, CLL, ALL <strong>and</strong><br />
AML <strong>and</strong> in hematological cell lines. We provide evidence<br />
that splicing variants of these transcription factors occur but<br />
they <strong>are</strong> not restricted to leukemic cells only. Further, the<br />
analysis of Aiolos, showed a clear difference among groups<br />
due to its lower expression in all types of acute leukemia<br />
investigated.<br />
Aims: In this work we analyzed the state of Ikaros family<br />
members in different leukemic cells with the aim to explore<br />
the transcriptional control of human hematopoietic lineages<br />
<strong>and</strong> shed some new light on our underst<strong>and</strong>ing of transcription<br />
factor significance in human leukemia.<br />
Methods: By means of qRT-PCR we investigated the<br />
mRNA expression of Ikaros transcription factors <strong>and</strong> their<br />
splicing variants in leukemia cell lines <strong>and</strong> in 30 samples of<br />
leukemia patients, with AML, ALL or CLL <strong>and</strong> healthy controls.<br />
Results: Ikaros family members <strong>are</strong> expressed as multiple<br />
splice variants <strong>and</strong> proteins arising from alternatively<br />
spliced transcripts may act as dominant negatives. In all of<br />
the cell lines examined Ikaros was present as dominant Ik1<br />
to Ik4 isoforms <strong>and</strong> the small Ik6 isoform was absent. Aiolos<br />
was expressed in the majority of the cell lines, of both, B<br />
<strong>and</strong> T origin, in the form of the full length Aio1. Helios was<br />
87
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
also present only in two long isoforms Hel1 <strong>and</strong> Hel2, <strong>and</strong><br />
was absent in one third of the samples. Although expression<br />
of these short isoforms has been linked to lymphoid <strong>and</strong><br />
myeloid leukemia the quantitative distribution of Ikaros,<br />
Aiolos <strong>and</strong> Helios mRNA expression level in hemopoietic<br />
cells of patients with lymphocytic leukemia, represented by<br />
the most frequent B-CLL <strong>and</strong> ALL (T cell ALL <strong>and</strong> common<br />
ALL), <strong>and</strong> comp<strong>are</strong>d to acute leukemia of myeloid lineage,<br />
AML has not been reported. We found that the relative<br />
quantity of Ikaros <strong>and</strong> Helios mRNA was similar in all subgroups.<br />
Though, analysis of Aiolos, showed a clear difference<br />
among groups due to its lower expression in all types<br />
of acute leukemia investigated.<br />
Conclusion: Our results, associating a lower Aiolos expression<br />
with acute leukemia point to Aiolos role in human<br />
lymphocyte development as it has been previously shown in<br />
mice.<br />
PP03 Multicenter performance evaluation<br />
of the multidrugquant assay kit<br />
Márki-Zay J 1 , Tauber Jakab K 1 , Sipka S 2 , Nagy G 2 ,<br />
Baráth S 2 , Gyimesi E 2 , Hevessy Zs 3 , Sziráki Kiss V 3 ,<br />
Szabó P 5 , Tõkés-Füzesi M 5 , Nagy É 7 , Trucza É 7 ,<br />
Udvardy M 4 , Borbényi Z 8 , Dávid M 6 , Kappelmayer J 3 .<br />
1 Solvo Biotechnology, Szeged, Hungary; 2 Regional<br />
Immunological Laboratory, 3 Department of Clinical<br />
Biochemistry <strong>and</strong> Molecular Pathology, 4 2nd Department<br />
of Internal Medicine, University of Debrecen-Medical <strong>and</strong><br />
Health Science Center, Debrecen, Hungary; 5 Department<br />
of Laboratory Medicine, University of Pécs-Medical<br />
School, 6 1st Department of Internal Medicine, Pécs,<br />
Hungary; 7 Department of Laboratory Medicine, 8 2nd<br />
Department of Medicine <strong>and</strong> Cardiology, University of<br />
Szeged – Albert Szent-Györgyi Clinical Center, Szeged,<br />
Hungary<br />
In the last decade it has become widely accepted that<br />
clinical resistance to chemotherapy correlates with the overexpression<br />
of ATP-binding cassette (ABC) transporters, such<br />
as ABCB1 (MDR1 or P-gp), ABCC1 (MRP1), <strong>and</strong> ABCG2<br />
(MXR or BCRP). There <strong>are</strong> numerous technical approaches<br />
to study multidrug resistance (MDR), which came into the<br />
centre of interest, but the correlating results derived from<br />
different methods. Although the functional methods separately<br />
gave promising results, st<strong>and</strong>ardization <strong>and</strong> reproducibility<br />
of these tests failed to conform to the values required<br />
from routine diagnostic methods. The MultiDrugQuant kit<br />
(MDQ kit) is a flow cytometric method to measure the functional<br />
activity of the three, clinically most relevant efflux<br />
transporters, such as MDR1, MRP1 <strong>and</strong> BCRP in viable<br />
cells. The kit applies fluorescent dyes (substrates) <strong>and</strong> inhibitors<br />
of the all three transporters implicated. After short<br />
incubation of the cell suspension, the MDR activities (MAF<br />
values) of the multidrug transporter were calculated from<br />
the difference between the geo-mean fluorescent intensity<br />
of cells w/o the specific inhibitors, respectively.<br />
Aim: The purpose of the study was the performance evaluation<br />
of the MDQ-kit as routine clinical laboratory flow<br />
cytometric assay.<br />
88<br />
Patients <strong>and</strong> methods: Performance evaluation of the<br />
MDQ kit was carried out to fulfil the requirements of the<br />
EU IVD directive (98/79/EC) <strong>and</strong> the harmonised European<br />
norms. Laboratory validation of the kit was performed in<br />
three university centres in Hungary according to the st<strong>and</strong>ards<br />
of the Clinical Laboratory St<strong>and</strong>ards Institute. Inaccuracy<br />
<strong>and</strong> comparative measurements were carried out using<br />
cell lines with low <strong>and</strong> high activity of transporters.<br />
Mononuclear cells from healthy donors were separated using<br />
Ficoll gradient <strong>and</strong> results on different flow cytometers<br />
were comp<strong>are</strong>d using CD45 or CD19 or CD3 monoclonal<br />
antibodies for gating the population of interest using a harmonized<br />
procedure. The reference interval of MDR activities<br />
in lymphocytes has been determined in a population of<br />
120 healthy volunteers.<br />
Results: The assay proved to be specific <strong>and</strong> robust at<br />
various concentrations of the fluorescent dyes (10–100% of<br />
the original) or inhibitors (50–150% of the original). Both<br />
intra-assay <strong>and</strong> inter-assay reproducibilities were < 24.2;<br />
MAF-MRP < 13.2; MAF-BCRP < 23.2.<br />
Conclusion: This functional assay is reliable <strong>and</strong> provides<br />
transporter specific quantitative results on the function<br />
of the MDR1, MRP1 <strong>and</strong> BCRP transporters in the<br />
target cells. Recently, clinical trials have been started in haematological<br />
diseases to evaluate the predictive <strong>and</strong> prognostic<br />
values of these biomarkers.<br />
PP04 NPM1 mutations in AML detected by<br />
fragment analysis <strong>and</strong> Sanger sequencing<br />
Crncec I, Musani V, Marusic Vrsalovic M, Livun A,<br />
Pejsa V, Jaksic O, Haris V, Ajdukovic R, Stoos Veic T,<br />
Kusec R. Departments of Hematology, Divison of<br />
molecular diagnostics <strong>and</strong> genetics <strong>and</strong> Cytology,<br />
Universtiy hospital Dubrava <strong>and</strong> Zagreb School of<br />
Medicine, Division of molecular medicine, Institute Rudjer<br />
Boskovic, Zagreb, Croatia<br />
NPM1gene mutations can be detected in approximately<br />
1/3 of all de novo AMLs particularly in cases with normal<br />
karyotype <strong>and</strong> predicts good prognosis. However, associated<br />
with FLT3-ITD is of adverse prognosis<br />
Aim: We have developed a two-step molecular assay for<br />
the detection of NPM1 mutations.<br />
Patients <strong>and</strong> methods: The first part, prescreening for<br />
mutation, consists of RT-PCR amplification of exon 12 of<br />
the gene with the subsequent gene scan (fragment analysis)<br />
by capillary electrophoresis in AB310 Sequencer analyzer.<br />
What follows is re-amplification of mutation-positive cases<br />
<strong>and</strong> direct sequencing for the determination of the precise<br />
type of mutation. We tested 60 patients with de novo (46)<br />
<strong>and</strong> secondary (14) AMLs from our institution. The karyotype<br />
was available for 32% of them <strong>and</strong> FLT3-ITD analysis<br />
was done in all.<br />
Results: NMP1 mutations were found in 12 patients with<br />
de novo AML (26% of de novo AML; 20% for all AMLs).<br />
None was from the sAML group. Sequencing revealed 8<br />
cases of A-type (TCTG), 2 of D-type (CCTG) <strong>and</strong> 1 each of<br />
H-type (CTTG) <strong>and</strong> Nm-type (CCAG) mutation. Expected<br />
frequencies <strong>are</strong> given in the table.
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
Mutation type N % (95% CI) Expected %<br />
A 8 67 (35-90) 70-80<br />
D 2 17 (2-48) approx. 6, < 10<br />
H 1 8 (0-27) approx. 2<br />
Nm 1 8 (0-27) approx. 0,4, < 1<br />
Σ 12 - -<br />
There was also a significant association of NPM1 <strong>and</strong><br />
FLT3-ITD mutation (H 2 =6,322; DF=1; P=0,012).<br />
Conclusion: In conclusion, the two-step molecular assay<br />
for NPM1 mutation detection is rational <strong>and</strong> acceptable<br />
method for the routine diagnostic application. Frequencies<br />
of NPM1 mutations in our patients <strong>are</strong> comparable to the<br />
ones reported previously, with type A being the most frequent.<br />
However, although in the small number of patients,<br />
we have observed increased occurrence of relatively r<strong>are</strong><br />
molecular types. We can also confirm that there is an increased<br />
association of FLT3-ITD with NPM1 mutation.<br />
PP05 NPM1 mutation A <strong>and</strong> FLT3/ITD in AML<br />
with myelodysplasia-related changes<br />
Radic Antolic M, Ries S, Zadro R, Davidovic S, Labar B.<br />
Clinical Hospital Center <strong>and</strong> School of Medicine,<br />
University of Zagreb, Croatia<br />
According to WHO criteria, acute myeloid leukemia<br />
(AML) with myelodysplasia-related changes requires the<br />
presence of at least 20% blasts in the bone marrow <strong>and</strong>/or<br />
blood <strong>and</strong> morphologic features of dysplasia in two or more<br />
mature bone marrow cell lines. Chromosomal abnormalities<br />
may be identical to those in myelodysplasia, with either<br />
complex or normal karyotypes. In patients with normal<br />
karyotype, it is important to detect mutations in NPM1 <strong>and</strong><br />
FLT3 gene as a predictor of clinical outcome.<br />
The aim of this study was to determine the prevalence of<br />
NPM1 mutation A <strong>and</strong> FLT3/ITD <strong>and</strong> to relate them to cytogenetic<br />
abnormalities in patients with AML with myelodysplasia-related<br />
changes.<br />
The study included 52 patients (23 female <strong>and</strong> 29 male)<br />
with de novo AML with myelodysplasia-related changes.<br />
Bone marrow aspirate at diagnosis was used for cytogenetic<br />
<strong>and</strong> molecular analysis. GTG-b<strong>and</strong>ing was used for karyotype<br />
analysis <strong>and</strong> FISH was used for detection of del(5q),<br />
del(5), del(7q), del(7) <strong>and</strong> rearrangement of the MLL gene.<br />
RQ-PCR was used to determine NPM1 mutation A (Ipsogen,<br />
France) <strong>and</strong> FLT3/ITD was determined by RT-PCR<br />
analysis (Nakao et al, Leukemia 1996).<br />
Among 52 patients included in the study, 29 (56%) had<br />
normal karyotype, 9 (17%) had intermediate, <strong>and</strong> 12 (23%)<br />
adverse cytogenetic risk, while cytogenetic analysis was not<br />
performed for two patients (4%). FLT3/ITD was positive in<br />
7 (13%) patients: 6 of them were with normal karyotype <strong>and</strong><br />
one had adverse cytogenetic risk. NPM1 mutation A was<br />
positive in 9 (17%) patients; 6 of them had normal karyotype,<br />
2 had intermediate <strong>and</strong> one patient adverse cytogenetic<br />
risk. Three patients (6%) with NPM1 mutation A <strong>and</strong><br />
FLT3/ITD had normal karyotype. Although patients with<br />
normal karyotype had higher incidence of NPM1 mutation<br />
A <strong>and</strong> FLT3/ITD than patients with intermediate <strong>and</strong> adverse<br />
cytogenetic risk, the difference was not statistically<br />
significant. There was no difference in patient distribution<br />
in cytogenetic risk groups according to gender. In normal<br />
karyotype patients group, higher incidence of NPM1 mutation<br />
A <strong>and</strong> FLT3/ITD was observed in female patients (4/14)<br />
than in male patients (2/15) but without statistical significance.<br />
AML with myelodysplasia-related changes is a distinctive<br />
myeloid disorder which requires multidisciplinary approach<br />
in diagnostics. Cytogenetic abnormalities have the<br />
most important role in predicting outcome, but in patients<br />
with normal karyotype only small gene mutations (NPM1,<br />
FLT3) can help in risk categorization. In future, those mutations<br />
could be real predicting factors correlating with therapy<br />
response <strong>and</strong> clinical outcome.<br />
PP06 Prognostic Signifi cance of CD56 Antigen<br />
Expression in Patients with Acute Myeloid<br />
Leukemia<br />
Djunic I, Virijevic M, Djurasinovic V, Novkovic A,<br />
Colovic N, Kraguljac-Kurtovic N, Vidovic A,<br />
Suvajdzic-Vukovic N, Tomin D. Clinic of hematology,<br />
Clinical Center Serbia, Belgrade, Serbia<br />
Aim: CD56 antigen, identified as an isoform of the neural<br />
adhesion molecules, has been found to be associated<br />
with poor prognosis in several hematologic malignancies,<br />
including acute myeloid leukemias (AML). The aims of this<br />
study were to investigate frequency <strong>and</strong> prognostic relevance<br />
of CD56 expression in patients with AML, as well as<br />
to comp<strong>are</strong> the importance of CD56 expression with st<strong>and</strong>ard<br />
prognostic factor such <strong>are</strong> age, cytogenetic abnormalities<br />
<strong>and</strong> performance status.<br />
Patients <strong>and</strong> methods: In this single-center study we<br />
analyzed the data of 184 newly diagnosed patients with<br />
nonpromyelocytic AML with follow-up of 36 months. As<br />
the risk factors for overall survival (OS), rate of achievement<br />
CR <strong>and</strong> duration of CR, were estimated: age, ECOG<br />
PS, FAB subtype AML, ELN cytogenetic risk group <strong>and</strong><br />
CD56 expression on blasts cells. Performance status (PS)<br />
was evaluated by <strong>East</strong>ern Cooperative Oncology Group<br />
(ECOG), ranged 0–4 (=2). AML subtypes were classified<br />
by French-American-British (FAB) Cooperative Group.<br />
Cytogenetic risk groups were assessed by recommendation<br />
of European LeukemiaNet (ELN): favorable, intermediate-<br />
I, intermediate-II <strong>and</strong> adverse group. For CD56 antigen expression,<br />
detected by flow-cytometry, a cut off >=20% was<br />
used as positive (CD56+). Patients were treated with Medical<br />
Research Council (MRC) 12 regimen. Risk factors were<br />
identified using the univariate <strong>and</strong> multivariate analysis.<br />
Results: The median patients’ age was 58 years, range<br />
18–79. CD56+ antigen was recorded in 40 patients (21.7%).<br />
Significant risk factors for poor OS in univariate analysis<br />
were: age >=55 years (p=2 (p=0.001), adverse cytogenetic<br />
(p=0.019) <strong>and</strong> CD56+ (p=0.003). The multivariate analysis<br />
indicated that CD56+ was the most significant risk factor<br />
89
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
for OS: p=0.05, relative risk (RR)=1.598 (95% CI 0.984-<br />
2.595). The most significant factor for poor rate of CR was<br />
age >=55 years: p=0.001, RR=0,274 (95% CI 0.125-0.597).<br />
CD56 positivity had not significant influence on CR rate,<br />
but it was the most significant risk factor for shorter duration<br />
of CR: p=0.005, RR=0.443 (95% CI 0.253-0.779). According<br />
to FAB subtypes of AML, CD56 positivity had the<br />
most significant impact on patients’ outcome in M5 subtype.<br />
In those patients CD56+ was the most significant risk<br />
factor for poor OS (p=0.021, RR=2.981, 95% CI 1.174-<br />
7.122) <strong>and</strong> shorter duration of CR (p=0.03, RR=3.563, 95%<br />
CI 1.132-11.215.<br />
Conclusion: Our data underline the independent negative<br />
prognostic role of CD56 antigen expression in AML,<br />
particularly in M5 subtype. Its presence should be regularly<br />
estimate for a better prognostic assessment of AML patients.<br />
PP07 FLT3 internal t<strong>and</strong>em duplication is a poor<br />
risk factor in patients with AML with<br />
diverse cytogenetic features<br />
M. Mikulic, R. Zadro, S. Davidovic, R. Serventi Seiwerth,<br />
D. Sertic, D. Nemet, J. Batinic, D. Batinic, K. Gjadrov,<br />
S. Ries, B. Labar. Department of Medicine <strong>and</strong><br />
Department of Clinical Laboratory, Clinical Hospital<br />
Center <strong>and</strong> School of Medicine, University of Zagreb,<br />
Croatia<br />
Aim: Mutations of Fms-like tyrosine kinase 3 (FLT3) <strong>are</strong><br />
present in about 30% of acute myelogenous leukemia<br />
(AML) patients that have been shown to have poor prognosis.<br />
The aim of this study was to analyze the prognostic impact<br />
of FLT3 internal t<strong>and</strong>em duplication (ITD) on the outcome<br />
of patients diagnosed with AML in comparison with<br />
patients with wild-type (WT) FLT3.<br />
Patients <strong>and</strong> methods: We retrospectively analyzed the<br />
laboratory <strong>and</strong> clinical data in 78 newly diagnosed patients<br />
with AML who have been treated in our Center from<br />
02/2000-03/2010. Median patients’ age was 45 years (range,<br />
22–72 yrs.). AML diagnosis was based on morphological,<br />
immunophenotypical <strong>and</strong> cytogenetical features. The presence<br />
of FLT3 ITD was detected by RT-PCR analysis. All<br />
patients received intensive induction chemotherapy followed<br />
by consolidation chemotherapy; 36 patients were<br />
treated with autologous hematopoietic stem cell transplantation<br />
(SCT) in 1 st CR, while 8 <strong>and</strong> 3 patients were allografted<br />
in 1 st <strong>and</strong> >1 st CR, respectively.<br />
Results: FLT3-ITD was detected in 20 patients (25%).<br />
Eight FLT3-ITD patients had normal karyotypes, two had<br />
good, <strong>and</strong> two had intermediate cytogenetic features. Thirteen<br />
FLT3-WT patients had normal karyotypes, five had<br />
good, nine had poor, <strong>and</strong> nine had intermediate cytogenetic<br />
features. In 30 patients from both groups cytogenetic studies<br />
had failed. CR rate was 85% in FLT3-ITD patients <strong>and</strong><br />
71% in FLT3-WT patients (p=0.249). 2-year DFS was 33.8<br />
<strong>and</strong> 52.5% in the FLT3-ITD <strong>and</strong> FLT3-WT group, respectively<br />
(p=0.029). 2-year OS was 47.3 <strong>and</strong> 63% in the FLT3-<br />
ITD <strong>and</strong> FLT3-WT group, respectively (p=0.665).<br />
90<br />
Conclusion: A higher remission rate after induction, although<br />
not statistically significant, was found in the FLT3-<br />
ITD group. Contrary to that, the DFS was significantly better<br />
in patients with FLT3-WT <strong>and</strong> a trend for better OS was<br />
observed in patients with FLT3-WT. This data support the<br />
evidence for FLT3-ITD being a poor risk factor, not only in<br />
patients with normal karyotypes, but also in patients with<br />
different cytogenetic risk factors.<br />
PP08 A Philadelphia-negative Chronic Myeloid<br />
Leukemia with a BCR/ABL Fusion Gene<br />
Lasan Trcic R 1 , Kardum I 2 , Jaksic B 2 , Jaksic O 3 , Kusec R 3 ,<br />
Pejsa V 3 , Zadro R 4 , Batinic D 4 , Labar B 5 , Begovic D 1 .<br />
1 Division of Medical Genetics, Department of Paediatrics<br />
Univesity Hospital Center Zagreb, Zagreb, Croatia.<br />
2 Division of Hematology, Department of Internal Medicine,<br />
Clinical Hospital Merkur, Zagreb, Croatia. 3 Division of<br />
Hematology Departmrnt of Internal Medicine, Clinical<br />
Hospital Dubrava, Zagreb, Croatia. 4 Clinical Laboratory<br />
Diagnostics, University Hospital Center Zagreb, Zagreb,<br />
Croatia. 5 Division of Hematology, Department of Internal<br />
Medicine Univesity Hospital Center Zagreb, Zagreb,<br />
Croatia<br />
Aim: Objective. The causing factor in chronic myeloid<br />
leukemia (CML) is the BCR/ABL chimeric gene. In most<br />
cases, it is cytogeneticlly visualized as a translocation between<br />
chromosomes 9 <strong>and</strong> 22 as the Philadelphia (Ph) chromosome.<br />
Five to ten percent of patients lack cytogenetics<br />
evidence of the Ph chromosome (CML-Ph) but show BCR/<br />
ABL fusion by fluorescence in situ hybridization (FISH) or<br />
reverse transcriptase-polymerase chain reaction (RT-PCR).<br />
Patients <strong>and</strong> methods: Methods. Diagnostic bone marrow<br />
samples were diagnosed by morphological, immunophenotypical<br />
criteria, <strong>and</strong> reverse transcriptase-polymerase<br />
chain reaction. Chromosome studies were performed on<br />
GTG-b<strong>and</strong>ed chromosomes obtained from bone marrow after<br />
direct preparation or short-time cultures. FISH studies<br />
were done using BCR/ABL1 dual-color/dual_fusion probes<br />
(Kreatech, Vysys)<br />
Results: Among 231 adult patients with CML, 10%<br />
(n=23) had variant translocations (9;22;v), involving one or<br />
two additional translocation partner chromosome. Two cases<br />
(0.8% in total) had an app<strong>are</strong>ntly normal karyotype. In<br />
first case, 56-year-old female diagnosed with CML, conventional<br />
cytogenetic analysis shoved a normal karyotype.<br />
Methaphase FISH showed an insertion of BCR sequences<br />
onto a chromosome 9 within ABL, the karyotype was<br />
46,XX. ish ins(9;22)(q34;q11.2). Second case, 58-year-old<br />
female with clinical findings consistent with CML, by conventionl<br />
cytogenetic analysis showed app<strong>are</strong>ntly normal<br />
karyotype. Findings with methapase FISH were interpreted<br />
as an insertion of the ABL gene onto chromosome 22 with<br />
BCR, the karyotype was 46,XX. ish ins(22;9)(q11.2;q34).<br />
The RT-PCR provided molecular evidence that a typical<br />
CML chimeric product resulting from a fusion of BCR exon<br />
with ABL exon is present in both cases.<br />
Conclusion: The clinical significance Ph-CML with app<strong>are</strong>ntly<br />
normal karyotype, with 5’BCR/3’ABL fusion gene
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
located on 9q34 <strong>and</strong> 22q11.2 is unclear. Some studies have<br />
suggested that these cryptic translocationes have no impact<br />
on prognosis, while others have suggested an adverse prognosis,<br />
it is more likely that the prognosis in Ph- is linked to<br />
the presence or absence of associated deletion on the der(9)<br />
rather than positioning of the fusion gene alone.<br />
PP09 Croatian CML Registry based on European<br />
LeukemiaNet CML Registry<br />
Sertic D 1 , Peric Z 1 , Sincic-Petricevic J 2 , Lozic D 3 ,<br />
M<strong>and</strong>ac-Rogulj I 4 , Duletic Nacinovic A 5 ,<br />
Gveric-Krecak V 6 , Corovic-Arneri E 7 , Pejsa V 8 ,<br />
Suvic-Krizanic V 9 , Skunca Z 10 , Babok-Flegaric R 11 ,<br />
Krmek-Zupanic D 12 , Carzavec D 13 , Lazic-Prodan V 14 ,<br />
Coha B 15 , Ajdukovic R 8 , Romic I 7 , Zadro R 1 , Davidovic S 1 ,<br />
Lasan-Trcic R 1 , Labar B 1 . Croatian Cooperative Group for<br />
Hematologic Diseases-CML Group: 1 University Hospital<br />
Center Zagreb, 2 University Hospital Center Osijek,<br />
3 University Hospital Center Split, 4 Clinical Hospital<br />
Merkur Zagreb, 5 University Hospital Center Rijeka,<br />
6 General Hospital [ibenik, 7 General Hospital Dubrovnik,<br />
8 Clinical Hospital Dubrava-Zagreb, 9 General Hospital<br />
Sisak, 10 General Hospital Zadar, 11 General Hospital<br />
Vara`din, 12 General Hospital Sv.Duh-Zagreb, 13 Clinical<br />
Hospital Center Sestre milosrdnice-Zagreb, 14 General<br />
Hospital Pula, 15 General Hospital Slavonski Brod<br />
Background: Based on European Leukemianet (ELN)<br />
Registry for Philadelphia positive chronic myeloid leukemia<br />
(CML) we collected data on CML epidemiology, the<br />
disease characteristics <strong>and</strong> treatment, as well as the data<br />
concerning the monitoring <strong>and</strong> clinical outcome of CML in<br />
Croatia. Here we present the preliminary data of CML Registry<br />
in Croatia.<br />
Methods: Data were prospectively collected from November<br />
15, 2009 until June 30, 2011. Data was sent to the<br />
national coordinator in the University Hospital Center Zagreb<br />
from all the hematologists in Croatia. All patients<br />
signed informed consent prior to the data reporting in the<br />
Registry.<br />
Results: From November 15, 2009 until June 30, 2011,<br />
69 patients with CML were registered. For 66 patients data<br />
were collected in CML Registry. Median age was 54.6 years<br />
(range 17–87). There were more male than female patients<br />
(63.6% versus, 36.4%). At time of diagnosis all were in<br />
chronic phase of CML. The Euro Score risk group distribution<br />
was: 36.4% low, 51.5% intermediate <strong>and</strong> 12.1% high<br />
risk; the Sokal risk distribution showed: 36.4% low, 30.3%<br />
intermediate <strong>and</strong> 30.3% high risk The majority of the patients<br />
showed a WHO performance status score of 0 (54.5%)<br />
or 1 (37.9%). FISH for bcr-abl was positive in 100% of<br />
cases <strong>and</strong> 51 (77.3%) of them were diagnosed by conventional<br />
cytogenetic (G-b<strong>and</strong>ing). Molecular Diagnostics (RT-<br />
PCR, quantitative PCR or both) was performed in 48<br />
(72.8%) patients Out of 27 patients who were committed<br />
quantitative-PCR at diagnosis, in 19 of them it is expressed<br />
by the international score. In relation to the population<br />
based approach preliminary data showed a higher frequency<br />
of newly diagnosed CML in two regions (Sisak <strong>and</strong> Sibenik).<br />
Summary: According to data collected so far the incidence<br />
of CML in Croatia is 0.99 / 100 000 inhabitants.<br />
There is uneven incidence distribution of CML by region,<br />
but due to the small number of patients we need a longer<br />
follow-up. Participation in ELN Registry study clearly improved<br />
the diagnostic possibilities (use of quantitative PCR<br />
for monitoring of CML). We also implemented for most patients<br />
ELN recommendations for treatment response with<br />
TKI.<br />
PP10 Use of Imatinib mesylate in Chronic Phase<br />
CML in Clinical Practice – Our Experience<br />
Miljkovic E, Markovic D, Cojbasic I, Nikolic V,<br />
Marjanovic G, Govedarovic N, Macukanovic-Golubovic L,<br />
Vucic M, Pavlovic M, Vukicevic T, Tijanic I, Simonovic O,<br />
Clinic of Hematology, Clinical Center Nis, Serbia<br />
Chronic myelogenous leukemia (CML) is a pluripotential<br />
stem cell disease characterized by anemia, extreme<br />
blood granulocytosis <strong>and</strong> granulocytic immaturity, basophilia,<br />
often thrombocytosis, <strong>and</strong> splenomegaly.<br />
Hallmark of chronic myeloid leukemia is Philadelphia<br />
chromosome that results from a reciprocal translocation between<br />
chromosomes 9 <strong>and</strong> 22.<br />
T (9;22)(q34;11) creates an aberrant fusion gene derived<br />
from the ABL gene encoded on chromosome 9 <strong>and</strong> the BCR<br />
gene encoded on chromosome 22.The product of this fusion<br />
BCR-ABL gene is a constitutively active protein-tyrosine<br />
kinase that promotes cellular proliferation <strong>and</strong> suppresses<br />
apoptosis.<br />
The incidence of CML increases with age, with a peak<br />
incidence of 53 years. Men <strong>are</strong> affected more often than<br />
women (3:2).<br />
CML has a tri-phasic clinical course: chronic phase, accelerated<br />
phase <strong>and</strong> blastic phase (myeloid or lymphatic)<br />
defines the transformation of CML in an acute leukemia <strong>and</strong><br />
is difficult to treat. Myeloid transformation of CML is more<br />
common (70%) than lymphoid blastic crisis (30%).<br />
Inevitable progression to blast crisis used to occur after a<br />
median of 3.5 years prior to the development of Bcr Abltargeted<br />
therapie.<br />
The Abl tyrosine kinase inhibitor imatinib (IM) induces<br />
durable responses in a high proportion of patients with<br />
chronic phase chronic myeloid leukemia <strong>and</strong> therefore represents<br />
the current st<strong>and</strong>ard first line treatment.<br />
Aim: Aim was to evaluate hematological <strong>and</strong> cytogenetic<br />
response in patients treating with IM longer then 6 months.<br />
Second aim was to evaluate molecular response in patients<br />
treating with IM longer then 24 months.<br />
Methods: Patients were monitored for hematologic <strong>and</strong><br />
cytogenetc reponse at 6 months intervals. Complete hematologic<br />
response is defined by WBC count
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
ter short-term culture (24 or 48 hours or both) with st<strong>and</strong>ard<br />
G or Q b<strong>and</strong>ing techniques.<br />
Achievement of a complete molecular response (CCyR)<br />
was assessed with the use of a quantitative reverse-transcriptase–polymerase-chain-reaction<br />
(RT-PCR) assay.<br />
Results: 38 patients, 21 men <strong>and</strong> 17 women were<br />
analised. Median age of patients was 46.6 years (18–73).<br />
After 32.6 months of median follow up (6–80), complete<br />
hematologic <strong>and</strong> cytogenetic response (mitosis with no<br />
Ph+) was achieved in 79.0 % patients (30),complete hematologic<br />
<strong>and</strong> no cytogenetic response (>95% mitosis Ph+) in<br />
2.6% (1). 15.8% of patients (6) had resistance to imatinib<br />
mesylate <strong>and</strong> were switched to other therapeutical options,<br />
two of them with additional chromosomal abnormalities.<br />
(one with 2 Ph+,<strong>and</strong> one with trisomy 8 <strong>and</strong> trisomy 22<br />
chromosomes). 1 patient (2.6%) had a severe adverse effect<br />
after 6 months with IM therapy-pancytopenia, mostly<br />
thrombocytopenia <strong>and</strong> the drug was interrupted.<br />
Achievement of CCyR was assessed with (RT-PCR) assay<br />
in patients treating with IM longer then 24 months. 15<br />
patients were tested for molecular response. A major molecular<br />
response was defined as a BCR-ABL transcript level<br />
of 0.1% or lower on the International Scale (conversion factor<br />
of 0.81), corresponding to a reduction in the BCR-ABL<br />
transcript level by at least 3 log from the st<strong>and</strong>ardized baseline<br />
level. Complete molecular response achieved 86.7% of<br />
patients (13) <strong>and</strong> 13.3% (2) had no molecular response.<br />
Conclusions: Chronic myeloid leukemia has substantially<br />
improved survival with the application of selective<br />
ABL tyrosine kinase inhibitor imatinib mesylate as st<strong>and</strong>rad<br />
treatment of chronic phase CML, with very good quality of<br />
life <strong>and</strong> few adverse effects.<br />
PP11 Imatinib for CML as a frontline therapy<br />
– Zagreb Experience<br />
Sertic D 1 , Zadro R 2 , Nemet D 1 , Davidovic S 3 ,<br />
Lasan-Trcic R 3 , Radic Antolic M 2 , Horvat I 2 ,<br />
Frani} Simic I 3 , Roncevic P 1 , Radman I 1 , Basic-Kinda S 1 ,<br />
Aurer I 1 , Labar B 1 . 1 Division of Hematolofy Department of<br />
Medicine, 2 Department of Clinical Laboratory,<br />
3 Department of Pediatric, Clinical Hospitral Center <strong>and</strong><br />
School od Medicine, University of Zagreb, Croatia<br />
Background: Imatinib is frontline therapy for chronic<br />
phase Philadelphia positive chronic myeloid leukemia (Ph+<br />
CML). In about 70% of patients optimal treatment response<br />
could be achieved <strong>and</strong> sustained for more than 7 years of<br />
therapy.<br />
We present the experience of the imatinib frontline treatment<br />
for CML in University Hospital Center Zagreb, Department<br />
of Hematology.<br />
Patients <strong>and</strong> Methods: A total of sixty seven patients<br />
with Ph+CML were treated with first line imatinib, from<br />
February 2003. Here we evaluated fifty eight of them, who<br />
were eligible for twelve months follow up. Median followup<br />
time was fifty two months (range 12–103, months).<br />
There were males <strong>and</strong> females, with a median age of forty<br />
nine years (range 14–74, years). Patients were treated with<br />
92<br />
400 mg/day. They were regularly checked for treatment response<br />
every 3 months with cytogenetic methods (G-b<strong>and</strong>ing<br />
<strong>and</strong> FISH) <strong>and</strong> quantitative RT-PCR.<br />
Results: In forty one patients (70%) complete cytogenetic<br />
response (CCR) was documented. Out of those forty<br />
one patients twelve patients (20%) achieved a complete molecular<br />
response (CMR). Twenty three patients (40%)<br />
achieved a major molecular response (MMR), while six patients<br />
(10%) had less than MMR. Two patients (3.4%) were<br />
resistant to first line treatment <strong>and</strong> were subsequently treated<br />
with nilotinib. Another two patients (3.4%) progressed to<br />
acute lymphoblastic leukemia, both after 2.5 months of therapy<br />
with imatinib. One of them had a T315I mutation, <strong>and</strong><br />
was subsequently treated with MUD allogeneic stem cell<br />
transplantation. One patient progressed to acute myeloid<br />
leukemia. Another patient had a progression of the disease<br />
during the chronic phase, with a verified T315I mutation.<br />
He was treated with allogeneic stem cell transplantation.<br />
Eight patients (13%) died during the course of the treatment,<br />
four of which related to CML therapy or progression<br />
of the disease. In four patients imatinib dose was increased<br />
to 600 mg or 800 mg. Subsequent optimal response was<br />
documented in all four patients. Two patients (3%) had serious<br />
side effects to the treatment <strong>and</strong> were therefore switched<br />
to nilotinib.<br />
Conclusion: Optimal response with imatinib is reported<br />
in 41 patients. Progression of the disease to accelerated/<br />
blastic phase was found in 3 patients. Eight patients died,<br />
four because of CML. Our experience has proved also that<br />
imatinib is an effective frontline therapy for Ph+CML.<br />
PP12 Frequency of 4 bcr-abl1 kinase domain<br />
mutations in chronic myeloid leukemia<br />
patients resistant to imatinib mesylate<br />
therapy<br />
Horvat I 1 , Radic Antolic M 1 , Zadro R 1 , Sertic D 2 , Labar B 2 .<br />
1 Department of Clinical Laboratory, 2 Department of<br />
Medicine, Clinical Hospital Center <strong>and</strong> School of<br />
Medicine, University of Zagreb, Croatia<br />
Introduction of imatinib mesylate (IM) for treatment of<br />
chronic myeloid leukemia (CML) has brought revolution in<br />
patient survival. Most patients in chronic phase of disease<br />
have high rates of responses to IM with the optimum response<br />
understood as major molecular response <strong>and</strong> bcrabl1<br />
transcript level ≤ 0.1% according to International Scale<br />
(IS). A proportion of patients become resistant to the drug<br />
after some time. Mutations in bcr-abl1 kinase domain <strong>are</strong><br />
found in 50% of resistant patients <strong>and</strong> IM cannot bind to its<br />
target.<br />
The aim of this study was to determine the frequency of<br />
4 bcr-abl1 kinase domain mutations (T315I, E255K, E255V<br />
<strong>and</strong> Y253H) in a group of CML patients who became resistant<br />
to IM therapy, <strong>and</strong> to show the percentage of bcr-abl1<br />
transcript levels in patients with <strong>and</strong> without mutations. The<br />
study included 28 CML patients, 27/28 were monitored during<br />
the course of IM therapy by real time quantitative PCR<br />
(Ipsogen, France) <strong>and</strong> their bcr-abl1 transcript values were
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
expressed according to IS. ASO-PCR for detection of T315I,<br />
E255K, E255V <strong>and</strong> Y253H mutations was performed according<br />
to Kang et al. (Haematologica, 2006).<br />
Among 28 patients tested, T315I was detected in 9 patients<br />
(32.1%), E255K in 3 patients (10.7%), E255V in 2<br />
patients (7.1%) <strong>and</strong> Y253H in 6 patients (21.4%). Overall,<br />
14/28 patients (50.0%) had one or more mutations. In T315I,<br />
E255K, E255V <strong>and</strong> Y253H positive patients, bcr-abl1 transcript<br />
levels were 7.7–39.1% IS (median 23.2%), 7.7–12.7%<br />
(median 12.3%), 1.7–12.7% (median 7.2%) <strong>and</strong> 12.7–39.1%<br />
(median 18.0%), respectively. In 14 patients tested negative<br />
for analyzed mutations, bcr-abl1 transcript levels were<br />
0.55–46.3% IS (median 12.3%). In 4 T315I positive patients<br />
one or more additional mutations were detected; one patient<br />
accumulated all four mutations over time (T315I, E255K,<br />
E255V, Y253H), 2 patients gained Y253H, <strong>and</strong> E255K mutation<br />
was detected in 1 patient. Among 4 patients who died,<br />
3 were T315I positive <strong>and</strong> 2 of them had additional mutations.<br />
Mutations in bcr-abl1 kinase domain <strong>are</strong> to a large extent<br />
responsible for resistance to IM therapy. We have shown<br />
that the monitoring of bcr-abl1 transcript level is important<br />
for detecting resistance to IM <strong>and</strong> that mutations <strong>are</strong> found<br />
in a high proportion of resistant patients. Searching for mutations<br />
in patient who lost response to IM therapy is significant<br />
part of CML patient management as the result of mutation<br />
analysis directly affects therapy approach, particularly<br />
in T315I positive patients for whom the treatment of choice<br />
is stem-cell transplantation.<br />
PP13 Imatinib mesylate in Patients with CML<br />
Relapse after Allogeneic Transplantation<br />
Serventi Seiwerth R 1 , Sertic D 1 , Radic Antolic M 2 ,<br />
Mrsic M 1 , Zadro R 2 , Davidovic S 3 , Grubic Z 2 , Mikulic M 1 ,<br />
Labar B 1 . 1 Department of Medicine, 2 Department of<br />
Clinical Laboratory, 3 Department of Pediatric, Clinical<br />
Hospital Center <strong>and</strong> School of Medicine, University of<br />
Zagreb, Croatia<br />
Intronduction: Allogenic stem cell transplantation is a<br />
curable therapy for substantial number of patients with Ph+<br />
CML. Because of high treatment related toxicity <strong>and</strong> mortality<br />
in the current era of TKI terapy allografting is not any<br />
more 1st line treatment. CML relapse after allogeneic transplantation<br />
is still a problem in 20% of patients. For these<br />
patient therapy with tyrosine kinase inhibitors (TKI) should<br />
be an treatment option. Here we present the outcome of<br />
three patients in realpse after allografting <strong>and</strong> treated with<br />
TKI.<br />
Patients <strong>and</strong> methods: Three patients, one male <strong>and</strong> two<br />
females with Ph+ CML in chronic phase recived bone marrow<br />
transplant from their HLA identical siblings after myeloablative<br />
conditioning with busulfan <strong>and</strong> cyclophosphamide.<br />
For GvHD prophylaxis cyclosporin <strong>and</strong> short methotrexate<br />
was given. In all patients sustained three lineage<br />
engraftmnet occured. Two of them experienced acute GvHD<br />
of gastrointestinal tract gr. II <strong>and</strong> skin gr. II respectively,<br />
which responded to corticosteroides. The relapse of CML<br />
was documented on 132, 168 <strong>and</strong> 30 months after allotransplantation<br />
Two of them experienced molecular relapse; one<br />
recieved donor lymphocyte infusion in escalating doses of<br />
CD3+ cells, but without any effect. Third patient had hematologycal<br />
relapse <strong>and</strong> was treated with hydroxyurea for two<br />
months.All patients received imatinib mesylate 400 mg<br />
daily dose within the 3 months of relapse. Two out of three<br />
patients achieved complete molecular response 10 <strong>and</strong> 12<br />
months after imatinib was started, while in third patient<br />
maior molecular response was documented 9 months after<br />
initiation of imatinib mesylate. All three patients <strong>are</strong> 100%<br />
donor chimeras according to the unseparated peripheral<br />
blood cells.<br />
Conclusion: imatinib mesylate is efficient in treating patients<br />
with Ph positive chronic myeloic leukemia in relapse<br />
after allogeneic transplantation. Major or complete molecular<br />
response could be achieved after 9–12 months of therapy<br />
with imatinib mesylate 400 mg/day. Longer follow up time<br />
is m<strong>and</strong>atory to asses if the treatment efficacy is sustained.<br />
PP14 Long-term survival <strong>and</strong> late-onset<br />
complications after reduced-intensity<br />
conditioning (RIC) allogeneic stem cell<br />
transplantation (allo-SCT)<br />
Peric Z, Clavert A, Chevallier P, Brissot E, Malard F,<br />
Guillaume T, Delaunay J, Ayari S, Dubruille V,<br />
Le Gouill S, Mahe B, Gastinne T, Blin N, Harousseau JL,<br />
Moreau P, Milpied N, Mohty M, Service d’Hématologie<br />
Clinique, Centre Hospitalier et Universitaire (CHU) de<br />
Nantes, Nantes, France<br />
RIC allo-SCT is increasingly used in elderly or frail patients<br />
not eligible for st<strong>and</strong>ard myeloablative conditioning.<br />
While the features <strong>and</strong> natural history of long-term complications<br />
(LTC) <strong>are</strong> rather well described in the st<strong>and</strong>ard allo-<br />
SCT setting, data <strong>are</strong> still sparse in the RIC setting.<br />
This report analyzed the outcome <strong>and</strong> features of LTC in<br />
110 RIC allo-SCT patients who survived for a minimum of<br />
2 years after transplantation. The median age of recipients<br />
was 55 (range, 19–68) years. In all, 74 patients (67%) had a<br />
lymphoid malignancy, whereas 34 (31%) patients were diagnosed<br />
with myeloid malignancies. Two patients (2%) were<br />
treated for severe aplastic anemia. In total, 94 patients (86%)<br />
received G-CSF-mobilized PBSCs whereas 9 patients (8%)<br />
received unmanipulated bone marrow, <strong>and</strong> 7 patients (6%)<br />
received cord blood. 67 grafts (61%) were obtained from<br />
HLA identical sibling donors, 35 (32%) from HLA matched<br />
unrelated donors <strong>and</strong> 8 (7%) from 1 Ag HLA mismatched<br />
unrelated donors. The majority of patients received a fludarabine,<br />
busulfan, <strong>and</strong> ATG-based RIC regimen (n=80; 73%),<br />
11 patients (10%) received fludarabine <strong>and</strong> low-dose TBI,<br />
while the remaining 17 patients (15%) received different<br />
chemotherapy-based RIC regimens.<br />
Recurrence of the primary malignancy was found in 4<br />
(4%) cases <strong>and</strong> was the primary cause of late death. A total<br />
of 6 (6%) patients died of non-relapse causes at a median of<br />
3.2 (range, 2.4–6.1) years post allo-SCT. The non-relapse<br />
causes of death were secondary malignancy (n=3), chronic<br />
93
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
GVHD (n=2), <strong>and</strong> infection (n=1). The Kaplan-Meier estimate<br />
of OS was 81% (95%CI, 71–94) at 10 years. With a<br />
median follow-up of 4.6 years (range, 2–12.1), chronic<br />
GVHD was the most prevalent late complication with a cumulative<br />
incidence of 74% (95%CI, 62–83) at 10 years.<br />
Cardiovascular complications were diagnosed in 47 (43%)<br />
patients, with arterial hypertension ocuring in 32 (29%) patients<br />
<strong>and</strong> cardial insufficiency in 15 (14%) patients. Renal<br />
impairment occured in 37 (34%) patients. Pulmonary complications<br />
were found in 28 (25 %) patients <strong>and</strong> were mostly<br />
related to chronic GVHD. Endocrine disorders were diagnosed<br />
in 18 (16%) involving thyroid dysfunction in 6 (5%)<br />
patients. Psychological disorders (mostly depression) were<br />
observed in 9 (8%) survivors. A secondary malignancy<br />
occured in 9 (8%) patients; 3 patients were diagnosed with<br />
two malignancies. The main organs involved were skin<br />
(n=4), colon (n=3), prostate (n=2), lungs (n=1), urinary bladder<br />
(n=1) <strong>and</strong> neuroendocrine tissue. (n=1)<br />
We conclude that although RIC allo-SCT has the potential<br />
to cure a significant proportion of patients with otherwise<br />
fatal diseases, <strong>and</strong> though many patients can survive the<br />
acute complications of the procedure, many other patients<br />
may not enjoy full restoration of health with onset of a significant<br />
rate of LTC, waranting lifelong surveillance through<br />
a close partnership between the transplant center, <strong>and</strong><br />
organ-specific specialties.<br />
PP15 Factors predicting overall survival in<br />
patients with advanced chronic graft versus<br />
host disease diagnosed by NIH consensus<br />
criteria.<br />
Grkovic L 1,2 , Steinberg SM 1 , Baird K 1 , Williams KM 1 ,<br />
Cowen EW 1 , Mitchell SA 1 , Pulanic D 1,2 , Avila DN 1 ,<br />
Taylor TN 1 , Wroblewski SG 1 , Serventi Seiwerth R 1,2 ,<br />
Gress RE 1 , Pavletic SZ 1 . 1 National Cancer Institute,<br />
National Institutes of Health, Bethesda, USA, 2 Department<br />
of Medicine, Clinical Hospital Center Zagreb, Croatia<br />
Aim: To determine factors predictive for survival in patients<br />
with advanced cGVHD (chronic graft-versus-host<br />
disease) defined by NIH (National Institutes of Health) criteria.<br />
Patients <strong>and</strong> methods: 189 adults were enrolled onto the<br />
cross-sectional prospective cGVHD natural history study<br />
between 2004 <strong>and</strong> 2010. Median patient age was 48 years<br />
[18–70], median time from transplant to enrollment was 3<br />
years [0.3–22], <strong>and</strong> median time from cGVHD diagnosis to<br />
enrollment was 2 years [0–19]. 66% of the patients had severe<br />
<strong>and</strong> 33% had moderate cGVHD according to the NIH<br />
global scoring with a median of 4 organs involved [1–8].<br />
80% of the patients were receiving systemic immunosuppression<br />
<strong>and</strong> have failed a median of 4 [0–9] prior systemic<br />
therapies for their cGVHD. Median follow-up of surviving<br />
patients was 2.5 years [0.1–5.8]. 28% of the patients had<br />
Karnofsky performance status less than 80% <strong>and</strong> 7% had<br />
thrombocytopenia (
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
plant, received HLA-matched related (n=79) or unrelated<br />
(n=60) BM after myeloablative BuCy conditioning. HiCy<br />
(50 mg/kg/day) was given on days +3, <strong>and</strong> +4 as only<br />
planned GVHD prophylaxis. Patients with acute grade II-IV<br />
GVHD were treated with methylprednisolone 1–2.5 mg/kg/<br />
day IV as a first line therapy, <strong>and</strong> those with visceral GVHD<br />
also received calcineurin inhibitors (CNI) or other non-CNI<br />
immunosuppressants.<br />
Results: In the competing risk model (death <strong>and</strong> graft<br />
failure as competing risks), the incidence of acute grade II-<br />
IV <strong>and</strong> III-IV GVHD by day 200 was 50% <strong>and</strong> 16%, respectively.<br />
Thirteen percent of patients who developed acute<br />
grade II-IV GVHD were not treated 15% were treated with<br />
steroids alone, 63% with steroids plus a CNI <strong>and</strong> 9% with<br />
steroids plus non CNI-based agents. Overall cumulative incidence<br />
of SSI use was 45%. Median time to initiation of<br />
SSI was 42 (19–142) days <strong>and</strong> the median duration of SSI<br />
use was 152 (13–981) days. The cumulative incidence of<br />
glucocorticoid use was 38% in related <strong>and</strong> 52% in unrelated<br />
group. Steroids were tapered rather quickly, 9 months after<br />
BMT all patients in related group were off glucocorticoid<br />
treatment, while in unrelated group only 14% of patients<br />
were on therapy at that time. Cumulative incidence of nonglucocorticoid<br />
therapy initiation was 29% in related <strong>and</strong><br />
44% in unrelated group At 6 months <strong>and</strong> 1 year, 63% <strong>and</strong><br />
83% of patients were off all immunosuppressive therapy,<br />
respectively. With a median follow-up of 26 months, cumulative<br />
incidence of chronic GVHD was 10%. Only 3 patients<br />
have died with refractory GVHD.<br />
Conclusion: These results extend our previous observations<br />
that post-transplantation Cy is effective single agent<br />
strategy for prophylaxis of acute GVHD with both a low<br />
rate of grade III-IV <strong>and</strong> more than half of the patients never<br />
requiring additional SSI. The limited use of SSI may be responsible<br />
for low infectious rate <strong>and</strong> excellent immune reconstitution<br />
seen in these patients. This approach also provides<br />
novel platform to facilitate the use of post-transplant<br />
immunotherapy aimed at reducing relapse.<br />
PP17 Allogeneic transplantation from HLA<br />
matched unrelated donor – single Center<br />
experience<br />
Serventi Seiwerth R 1 , Mikulic M 1 , Mrsic M 1 , Grubic Z 2 ,<br />
Bojanic I 3 , Durakovic N 1 , Stingl K 2 , Labar B 1 . 1 Division of<br />
Hematology, Department of Medicine, 2 Department of<br />
Clinical Laboratory, 3 Department of Transfusiology,<br />
Clinical Hospital Center <strong>and</strong> School of Medicine,<br />
University of Zagreb, Croatia<br />
Introduction: Allogeneic transplantation is a st<strong>and</strong>ard<br />
therapeutic approach for malignant <strong>and</strong> some nonmalignant<br />
congenital <strong>and</strong> acquired hematopetic diseases. Only one<br />
third of patients who would benefit from allogeneic transplantation<br />
have an HLA identical family donor. Search for<br />
an HLA matched unrelated donor from the International<br />
Bone Marrow Donor Registry gives more patients the opportunity<br />
to get optimal treatment. Acute leukemias <strong>and</strong><br />
myelodysplastic syndromes followed by bone marrow failure<br />
syndromes <strong>are</strong> major indications for allogeneic stem<br />
cell transplantation from matched unrelated donor. With<br />
high resolution HLA typing techniques on the allele level,<br />
results of alogeneic transplantation from matched unrelated<br />
donors have reached results in family transplants.<br />
We present patients transplanted from HLA matched unrelated<br />
donor in University Hospital Center Zagreb in the<br />
period from 1991. – 2010.<br />
Patients <strong>and</strong> treatment: From 1991 till December 2010.<br />
71 patients, median age 28 years (range 1 month – 61 year)<br />
received HLA matched unrelated donor transplant; 30 female<br />
<strong>and</strong> 41 male. HLA matches were 10/10 for 23 patients,<br />
9/10 for 14 patients, 8/10 in two patients, 13 patients were<br />
transplanted from 8/8 HLA matched donors; one patient<br />
was transplanted with two umbilical cord blood 6/6 HLA<br />
match. Eight patients transplanted before 2000 received<br />
stem cells from unrelated donor 6 out of 6. Most of our patients<br />
were transplanted for acute leukemia (34 out of 71<br />
patient): 18 for acute myeloid <strong>and</strong> 16 for acute lymphoblastic<br />
leukemia; 19 out of 71 patients were transplanted because<br />
of chronic myeloid leukemia <strong>and</strong> myelodisplastic<br />
syndrome while 9 of them received stem cells because of<br />
lymphoproliferative neoplasm. Seven patients were allografted<br />
for other diseases. Only 9 out of 34 acute leukemia<br />
patients (26,5%) were transplanted in first complete remission;<br />
7 out of 16 CML patients received stem cells in first<br />
chronic phase; while patients with non-Hodgkin lymphoma<br />
were allografted in refractory disease; 16 out of 71 patients<br />
who were previously autografted received stem cells from<br />
matched unrelated donor in relapse; one patient received<br />
MUD transplant after rejection of first unrelated transplant<br />
from different donor.<br />
St<strong>and</strong>ard myeloablative conditioning regimen consisting<br />
of busulfan <strong>and</strong> cyclophosphamide or cyclophosphamide<br />
<strong>and</strong> total body irradiation with antitymocytic globulin were<br />
given to 46 patients;;. 25 (35, 2%) patients were transplanted<br />
after reduced intensity conditioning regimens, most of<br />
them being fludarabine based (fludarabine + cyclophosphamide;<br />
fludarabine + busulfan) in combination with antithymocytic<br />
globulin. Cyclosporine <strong>and</strong> short courses of metothrexate<br />
(for st<strong>and</strong>ard conditioning) <strong>and</strong> cyclosporine <strong>and</strong><br />
mofetil mycophenolate (for nonmyeloablative conditioning)<br />
were used in GvHD prophylaxis. As a stem cell source<br />
marrow, peripheral blood <strong>and</strong> umbilical cord blood were<br />
used in 31 patients, 36 patients <strong>and</strong> 4 patients respectively.<br />
Results: In this high risk group of patients 55% (39/71)<br />
of them were alive on day +100. Infections, acute Graft versus<br />
Host Disease grade III-IV, multiorgan failure <strong>and</strong> underlying<br />
disease were the principal cause of death in 17, 14, 4<br />
<strong>and</strong> 8 patients respectively. Data <strong>are</strong> missing for 9 patients.<br />
Most of the deaths occurred during first 12 months; Overall<br />
survival at 5 years is 24% (17/ 71); Platou was reached after<br />
18 months. Although not significant there is a trend for better<br />
survival in patients with unrelated donor (10/10) comp<strong>are</strong>d<br />
to patients with a donor 9/10 or 8/8.<br />
Conclusion: In this high risk group of patients 55% of<br />
them <strong>are</strong> alive on 100 days after allografting, with 5-year<br />
overall survival of 24%. Main causes of death <strong>are</strong> serious<br />
infections, GvHD, multiorgan failure <strong>and</strong> underlying disease.<br />
Better patient selection <strong>and</strong> transplantation in earlier<br />
phase of the disease would give better antitumor effect with<br />
less toxicity <strong>and</strong> superior long-term survival.<br />
95
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
PP18 Extracorporeal Photochemotherapy in<br />
Treatment of Chronic Graft-versus-Host<br />
Disease<br />
Bojanic I 1 , Serventi Seiwerth R 2 , Golubic Cepulic B 1 ,<br />
Mazic S 1 , Lukic M 1 , Raos M 1 , Plenkovic F 1 ,<br />
Golemovic M 1 , Dubravcic K 3 , Perkovic S 3 , Batinic D 3 ,<br />
Labar B 2 . 1 Department of Transfusiology, 2 Division of<br />
Hematology, Department of Medicine, 3 Department of<br />
Clinical Laboratory, Clinical Hospital Center <strong>and</strong> School<br />
of Medicine University of Zagreb, Croatia.<br />
Extracorporeal photochemotherapy (ECP) is an immunomodulatory<br />
therapy which has been used in treatment of<br />
chronic GVHD (cGVHD). ECP involves separation of the<br />
mononuclear cells (MNC) with leukapheresis, followed by<br />
ex vivo administration of photosensitizer 8-methoxypsoralen<br />
(8-MOP) <strong>and</strong> ultraviolet A (UV-A) radiation, before<br />
reinfusion to the patient.<br />
Aim: Aim of the study was to evaluate clinical <strong>and</strong> immunomodulatory<br />
effect of ECP procedures performed in<br />
patients with cGVHD. The frequency of adverse reactions<br />
associated with ECP was also evaluated.<br />
Patients <strong>and</strong> methods: We analyzed 351 ECP procedures<br />
performed in 6 patients; median ECP per patient was 52<br />
(range 13–127). Patients’ median age was 29 years (range,<br />
12–76 yrs). The patients suffered from generalized sclerodermatous<br />
skin changes, impaired join mobility <strong>and</strong> one<br />
patient had symptoms of oral disease. In all patients concomitant<br />
immunosuppressive treatments for cGVHD were<br />
used as necessary. ECP procedures were performed for two<br />
consecutive days: in initial phase weekly, followed every<br />
two weeks <strong>and</strong> than monthly according to clinical response.<br />
ECP was performed using the »off line« technique. MNCs<br />
were collected using COBE Spectra cell separator (Caridian<br />
BCT). In all leukapheresis 2 patient’s total blood volumes<br />
were processed. Collected MNC concentrate was transferred<br />
to Extracorporeal UV-A Bag Set (Cell Max GmbH)<br />
<strong>and</strong> diluted with saline solution. 8-MOP (Gerot) was injected<br />
into the UV-A Bag Set <strong>and</strong> bag was irradiated by PUVA<br />
Combi-Light UVA Illuminator at wave length of 350 nm<br />
with the irradiation dose of 2 J/cm 2 . Irradiated cells were<br />
reinfused back to the patient. During apheresis <strong>and</strong> reinfusion<br />
of irradiated cells patients were monitored for adverse<br />
reactions. Number of T-lymphocyte subsets (CD3+, CD3+4+,<br />
CD3+8+, CD4+ CD8+ ratio) <strong>and</strong> B-lymphocytes (CD 19+),<br />
in patient’s peripheral blood were tested monthly.<br />
Results: The effect of ECP in patients with cGVHD with<br />
skin <strong>and</strong> joint involvement was mostly beneficial. Five patients<br />
experienced either improvement or stabilization in<br />
sclerodermatous skin changes <strong>and</strong> joint mobility. The overall<br />
cutaneous response rate was 83% (complete response<br />
rate 50% 3/6 pts), <strong>and</strong> partial response rate 33% (2/6 pts). In<br />
patient who suffered from oral disease, the total recovery<br />
was observed. Clinical response was typically delayed until<br />
2 to 3 months. In patients who responded to ECP efficiently,<br />
the influence of ECP on T-cell subsets leads to the suggestion<br />
that interactions between T-cell subsets may participate<br />
in the process of ECP.<br />
96<br />
In general ECP was well tolerated. No increased incidence<br />
of infections <strong>and</strong> no serious adverse reactions have<br />
been observed. After reinfusion of MNCs, one patient experienced<br />
increase in body temperature, likely due to the release<br />
of cytokines from photomodified cells.<br />
Conclusion: ECP proved to be efficient <strong>and</strong> safe procedure<br />
that may be recommended for patients with cGVHD<br />
who do not respond to conventional therapy.<br />
PP19 Wernicke’s encephalopathy in an<br />
adolescent after allogeneic hematopoietic<br />
stem cell transplantation: a case report<br />
Rajic Lj 1 , Pavlovic M 1 , Femenic R 1 , Bilic E 1 , Krnic N 1 ,<br />
Barisic N 1 , Ozretic D 1 , Tesovic G 4 , Dusek D 4 , Zadro R 2 ,<br />
Serventi Seiwerth R 3 , Mikulic M 3 , Konja J 1 , Labar B 3 .<br />
1 Department of Pediatric, 2 Department of Clinical<br />
Laboratory, 3 Department of Medicine, Clinical Hospital<br />
Center Zagreb, 4 Clinical Hospital for Infectious Diseases,<br />
1,2,3,4 School of Medicine University of Zagreb, Croatia<br />
Introduction: Wernicke’s encephalopathy (WE) is a neurological<br />
emergency caused by a thiamine (vitamin B1) deficiency.<br />
It was first described in 1881 by German neurologist<br />
Carl Wernicke as a triad comprising of global confusion,<br />
ataxia <strong>and</strong> ophtalmoplegia. The proposed mechanism<br />
of brain lesions is impaired myelination due to decreased<br />
NADPH production. Although most commonly associated<br />
with chronic alcoholism in adults, non-alcoholic WE has<br />
been described in conditions predisposing to poor nutritional<br />
status. Reports of WE in infants <strong>and</strong> children <strong>are</strong> r<strong>are</strong>, <strong>and</strong><br />
the majority of paediatric cases <strong>are</strong> associated with malignancy<br />
<strong>and</strong> gastrointestinal disease. Patients undergoing hematopoietic<br />
stem cell transplantation (HSCT) <strong>are</strong> at high<br />
risk of this potentially lethal condition due to chemotherapy-induced<br />
nausea <strong>and</strong> vomiting, <strong>and</strong> depletion of thiamine<br />
stores by long-term total p<strong>are</strong>nteral nutrition (TPN) <strong>and</strong> glucose-containing<br />
i.v.solutions.<br />
Aim: To present the case report of an 18 yr old male adolescent<br />
presenting with Wernicke’s encephalopathy following<br />
unrelated allogeneic HSCT for underlying acute myelogenous<br />
leukemia.<br />
Case report: On day + 42 after HSCT, the patient presented<br />
with vertical nystagmus <strong>and</strong> hallucinations. He complained<br />
of generalized weakness, gait disturbance, hyperacusia,<br />
difficult swallowing <strong>and</strong> insomnia. Neurogical examination<br />
revealed mild confusion, lower limb <strong>and</strong> truncal<br />
ataxia, bilateral abducens nerve palsy, both vertical <strong>and</strong> rotatory<br />
nystagmus, soft palate palsy <strong>and</strong> <strong>are</strong>flexia. Cerebrospinal<br />
fluid analysis <strong>and</strong> cranial CT scans imaging revealed<br />
no abnormality. Magnetic resonance imaging (MRI) of the<br />
brain showed symmetric high-signal intensities in dorsomedial<br />
nuclei of the thalamus, mamillary bodies, inferior colliculi,<br />
periaqueductal gray <strong>and</strong> pontine tegmentu, which<br />
were consistent with diagnosis of WE. The patient was<br />
treated with thiamine 500 mg/day i.v. for one month. His<br />
general condition <strong>and</strong> neurological signs were improved but<br />
not completely.<br />
Discussion: Neurological complications occur in 30–<br />
40% of patients undergoing HSCT. They may be of infec-
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
tious, cerebrovascular, toxic, immune-mediated, or metabolic<br />
origin. The diagnosis of WE is clinical but only 16%<br />
of affected patients develop pathognomonic clinical triad.<br />
Measurements of blood or erythrocyte thiamine concentrations<br />
<strong>are</strong> limited by a lack of specificity <strong>and</strong> <strong>are</strong> not routinely<br />
available in hospital laboratories. Due to selective<br />
vulnerability of the midline gray matter <strong>are</strong>as, MRI plays an<br />
important role in the diagnosis of this condition. It is crucial<br />
to consider WE in the differential diagnosis for all patients<br />
after HSCT presenting with confussion, ataxia <strong>and</strong> ophtalmoplegia.<br />
To prevent this devastating <strong>and</strong> often fatal neurologic<br />
complication, all patients underwent HSTC should be<br />
empirically treated with thiamine.<br />
PP20 Need + Information + Satisfaction<br />
Vieira S, Monroe D, Librojo M. London, United Kingdom<br />
Over the last decade, information for cancer patients has<br />
become increasingly more importance.<br />
The very nature of the cancer requires patients to learn<br />
about their disease in order to cope with the consequences<br />
of treatment <strong>and</strong> in inform the decision making process.<br />
It is therefore vital to provide enough information for patients<br />
<strong>and</strong> relevant others.<br />
People/patients vary in the amount of information they<br />
require. Evidence suggests that some patients do not want<br />
very much information about their diseases or any treatments.<br />
Stage Information provided on the following topics<br />
On admission<br />
N %<br />
1. Side effects of therapy or chemotherapy 20 (40%)<br />
2. Procedures<br />
(Bone Marrow Aspiration, Hickman Line insertion etc)<br />
19 (38%)<br />
3. Sexuality 5 (10%)<br />
4. Fertility 9 (18%)<br />
5. Results of diagnostic test 27 (54%)<br />
6. Follow up, appointments 25 (50%)<br />
7. Diet 14 (28%)<br />
other 0 (0%)<br />
During their stay 1. Side effects of therapy or chemotherapy 18 (36%)<br />
2. Procedures<br />
(Bone Marrow Aspiration, Hickman Line insertion etc)<br />
20 (40%)<br />
3. Infection Control 21 (42%)<br />
4. Sexuality 4 (8%)<br />
5. Fertility 6 (12%)<br />
6. Results of diagnostic test 29 (58%)<br />
7. others<br />
blood exams<br />
3 (6%)<br />
On discharge 1. Outcome of your treatment 30 (60%)<br />
2. Follow up, appointment 47 (94%)<br />
3. Medication 49 (98%)<br />
4. What happens next 38 (76%)<br />
5. When to call the medical team (Hospital) 41 (82%)<br />
6. Work life 26 (52%)<br />
7. others:<br />
alternative treatment models<br />
1 (2%)<br />
Total 50 (100%)<br />
Aim: This study aims to explore how much information<br />
our patient group wants to know <strong>and</strong> how much information<br />
our team provides to the patients<br />
Patients <strong>and</strong> methods: A questionnaire was prep<strong>are</strong>d to<br />
collect data on how much information was given to patients<br />
on three different stages of their treatment plans. These<br />
stages were: on admission, during their inpatient stay <strong>and</strong><br />
on discharge. A fourth section was added, to investigate<br />
other information need patient felt required.<br />
The questionnaire was used between May 2010 till October<br />
2010, total of 50 questionnaire. Outcome of these data<br />
collection is shown in table I.<br />
Results: 50 malignant haematology patients were admitted<br />
to our unit for various reasons (See Table I).<br />
Our audit was evaluated in three different stages. In admission<br />
stage most of the information provided were about<br />
side effects of treatment, test results. (See Table I).<br />
During in patient period was the llowest stages where information<br />
provided. It should be b<strong>are</strong> in mind that haematology<br />
patient group has long hospitalisation, the data collection<br />
tool was given on discharge. Therefore, data might<br />
be lost due to poor recalling the information required.<br />
Results also showed our patient were happy about the information<br />
they were given especially on discharge as most<br />
aspect of information covered (See Table I)<br />
PP21 CD43 expression is associated with inferior<br />
survival within activated B-cell group of<br />
diffuse large B-cell lymphoma<br />
Mitrovic Z 1,4 *, Iqbal J 1 , Fu K 1 , Smith LM 2 ,<br />
Weisenburger DD 1 , Greiner T 1 , Auon P 1 , Bast M 3 ,<br />
Armitage JO 3 , Vose JM 3 , Chan WC 1 . Departments of<br />
1 Pathology/Microbiology <strong>and</strong> 3 Hematology/Oncology,<br />
2 College of Public Health, University of Nebraska Medical<br />
Center, Omaha, NE, USA, 4 School of Medicine University<br />
of Zagreb, Croatia<br />
CD43 expression is associated with inferior survival within<br />
activated B-cell group of diffuse large B-cell lymphoma.<br />
Aim: The expression of CD43, an abundant membrane<br />
glycoprotein, was associated with an inferior survival of patients<br />
with diffuse large B-cell lymphoma (DLBCL) in a<br />
single-center study. The aim of the present study is to evaluate<br />
the prognostic significance of CD43 in our cohort of<br />
patients <strong>and</strong> correlate protein expression data with gene expression<br />
profiling (GEP).<br />
Patients <strong>and</strong> methods: A total of 129 patients treated<br />
with R-CHOP from Nebraska Lymphoma Study Group<br />
were included. Tumor samples on tissue microarray (TMA)<br />
were stained for CD43, CD10, BCL6, <strong>and</strong> MUM1 to correlate<br />
CD43 expression <strong>and</strong> cell of origin according to the<br />
Hans algorithm. GEP data were available for 31 patients.<br />
Results: CD43 was expressed in 25 of 129 DLBCLs<br />
(19.4%). There was no difference in the pre-treatment clinical<br />
characteristics between CD43+ <strong>and</strong> CD43-group of patients.<br />
CD43 expression was associated with inferior failure-free<br />
survival (FFS) <strong>and</strong> overall survival (OS), p=0.032<br />
<strong>and</strong> p=0.018, respectively. Furthermore, CD43 was signifi-<br />
97
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
cantly related to activated B-cell (ABC) group defined by<br />
GEP <strong>and</strong> by immunohistochemistry, p=0.006 <strong>and</strong> p=0.0485,<br />
respectively. Interestingly, patients with CD43+ DLBCL<br />
had very poor OS (p < 0.001) within the ABC group <strong>and</strong> 4.3<br />
times the risk of death by multivariate analysis comp<strong>are</strong>d to<br />
CD43-. When patients with GEP data were comp<strong>are</strong>d within<br />
the ABC group, a significant enrichment in stromal-1 signature<br />
<strong>and</strong> immune-response-1 signature was observed in<br />
CD43- group.<br />
Conclusion: CD43 is an adverse prognostic marker in<br />
DLBCL <strong>and</strong> is preferentially expressed in the ABC group. It<br />
can identify patients with extremely poor outcome within<br />
the ABC group. A possible explanation is the association<br />
with more favorable microenvironment signatures for CD43-<br />
cases within the ABC group.<br />
* This work was financed in part by a grant from the National<br />
Foundation for Science, Higher Education <strong>and</strong> Technological<br />
Development of the Republic of Croatia<br />
PP22 Association of Interleukin-10,TNF-Alpha<br />
<strong>and</strong> TGF-Beta Gene Polymorphisms on The<br />
Outcome of Diffuse Large B-cell Lymphoma<br />
Tarabar O, Tukic Lj, Cikota B, Milanovic N, Aleksic A,<br />
Magic Z. Military Medical Academy, Belgrade, Serbia<br />
Abstract: Diffuse large B-cell lymphomas (DLBCL)<br />
represent a heterogeneous group of lymphoproliferative disorders<br />
with highly variable clinical course <strong>and</strong> outcome.<br />
Published date indicated that common genetic variants in<br />
immune/ inflammatory response genes can affect outcome<br />
of diffuse large B-cell lymphomas (DLBCL).<br />
Aim: To analyze the association of IL-10 –3575, –1082,<br />
TNF-alpha –308 <strong>and</strong> TGF-beta Leu10Pro polymorphic<br />
variants with clinical characteristics <strong>and</strong> outcome of DLB-<br />
CL patients (pts) treated with rituximab (R)-CHOP therapy.<br />
Patients <strong>and</strong> methods:Between January 2004 <strong>and</strong> December<br />
2007, a total of 64 pts (M/F 33/31; aged 22–76, median<br />
48 yrs) with newly diagnosed DLBCL were entered<br />
into this study. Factors examined for prognostic significance<br />
included sex, age (60 yrs or younger vs. older), Ann Arbor<br />
(CS) stage (I-II vs. III-IV), serum lactate dehydrogenase<br />
level (normal vs. elevated), number of extranodal sites of<br />
disease (0 or 1 vs. 2 or more), performance status (0 or 1 vs.<br />
2 or more), <strong>and</strong> IPI score (0–2 vs. 3–5). The therapy for all<br />
pts was R-CHOP (6–8 cycles). Genotypes were determined<br />
with PCR-based methodology.<br />
Results:TGF-beta Pro10 was associated with an unfavorable<br />
features of DLBCL. A significantly more frequent<br />
stage III-IV (OR 4.65, 95% CI 1.33-16.12; p=0.016) <strong>and</strong> IPI<br />
score 3–5 (OR 5.37, 95% CI 1.45-20.0; p=0.012) were<br />
found in pts with the Pro allele variant (LeuPro/ProPro)<br />
than in carriers of LeuLeu genotype. IL-10 <strong>and</strong> TNF-alpha<br />
gene polymorphisms were not associated with established<br />
prognostic factors. Considering survival, only TNF-alpha –<br />
308 influenced overall survival (OS) in R-CHOP treated<br />
pts. With a median follow-up of 23 months, there was significantly<br />
difference between GG <strong>and</strong> GA/AA carriers (log<br />
98<br />
rank test, p=0.048). Overall survival at 3 years was 61.5%<br />
(95% CI 28.8-46.9) for GA/AA genotypes <strong>and</strong> 83.2% (95%<br />
CI 50.8-98.9) for GG genotype of TNF-alpha –308.<br />
Conclusion:Our results indicate that TNF-alpha –308<br />
<strong>and</strong> TGF-beta Leu10Pro gene variations could be associated<br />
to the clinical course <strong>and</strong> outcome of R-CHOP treated DL-<br />
BCL patients.<br />
PP23 Dose Adjusted EPOCH – Rituximab as First<br />
Line Treatment for High Risk Diffuse Large<br />
B-Cell Lymphoma: A Single Center<br />
Experience<br />
Pejsa V, Prka Z, Lucijanic M, Jaksic O, Pirsic M,<br />
Ajdukovic R, Kusec R. Division of Hematolofy,<br />
Department of Medicine, Universiti Hospital Dubrava<br />
<strong>and</strong> School of Medicine, University of Zagreb, Croatia<br />
Abstract: Dose-adjusted EPOCH- rituximab (DA-EP-<br />
OCH-R) is an infusional protocol which is based on pharmacodinamical<br />
adjustment of drug dosage depending on<br />
laboratory values of absolute neutrophil count <strong>and</strong> platelets<br />
(Wilson WH et al. Blood 2002;99:2685–2693). Rationale<br />
for this regimen is well known fact that tumor cells <strong>are</strong> less<br />
resistant on prolonged exposition to low dose of chemotherapy<br />
than to short exposition to high dose of drugs.<br />
Aim: To assess clinical outcome in patients with diffuse<br />
large B-cell lymphoma (DLBCL) with poor prognostic factors<br />
(IPI ≥2 <strong>and</strong>/or high proliferation index; PI>80%, measured<br />
as percentage of Ki67+ cells) treated with DA-EP-<br />
OCH-R as first line treatment.<br />
Patients <strong>and</strong> methods: From May 2005. to July 2011.,<br />
22 patients, median age 48.5 years (range 17–75) with diffuse<br />
large B-cell lymphoma were included. Elevated LDH<br />
had 16 out of 22 patients (73%) <strong>and</strong> 17 out of 22 patients<br />
(77%) were in Ann Arbor stages 3 <strong>and</strong> 4. IPI ≥2 had 18 out<br />
of 22 patients (82%). DA-EPOCH-R was administred according<br />
to original schedule. Six of these patients proceed<br />
to autoHSCT as consolidation therapy due to very aggressive<br />
histology <strong>and</strong> biology of disease.<br />
Results: Overall response rate (ORR) was 86% (19/22),<br />
including 13 (59%) complete responses (CR) <strong>and</strong> 6 (27%)<br />
partial responses (PR). Overall survival (OS) was 64% at 5<br />
years (median not reached) with median follow up of 14<br />
months (range 3–68). Progression free survival (PFS) was<br />
70% at 5 years. Of patients who achieved CR, 12 <strong>are</strong> still in<br />
complete remission.<br />
Conclusion: In this report we presented 22 patients with<br />
high risk diffuse large B-cell lymphoma. Our results showed<br />
that DA-EPOCH-R is highly effective regimen in this group<br />
of patients. These results <strong>are</strong> conclusive with results of Garcia-Su<strong>are</strong>z<br />
<strong>and</strong> colleagues (Garcia-Su<strong>are</strong>z J et al. British<br />
journal of Haematology 2007;136:276–285) who also find<br />
this regimen effective as first line treatment in DLBCL patients.<br />
Some of our patients were consolidated with autoHSCT<br />
due to high proliferation index or IPI≥3. Only 1<br />
patient relapsed during follow up period. Of 6 patients who<br />
were transplated, all but one <strong>are</strong> still in CR. We conclude<br />
that DA-EPOCH-R is highly effective regimen as first line<br />
treatment in high risk diffuse large B-cell lymphoma.
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
PP24 Immunoblastic Morphology as a Possible<br />
Prognostic Indicator for the Outcome of the<br />
Patients with Diffuse Large B cell<br />
Lymphoma in Era of the Rituximab Based<br />
Treatment: Single Centre Experience<br />
Trajkova S, Panovska-Stavridis I, Stojanovik A,<br />
Petrusevska G, Dukovski D, Cevreska L. Department of<br />
Hematology, Medical Faculty, Skopje, Republic of<br />
Macedonia<br />
Immunoblastic morphology as a possible prognostic indicator<br />
for the outcome of the patients with diffuse large B<br />
cell lymphoma in era of the Rituximab based treatment:<br />
single centre experience<br />
Aim: In order to investigate the prediction value of the<br />
immunoblastic morphology(IB) as a possible prognostic indicator<br />
for the outcome of our DLBL patient treated with<br />
the Rituximab (R)-CHOP regimen we conducted a retrospective<br />
study.<br />
Patients <strong>and</strong> methods: Our study enrolled 192 DLBL<br />
patients diagnosed <strong>and</strong> treated at the University Clinic of<br />
Hematology in the period between February 2002 <strong>and</strong> December<br />
2007. They were all treated with R-CHOP regimen<br />
<strong>and</strong> the median follow-up of the patient was 36 months. We<br />
analyzed the biopsy samples immunohistochemically for<br />
markers of germinal center (Bcl6), post-germinal center<br />
(MUM1) <strong>and</strong> apoptosis (Bcl-2).<br />
Results: The patients were categorized as DLBL(132;<br />
68,7%), IB(60;31,2). The median overall survival time (OS)<br />
were 59,3 months in DLBL group <strong>and</strong>,<strong>and</strong> 42,2months in<br />
IB group, <strong>and</strong> time to treatment (TT) were 56,8, <strong>and</strong><br />
30,6months respectively for the IB group. The DLBL <strong>and</strong><br />
IB groups were comparable regarding the age, gender distributions<br />
<strong>and</strong> all others already established prognostic parameters<br />
as performance status, advanced IPI, albumin level<br />
except for the low IPI 0–2 which was statistically associated<br />
with the DLBL group (p=.024).<br />
Conclusion: Our results did not show any statistical survival<br />
advantage <strong>and</strong> better outcome for the patient classified<br />
as DLBL when treated with R-CHOP <strong>and</strong> indicate that immunohistohemical<br />
markers do not really reflect the molecular<br />
diversity of the tumor. Our work shows that IB morphology<br />
is a major risk factor in DLBL patients treated with R-<br />
CHOP. Therefore this morphology appears to capture some<br />
adverse molecular events that a currently hard to detect with<br />
routine diagnostic procedures.<br />
PP25 Primary Mediastinal Large B-Cell<br />
Lymphoma – Results of our Center<br />
Miljkovic E, Marjanovic G, Cojbasic I, Tijanic I,<br />
Markovic D, Nikolic V, Macukanovic-Golubovic L,<br />
Govedarovic N, Vucic M. Clinic of Hematology, Clinical<br />
Center Nis, Serbia<br />
Abstract: Primary mediastinal large B-cell lymphoma<br />
(PMBCL) is a distinct clinico-pathological subtype of diffuse<br />
large B-cell lymphoma (DLBCL) <strong>and</strong> represents less<br />
than 3% of all non-Hodgkin lymphoma cases.The tumor ap-<br />
pears to be derived from medullary B cells within the thymus<br />
gl<strong>and</strong>.Phenotypically tumor cells <strong>are</strong> positive for CD45,<br />
B cell markers(Pax-5, CD19, CD20, CD22, CD79a) <strong>and</strong><br />
bcl-2, often positive for CD30, MUM1 <strong>and</strong> bcl-6. <strong>and</strong> negative<br />
for CD10 <strong>and</strong> CD21. The optimal treatment is unknown,<br />
with some studies suggesting a superior outcome with doseintensive<br />
chemotherapy regimens. The role of mediastinal<br />
radiotherapy upon completion of chemotherapy remains unclear<br />
Aim: Aim was to evaluate response in patients treating<br />
with R-MACOP-B regimen.<br />
Patients <strong>and</strong> methods:We performed a retrospective review<br />
of 5 patients with PMBCL, who were treated at our<br />
clinic during the period between Januar 2009 <strong>and</strong> December<br />
2010.<br />
Results: Among 5 patients there were 4 women <strong>and</strong> 1<br />
man.Median age was 31 years (24–33). Most patients were<br />
in stage II–80% (4) <strong>and</strong> one in stage III–20%, all of them<br />
with B simptoms. Bulky mediastinal mass (>5cm in diameter)<br />
was present in all of our patients. Superior vena cava<br />
syndrom with facial edema, neck vein distention <strong>and</strong> upper<br />
extemity swelling was seen in 60% of the patients (3). After<br />
treating with R-MACOP-B regimen (rituximab, methotrexate,<br />
doxorubicin, cyclophoshamide, vincristine, prednisone,<br />
beomycin) complete response was accomplished in 40%<br />
(2),partial response in 20% (1).Two patients (40%) died,<br />
one due to progression of disease <strong>and</strong> one due to the toxicity<br />
of the treatment. Two patients who complited R-MA-<br />
COP-B had involved-field radiation therapy (IFRT) following<br />
chemotherapy <strong>and</strong> complete remission was confirmed<br />
by performing PET scan.<br />
Conclusion: PMBCL, an uncommon disease affects<br />
young people with a female prevalence <strong>and</strong> frequent bulky<br />
mediastinal mass.Studies have demonstrated advantage of<br />
R-MACOP B comp<strong>are</strong>d to CHOP,so we were treated our<br />
patients with this regimen. Two patients who complited R-<br />
MACOP B <strong>and</strong> had IFRT <strong>are</strong> still in complete remission<br />
after two years of follow up.<br />
PP26 Dose-intense BACOP for Treatment<br />
of High-risk Peripheral T-cell NHL<br />
Aurer I 1 , Dujmovic D 1 , Basic-Kinda S 1 , Nemet D 1 ,<br />
Radman I 1 , Ilic I 2 , Stern-Padovan R 3 , Santek F 4 , Sertic D 1 ,<br />
Cigrovski N 3 , Labar B 1 . 1 Department of Medicine,<br />
2 Pathology, 3 Radiology <strong>and</strong> 4 Oncology, University Hospital<br />
Center <strong>and</strong> School of Medicine, University of Zagreb,<br />
Croatia<br />
PTCLs, except ALK+ ALCL, have a bad prognosis with<br />
overall 5-year survival rates below 30%. Because of their<br />
relative rarity, no large r<strong>and</strong>omized trials have been performed<br />
<strong>and</strong> the importance of individual cytotoxic agents,<br />
their dose density <strong>and</strong> intensity as well as that of autografting<br />
remains unproven. At our center we have been using<br />
dose-intense BACOP, a regimen modeled after the French<br />
ACVBP, for treatment of patients with high risk PTCL. The<br />
regimen consisted of cyclophosphamide 1500 mg/m 2 day 1,<br />
doxorubicin 75 mg/m 2 day 1, bleomycin 15 mg days 1 <strong>and</strong><br />
99
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
5, vincristine 2 mg days 1 <strong>and</strong> 5 <strong>and</strong> prednisone 50 mg/m 2<br />
days 1–5 every 3 weeks for 4–6 cycles. Responding patients<br />
underwent stem-cell collection <strong>and</strong> autografting after<br />
BEAM conditioning. Areas of initially bulky disease <strong>and</strong><br />
those not in CR prior to transplantation were irradiated posttransplant<br />
with 30–40 Gy. Patients with high risk for development<br />
of CNS disease received intrathecal methotrexate<br />
prophylaxis. Response evaluations were performed after<br />
2–3 cycles <strong>and</strong> at the end of chemotherapy. Patients were<br />
considered high risk if they had any PTCL type with IPI 3<br />
or more, bulky disease or failed to respond to 2–3 cycles of<br />
st<strong>and</strong>ard CHOP-21. We treated 28 patients, 20 men <strong>and</strong> 8<br />
women, 17–67 years old (median 46). Thirteen had PTCL-<br />
NOS, 8 ALCL, 3 AILD, 2 nasal type, 1 panniculitis-like <strong>and</strong><br />
1 hepatosplenic PTCL. Two had stage IE bulky, 1 stage II<br />
bulky, 2 stage III <strong>and</strong> 23 stage IV disease. The toxicity of<br />
treatment was substantial, all patients experienced serious<br />
hematological toxicity <strong>and</strong> infections or neutropenic fever,<br />
3 died of infection during chemotherapy <strong>and</strong> 1 during stemcell<br />
transplantation, 2 had DVT/PE, 1 died of complications<br />
related to the necrosis of an extremely bulky tumor <strong>and</strong> one<br />
underwent emergency splenectomy after tumor necrosis<br />
caused splenic rupture. Three patients were unavailable for<br />
efficacy analysis due to early death, 4 progressed <strong>and</strong> 21<br />
initially responded (75%); 14 achieved CR <strong>and</strong> 7 PR. None<br />
of the 3 patients with nasal type or hepatosplenic PTCL responded.<br />
Of the responders, 11 underwent autografting as<br />
100<br />
intended, 3 relapsed prior to transplantation, treatment was<br />
modified in 3 due to toxicity, 2 were not transplanted due to<br />
patient refusal or physician decision, 1 underwent allogeneic<br />
transplantation <strong>and</strong> 1 failed to mobilize.<br />
After a median follow-up of survivors of 20 months, 9<br />
patients <strong>are</strong> still alive, including 8 who were autografted as<br />
intended. Median response duration was 12 months, FFS 6<br />
months <strong>and</strong> OS 10 months (Fig 1 <strong>and</strong> 2.). In conclusion, a<br />
significant proportion of high-risk PTCL-NOS, ALCL <strong>and</strong><br />
AILD patients respond to dose-intense BACOP followed by<br />
autologous stem-cell transplantation but the toxicity of<br />
treatment is substantial.<br />
PP27 Oral lomustine, chlorambucil, etoposide<br />
<strong>and</strong> prednisolone (CCEP) for treatment of<br />
patients with advanced lymphoma<br />
Radman I, Vodanovic M, Mitrovic Z, Aurer I, Basic-Kinda<br />
S, Labar B. Division of Hematology, Department of<br />
Medicine, Clinical Hospital Center <strong>and</strong> School of<br />
Medicine, University of Zagreb, Croatia<br />
Abstract: Oral palliative chemotherapy is reserved for<br />
the refractory <strong>and</strong> relapsed lymphoma patients who <strong>are</strong> not<br />
c<strong>and</strong>idates for further aggressive treatment. Herein we report<br />
single institution experience.<br />
Aim: CCEP, all – oral chemotherapy containing CCNU,<br />
chlorambucil, etoposide <strong>and</strong> prednisone was tested in refractory<br />
<strong>and</strong> relapsed lymphoma patients in advanced stages.<br />
Patients <strong>and</strong> methods: Twenty patients with refractory/<br />
relapsed lymphoma observed between 2000 <strong>and</strong> 2010 were<br />
treated with CCEP. Eight patients were diagnosed with<br />
Hodgkin lymphoma, 9 with aggressive non-Hodgkin lymphoma<br />
<strong>and</strong> 3 with indolent lymphoma. All patients were in<br />
advanced stage disease (Ann Arbor III/IV) <strong>and</strong> previously<br />
treated > 2 lines of therapy.<br />
Results: The median age was 51 (range 20–76 years).<br />
Thirteen patients (65%) had been extensively pretreated (≥3<br />
treatment), including autologous or allogeneic stem cell<br />
transplantation. All patients were in advanced stage disease<br />
(Ann Arbor III/IV), with extramedullary spread; lung 10 patients<br />
(50%), liver 7 patients (35%), spleen 5 patients (25%)<br />
<strong>and</strong> bone marrow 4 patients (20%). Overall response rate<br />
was 50%; 6 patients (30%) obtained stable state <strong>and</strong> 4 (20%)<br />
progressive disease. Median follow-up was 11 months with<br />
30% of 2-year survival rate. Patients receiving ≥ 3 cycles of<br />
CCEP achieved better response rate <strong>and</strong> longer survival.<br />
The progressive disease <strong>and</strong> toxicity were the main reasons<br />
for discontinuation of treatment.<br />
Conclusion: CCEP is low cost <strong>and</strong> effective chemotherapy<br />
with acceptable toxicity <strong>and</strong> good tolerability. In half of<br />
the patients with very adverse prognosis one can expect<br />
temporary treatment success.
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
PP28 Effi cacy <strong>and</strong> Safety of Ruxolitinib, a JAK1<br />
<strong>and</strong> JAK2 Inhibitor, in Patients With<br />
Myelofi brosis: Results From a R<strong>and</strong>omized,<br />
Double-Blind, Placebo-Controlled, Phase III<br />
Trial (COMFORT-I)<br />
Verstovsek S 1 , Mesa R 2 , Gotlib J 3 , Levy R 4 , Gupta V 5 ,<br />
DiPersio J 6 , Catalano J 7 , Deininger M 8 , Miller C 9 ,<br />
Silver R 10 , Talpaz M 11 , Winton E 12 , Harvey J 13 ,<br />
Arcasoy M 14 , Hexner E 15 , Lyons R 16 , Paquette R 17 ,<br />
Raza A 18 , Vaddi K 4 , Erickson-Viitanen S 4 , Koumenis I 4 ,<br />
Sun W 4 , S<strong>and</strong>or V 4 , Kantarjian H 1 . 1 The University of Texas<br />
MD Anderson Cancer Center, Houston, TX, USA; 2 Mayo<br />
Clinic, Scottsdale, AZ, USA; 3 Stanford Cancer Center,<br />
Stanford, CA, USA; 4 Incyte Corporation, Wilmington, DE,<br />
USA; 5 Princess Marg<strong>are</strong>t Hospital, Toronto, Canada;<br />
6 Washington University School of Medicine, St. Louis, MO,<br />
USA; 7 Frankston Hospital, Frankston, Australia;<br />
8 University of Utah Huntsman Cancer Institute, Salt Lake<br />
City, UT, USA; 9 Saint Agnes Cancer Institute, Baltimore,<br />
MD, USA; 10 Weill Cornell Medical College, New York, NY,<br />
USA; 11 University of Michigan, Ann Arbor, MI, USA;<br />
12 Emory University School of Medicine, Atlanta, GA, USA;<br />
13 Birmingham Hematology & Oncology, Birmingham, AL,<br />
USA; 14 Duke University Health System, Durham, NC,<br />
USA; 15 University of Pennsylvania Health System,<br />
Philadelphia, PA, USA; 16 Cancer C<strong>are</strong> Center of South<br />
Texas, San Antonio, TX, USA; 17 UCLA Medical Hematology<br />
& Oncology, Los Angeles, CA, USA; 18 Columbia<br />
Presbyterian Medical Center, New York, NY, USA<br />
Background: Myelofibrosis (MF) is characterized by<br />
splenomegaly, debilitating symptoms, cytopenias, <strong>and</strong> shortened<br />
survival. No effective drug therapies <strong>are</strong> available;<br />
however, dysregulated JAK-STAT signaling, a key feature<br />
of MF, is a promising therapeutic target. Ruxolitinib (Rux),<br />
a selective JAK1 <strong>and</strong> JAK2 inhibitor, showed clinical activity<br />
in MF.<br />
Aim: COMFORT-I was designed to comp<strong>are</strong> the efficacy<br />
<strong>and</strong> safety of Rux with that of placebo (PB) in MF patients<br />
(pts).<br />
Patients <strong>and</strong> methods: Pts with intermediate-2 or highrisk<br />
MF (per IWG-MRT) were r<strong>and</strong>omized to Rux or PB.<br />
Rux starting dose was 15 mg or 20 mg PO BID for pts with<br />
baseline platelet count of 100–200 x 10 9 /L or >200 x 10 9 /L,<br />
respectively; the dose could be adjusted during the study to<br />
optimize efficacy <strong>and</strong> safety. The primary endpoint was the<br />
proportion of pts with >=35% reduction in spleen volume at<br />
week (wk) 24, as assessed by magnetic resonance imaging<br />
or computed tomography (blinded review). Secondary endpoints<br />
included duration of spleen response, changes in<br />
daily symptom burden (Total Symptom Score [TSS] using<br />
the modified Myelofibrosis Symptom Assessment Form<br />
[MFSAF] v2.0), <strong>and</strong> survival. Changes in quality of life<br />
(QOL) <strong>and</strong> fatigue were exploratory measures, as were molecular<br />
<strong>and</strong> serum biomarkers <strong>and</strong> transfusion dependence.<br />
Results: 155 pts were r<strong>and</strong>omized to Rux <strong>and</strong> 154 to PB<br />
(median follow-up: 32.2 wks). At 24 wks, the proportion of<br />
pts achieving a >=35% reduction in spleen volume was<br />
41.9% for Rux vs 0.7% for PB (p=50% improvement in<br />
TSS was 45.9% for Rux vs 5.3% for PB (p< 0.0001). Ruxtreated<br />
pts had a mean 46.1% improvement in TSS; PBtreated<br />
pts experienced a 41.8% worsening (p20% of pts)<br />
non-hematologic adverse events in pts on Rux vs PB were<br />
abdominal pain (10.3% vs 41.1%), fatigue (25.2% vs<br />
33.8%), diarrhea (23.2% vs 21.2%), <strong>and</strong> peripheral edema<br />
(18.7% vs 22.5%). The most common grade 3 or 4 hematologic<br />
laboratory abnormalities at any time during the study<br />
(Rux vs PB) were low hemoglobin (45.2% vs 19.2%) <strong>and</strong><br />
low platelets (12.9% vs 1.3%). Anemia <strong>and</strong> thrombocytopenia<br />
were manageable through dose modification/ temporary<br />
hold <strong>and</strong> r<strong>are</strong>ly led to study discontinuation (1 pt in each<br />
arm for each event).<br />
Conclusion: Rux demonstrated rapid <strong>and</strong> sustained clinical<br />
benefits in spleen size <strong>and</strong> debilitating symptoms, <strong>and</strong><br />
improved QOL in pts with MF; conversely, pts on PB had<br />
progressive worsening of disease. Rux was generally well<br />
tolerated. These results suggest that Rux may become an<br />
important new treatment option for the management of this<br />
chronic, advancing neoplasm.<br />
Support: Incyte Corp<br />
PP29 Prevalence of the JAK2 V617F Mutation in<br />
Croatian Patients with Classic Ph-Negative<br />
Myeloproliferative neoplasm<br />
Duletic Nacinovic A, Dekanic A, Hadzisejdic I, Seili I,<br />
Grahovac B, Grohovac D, Valkovic T, Host I, Petranovic<br />
D, Jonjic N. Department of Medicine <strong>and</strong> Deppartment of<br />
Pathology, Clinical Hospital Center <strong>and</strong> School of<br />
Medicine, University of Rijeka, Croatia.<br />
The classic Ph-negative myeloproliferative neoplasms<br />
(MPNs) <strong>are</strong> clonal disorders of multipotent haematopoietic<br />
progenitors. The Janus-associated Kinase-2 mutation JAK2<br />
V617F in such neoplasms has been described as a frequent<br />
genetic event in majority of these patients.<br />
Aim: To investigate the status of the JAK2-V617F mutation<br />
in patients with classic Ph-negative MPNs treated in<br />
Clinical Hospital Center Rijeka <strong>and</strong> to comp<strong>are</strong> it with hemoglobin<br />
<strong>and</strong> hema-tocrit level, white blood cells <strong>and</strong> platelet<br />
count, splenomegaly, leukocyte alkaline phosphatase<br />
score <strong>and</strong> clinical features.<br />
Patients <strong>and</strong> methods: DNA was isolated from peripheral<br />
blood granulocytes in 115 patients: 41 with polycythemia<br />
vera (PV), 43 with essential thrombocythemia (ET), 9<br />
with primary myelofibrosis (PMF), 10 with myeloproliferative<br />
neoplasm-unclassifiable (MPN-u), 4 with secondary<br />
erithrocytosis <strong>and</strong> 5 patients with secondary thrombocytosis.<br />
The JAK2-V617 mutation was determined using allele<br />
specific PCR.<br />
Results: The JAK2-V617F mutation was found in 71/106<br />
(66.98%) patients with MPNs or in 36/41 with PV (87.80%),<br />
25/43 with ET (58.14%), 5/9 with PMF (55.56%) <strong>and</strong> 5/13<br />
MPNs-unclassified (38.46%) disorders. The JAK2-V617<br />
mutation was absent in patients with secondary erythrocytosis<br />
<strong>and</strong> seconrary thrombocytosis. There were significant<br />
differences in hemoglobin <strong>and</strong> hematocrit level, leukocyte<br />
alkaline phosphatase score <strong>and</strong> white blood cells at diagno-<br />
101
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
sis in JAK2-V617F non mutated versus mutated patients<br />
with MPNs. Vascular events were present in 23/106 (21.7%)<br />
patients with MPNs or more specifically in 13/41 (31.7%)<br />
with PV, 8/43 (18.6%) with ET, 1/9 (11.1%) with PMF <strong>and</strong><br />
1/13 (7.7%) with MPN-u. The majority of those patients<br />
with one or more vascular events were JAK2-V617F positive.<br />
When analyzed within each entity than it could be emphasized<br />
that one or more vascular events, or recurrent<br />
thrombosis was detected in 13/41 (31.7%), 7/41 (17.1%)<br />
cases, respectively with PV, or in 10/13 with JAK2-V617F<br />
positive status. In patients with ET, comp<strong>are</strong> to PV, vascular<br />
events (8/43) were less present (18.6%). Though, as noticed<br />
for PV, most of those patients (6/8) were associated with<br />
JAK2-V617F mutation. In patients with PMF only 1vascular<br />
event was confirmed (patient was JAK2V617F negative),<br />
as well as in patients with MPN-u (patient was JAK2 positive).<br />
Conclusion: The JAK2-V617F mutation was frequently<br />
detected in our patients with MPNs in accordance with literature<br />
data, <strong>and</strong> therefore should be incorporated in the<br />
diagnostic evaluation of patients with suspected MPNs.<br />
Further analysis should focus on contribution of the JAK2-<br />
V617F mutation in the clinical phenotype of patients with<br />
distinct subgroups of MPNs. These correlations imply that<br />
detection of this mutation will not only have a diagnostic<br />
value, but also a role in treatment given the development of<br />
STAT/JAK patway inhibiting drugs.<br />
PP30 Frequency <strong>and</strong> Clinical Correlates of JAK2<br />
46/1 Haplotype in Essential<br />
Thrombocythemia: Single Center<br />
Experience<br />
Panovska-Stavridis I, Matevska N, Ivanovski M,<br />
Trajkova S, Dukovski D, Pivkova Veljanovska A,<br />
Cevreska L, Dimovski A. Department of Hematology,<br />
Medical Faculty, Skopje, Republic of Macedonia<br />
Background: It is predicted that the inherited genetic<br />
background in the individual patients with myeloproliferative<br />
neoplasm (MPN) influences the disease susceptibility<br />
<strong>and</strong> the phenotype expression of the MPN. Several groups<br />
discovered that the germline JAK2 haplotype, tagged by the<br />
»C« allele of single nucleotide polymorphism (SNP)<br />
rs12343867 (C/T) is associated with the JAK2V617F positive<br />
MPN. Also, some recent studies showed equal distribution<br />
of this SNP among JAK2V617F negative MPN <strong>and</strong><br />
questioned the role of this hyplotype in MPN patients.<br />
Aim: In order to extend further those observations we<br />
conduct a retrospective study. First, we assess the frequency<br />
of JAK2 46/1 haplotype in Essential thrombocyhemia (ET)<br />
patients in comparison with population controls. As second<br />
we evaluate the association of 46/1 with the JAK2V617F<br />
mutational status <strong>and</strong> the clinical characteristics in the series<br />
of patients with ET that were diagnosed <strong>and</strong> treated at<br />
the University Clinic of hematology-Skopje, Republic of<br />
Macedonia.<br />
Patients <strong>and</strong> methods: Ninthly five consecutive patients<br />
diagnosed with ET according to proposed criteria for diag-<br />
102<br />
nosis in 2008 by the World Health Organization were included<br />
in our study. The 46/1 tag SNP rs12343867 (C/T)<br />
was genotyped on a MxPro 3005P real-time PCR system<br />
(Stratagene, La Jolla, CA,USA) using the TaqMan SNP genotyping<br />
assay (Applied Biosystems, Foster City, CA,<br />
USA) according to the manufacturer’s instructions.<br />
Results: The incidence of 46/1-linked C allele was significantly<br />
higher in ET (genotype: CC 13%, CT 60%, TT<br />
27%; C-allele frequency: 43,7) than in population control<br />
(C-allele frequency 29%), P
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
resection.Three patients treated with CT underwent haematopoietic<br />
stem cell transplantation (HSCT), autologous in<br />
one, <strong>and</strong> allogeneic from related donor in other two patients,<br />
Tottaly, five patients died. Median group overall survival<br />
was 28 months. Mean survival time in the group of patients<br />
treated with chemotherapy was 22.1 months. Within the<br />
group of patients initially treated with surgical resection<br />
who were followed later on, mean survival time was 25.2<br />
months. No significant difference in survival was observed<br />
between these two groups of patients (p>0.05). Mean survival<br />
time to systemic leukemia development was 21.9<br />
months.<br />
Conclusion: According to the results in our series of patients,<br />
it is clear that in cases of suspected MS, employment<br />
of wide spectrum of antibodies during immunohistochemical<br />
work-up of tumor tissue is m<strong>and</strong>atory. Also, optimal<br />
treatment is not defined, in part because of different clinical<br />
presentation. Chemotherapy, HSCT, surgical resection, or<br />
combination of these approaches, is used depending on actual<br />
case.<br />
PP32 The Risk of Hematopoetic Malignancy<br />
in Children Born after in vitro Fertilization<br />
Bilic E, Stemberger L, Slipac J, Stojsavljevic S, Bilic E,<br />
Konjevoda P, Konja J, Femenic R, Rajic Lj. Department<br />
of Pediatrics <strong>and</strong> Departmen of Neurology, Clinical<br />
Hospital Center <strong>and</strong> School of Medicine, University<br />
of Zagreb, Croatia<br />
Infertility is one of the major health <strong>and</strong> social problems<br />
where assisted reproductive technology such as in vitro fertilization<br />
(IVF) can offer an efficient solution. Evaluation of<br />
children conceived by IVF is neccessary to determine the<br />
safety of the method. Hematopoetic tumors (leukemia <strong>and</strong><br />
lymphoma) <strong>are</strong> the most common childhood cancers. Some<br />
study found an association with IVF <strong>and</strong> increased risk for<br />
acute lymphoblastic leukemia (ALL) <strong>and</strong> non-Hodgkin<br />
lymphoma (NHL) in children.<br />
Aim: The aim of present study was to determine whether<br />
there is an increased risk for hematopoetic tumors in children<br />
conceived by IVF in comparison to children born after<br />
natural conception.<br />
Patients <strong>and</strong> methods: The study included 550 children<br />
treated for leukemia or lymphoma (345 ALL, 67 acute myeloblastic<br />
leukemia (AML), 63 Hodgkin lymphoma <strong>and</strong> 75<br />
NHL) in the Department of Pediatric, University of Zagreb,<br />
School of Medicine Zagreb, Croatia, between 1994. <strong>and</strong><br />
2009.y.<br />
Results: Three children of 550 included in the study were<br />
born after IVF. Two suffered from ALL <strong>and</strong> one from AML<br />
Conclusion: Results of our study showed no increased<br />
risk for childhood leukemia <strong>and</strong> lymphoma in children conceived<br />
by IVF in comparison to children conceived naturally.<br />
The main limitation of our, <strong>and</strong> most of other similar<br />
studies was the sample size not large enough to decline the<br />
discrepancy of literature data <strong>and</strong> to provide an unambiguous<br />
answer to the question of increased risk of hematopoetic<br />
tumors in children concieved by IVF<br />
PP33 H1N1 Infl uenza pneumonia in patient with<br />
chronic lymphocytic leukemia – case report<br />
Vince A 1 , Barsic B 1 , Dusek D 1 , Vrhovac R 2 , Kutlesa M 1 ,<br />
Santini M 1 . 1 University Hospital for Infectious Diseases<br />
»Dr. Fran Mihaljevic«, Zagreb, Croatia, 2 Department of<br />
Medicine, Division of Hematology, University Hospital<br />
»Merkur« Zagreb, Croatia<br />
Initial experience with the 2009 H1N1-Influenza A<br />
(H1N1) suggests that this virus can cause severe disease in<br />
immunosuppressed patients such as influenza pneumonia<br />
<strong>and</strong> respiratory failure.<br />
We present a case of 41-year old man with chronic lymphocytic<br />
leukemia (CLL) who was treated at the University<br />
Hospital for Infectious Diseases in February 2011 because<br />
of influenza pneumonia. The patient was first diagnosed in<br />
2008, with small tumor mass (TTM 5.7) CLL, Rai stage I.<br />
His phenotype was typical for B-CLL, <strong>and</strong> due to low CD38<br />
expression <strong>and</strong> trisomy 12 he was not regarded as a patient<br />
with adverse prognosis. Although his tumor mass gradually<br />
increased over time, he never required specific treatment.<br />
Patient was not vaccinated against influenza although recommended<br />
by his hematologist. Present illness started on<br />
2/11/2011 with dry cough <strong>and</strong> low-grade temperature. He<br />
was initially prescribed clarithromycin. On 2/16/2011 patient<br />
became febrile up to 40 C with shaking chills <strong>and</strong> productive<br />
cough. He was admitted to small local hospital on<br />
2/17/2011 because of bilateral pneumonia. Upon admission,<br />
the patient was febrile (40 C), with decreased breath sounds<br />
on the left side with fine crackles bilaterally. The remainder<br />
of physical examination was unremarkable. Therapy with<br />
oseltamivir, ceftriaxone <strong>and</strong> doxycycline was commenced.<br />
On the fifth day of hospital stay patient’s condition started<br />
to deteriorate with development of respiratory insufficiency<br />
<strong>and</strong> he was transferred to Intensive C<strong>are</strong> Unit (ICU) where<br />
mechanical ventilation was started. Ceftriaxone was changed<br />
to meropenem <strong>and</strong> vancomycin; doxycycline <strong>and</strong> oseltamivir<br />
were continued. Unfortunately, respiratory insufficiency<br />
worsened <strong>and</strong> extracorporeal membrane oxygenation was<br />
considered as only life-saving procedure. He was transferred<br />
to ICU of University Hospital for Infectious Diseases<br />
on the twelfth day of illness. Upon admission patient was<br />
mechanically ventilated (fiO2 100%) <strong>and</strong> hypoxemic (satO2<br />
80%). Pulmonary X-ray showed bilateral confluent, mixed<br />
alveolar <strong>and</strong> interstitial infiltrates, consistent with acute respiratory<br />
distress syndrome (ARDS). ECMO was started<br />
upon admission. On the seventh day of hospitalization there<br />
was further deterioration of patient’s condition, probably<br />
because of nosocomial sepsis with development of septic<br />
shock <strong>and</strong> multiple organ dysfunction syndrome. Patient<br />
died on the tenth day of hospitalization, i.e. twenty-first day<br />
of influenza illness. Diagnosis of influenza A-H1N1 was<br />
confirmed by RT-PCR from tracheal aspirate.<br />
CLL patients <strong>are</strong> particularly at risk for influenza complications<br />
because of hypogammaglobulinemia <strong>and</strong> deficient<br />
T-cell compartment. Therefore physicians should strongly<br />
encourage their patients to get influenza vaccine. Otherwise,<br />
during influenza season empirical therapy with oseltamivir<br />
should be started at the first symptoms of influenza.<br />
103
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
PP34 Treatment of paroxismal nocturnal<br />
hemoglobinuria – a case report<br />
Boban A 1 , Serventi Seiwerth R 1 , Basic-Kinda S 1 , Peric Z 1 ,<br />
Dubravcic K 2 , Batinic D 2 , Labar B 1 . 1 Division of<br />
Hematology, Department of Medicine, 2 Department of<br />
Clinical Laboratory, Clinical Hospital Center <strong>and</strong> School<br />
of Medicine, University of Zagreb, Croatia<br />
Introduction: Paroxismal nocturnal hemoglobinuria<br />
(PNH) is clonal acquired disorder characterized by hemolytic<br />
anemia, thrombosis, fatigue <strong>and</strong> bone marrow failure.<br />
It is caused by acquired mutation of PIG-A gene in mutipotent<br />
hematopoietic stem cell. As a consequence, cells <strong>are</strong><br />
lacking glycosil phosphatidylinosiol (GPI) – anchored proteins,<br />
namely CD55 <strong>and</strong> CG 59, which <strong>are</strong> complement<br />
regulatory proteins. The lack of complement regulatory proteins<br />
makes erythrocytes susceptible to both intravascular<br />
<strong>and</strong> extravascular hemolysis. Intravascular hemolysis is responsible<br />
for majority of morbidity form the disease. Eculizumab<br />
is a monoclonal antibody that inhibits terminal complement<br />
activation, which reduces intravascular hemolysis<br />
in PNH patients.<br />
Aim: Here we present the first PNH patient in our Center<br />
treated with eculizumab.<br />
Case presentation: The patient was diagnosed having<br />
aplastic anemia in 2009, at the age of 21. The treatment<br />
started with corticosteroids, <strong>and</strong> later altered into cyclosporine.<br />
In 2005 the patient presented with severe headache <strong>and</strong><br />
transitory ischemic attack. At that point PNH was suspected,<br />
<strong>and</strong> diagnostic procedure was carried out. Diagnose of<br />
PNH was made based on PNH clone on flow cytometry. In<br />
2007, the progression of intravascular hemolysis was noted,<br />
with significant increase in bilirubin <strong>and</strong> lactate dehidrogenase<br />
levels, followed by the signs of bone marrow failure.<br />
The need for blood transfusions <strong>and</strong> fatigue increased, while<br />
quality of life decreased. Allogenic stem cell transplantation<br />
was indicated, but no related donor was found. The patient<br />
was eligible for eculizumab treatment.<br />
The treatment with eculizumab started in January 2010.<br />
Patient was vaccinated for Naisseria meningitides, <strong>and</strong> developed<br />
severe cellulitis with skin necrosis on the place of<br />
the puncture, hence the reconstructive surgery of the left upper<br />
arm was needed. At the time when eculizumab was<br />
started, patient had severe hemolysis, thrombocytopenia,<br />
<strong>and</strong> anemia with need of blood transfusions every 2–3 weeks<br />
<strong>and</strong> secondary hemochromatosis. Subjectively, she complained<br />
mostly on severe fatigue. The patient received induction<br />
treatment without side effects <strong>and</strong> continued with<br />
maintenance treatment for 19 months. A significant decrease<br />
of hemolysis was noted, <strong>and</strong> consequently reduced<br />
need for transfusions <strong>and</strong> disappearance of symptoms,<br />
mainly fatigue with dramatic improvement in her quality of<br />
life.<br />
Conclusion: Eculizumab treatment significantly improved<br />
quality of life of the PNH patient form our center. Patients<br />
main symptom, fatigue, disappe<strong>are</strong>d almost completely,<br />
<strong>and</strong> rate of blood transfusion was reduced to once in<br />
5–6 weeks. We found eculizumab effective in treatment of<br />
PNH patients.<br />
104<br />
PP35 Anti-proliferative <strong>and</strong> pro-apoptotic action<br />
of the combined cytostatic/<br />
immunosuppressive treatment of myeloma<br />
cell lines in vitro<br />
Zelic A 1 , Ivcevic S 1 , Kovacic N 1 , Kusec R 2 , Grcevi} D 1 .<br />
1 Zagreb University School of Medicine; 2 Dubrava<br />
University Hospital, Zagreb, Croatia<br />
Multiple myeloma (MM) is B-lymphocyte neoplasia,<br />
characterized by the slow proliferation of malignant plasma<br />
cells in the bone-marrow (BM). Multiple anti-apoptotic signaling<br />
mechanisms contribute to the accumulation of myeloma<br />
cells within the BM <strong>and</strong> account for their resistance<br />
to chemotherapy. Therefore, investigation of the effects of<br />
different agents on the balance between pro- <strong>and</strong> anti-apoptotic<br />
factors in the malignant clone would contribute to the<br />
development of novel therapeutic strategies in MM.<br />
Aim: We determined the effects of several currently used<br />
anti-myeloma agents <strong>and</strong> their possible additive action on<br />
the inhibition of proliferation <strong>and</strong> enhancement of apoptosis<br />
of different human myeloma cell lines.<br />
Material <strong>and</strong> methods: Human myeloma cell lines NCI-<br />
H929, RPMI 8226 <strong>and</strong> JJN3 (ADCC-LGC <strong>and</strong> DSMZ cell<br />
line collection) <strong>and</strong> Theil (a gift from Dr. K. Pulford, University<br />
of Oxford, UK) were treated with bortezomib (Millenium<br />
Pharmaceuticals), dexamethasone, cyclosporine <strong>and</strong><br />
thalidomide (Sigma-Aldrich) for 48 hrs. Cell line proliferation<br />
was assessed by the colorimetric MTT assay, whereas<br />
viability <strong>and</strong> apoptosis were evaluated by annexin V/propidium<br />
iodide staining. Gene expression of pro-apoptotic<br />
(Bax <strong>and</strong> p21) <strong>and</strong> pro-survival molecules (Bcl-2 <strong>and</strong> c-<br />
Myc) was assessed by real-time AB7500 instrument (Applied<br />
Biosystems). Additionally, we assessed the expression<br />
of SPARC (secreted protein acidic <strong>and</strong> rich in cysteine), involved<br />
in the cell de-adhesion from BM matrix <strong>and</strong> tumor<br />
pathogenesis.<br />
Results: Anti-myeloma agents (dexamethasone, bortezomib<br />
<strong>and</strong> thalidomide) achieve their effects by different cellular<br />
mechanisms. In addition, cyclosporine was included<br />
for its ability to increase cell sensitivity to other cytostatics.<br />
Each cell line, representing different biological variant of<br />
MM, has shown unique pattern of the expression of pro- <strong>and</strong><br />
anti-apoptotic genes <strong>and</strong>, in addition, responded differently<br />
to anti-myeloma treatment. The most potent additive effect<br />
of drug combinations, including thalidomide/bortezomib,<br />
thalidomide/cyclosporine <strong>and</strong> bortezomib/cyclosporine,<br />
was noticed on the cellular <strong>and</strong> molecular level, as suppressed<br />
proliferation <strong>and</strong> shift in the balance of pro- <strong>and</strong><br />
anti-apoptotic genes.<br />
Conclusion: Resistance to apoptosis, common in myeloma<br />
cells, depends on the constitutive expression of molecules<br />
acting at cell-cycle checkpoints <strong>and</strong> activated intracellular<br />
pathways in the particular circumstances. We observed<br />
that the susceptibility of myeloma cells to specific<br />
treatment is determined by their intrinsic balance between<br />
pro-survival <strong>and</strong> pro-apoptotic factors. Certain drug combinations,<br />
specifically thalidomide or bortezomib with cyclosporine,<br />
decreased Bcl-2/Bax ratio, a key indicator of enhanced<br />
apoptosis. Our findings suggest that the insight into
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
the molecular events in the affected clone could enable administration<br />
of a specific individualized therapy which<br />
would be more effective in eradicating the malignant clone.<br />
PP36 T<strong>and</strong>em Transplantation in Multiple<br />
Myeloma – Single Center Experience<br />
Batinic J 1 , Durakovic N 1 , Sertic D 1 , Bojanic I 2 , Batinic D 3 ,<br />
Golubic-Cepulic B 2 , Mazic S 2 , Radman Livaja I 1 ,<br />
Basic-Kinda S 1 , Aurer I 1 , Labar B 1 , Nemet D 1 . 1 Division of<br />
Hematology, Department of Medicine, 2 Department of<br />
Transfusiology, 3 Deaprtment of Clinical Laboratory,<br />
Clinical Hospital Center <strong>and</strong> School of Medicine,<br />
University of Zagreb, Croatia<br />
High-dose chemotherapy followed by autologous hematopoetic<br />
stem cell transplantation is well established first<br />
line therapy for multiple myeloma. It has been previously<br />
shown that t<strong>and</strong>em transplantation carries survival benefit<br />
when comp<strong>are</strong>d to a single transplantation. We have conducted<br />
a trial of two successive high-dose chemotherapy<br />
followed by peripheral blood stem cell rescue for patients<br />
with advanced stage multiple myeloma.<br />
Aim: Aim was to evaluate feasibility, efficacy <strong>and</strong> toxicity<br />
of t<strong>and</strong>em transplantation.<br />
Patients <strong>and</strong> Methods: We included 107 patients, median<br />
age 54 years (32–66), 49 were female, <strong>and</strong> 58 male<br />
patients. Most of the patients had IgG monoclonal protein<br />
(54.2%), 17.7% patients had IgA monoclonal protein,<br />
17.7% had light chain myeloma, while 9.3% had non-secretory<br />
myeloma, <strong>and</strong> one patient had IgD monoclonal protein.<br />
Patients were evaluated on a intention to treat basis, <strong>and</strong><br />
from 107 included patients, 83 (77.5%) received t<strong>and</strong>em<br />
transplantation; 4 patients did not collect adequate number<br />
of cells for two transplantations, 10 patients had low performance<br />
score, 7 were not transplanted due to physician decision,<br />
1 patient refused second transplantation, 1 patient relapsed<br />
<strong>and</strong> for 1 patient the reason is unknown.<br />
Results: Progression free survival (PFS) <strong>and</strong> overall survival<br />
(OS) were evaluated. Median time of progression free<br />
survival for the entire group was 77 months, while median<br />
time of overall survival was 138 months. Prior to first transplantation<br />
8.6% of patients were in complete remission or<br />
very good partial remission (CR/VGPR), 78% were in partial<br />
remission (PR) <strong>and</strong> 11.4% had minimal response, while<br />
1.9% had progressive disease. After the first transplantation<br />
42.3% achieved CR/VGPR <strong>and</strong> 50% of patients were in PR,<br />
while after the second transplantation 71.8% of patients<br />
were in CR/VGPR <strong>and</strong> 26.2% were in PR. We conducted<br />
analysis of PFS <strong>and</strong> OS according to disease status prior to<br />
second transplantion <strong>and</strong> found no significant difference between<br />
patients that achieved CR or VGPR <strong>and</strong> the patients<br />
that did not do so. However, when the same analysis was<br />
done according to disease status 6 months after the second<br />
transplantation, a significant difference in both PFS <strong>and</strong> OS<br />
was found between patients that achieved CR/VGPR <strong>and</strong><br />
the patients that did not achieve CR/VGPR (p=0.0179 <strong>and</strong><br />
p=0.0056 respectively).<br />
Conclusion: T<strong>and</strong>em transplantation as first line treatment<br />
for multiple myeloma is an effective therapy offering<br />
patients long term progression free survival <strong>and</strong> overall survival.<br />
We found no significant difference in long term PFS<br />
<strong>and</strong> OS between patients that achieved CR/VGPR prior to<br />
second transplantation <strong>and</strong> those that did not, indicating important<br />
therapy efficacy of second transplantation. Also, patients<br />
achieving CR/VGPR after second transplantation<br />
have statistically better PFS <strong>and</strong> OS than patients failing to<br />
do so, which emphasizes importance of achieving CR as a<br />
final outcome.<br />
PP37 The Role of Thalidomide as Maintenance<br />
Therapy in Multiple Myeloma<br />
Bila J 1,2 , Bodrozic J 2 , Todorovic M 1,2 ,<br />
Sefer D 2 , Kraguljac N 2 , Antic D 2 , Andjelic B 2 , Elezovic I 1,2 ,<br />
Tomin D 1,2 , Gotic M 1,2 , Mihaljevic B 1,2 . 1 Medical Faculty,<br />
University of Belgrade, 2 Clinic of Hematology, CCS,<br />
Belgrade, Serbia<br />
The aim of study was to analyse results of thalidomide<br />
maintenance in patients with multiple myeloma.<br />
Patients <strong>and</strong> methods: The study included 130 newly<br />
diagnosed patients: 1) 50pts treated with high-dose treatment<br />
(HDT) <strong>and</strong> autologous stem cell transplant (ASCT, 29<br />
male/21 female, mean age 53 yrs, range 41–65); <strong>and</strong> 2) 80<br />
elderly pts (45 male/35 female, mean age 68 yrs, range 66–<br />
83yrs); with IgG myeloma in 75pts; IgA 27pts; light chains<br />
25pt; non-secretory 3pts. Distribution according to the clinical<br />
stage <strong>and</strong> ISS score was as follows: 1) II 56pts; III<br />
74pts; ISS3 in <strong>and</strong> 59pts with ISS3 score. Induction treatment<br />
in the first group was: a) VAD (average 4 cycles, range<br />
3–6 cycles in 35/50pts); b) CTD (average 4 cycles, range<br />
3–6 cycles in 15/50pts), followed by Melphalan 200mg/m²<br />
<strong>and</strong> ASCT. The maintenance therapy was: Alfa-Interferon<br />
(aIFN) in 10/35pts after VAD; Thalidomide (100mg/day) in<br />
35/50pts after VAD/CTD. Median duration of maintenance<br />
was 19m (range 6–36 m). Initial treatment for the elderly<br />
pts: a) MP (30/80pts); b) MPT (35/80pts); c) Thal-Dex<br />
(15/80pts). The maintenance therapy was: Alfa-Interferon<br />
(aIFN) after MP (30/30pts); Thalidomide (100mg/day) after<br />
MPT/Thal-Dex (50/80pts). Median duration of maintenance<br />
was 16m (range 4–28 m).<br />
Results: In the first pts group, after VAD, VGPR was<br />
achieved in 4/35pts; PR in 25/35pts. Following HDT,<br />
7/35pts achieved CR; VGPR 9/35pts; PR 14/35pts. After<br />
CTD induction, CR existed in 3/15pts; VGPR/PR in 8/15pts.<br />
Median follow-up was 26m (range 18–60 m). Thalidomide<br />
maintenance after CTD significantly improved 3-yrs probability<br />
of relapse-free survival (VAD+HDT+aIFN: RFS<br />
25% vs. VAD+HDT+Thal: RFS 37% vs. CTD+HDT+Thal:<br />
RFS 51%, P<br />
Conclusion: Thalidomide as maintenance therapy significantly<br />
improves treatment results in myeloma patients<br />
with limitations due to toxic effects.<br />
105
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
PP38 Modifi cated dosing of the VMP /Velcade +<br />
melphalan + prednisone/ regime in multiple<br />
myeloma /MM/ patients<br />
Masarova K, Stefanikova Z, Mistrik M. Department of<br />
Hematology <strong>and</strong> Transfusiology, University Hospital,<br />
Bratislava, Slovakia<br />
Aim: To establish efficacy <strong>and</strong> sefety modificated dosing<br />
of VMP regime once weekly in MM patients not eligible for<br />
autologous stem cell transplantation /ASCT/.<br />
Abstract: In september 2008, J. San Miguel et al. published<br />
the results of the study Phase III VISTA comparing<br />
treatment regime VMP /Velcade+melphalan + prednisone/<br />
vs MP in newly diagnosed patients with MM not eligible for<br />
ASCT. In the VISTA study bortezomib administration was<br />
1,3 mg/m 2 in 9 six weeks cycles, in the first 4 cycles the<br />
administration was more intense /day 1,4,8,11,22,25,29,32/<br />
<strong>and</strong> the following 5 cycles the administration of bortezomib<br />
in days 1,8,22,29. This study confirmed significantly longer<br />
medium OS /medium overal survival/ of patients in the<br />
VMP arm. ORR in this arm was 71% /CR: 31%, PR: 40%/,<br />
existence of negative adverse events of grade 3 /4 was: neutrophenia<br />
40%, trombocytophenia 37%, anaemia 19%,<br />
polyneuropathy /PN/ 13%. In 2008 A.Palumbo at al. published<br />
a study which comp<strong>are</strong>d effectiveness <strong>and</strong> safety of<br />
the VMP regime vs. VMPT in newly diagnosed patients not<br />
eligible for ASCT. In this study, at the beginning the bortezomib<br />
administration was as in the VISTA study, but in<br />
march 2007 the protocol was changed <strong>and</strong> the administration<br />
of bortezomib was changed to 9 five weeks cycles /1,3<br />
mg/m 2 in days 1,8,15,22/. The effectiveness of bortezomib<br />
remained unchanged /ORR: 81%, CR: 21%/ but the adverse<br />
events, especially PN of grade 3/4 /2%/ decreased <strong>and</strong> also<br />
decreased the amount of the treatment discontinuations<br />
/10%/.<br />
Published results led us to administration VMP regime in<br />
treatment of MM in patients not eligible for ASCT in five<br />
weeks cycles with administration of bortezomib 1x weekly<br />
/1,3 mg/m 2 in days 1,8,15,22/, melphalan 9mg/m 2 <strong>and</strong> prednisone<br />
60 mg/m 2 in days 1–4. Since April 2009 we have<br />
collected group of 33 patients with median line of previous<br />
MM treatment 3. Currently is possible to evauluate 33 patients<br />
who absolved min. 4 cycles of previous treatments. In<br />
this patients we achieved CR in 33%, PR in 42%, ORR in<br />
75% with no PN of grade 3 /4. No patient had to discontinuate<br />
or terminate treatment due to adverse events. Median of<br />
administered cycles was 6,9 cycles. Median TTP /time to<br />
progression/ was 25,7 months /VISTA 24 months/. Median<br />
OS was not yet reached /VISTA not yet reached/.<br />
Conclusion: On the base of our experience we can confirm<br />
that the effectiveness of modificated VMP regime in<br />
MM patients not eligible for ASCT remained stable <strong>and</strong> we<br />
did not observed any adverse events of grade 3/4 or discontinuations<br />
of the treatment due to adverse events. Decreased<br />
frequency of bortezomib administration was well tolerated<br />
also by the patients who were comming for the administration<br />
once weekly.<br />
106<br />
PP39 Tevagrastim <strong>and</strong> Plerixafor as fi rst line<br />
mobilizing regimen in patients with<br />
lymphoma <strong>and</strong> Multiple Myeloma<br />
Andreola G., Babic A., Negri M., Drera M., Martinelli G.,<br />
Laszlo D. Department of Haematology, European Institute<br />
of Oncology, Milan, Italy<br />
Patients affected by hematologic malignancies might benefit<br />
from high dose chemotherapy followed by peripheral<br />
stem cells (PBSC) transplant. Chemotherapy in combination<br />
with G-CSF is effective in mobilizing stem cells but<br />
often toxic, might require prolonged hospitalization <strong>and</strong> extensive<br />
supportive c<strong>are</strong>. Moreover a high proportion of patients,<br />
ranging from 11 to 53%, fail to collect an adequate<br />
number of stem cells with this approach. Plerixafor, a<br />
CXCR4 chemokine antagonist, has shown to increase the<br />
number of circulating CD34+ cells in cancer patients when<br />
used alone or with G-CSF <strong>and</strong> to be able to rescue patients<br />
unable to mobilize with traditional regimens. Recently several<br />
forms of biosimilar nonglycosylated recombinant human<br />
G-CSF have been clinically developed <strong>and</strong> approved<br />
by the European Medicines Agency for the same indications<br />
as the reference filgrastim product on the basis of comparable<br />
quality, efficacy <strong>and</strong> safety. Biosimilars also represent<br />
a more cost-effective strategy <strong>and</strong> their use in clinical setting<br />
may provide cost savings in their indicated uses. In order<br />
to test the efficacy of the combination of biosimilar version<br />
of G-CSF (Tevagrastim) <strong>and</strong> plerixafor in mobilizing<br />
PBSC, from 12/10 to 5/11, 11 patients, affected by Non-<br />
Hodgkin Lymphoma (3), Hodgkin Disease (2) <strong>and</strong> Multiple<br />
Myeloma (MM) (6), were treated as follows: Tevagrastim<br />
(10µg/kg/die) was self administered for 3 days; on day 4<br />
patients were admitted to the hospital, circulating CD34+<br />
cells counted <strong>and</strong> if 500 of 12 (9–13) <strong>and</strong> of PLT>20.000 of<br />
13 (9–19) days.<br />
The combination of tevagrastim <strong>and</strong> plerixafor is safe <strong>and</strong><br />
effective in mobilizing PBSC <strong>and</strong> allows a collection of a<br />
more than adequate number of cells in most of the patients<br />
in a maximum of 2 apheresis procedures, even in patients<br />
with MM who need to collect a double amount of cells.<br />
PP40 Does Prelixafor do the trick in mobilising<br />
Stem Cells?<br />
Vieira S, Monroe D, Librojo M. London, United Kingdom<br />
Abstract: Plerixafor (MOZOBIL) is an antagonist of alpha-chemokine<br />
receptor CXCR <strong>and</strong> one of the new additions<br />
to Haematology discipline <strong>and</strong> it is used as a stem cell<br />
mobiliser. CXCR4 alpha-chemokine receptors <strong>are</strong> important<br />
in a hematopoietic stem cell homing to the bone marrow<br />
<strong>and</strong> in hematopoietic stem cell quiescence. It is indicated<br />
in combination with Granulocyte Colony Stimulating<br />
Factor (GCSF) for Peripheral Blood Stem Cell (PBSC) collections<br />
in the Multiple Myeloma (MM) <strong>and</strong> Lymphoma<br />
patient group with a poor mobilisation history<br />
Patients <strong>and</strong> methods: In our organisation, data was collected<br />
prospectively. 14 patients received Plerixafor for<br />
PBSC collection between May 2009 <strong>and</strong> September 2010.
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
All patients except one met the criteria prior to treatment<br />
(White Blood Count> 2.5 x 109/L, Absolute Neutrophil<br />
Count > 1.5 x 109/L, Platelet> 85 x 109/L, Serum Creatinine<br />
< 1.5 mg/dL, Aspartate transaminase (AST), Alanine<br />
Transaminase (ALT), Bilirubin < 2 x ULN with no evidence<br />
of Hepatitis B <strong>and</strong> C. One patient had low platelet count.<br />
Patient demographic data is shown in Table 1. Three patients<br />
had an underlying documented medical problem (cortochondritis<br />
<strong>and</strong> glaucoma).<br />
Results: Nine of the patients were diagnosed with MM<br />
<strong>and</strong> three with Non-Hodgkin’s Lymphoma (NHL), two patients<br />
with Hodgkin’s Disease <strong>and</strong> one with Neuroblastoma.<br />
All patients received four consecutive days of GCSF 10 ľg/<br />
kg prior to Plerixafor. Plerixafor was given 10 hours before<br />
the PBSC collection <strong>and</strong> GCSF was repeated one hour prior<br />
to PBSC collection time in the morning. All patients received<br />
0.24mg/kg/day of Plerixafor. There were no side effects<br />
observed. Only one patient required a second dose of<br />
Plerixafor.<br />
For all cases, the target CD34+ count was 4 x 106 cells/<br />
kg of recipient body weight. Two patients responded extremely<br />
well with a CD34+ count of 21.79 x 106 cells/kg<br />
<strong>and</strong> 15.16 x 106 cells/kg achieved <strong>and</strong> six patient had<br />
achieved the target of 4 X 106 cells/kg or above with positive<br />
outcome. However seven patients failed to achieve to<br />
reach target CD+ 34 4 X109cells/kg of CD34 count was<br />
collected. Six of these patients had adequate amount of<br />
CD34 count for an autologus transplant. Only one patient<br />
failed to mobilise any CD34 at all.<br />
Conclusion: Plerixafor was used at The London Clinic<br />
recently with mostly favourable outcomes. According to<br />
this study Plerixafor has improved PBSC outcomes with<br />
one exception case. Prelixafor definitely made a positive<br />
difference 54% of our patient <strong>and</strong> 40% of our patient had<br />
enough cells for an aoutologus transplant. However, results<br />
<strong>are</strong> inconclusive due to small patient numbers. Ongoing<br />
studies with new patient experiences <strong>are</strong> needed. More than<br />
one dose of Plerixafor maybe required for heavily pre-treated<br />
patients who <strong>are</strong> historically poor mobiliser of PBSC<br />
collections.<br />
PP41 Multidrug Resistance: From Research<br />
to Clinics<br />
Tauber Jakab K 1 , Márki-Zay J 1 , Kis E 1 , Udvardy M 2 ,<br />
Borbényi Z 3 , Dávid M 4 , Krajcsi P 1 . 1 Solvo Biotechnology,<br />
Szeged, Hungary; 2 2nd Department of Internal Medicine,<br />
University of Debrecen-Medical <strong>and</strong> Health Science<br />
Center, Debrecen, Hungary; 3 2nd Department of Medicine<br />
<strong>and</strong> Cardiology, University of Szeged – Albert Szent-<br />
Györgyi Clinical Center, Szeged, Hungary; 4 1st<br />
Department of Internal Medicine, Pécs, Hungary<br />
Since the beginning of the 90’s several studies have confirmed<br />
the role of multidrug transporter proteins as major<br />
mechanism of chemoresistance in a variety of haematological<br />
malignancies. This phenomenon usually results from the<br />
overexpression of ATP-binding cassette (ABC) transporters,<br />
such as ABCB1 (MDR1 or P-gp), ABCC1 (MRP1), <strong>and</strong><br />
ABCG2 (MXR or BCRP), which <strong>are</strong> known to function as<br />
drug efflux pumps causing drug resistance by actively extruding<br />
multiple anticancer drugs with expenses of ATP. According<br />
to a number of multicentric trials, P-glycoprotein or<br />
ABCG2 expression <strong>are</strong> bad prognostic markers in acute myeloid<br />
leukemia (AML) regarding remission rate <strong>and</strong> overall<br />
survival.<br />
Aim: The primary goal of our study was to evaluate the<br />
frequency of the three clinically relevant ABC transporters<br />
in AML <strong>and</strong> chronic lymphoid leukemia (CLL) using a<br />
functional routine clinical laboratory flow cytometric assay.<br />
In addition, we have characterized several anticancer drugs<br />
for their interactions with efflux transporters using cellular<br />
<strong>and</strong> membrane-based assays.<br />
Patients <strong>and</strong> methods: In the frame of a multicentric<br />
trial, flow cytometric assays were performed using the MultiDrugQuant<br />
kit (MDQ kit) on CD45dim blast cells of 26<br />
AML patients <strong>and</strong> CD19+ 28 CLL patients prior to the initiation<br />
of chemotherapy. The MDQ kit applies the calcein-<br />
<strong>and</strong> mitoxantrone-assays for the measurement of the function<br />
of MDR1, MRP1 <strong>and</strong> BCRP transporters. Activities of<br />
the multidrug transporters <strong>are</strong> calculated from the difference<br />
between the geomean cellular fluorescent intensities<br />
determined w/o transporter specific inhibitors <strong>and</strong> <strong>are</strong> expressed<br />
as multidrug resistance activity factor (MAF) values.<br />
Substrate or inhibitory profiles of 20 anticancer drugs<br />
have been characterized using membrane-based ATPase <strong>and</strong><br />
vesicular transport assays <strong>and</strong> cellular dye efflux assays<br />
such as the Calcein- <strong>and</strong> Hoechst-assays. The results of<br />
these experiments have been correlated to the cytotoxicity<br />
of the compounds on control (HL60, PLB) <strong>and</strong> transporter<br />
overexpressing (HL60-MDR1, HL60 MRP1 <strong>and</strong> PLB-<br />
BCRP) cell lines.<br />
Results: The median age of AML <strong>and</strong> CLL pts was 55<br />
<strong>and</strong> 67 years, respectively. MAF values were above the cutoff<br />
value in 9 of the 26 AML <strong>and</strong> in 12 of the 28 CLL patients<br />
at enrollment. Results of the membrane-based <strong>and</strong><br />
cellular assays to test the drug-transporter interactions<br />
agreed well.<br />
Conclusion: Based on these preliminary data the MDQ<br />
kit is reliable <strong>and</strong> provides transporter specific quantitative<br />
results on the function of the MDR1, MRP1 <strong>and</strong> BCRP<br />
transporters in the target cells. Besides other prognostic factors<br />
measurement of transporter activity allows risk stratification<br />
of the AML or CLL patients. The high-throughput in<br />
vitro assays presented here enable to characterize the interactions<br />
of antineoplastic drugs with multidrug transporters.<br />
PP42 P-glycoprotein activity <strong>and</strong> Flt3 internal<br />
t<strong>and</strong>em duplication in 39 patients with<br />
acute myeloid leukemia<br />
Batinic D 1 , Perkovic S 1 , Zadro R 1 , Labar B 2 , 1 Department<br />
of Clinical Laboratory, 2 Division of Hematology, Clinical<br />
Hospital Center <strong>and</strong> School of Medicine, University of<br />
Zagreb, Croatia<br />
Aim: Flt3 internal t<strong>and</strong>em duplication (Flt3/ITD) <strong>and</strong><br />
high P-glycoprotein (Pgp) activity <strong>are</strong> adverse prognostic<br />
factors in patients with acute myeloid leukemia (AML). The<br />
107
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
aim of this study was to determine the association of Flt3/<br />
ITD, Pgp activity <strong>and</strong> CD34 antigen expression in AML.<br />
Patients <strong>and</strong> methods: Data on Flt3/ITD status <strong>and</strong> Pgp<br />
activity were retrospectively analyzed in a group of 39 patients<br />
with AML diagnosed <strong>and</strong> treated at the University<br />
Hospital Centre Zagreb between January 2010 <strong>and</strong> May<br />
2011. Patients with acute promyelocytic leukemia were excluded<br />
from the study. CD34 antigen expression was determined<br />
by routine flow cytometric immunophenotyping of<br />
AML blasts. Pgp functional activity was assessed using<br />
Rhodamine 123 (Rho123) as a fluorescent probe <strong>and</strong> Pgp<br />
substrate, <strong>and</strong> verapamil (Vpm) as an inhibitor of Pgp activity.<br />
Pgp was considered to be active if ratio of fluorescence<br />
intensity (RFI) (Vpm+/Vpm-) was ≥ 2,0. FLT3/ITD was detected<br />
by RT-PCR analysis (Nakao et al, Leukemia 1996).<br />
Results: Flt3/ITD was found in 7/39 (18%), Pgp activity<br />
in 22/39 (56%) <strong>and</strong> CD34 expression in 26/39 (67%) of all<br />
our patients. Flt3/ITD- Pgp- group accounted for 13/39<br />
(33%); Flt3/ITD+ Pgp- 4/39 (10%); Flt3/ITD- Pgp+ 19/39<br />
(49%); Flt3/ITD+ Pgp+ 3/39 (8%). Four out of seven (57%)<br />
Flt3/ITD+ patients did not express active Pgp, <strong>and</strong> only 3<br />
out of 22 (14%) Pgp+ patients were Flt3/ITD+, demonstrating<br />
no significant association between these two parameters<br />
(Fisher’s exact test; p=0.6765). In addition, Flt3/ITD status<br />
was not associated with CD34 expression (p=0.1938), in<br />
contrast to Pgp+ cases that were CD34+ positive in 19/22<br />
(86%) AMLs (p=0.0054).<br />
Conclusion: Our results confirm the published data on<br />
the association between Pgp activity <strong>and</strong> CD34 marker expression,<br />
<strong>and</strong> the lack of association between the Pgp activity<br />
<strong>and</strong> Flt3/ITD in patients with AML. One possible explanation<br />
for this mutual exclusion might be the origin of leukemic<br />
cells, i.e. more frequent finding of Flt3/ITD in CD34negative<br />
blasts of monocytic origin. Further analysis of<br />
Flt3/ITD <strong>and</strong> Pgp in well-defined subgroups of AML in a<br />
larger cohort of our patients should clarify the role of combined<br />
Pgp <strong>and</strong> Flt3/ITD determination in risk assessment<br />
<strong>and</strong> prognostic classification of patients with AML.<br />
PP43 The pretreatment risk factors <strong>and</strong><br />
importance of comorbidity index for overall<br />
survival, complete remission <strong>and</strong> early<br />
death in patients with acute myeloid<br />
leukemia<br />
Djunic I, Virijevic M, Novkovic A, Djurasinovic V,<br />
Colovic N, Vidovic A, Suvajdzic-Vukovic N, Tomin D,<br />
Clinic of hematology, Clinical Center Serbia, Belgrade,<br />
Serbia<br />
Aim: The aims of this study were to determine as the<br />
pretreatment risk factors for overall survival (OS), rate of<br />
complete remission (CR) <strong>and</strong> early death in patients with<br />
acute myeloid leukemia (AML), as to estimate the influence<br />
of comorbidity on patients’ outcome.<br />
Patients <strong>and</strong> methods: This single-center study involved<br />
184 patients with nonpromyelocytic AML with follow-up<br />
of 58 months. The following parameters were estimated as<br />
the risk factors for OS, CR <strong>and</strong> early death: age, WBC<br />
(=30x10 6 /L), level of serum lactate dehydrogenase (LDH)<br />
108<br />
more than 1.5 x upper limit of normal <strong>and</strong> expression of<br />
CD34 antigen on leukemic blasts (=10%). Performance status<br />
(PS) was evaluated by <strong>East</strong>ern Cooperative Oncology<br />
Group (ECOG), ranged 0–4 (=2). Cytogenetic risk group<br />
was assessed by recommendation of European LeukemiaNet<br />
(ELN). Comorbidities evaluated by using the hematopoietic<br />
cell transplantation-specific comorbidity index<br />
(HCT-CI). Patients treated by Medical Research Council<br />
(MRC) 12 regimen. Risk factors were identified using the<br />
univariate <strong>and</strong> multivariate analysis.<br />
Results: The mean patients age was 56 years, range 18–<br />
79. The most significant risk factor for poor OS was the<br />
adverse cytogenetics: p=0.014, relative risk (RR)=1.314<br />
(95% CI 1.057-1.633). The age >=55 years indicated as the<br />
most significant risk factor for poor rate of CR: p=0.001,<br />
RR=0.274 (95% CI 0.125-0.597). The most significant factor<br />
for early death was the HCT-CI>=3: p=0.027, RR=4.310<br />
(95% CI 1.186-15.665). The cut-off of the age >=55 years<br />
was significant for poor OS <strong>and</strong> CR. The incidence of HCT-<br />
CI>=3 was significantly increased in patient with age >=55<br />
years than in patients younger than 55 years (p=3 had half<br />
of patient aged >=55 years, while 75% of patients younger<br />
than 55 years have HCT-CI=0. Mostly patients (87.9%)<br />
with age=1) had impact of infection on HCT-CI score (according<br />
HCT-CI definition). So, we estimated risk factors<br />
for both of these groups. The most significant risk factor for<br />
OS in group aged=55 years it was HCT-CI>=3: p=0.005,<br />
RR=1.874 (95% CI 1.208-2.907). In the group aged=55<br />
years, elevated serum LDH level was the most significant<br />
factor for poor rate of CR: p=0.015, RR=0.291, (95% CI<br />
0.107-0.790) <strong>and</strong> ECOG PS>=2: p=0.005, RR=0.730 (95%<br />
CI 0.586-0.910) for early death.<br />
Conclusion: This study identified the pretreatment risk<br />
factors for OS, CR <strong>and</strong> early death in patients with AML.<br />
We point out the importance of comorbidity for OS <strong>and</strong><br />
early death, as well as the impact of infection on outcome in<br />
patients with AML.<br />
PP44 Treatment of Adolescents with Acute<br />
Lymphoblastic Leukemia<br />
Konja J, Rajic Lj, Bilic E, Femenic R, Anicic M.<br />
Department of Pediatric, Clinical Hospital Center <strong>and</strong><br />
School of Medicine, University of Zagreb, Croatia<br />
Adolescents with acute lymphoblastic leukemia (ALL)<br />
have languished in the shadow of successful therapeutic<br />
outcome in childhood ALL. While 80% of children aged<br />
1–15 years <strong>are</strong> long-term survivors, less than 40% of adults<br />
<strong>are</strong> cured with current therapies. Adolescents <strong>and</strong> young<br />
adults who may be eligible for both adult <strong>and</strong> pediatric protocols<br />
have continued to have an intermediate outcome,<br />
which has remained inferior to that in children.<br />
Aim: This article has summarized the recent <strong>and</strong> updated<br />
retrospective comparative analysis of adolescents treated<br />
with pediatric <strong>and</strong> adult trials.<br />
Patients <strong>and</strong> methods: Data on ALL adolescents aged<br />
16–18 treated with pediatric trial ALL IC-BFM 2002 were<br />
comp<strong>are</strong>d with literature reports on the treatment of ALL<br />
adolescents according to adult protocols.
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
Results: During the 2002–2006 period, 143 ALL patients<br />
aged 16–18 were treated with pediatric trial ALL IC-BFM<br />
2002. The 3-year event free survival (EFS) was 71%. During<br />
the 1997–2002 period, 67 ALL patients aged 15–17<br />
were treated with adult trial UKALLXII/E2993, <strong>and</strong> 61<br />
ALL age-matched patients were treated with pediatric trial<br />
MRC ALL97, with 5-year EFS of 49% <strong>and</strong> 65%, respectively.<br />
A similar 6-year EFS has been reported for the American<br />
pediatric regimen (CCG) that was by 26% higher in<br />
comparison with their adult regimen (Cancer <strong>and</strong> Leukemia<br />
Group B,CALCB).<br />
Conclusion: Therapeutic outcome in adolescents with<br />
ALL treated according to pediatric protocols is better (16 –<br />
26%) in comparison with adult regimen.<br />
PP45 FLAG-IDA as the Salvage Regime for<br />
Relapsed <strong>and</strong> Refractory Acute Leukemias<br />
Virijevic M, Suvajdzic N, Djunic I, Novkovic A,<br />
Djurasinovic V, Colovic N, Vidovic A, Tomin D. Clinic<br />
for hematology, Clinical Center Serbia, Belgrade, Serbia<br />
Aim: Relapsed <strong>and</strong> refractory acute leukemias (AL) have<br />
poor prognosis. There is no st<strong>and</strong>ard chemotherapy regimen<br />
that provides a durable second complete remission (CR).<br />
One of the most effective salvage regimen is FLAG-Ida.<br />
This study evaluated the efficiency <strong>and</strong> the toxicity of<br />
FLAG-Ida regimen in a relapsed <strong>and</strong> primary refractory AL.<br />
Patients <strong>and</strong> methods: This single-center study involved<br />
42 patients (pts) with AL with follow-up of 5 years. Twentyfour<br />
(52.4%) pts with acute myeloid leukemia (AML) <strong>and</strong><br />
18 (42.9%) with acute lymphoblastic leukemia (ALL) were<br />
included. All patients were treated with FLAG-Ida regimen<br />
(Fludarabin 30mg/m 2 days 1–5; Cytarabin 2000mg/m 2 days<br />
1–5; Idarubicin 8mg/m 2 days 1–3; G-CSF 300mg/m 2 was<br />
given subcutaneously from day 1 until neutrophil recovery).<br />
The following parameters were estimated as the risk factors<br />
for CR achievement <strong>and</strong> overall survival (OS): age, WBC<br />
(=30x10 9 /l), cytogenetics at diagnosis, refractory vs relapsed<br />
AL, early (in first 6–12 months after CR) vs late relapse<br />
(after 1 year) of disease. Cytogenetic risk in AML<br />
patients was according to European LeukemiaNet (ELN).<br />
Patients with ALL with unfavorable cytogenetics (Philadelphia<br />
chromosome or bcr-abl positivity) were considered as<br />
a high risk group. Event-free survival (EFS) <strong>and</strong> OS were<br />
calculated by Kaplan-Meier <strong>and</strong> differences log rank method.<br />
Toxicity was evaluated according to the World Health<br />
Organization (WHO) classification.<br />
Results: The mean pts’ age was 35 years, range 18–55;<br />
twenty-two (52.4%) had relapsed <strong>and</strong> 20 (47.6%) primary<br />
refractory AL. Sixteen of 42 (38.1%) patients achieved CR,<br />
10 (41.7%) pts with AML <strong>and</strong> 6 (33%) pts with ALL<br />
(p=0.03). Hematological toxicity (grade III-IV) occurred in<br />
all AL cases. The median time to neuthrophil recovery<br />
(ANC >500/µl) <strong>and</strong> platelet recovery (>20x10 9 /l) were 17<br />
<strong>and</strong> 20 days from the start of therapy. Nonhematological<br />
toxicity was mild (grade I-II). Febrile neutropenia was registered<br />
in 39 (90.5%) pts. Infection of unknown cause was<br />
registered in 21 (54.7%) <strong>and</strong> of known cause in 18 (46.3%)<br />
pts, respectively. The significant risk factor for poor CR rate<br />
in relapsed AL was WBC>=30x10 9 /l (p=0.043). The most<br />
significant risk factor for OS was early relapse vs late relapse<br />
(10 vs 24 months, p<br />
Conclusion: FLAG-Ida proved to be highly effective <strong>and</strong><br />
low toxic regimen, very useful in our group of relapsed <strong>and</strong><br />
primary refractory AL pts, enabling them to achieve CR <strong>and</strong><br />
to undergo allogeneic stem cell transplantation.<br />
PP46 Clinical outcome <strong>and</strong> prognosis related<br />
factor in acute promyelocytic leukemia<br />
patients treating with PETHEMA LPA 099<br />
protocol.<br />
Mitrovic M, Suvajdzic N, Bogdanovic A, Novkovic A,<br />
Kraguljac N, Sretenovic A, Antic D, Djunic I, Vidovic A,<br />
Colovic N, Virijevic M, Djurasinovic V, Elezovic I,<br />
Tomin D. Clinic of hematology, Clinical Center Serbia,<br />
Belgrade, Serbia<br />
In acute promyelocytic leukemia (APL) a cure rate of<br />
75–80% can be anticipated with a combination of all-trans<br />
retinoic acid (ATRA) <strong>and</strong> anthracyclines. But, underst<strong>and</strong>ing<br />
of the prognostic factors associated with the induction<br />
mortality has remained controversial <strong>and</strong> limited.<br />
Aim: To analyze the clinical outcome <strong>and</strong> the prognostic<br />
factor in APL patients (pts) treating with PETHEMA LPA<br />
099 protocol.<br />
Patients <strong>and</strong> methods: From 2004 to 2010, 42 consecutive<br />
APL pts confirmed either by t(15; 17) or PML/RARA<br />
were treated with PETHEMA LPA 99. The median followup<br />
was 32 months (range: 1–78).<br />
Results: Median time from the first symptoms to diagnosis<br />
was 23 days (range: 5–90). Pretreatment pts characteristic<br />
were as follows: median age 42 years (range: 21–69),<br />
22/42 male; mean WBC 25.6 x10 9 /L (range: 0.6–183); mean<br />
platelet count 34x10 9 /L (range: 4–101); hypergranular form<br />
in 39/42 (93%) pts; PETHEMA risk stratification: high<br />
17/42 (40%), intermediate 17/42 (40%), low 8/42 (20%);<br />
mean D-dimer 3606 ľg/L (range: 996–11340). DIC was<br />
confirmed in 32/42 (86%) pts, mean DIC score 6 (range:<br />
3–7). Additional cytogenetics abnormalities were detected<br />
in 8/42 (19%) pts.<br />
Therapy results: 33/42 (76%) pts achieved complete remission<br />
(CR). Induction death occurred in 9/42 (21%) pts,<br />
due to: differentiation syndrome (DS)- 4/42 (9.5%), central<br />
nervous system hemorrhage- 4/42 (9.5%) <strong>and</strong> infection-<br />
1/42 (2.3%). Early died pts had higher WBC (55.9x10 9 /L<br />
vs. 14.1x10 9 /L, p=0.014), higher percentage of peripheral<br />
blood (PB) promyelocytes (15.0% vs. 9.59%, p=0.03) <strong>and</strong><br />
higher DIC score (6.32 vs. 5.85, p=0.014). All died patients<br />
were CD15- with DIC score >5. Predictors of induction<br />
death in univariate analysis were: WBC >30x10 9 /l (p=0.03),<br />
DIC score >5 (p=0.01), CD15- (p=0.04). In multivariate<br />
analysis only WBC >30x10 9 /l was an independent predictor<br />
factor. DS occurred in 11 pts (26%). Pts with DS had significantly<br />
higher percentage of PB promyelocytes (48% vs.<br />
28.68%, p=0.04). Microgranular subtype (p=0.048) <strong>and</strong><br />
CD15- (p=0.04) were predictive for DS. There <strong>are</strong> no predictive<br />
parameters for bleeding. Three relapses occurred<br />
after the third consolidation, during maintenance <strong>and</strong> 6<br />
109
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
months after the maintenance termination, respectively.<br />
Mean time to relapse was14 months (range: 2–31). The<br />
26/42 (62%) pts <strong>are</strong> alive in first continuous CR. Three-year<br />
overall survival (OS) is 76% <strong>and</strong> disease free survival (DFS)<br />
82%.<br />
Conclusion: PETHEMA LPA-99 proved effective in our<br />
APL patients concerning OS, DFS <strong>and</strong> relapse rate. High<br />
rate of early death could be attributed to the numerous highrisk<br />
pts <strong>and</strong> increased rate of DIC. WBC>10x10 9 /L, DIC<br />
score>5 <strong>and</strong> CD15 negativity were poor prognostic factors<br />
for early death. Reduction of the incidence of early deaths is<br />
m<strong>and</strong>atory <strong>and</strong> requires a timely diagnosis <strong>and</strong> better management<br />
of both DS <strong>and</strong> bleeding.<br />
PP47 Acute myeloid leukemia with<br />
t(8;21)(q22;q22); RUNX1-RUNX1T1<br />
– case report<br />
Radic Antolic M, Rajic Lj, Femenic R, Bilic E,<br />
Pavlovic M, Perkovic S, Lasan R, Markovic-Glamocak M,<br />
Zadro R. Department of Clinical Laboratory <strong>and</strong><br />
Department of Pediatrics, Clinical Hospital Center <strong>and</strong><br />
School of Medicine, University of Zagreb, Croatia<br />
A 17-year-old male patient was diagnosed with AML in<br />
December 2009; hepatosplenomegaly was present along<br />
with increased white blood cell count (12.1x10 9 /L), anemia<br />
<strong>and</strong> thrombocytopenia. Cytomorphological diagnosis was<br />
AML M2 with eosinophils according to FAB classification.<br />
Immature aberrant myleoid cell immunophenotype (MPO+<br />
CD13+/–CD33+CD34+CD117+CD133+HLADR+) with<br />
coexpression of TdT but without other lymphoid, erythroid,<br />
monocytic or megakaryocytic markers was confirmed. Presence<br />
of t(8;21)(q22;q22) <strong>and</strong> RUNX1-RUNX1T1 fusion<br />
gene was detected in the bone marrow with negative FLT3/<br />
ITD. The patient was treated according to AML-BFM 2004<br />
(combination of intensive chemotherapy <strong>and</strong> hematopoietic<br />
stem cell transplantation, HSCT). Although the patient<br />
achieved cytogenetic response in March 2010, one month<br />
later 3% of bone marrow cells showed t(8;21)(22q;22q).<br />
Because of his age, gender <strong>and</strong> poor response after 15th day<br />
of intensive chemotherapy, the patient was scheduled for allogeneic<br />
HSCT. After allogeneic HSCT, the patient developed<br />
Wernicke encephalopathy with bacterial infections<br />
that were successfully treated. However, he never achieved<br />
molecular response during chemotherapy as well as in posttransplantation<br />
period. This prompted us to quantify<br />
RUNX1-RUNX1T1 fusion gene <strong>and</strong> WT1 gene expression.<br />
Expression of WT1 gene showed decreased tendency prior<br />
to allogeneic HSCT <strong>and</strong> was lower than that of RUNX1-<br />
RUNX1T1 fusion gene. In posttransplatation period WT1<br />
gene expression increased 3.5 times <strong>and</strong> was higher than<br />
RUNX1-RUNX1T1 fusion gene expression. Three months<br />
later allogeneic HSCT bone marrow was negative for t(8;21)<br />
but del(20q) was present in 10% of nuclei with the lowest<br />
value of RUNX1-RUNX1T1 fusion gene expression during<br />
the entire follow-up period. NPM1 mutation A <strong>and</strong> FLT3/<br />
ITD were negative at that time as well. Two months later<br />
del(20q) was present in 2% of nuclei. Nine months after<br />
110<br />
SCT the patient is still in clinical, cytologic <strong>and</strong> cytogenetic<br />
remission, but with positive molecular finding of RUNX1-<br />
RUNX1T1 fusion gene expression. This case report shows<br />
that patients, despite favorable clinical, cytogenetic <strong>and</strong><br />
molecular prognostic markers, do not always have a good<br />
outcome. It also confirms that molecular monitoring of a<br />
patient with leukemia represents the most sensitive method<br />
for estimating response to therapy <strong>and</strong> assessing disease<br />
course.<br />
PP48 Successful treatment of B-cell<br />
prolymphocytic leukemia (B-PLL)<br />
with FCR-Lite protocol<br />
Batar P, Telek B, Udvardy M. Department of Hematology,<br />
University of Debrecen Health Sciences Center, Debrecen,<br />
Hungary<br />
B-cell prolymphocytic leukemia is a r<strong>are</strong> disorder accounting<br />
approximately for 2% of all lymphoid malignancies.<br />
It is chracterized by marked lymphocytosis in the peripheral<br />
blood, matured lymphocytic infiltration in the bone<br />
marrow <strong>and</strong> prominent splenomegaly. It has a distinct immunophenotype<br />
pattern (CD19, CD20, CD22, FMC7, intensive<br />
surface immunoglobulin positivity) which helps to<br />
differentiate from other lymphoproliferative malignancies.<br />
The disease has poor prognosis <strong>and</strong> its treatment is unsettled.<br />
Here we present a case of a 71 year old male patient<br />
who was admitted to the outpatient facility of the University<br />
of Debrecen Health Sciences Center Department of Hematology<br />
on December 2008. He was presented with 71.0 G/L<br />
WBC of witch 65% were prolymphocyte. Prominent splenomegaly<br />
was also present. The lower border of the spleen<br />
exceeded the left costal margin by 14 cm. No anaemia,<br />
thrombocytopenia or lymphadenopathy were present. Bone<br />
marrow aspiration revealed hypercellularity <strong>and</strong> 80% matured<br />
lymphocytic infiltration. Flow cytometry identified CD5-<br />
, CD19+, CD20+, CD22+ <strong>and</strong> FMC+ phenotype. Surface<br />
kappa light chain positivity was also present. Cytogenetics<br />
<strong>and</strong> FISH were also performed. Chromosomal abnormalities<br />
were not detected. The patient had an excellent clinical<br />
performance status (ECOG: 0). FCR-Lite protocol (fludarabine,<br />
cyclophosphamide, rituximab)l was initiated. Lymphocytosis<br />
<strong>and</strong> splenomegaly have disappe<strong>are</strong>d after 4 cycles.<br />
Six weeks after 6 cycles of chemotherapy flow cytometry<br />
showed complete remission. No major hematological<br />
complications were observed during treatment. However G-<br />
CSF support was needed due to grade III-IV neutropenia<br />
but no fever or infection has developed. After completion of<br />
6 cycles of FCR-Lite treatment maintenance rituximab<br />
monotherapy was started administering 500 mg/m 2 rituximab<br />
every three monts. After a follow up of 2.5 years the<br />
patient is still in complete remission. According to our experience<br />
the FCR-Lite protocol can not only be used in patients<br />
with B-CLL but it also can be effective in patients<br />
with B-PLL. No clinical experience has been reported yet in<br />
the literature with this protocol.
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
PP49 Combination of rituximab <strong>and</strong> high-dose<br />
chlorambucil in therapy of small<br />
lymphocyte lymphoma / chronic<br />
lymphocytic leukemia<br />
Aurer I 1 , Hude I 1 , Basic-Kinda S 1 , Dujmovic D 1 ,<br />
Nemet D 1 , Radman I 1 , Ilic I 2 , Stern-Padovan R 3 , Santek F 4 ,<br />
Sertic D 1 , Labar B 1 . 1 Department of Medicine, 2 Parthology,<br />
3 Radiology, 4 Oncology, University Hospital Center <strong>and</strong><br />
School of Medicine, University of Zagreb, Croatia.<br />
Introduction: Chronic lymphocytic leukemia / small lymphocyte<br />
lymphoma (CLL) is the most common leukemia<br />
among adult Caucasians. It is typically a disease of the elderly,<br />
with a median age of onset of 69 years. Clinical course<br />
of the disease is variable <strong>and</strong> the prognosis depends on the<br />
clinical stage at the time of diagnosis <strong>and</strong> other established<br />
prognostic factors. Despite the intensive promotion of fludarabin-based<br />
protocols as the fundamental treatment of CLL,<br />
high dose chlorambucil remains the most efficient monochemotherapy<br />
for these patients. Low toxicity, short treatment<br />
duration <strong>and</strong> favorable cost make this therapy a convenient<br />
platform for addition of non-toxic targeted drugs, like rituximab.<br />
Rituximab is a monoclonal antibody aimed at the<br />
CD20-antigen on the surface of B-lymphocytes.<br />
Aim: Combination of rituximab <strong>and</strong> chlorambucil has<br />
been in routine clinical use for some time. The aim of this<br />
research is to assess its effectiveness.<br />
Patients <strong>and</strong> methods: Twenty-five patients treated at<br />
KBC-Zagreb were included in this study. Median age was<br />
67 years. Patients had received high-dose chlorambucil (10–<br />
20 mg, median 18 mg) continuously <strong>and</strong> 700–800 mg of<br />
rituximab. Eight cycels were planned. Treatment was conducted<br />
with or without addition of glucocorticoids. In analysis,<br />
patients were divided into groups depending on Binet<br />
<strong>and</strong> Rai stages <strong>and</strong> total tumor mass score as well as other<br />
prognostic factors. Adverse events (AE) were evaluated. Assessed<br />
outcomes were response rates <strong>and</strong> survival.<br />
Results: Complete remission (CR) was achieved in 12<br />
patients (48%), partial remission (PR) in 7 (28%), 2 patients<br />
were refractory to therapy (8%) <strong>and</strong> in 4 treatment is still<br />
ongoing. After median follow-up of 15 months of survivors,<br />
progression-free survival (PFS) is 72% <strong>and</strong> overall survival<br />
(OS) 92%. Patients with Binet stage C <strong>and</strong> Rai stages 3 <strong>and</strong><br />
4 have a statistically significant lower PFS than patients<br />
with favorable stages (26% vs, 86%, p=0, 047). The effect<br />
of total tumor mass (TTM) score as well as other prognostic<br />
factors on PFS was not statistically significant (p > 0,05).<br />
Likewise, correlation between assessed prognostic factors<br />
hasn’t been proven. Serious toxicity occurred in 7 patients,<br />
6 of whom were ≥ 65 years. However, correlation between<br />
age <strong>and</strong> toxicity wasn’t statistically significant. The most<br />
common serious AE was leukopenia.<br />
Conclusion: Combination of rituximab <strong>and</strong> continuous<br />
high-dose chlorambucil is a very effective front-line treatment<br />
of CLL, leading to high overall response. Therapy<br />
does not cause unexpected toxicity <strong>and</strong> is well tolerated. To<br />
obtain more relevant results for comparison with larger<br />
studies, further follow-up <strong>and</strong> inclusion of new patients is<br />
needed.<br />
PP50 Atypical Blastoid Variant of Hairy Cell<br />
Leukemia: a Case Report<br />
Hadji-Pecova L, Petrusevska G, Panovska I, Stojanovski Z,<br />
Stojanovic A. Department of Hematology, Medical Faculty,<br />
Skopje, Republic of Macedonia<br />
Hairy Cell Leukemia (HCL) is a r<strong>are</strong> B-cell indolent lymphoproliferative<br />
disorder, also known as one of the B-cell<br />
chronic lymphatic leukemia (B-CLL). HCL-blastoid variant<br />
describes an entity of HCL that is important from the point<br />
of view of requiring differential diagnosis from classic<br />
HCL, HCL-variant <strong>and</strong> others Non-Hodgkin’s Lymphoma.<br />
Differential diagnosis includes HCL, HCL-v, B-CLL,<br />
Mantle cell lymphoma, Folicular lymphoma (FL). <strong>and</strong><br />
Splenic lymphoma vith vilous lymphocyte.<br />
HCL-blastoid variant differs from the classic form of<br />
HCL with respect to the lack of monocytopenia, leucocyosis<br />
<strong>and</strong> unique morphology <strong>and</strong> immunophenotype.<br />
We report a 30 years male patient who presented at our<br />
department in May 2005 with leucocytosis, mild anemia,<br />
skin bleeds <strong>and</strong> splenimegaly. The blood smear showed<br />
more than 50% of heterogenous lymphoid population with<br />
balstoid hairy cells prdominance. In the bone marrow biopsy<br />
diffuse infiltration of lymphoid cells were seen positive<br />
for CD20, CD79a <strong>and</strong> HLA-DR, <strong>and</strong> negative for CD103,<br />
CD11, DBA44, CD5, <strong>and</strong> CD23. The splenic biopsy showed<br />
diffuse lymphoid infiltration of the white <strong>and</strong> red pulp immunohoistochemically<br />
positive for CD20, CD79a, BCL-2,<br />
HLA-DR, <strong>and</strong> CD10 slightly positive in a subset of cells,<br />
<strong>and</strong> negative for CD103, CD11 <strong>and</strong> DBA44.<br />
Based on bone marrow <strong>and</strong> spleen morphology <strong>and</strong> immunohistochemistry<br />
the patient was unfortunately misdiagnosed<br />
as having diffuse FL.<br />
He was initially treated with splenectomy followed by<br />
seven cycles of CHOP chemotherapy but with minimal response.<br />
In the meantime the second opinion of the bone marrow<br />
<strong>and</strong> spleen histopathology <strong>and</strong> immunohistochemistry were<br />
received, <strong>and</strong> the patient was rediagnosed as a case with r<strong>are</strong><br />
atypical blastoid variant of HCL exhibiting aberrant phenotype.<br />
The therapy with cladribine was immediately started<br />
which resulted with complete remission (CR). The patient<br />
was in CR for two years (April 2006 – April 2008).<br />
By the end of April 2008 relapse was confirmed. Peripheral<br />
blood <strong>and</strong> bone marrow showed massive, almost 100%<br />
infiltration with bizarre blastoid cells.<br />
The patient was treated as acute leukemia. He received 3<br />
cycles of Hyper C-VAD chemotherapy (he was in CR after<br />
the first cycle) followed by consolidation with cladribine.<br />
Recently, positive mutation of BRAF was confirmed.<br />
Since November 2008 the patient is in CR.<br />
This case suggests that we should be extremely c<strong>are</strong>ful<br />
during the period of diagnosis having in account the existence<br />
of aberrant phenotypes, <strong>and</strong> that the morphology still<br />
remains important tool. Literature research reveals that aberrant<br />
phenotype CD20+, CD10+ in particular the conjunction<br />
with CD103 negative has been known for several years,<br />
comprising roughly 2–5% of HCL cases.<br />
111
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
PP51 Intravascular T-cell lymphoma presented as<br />
a subcutaneous panniculitis-like lymphoma:<br />
A case report<br />
Ilic I 1 , Basic-Kinda S 2 , Bosnic D 2 , Aurer I 2 , Dotlic S 2 ,<br />
Gasparovic V 1 . 1 Department of Pathology, 2 Department of<br />
Medicine, Clinical Hospital Center <strong>and</strong> School of<br />
Medicine, University of Zagreb, Croatia<br />
Introduction: Intravascular lymphoma (IVL) is a r<strong>are</strong><br />
type of non-Hodgkin lymphoma characterized by proliferation<br />
of lymphoma cells only within the vessel lumina involving<br />
in most cases the skin <strong>and</strong>/or the brain. Majority of<br />
IVL <strong>are</strong> of B-cell origin but r<strong>are</strong> cases of T-cell <strong>and</strong> NK cell<br />
IVL have been reported.<br />
Case presentation: A 45-year old female was admitted<br />
to the hospital because of the fever of four month duration,<br />
elevated erythrocyte sedimentation rate, elevated level of<br />
lactate dehydrogenase, thrombocytopenia <strong>and</strong> multiple erythematous<br />
patches <strong>and</strong> nodules on her legs <strong>and</strong> lower back,<br />
suggesting a subcutaneous panniculitis-like T-cell non Hodgkin<br />
lymphoma. During the observation she developed severe<br />
dyspnea <strong>and</strong> impairment of consciousness. Biopsy of<br />
skin lesion was performed <strong>and</strong> it showed dermal vessels<br />
filled with large atypical lymphatic cells. Immunophenotypic<br />
analysis showed that the tumor cells were CD2-,<br />
CD3+, CD4+, CD5−, CD7+, CD8−, CD30-, EMA-, CD56−,<br />
ALK−, TIA1-, Granzyme B-, Perforin-, CD20-, Cytokeratin<br />
-. There was no tumor cell infiltrate outside the vessels or<br />
in the subcutaneous fat tissue. Treatment with Methotrexate<br />
combined with Asparginase <strong>and</strong> Dexamethasone was initiated,<br />
but the patient died of multiple organ failure about a<br />
month after admission to the hospital.<br />
Discussion: We found about 20 cases of intravascular Tcell<br />
lymphoma reported so far in the literature, <strong>and</strong> therefore<br />
T-cell IVL is still considered a very r<strong>are</strong> entity. The<br />
patients may show a variety of symptoms, usually nonspecific,<br />
such as abdominal pain, altered mental status or fever,<br />
making this diagnosis difficult to recognize <strong>and</strong> delaying<br />
the treatment. Some of the patients with IVL present with<br />
skin lesions reminiscent of panniculitis or subcutaneous<br />
panniculitis-like T-cell lymphoma. The only way to obtain a<br />
correct diagnosis is to perform a biopsy of such lesions.<br />
Histopathological differential diagnosis includes intravascular<br />
lymphomatosis seen in hepatosplenic T-cell lymphoma<br />
or in angioimmunoblastic peripheral T-cell lymphoma,<br />
making an IVL a diagnosis of exclusion. Thus, without<br />
proper clinical information the diagnosis cannot be established.<br />
Conclusion: Intravascular lymphoma is a r<strong>are</strong> disease,<br />
however in patients with fever of unknown origin, pancytopenia<br />
or nonspecific neurological symptoms, IVL should be<br />
considered. The biopsy, as well as thorough examination of<br />
the patient is crucial for reaching the exact diagnosis.<br />
112<br />
PP52 Primarily Localized non Hodgkin<br />
Lymphoma of Testes with Relapse<br />
Localized in Buccal Area – Case Report<br />
Hotic-Laz<strong>are</strong>vic S, Kezic Lj, M<strong>and</strong>ic D, Stojcic B,<br />
Malinovic J, Mrdja J. Division of Hematology, Department<br />
of Internal Medicine, Clinical Center Banja Luka, Banja<br />
Luka, Bosnia <strong>and</strong> Herzegovina<br />
Introduction: Primarily localized lymphoma of testes is<br />
r<strong>are</strong> <strong>and</strong> aggressive extranodal non Hodgkin lymphoma. It<br />
is the most frequent tumor of testes in men aged 60–80<br />
years.<br />
The Aim of the study: to present the case of a patient<br />
with primarily localized lymphoma of testes, in whom there<br />
has been performed orchiectomy within two different periods,<br />
performed chemotherapy <strong>and</strong> radio therapy, <strong>and</strong> the<br />
relapse of the disease in both cheeks <strong>and</strong> subm<strong>and</strong>ibular<br />
gl<strong>and</strong> on the left.<br />
Case presentation: a patient of 56 years of age, with<br />
painless swelling of the left scrotal <strong>are</strong>a <strong>and</strong> non-homogenhypoechogne<br />
mass (48x32 mm) of the left testis with microcalcifications<br />
verified by ultrasound. After the left orchiectomy<br />
(pathohystological diagnosis was Lymphoma non<br />
Hodgkin of the left testis- diffused large cell B-phenotype,<br />
CD-20+, of high proliferation activity) there was implemented<br />
the chemotherapy R-CVP on the 21st day in the<br />
planned therapy doses, as well, which the patient underwent<br />
well. During the therapy of maintaining by rituximab, after<br />
the second treatment, swelling of the right scrotal <strong>are</strong>a.<br />
There was indicated the right orchiectomy, <strong>and</strong> the obtained<br />
pathohystological finding was almost identical to the first<br />
one. The implemented irradiation of both testes boxes, abdomen<br />
<strong>and</strong> pelvis with 36 Gy/20 fractions by the method of<br />
reversed Y. Seven moths upon the completed irradiation,<br />
<strong>and</strong> after the first dose of substance of Testosterone depot<br />
(due to exceptionally low values of testosterone <strong>and</strong> difficulties<br />
related to it), occurrence of tm forming of both buccal<br />
<strong>are</strong>as <strong>and</strong> subm<strong>and</strong>ibular gl<strong>and</strong> on the left. After biopsy,<br />
by pathohystological finding, there was verified the Hodgkin<br />
lymphoma understood as the relapse of the disease <strong>and</strong><br />
there started the therapy according to MINE protocol, which<br />
is still being realized.<br />
Conclusion: Primarily localized lymphoma of testes <strong>and</strong><br />
buccal <strong>are</strong>a <strong>are</strong> r<strong>are</strong> extranodal localizations of non Hodgkin<br />
lymphoma.<br />
PP53 A 48 Year Old Woman with a R<strong>are</strong> Case<br />
of a Midline Destructive Disease Presenting<br />
as Having both Midline <strong>and</strong> Nonmidline<br />
Lesions – a Case Report<br />
Fern<strong>and</strong>ez S, Lapus F, B<strong>are</strong>z MY. Davao Medical Center,<br />
Davao City, Philippines<br />
Objectives: To describe a r<strong>are</strong> case of lethal midline granuloma<br />
presenting in a r<strong>are</strong> location. This type of lymphoma<br />
which needs a tissue biopsy for diagnosis <strong>and</strong> immunohistochemical<br />
staining for confirmation is a challenge in a developing<br />
nation to diagnose, treat <strong>and</strong> follow up. This paper is
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
presented to be able to show how a r<strong>are</strong> case of lymphoma<br />
was appropriately diagnosed in sans the modern methods of<br />
immunohistochemical staining with promising results of<br />
chemotherapy.<br />
Midline destructive lesions <strong>are</strong> a heterogeneous group of<br />
r<strong>are</strong> lesions where the classification angiocentric lymphoma,<br />
or peripheral Natural Killer/T cell lymphoma, nasal<br />
type belongs. It usually presents with destructive mass lesions<br />
<strong>and</strong> extensive destruction in the midfacial <strong>are</strong>as. We<br />
describe a case of an angiocentric lymphoma, or Natural<br />
Killer/T cell lymphoma who presented with both a nasal<br />
mass <strong>and</strong> a skin lesion in the medial aspect of her left leg. A<br />
tissue biopsy was done to make the diagnosis. She underwent<br />
six cycles of chemotherapy <strong>and</strong> radiotherapy with very<br />
promising results<br />
Conclusions: We report this case to document a r<strong>are</strong> type<br />
of lymphoma. Our patient was unique in that she presented<br />
with a r<strong>are</strong> type of lymphoma that is not usually documented<br />
in the Philippines <strong>and</strong> is r<strong>are</strong> even in international reports.<br />
Moreover, she presented also unusually having both a<br />
nasal mass <strong>and</strong> a skin lesion in the medial aspect of her left<br />
leg.<br />
PP54 Successful mobilisation with Plerixafor-<br />
clinical report<br />
Babic A, Istituto Europeo di Oncologia, Divisione di<br />
Ematologia, Milan, Italy<br />
Background: Our Clinical Transplantation Program sometimes<br />
sees a young people treated in abroad interrupting<br />
or changing their clinical pathway.<br />
Clinical Case: Here is the case of a young russian girl,<br />
16 year old girl, affected by Hodgkin Lymphoma, nodular<br />
sclerosis, stage IIIB. Diagnosis was performed in Russia in<br />
October 2009 on a biopsy of a supraclavicolar lymphnode.<br />
She then underwent 6 cycles of chemotherapy including antracycline,<br />
cyclophosphamide, vincristine, procarbazine <strong>and</strong><br />
prednisone which was followed by mantle <strong>and</strong> inverted Yfield<br />
radiotherapy until June 2010. All these treatments has<br />
been performed by using peripheral veins. During the treatment<br />
she developed Herpes Zoster <strong>and</strong> Parvovirus infection<br />
treated respectively with antiviral drugs <strong>and</strong> Ig ev. In August<br />
2010, a CT scan showed relapse of disease. She was inserted<br />
the Gronshong central catheter <strong>and</strong> on October 25th, she<br />
underwent the first cycle of chemotherapy with ifosfamide,<br />
etoposide <strong>and</strong> prednisone <strong>and</strong> on November 2nd she was<br />
admitted in our inpatient department<br />
Methods: We wanted to use this chemotherapy cycle as<br />
»mobilization« adding GCSF if necessary to see if we <strong>are</strong><br />
able to collect her stem cells for autologous transplant. We<br />
followed her blood cell counts recovery, monitoring circulating<br />
CD34+ as soon as white blood cells reached 500 /ul,<br />
but counts showed very low numbers, only 2 cells/ul at 11th<br />
November. We therefore decided to ad plerixafor <strong>and</strong> the<br />
very next day she had 10 cells/ul of CD34+ <strong>and</strong> we positioned<br />
a central venous cathether in the femoral vein deciding<br />
to perform the firsth apheresis procedure <strong>and</strong> permitting<br />
her to achieve 0.7 x 106 cells/kg at the very day (12 November).<br />
We therefore administered a second dose of plerixafor<br />
<strong>and</strong> repeated the procedure the day after with 19 cells/ul <strong>and</strong><br />
a collection of 1.5 x 106 cells/kg, for a total of 2.2 x10E6<br />
CD34+/kg.<br />
Results: Therefore she underwent additional two cycles<br />
with ifosfamide, carboplatin <strong>and</strong> etoposide therapy <strong>and</strong><br />
achieved a complete response PET <strong>and</strong> CT scan documented<br />
in Jaunary 2011.<br />
Conclusions: She then was able to undergo the autologous<br />
stem cell transplantation after a conditioning regimen<br />
according to BEAM schedule <strong>and</strong> in February 2011 PET<br />
<strong>and</strong> CT scans confirmed the complete response.<br />
PP55 Isolation <strong>and</strong> in vitro cell culture of<br />
mesenchymal stem cells from human<br />
umbilical cord blood<br />
Mazic S 1 , Golemovic M 1 , Skific M 1 , Bojanic I 1 , Humar I 2 ,<br />
Golubic Cepulic B 1 . 1 Department of Transfusiology,<br />
2 Deaprtment of Clinical Laboratory, Cliniacal Hospital<br />
Center, Zagreb, Croatia<br />
Mesenchymal stem cells (MSCs) <strong>are</strong> multipotent bone<br />
marrow (BM) cells that give stromal support for hematopoiesis<br />
<strong>and</strong> express immunomodulatory properties <strong>and</strong> regenerative<br />
potential. Although cord blood (CB) is easily accessible<br />
source of MSCs <strong>and</strong> could serve as alternative to BM,<br />
isolation success of MSCs is very low. Therefore attempts<br />
<strong>are</strong> made to enhace isolation <strong>and</strong> expansion rates <strong>and</strong> in this<br />
regard different culture conditions in vitro <strong>are</strong> being examined.<br />
Lately, human platelet lysate (PL) has been proposed<br />
as fetal bovine serum substitute.<br />
Aim: The aim of this study was to evaluate success rate<br />
of MSCs isolation from CB by imunomagnetic depletion of<br />
CD34+ hematopoietic fraction <strong>and</strong> to investigate biological<br />
properties of MSCs exp<strong>and</strong>ed in presence of 10%PL.<br />
Samples <strong>and</strong> methods: 15 CB units were selected according<br />
to predefined criteria; volume >40ml, total nucleated<br />
cells (TNC) >6x10 8 , mononucleated cells (MNC) >1x10 8<br />
<strong>and</strong> processing within 15 hr from collection. Each CB was<br />
divided in two cell fractions; CD34- <strong>and</strong> unmanipulated<br />
fraction. MNCs of each fraction were plated at 1x10 6 /cm 2 .<br />
Adherent cells were cultured in presence of 10% PL until<br />
reaching confluence <strong>and</strong> then harvested by trypsinization<br />
<strong>and</strong> replated at 5000 MSCs/cm 2 . At each passage (P) cells<br />
were counted <strong>and</strong> population doublings (PD) were calculated.<br />
In order to evaluate clonogenic potential of cultured<br />
cells, colony-forming unit-fibroblast (CFU-F) assays were<br />
performed starting at P2. Flow cytometry analysis of surface<br />
phenotype was done in P3. Cells harvested in P5 were<br />
added to mixed lymphocyte cultures (MLR) in order to test<br />
their immunomodulatory properties.<br />
Results: Expansion of MSCs in presence of PL resulted<br />
in 27% (4/15) overall success rate. Within successfully cultured<br />
MSCs 3/4 (75%) originated from CD34- fraction.<br />
Cells cultivated from two fractions were morfologicaly different.<br />
Cultured MSCs showed slow growth kinetics; time<br />
needed for one MSCs PD in 4 samples was 8.5, 18, 16 <strong>and</strong><br />
7.4 days respectively. Initialy high clonogenic potential rapidly<br />
decreased by P5. Analysis of surface phenotype showed<br />
113
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
expected lack of hematopoietic markers <strong>and</strong> variable expression<br />
of typical MSCs markers. All cultivated MSCs expressed<br />
CD73 while CD90 was expressed in variable intensity.<br />
Expression of CD105 was not detected. Addition of<br />
cultivated MSCs in different concentrations to MLR resulted<br />
in modest immunomodulatory effect.<br />
Conclusion: None of the predefined selection criteria<br />
correlated with MSCs isolation success. Depletion of<br />
CD34+ cells favoured growth of MSCs. Whether unexpected<br />
immunophenotype of cultured MSCs correlates with<br />
specific culture conditions or with some additonal parameter<br />
needs to be evaluated in larger group of samples. Despite<br />
availability of CB as potential source of MSCs, their low<br />
frequency <strong>and</strong> unpredictable expansion success along with<br />
time consuming <strong>and</strong> laborious procedure, make CB unreliable<br />
source of MSCs for clinical use.<br />
PP56 Biological properties of human<br />
mesenchymal stem cells exp<strong>and</strong>ed in vitro<br />
in media supplemented with human<br />
platelet lysate<br />
Skific M 1 , Golemovic M 1 , Mazic S 1 , Bojanic I 1 , Humar I 2 ,<br />
Davidovic S 3 , Crkvenac Gornik K 3 , Ilic I 4 , Durakovic N 5 ,<br />
Mikulic M 5 , Serventi Seiwerth R 5 , Labar B 5 ,<br />
Golubic Cepulic B 1 . 1 Department of Transfusiology,<br />
2 Department of Clinical Laboratory, 3 Department of<br />
Pediatric, 4 Department of Pathology, 5 Department of<br />
Medicine, Clinical Hospital Center <strong>and</strong> School of<br />
Medicine, Universiuty of Zagreb, Croatia<br />
Human mesenchymal stem cells (MSCs) <strong>are</strong> nonhematopoietic<br />
multipotent cells that express regenerative <strong>and</strong> immunomodulatory<br />
properties in vitro <strong>and</strong> appear immunoprivileged<br />
what gives them considerable therapeutic potential.<br />
Because of very low incidence in the bone marrow<br />
(BM) aspirates MSCs need to be exp<strong>and</strong>ed in vitro. Recently<br />
human platelet lysate (PL) has been evaluated as fetal<br />
bovine serum (FBS) substitute in MSCs in vitro expansion.<br />
Aim: The aim of this study was to evaluate biological properties<br />
of MSCs exp<strong>and</strong>ed in vitro in the presence of PL <strong>and</strong><br />
create basis for the development of clinical expansion protocol.<br />
Patients <strong>and</strong> methods: Mononuclear cells (MNC)<br />
were isolated from the BM of 8 healthy individuals by Ficoll<br />
density gradient centrifugation <strong>and</strong> plated at 160000<br />
MNC/cm 2 in media suplemented with 10%FBS, 10%PL or<br />
5%PL. When the cells reached 80% confluence, they were<br />
harvested by trypsinization <strong>and</strong> replated at 1000 MSCs/cm 2<br />
until reaching passage 5 (P5). To evaluate growth kinetics in<br />
different culture conditions, number of cells was determined<br />
by light microscopy techniques <strong>and</strong> to evaluate MSCs clonogenic<br />
potential, colony forming unit-fibroblast (CFU-F)<br />
assays were performed at each P. Characteristic immunophenotype<br />
was assesed by flow cytometry whenever sufficient<br />
number of cells was obtained. To assess their multipotency,<br />
MSCs were induced into adipogenesis <strong>and</strong> osteogenesis<br />
in vitro (n=6). Immunomodulatory properties were<br />
evaluated by adding 10-40000 MSCs to mixed lymphocyte<br />
reaction (MLR) (n=1). Karyotype analysis was performed<br />
to validate chromosomal stability of exp<strong>and</strong>ed cells (n=5).<br />
114<br />
Results: Dominant growth of MSCs was observed in the<br />
presence of 10%PL <strong>and</strong> confirmed by CFU-F tests. Cell<br />
growth analysis showed that, by the P5, median time needed<br />
for one MSC population doubling (PD) in the presence of<br />
10%FBS was 154hr comp<strong>are</strong>d to 50hr <strong>and</strong> 40hr in 5%PL<br />
<strong>and</strong> 10%PL, respectively. More than 96% of cells cultured<br />
in the presence of 10%PL expressed CD90 <strong>and</strong> CD73 already<br />
in P1 <strong>and</strong> P2, while CD105 expression was either<br />
very low or not detected. Cultured cells were devoid of hematopoietic<br />
markers already in P1. Cells cultured in presence<br />
of 10%PL differentiated into adipocytes <strong>and</strong> osteoblasts.<br />
In MLR experiment, MSCs cultured with 10%PL<br />
displayed stronger immunomodulatory effect comp<strong>are</strong>d to<br />
those cultured in 5%PL. Karyotype was analyzed in 5 samples<br />
of different donors mostly obtained in P3 or P4. Analysed<br />
metaphases displayed normal karyotype with the exception<br />
of one sample where trisomy 8 was detected in P4,<br />
but not in subsequent P5.<br />
Conclusion: MSCs cultured in the presence of 10%PL<br />
display almost all expected biological <strong>and</strong> immunomodulatory<br />
properties. Whether absence of CD105 expression correlates<br />
with specific culture conditions, needs to be confirmed<br />
in the bigger cohort of samples. This study provides<br />
a basis for further efforts in evaluating PL as a valuable FBS<br />
substitute in clinical grade MSCs expansion.<br />
PP57 Croatian Cord Blood Bank: the fi rst 4 years<br />
Mazic S 1 , Bojanic I 1 , Zlopasa G 2 , Mrsic M 3 , Plenkovic F 1 ,<br />
Lukic M 1 , Raos M 1 , Gojceta K 1 , Golemovic M 1 , Skific M 1 ,<br />
Tomac G 1 , Burnac IL 1 , Novoselac J 1 , Vidovic I 1 ,<br />
Biskup M 1 , Labar B 3 , Golubic Cepulic B 1 . 1 Department of<br />
Transfusiology, 2 Department of Gynecology <strong>and</strong><br />
Obstetrics, 3 Department of Medicine, Clinical Hospital<br />
Center <strong>and</strong> School of Medicine, Universiuty of Zagreb,<br />
Croatia<br />
Croatian cord blood bank (CBB) was established in<br />
March 2007 with the aim to provide patients with transplants<br />
according to international st<strong>and</strong>ards <strong>and</strong> increase<br />
their chance in finding a match. Furthermore, our goal was<br />
to promote cord blood (CB) donation <strong>and</strong> by educating all<br />
croatian maternities give every mother an opportunity for<br />
donation.<br />
In that regard a team of doctors from CBB, maternity<br />
hospital <strong>and</strong> national bone marrow donor registry, starting<br />
with Zagreb <strong>and</strong> gradually spreading out throughout the<br />
country, visited every maternity ward <strong>and</strong> educated complete<br />
staff about donor information <strong>and</strong> selection, CB collection,<br />
processing, storage <strong>and</strong> therapeutic use. Our CBB<br />
collaborates with 22 maternities for which we give full logistic<br />
support. We give them feedback through quaterly reports<br />
of collected <strong>and</strong> discarded donations, point out problems<br />
<strong>and</strong> if necessary reeducate the staff.<br />
Samples <strong>and</strong> methods: CB is collected in utero, in term<br />
deliveries with mother´s informed consent. Transport is organized<br />
within 24 h through courier service. The unit is<br />
checked for volume <strong>and</strong> total nucleated cell number (TNC)<br />
<strong>and</strong> accepted if TNC is > 10x10 8 . CB is processed using
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
Sepax cell separator, ISBT code labelled <strong>and</strong> stored in Bioarchive.<br />
Results: In a period from 2007–2011 our CBB received<br />
2879 donations out of which 1411 (49%) were stored. The<br />
reasons for rejection of donated units at initial control were<br />
low TNC (97,7%), period from collection to storage exceeding<br />
48 h (0,3%), administrative error (0,1%), twin pregnancy<br />
(0,1%), validation study (1,6%). Additional 240 doses<br />
were rejected at final control due to quality of CB unit<br />
(76,7%), problems during transport or processing (14,7%),<br />
medical information about newborn (0,8%), mother (3,3%)<br />
or father (2,9%), or incomplete documentation (0,4%).<br />
Among reasons for inadequate quality of CB unit, low TNC<br />
after processing accounted for most rejections (44%), microbiological<br />
contamination for 31,1% while no detectable<br />
growth in clonogenic assay accounted 1,6% of cases.<br />
For this period we had 1171 doses enter the registry of<br />
World Marrow Donor Association (WMDA) which makes<br />
40,6% of recieved donations. Despite numerous preliminary<br />
search requests for our units up till now we issued only one<br />
CB to treat a patient in Croatia.<br />
In the past year we had a noticable drop in the percentage<br />
of stored CB units; 39% versus average of 56,6% in first 3<br />
years. Reason for this is increased number of donations<br />
which allowed us to set higher initial TNC criteria. Units<br />
that entered the WMDA registry in 2010. had mean TNC<br />
count of 9,64±2,7 <strong>and</strong> mean CD34+ count of 5,58±3,85.<br />
Conclusion: To increase our chances for issuing units for<br />
transplantation we plan to continue promoting CB donation,<br />
setting higher initial TNC criteria <strong>and</strong> working on receiving<br />
FACT accreditation <strong>and</strong> entering Netcord.<br />
PP58 Italian nurses group in mobilisation <strong>and</strong><br />
apheresis (GIIMA): ideation <strong>and</strong> activity<br />
Babic A, Laszlo D, Galgano L, De Marchi E, Orl<strong>and</strong>o L,<br />
Martinelli G. Istituto Europeo di Oncologia, Divisione di<br />
Ematologia, Milan, Italy<br />
Background: The Clinical Transplantation Program consists<br />
in a process performed by a multidisciplinary team<br />
working with common staff training, programs, protocols,<br />
<strong>and</strong> quality management systems. Peripheral blood stem cells<br />
represent the most used source of hematopoietic cells <strong>and</strong><br />
apheresis is a routine technique applied to collect them.<br />
The collection is generally performed by National Transfusion<br />
Services while the mobilization <strong>and</strong> reinfusion of<br />
stem cells is carried out by Clinical Units. For these reason,<br />
there is difficult to assure a continuity of patient assistance,<br />
especially from a nurse’s point of view.<br />
Methods: We therefore created in April 2010 a dedicated<br />
group (Gruppo Italiano Infermieristico in Mobilizzazione<br />
ed Aferesi – GIIMA), with a committee linked to the GIT-<br />
MO <strong>and</strong> EBMT nurses groups. The group includes medical<br />
doctors <strong>and</strong> nurses working in National Transfusion Services<br />
<strong>and</strong> Transplant Centers with the aim to:<br />
1) create the stabile link between the apheresis nurses<br />
who works in transfusion centers <strong>and</strong> those who operate<br />
in transplant centers, following both the patients in<br />
mobilization <strong>and</strong> apheresis.<br />
2) create the material for nurse education in apheresis<br />
<strong>and</strong> for patient information<br />
3) develop the program for nurses education in apheresis<br />
for new students based by Jacie’s regulation <strong>and</strong> coherent<br />
with Italian low.<br />
Results: The group translated the EBMT h<strong>and</strong>book »The<br />
Practical Guide for Nurses <strong>and</strong> Other Health C<strong>are</strong> Professionals«<br />
in Italian language <strong>and</strong> have distributed it to each<br />
Italian transplant <strong>and</strong> transfusion center. Currently the GI-<br />
IMA is distributing the DVD already available on dem<strong>and</strong><br />
on: Giima.italy@gmail.com after been distributed, again to<br />
all transplant <strong>and</strong> transfusion centers in Italy <strong>and</strong> Switzerl<strong>and</strong><br />
(Italian Canton). This DVD will be an additional tool<br />
for nurse education. It contains interactive presentation of<br />
autoPBSC process, from mobilization, apheresis, autoPBSC<br />
to follow-up.<br />
The next step is to collaborate in developing the specialized<br />
university program for apheresis nurse education to be<br />
inserted in regional university program REL – SIDEM<br />
Conclusions: GIIMA is a group who created a link between<br />
two realities who performs similar protocols in parallel<br />
ways. The aim of the group is to promote the unique<br />
pathway in stem cell mobilization <strong>and</strong> apheresis. The next<br />
step is to collaborate in developing the specialized university<br />
program for apheresis nurse education hopefully to be<br />
inserted in regional university program REL-SIDEM.<br />
PP59 Unrelated Donor Search Experience<br />
in the Croatian Hematopoietic Stem Cell<br />
Transplantation Program<br />
Grubic Z 1 , Stingl K 1 , Serventi Seiwerth R 2 , Labar B 2 ,<br />
Zunec R 1 . 1 Tissue Typing Centre, 2 Department of<br />
hematology, Clinical Hospital Centre Zagreb, Croatia<br />
The donor search protocols in the unrelated hematopoietic<br />
stem cell transplantation (HSCT) program vary between<br />
transplantation centers due to many different factors, such<br />
as preferences in the source of stem cells (unrelated donor<br />
or umbilical cord unit – CBU), characteristics of the donor,<br />
resolution of the required HLA typing etc. However, the differences<br />
among populations arising from the HLA polymorphism<br />
also play a role <strong>and</strong> should be considered in establishing<br />
the donor search protocol. The aim of this study<br />
was to address this question with respect to the Croatian<br />
population.<br />
In the period 2009–2010, a successful search for an unrelated<br />
donor/CBU in the Bone Marrrow Donors Worldwide<br />
(BMDW) was performed at our centre for 51 patients for<br />
whom a matched donor could not be previously found<br />
among family members. The donor was an unrelated individual<br />
in 48 cases while for the remaining two patients CBU<br />
was chosen as a source of HSCT, double CBU transplantation<br />
in one case. The gender mismatched donor was chosen<br />
for 43% of male patients, while this percentage was slightly<br />
higher for female patients (54%). The median donor age<br />
was 36.2 (range 21 to 57). The HLA resolution typing criteria<br />
in our transplantation centre is high resolution typing for<br />
HLA-A, -B, -C, -DRB1 <strong>and</strong> -DQB1 loci. However, the<br />
115
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
10/10 matching level was not achieved for 24 patients.<br />
Twenty-one patient received a 9/10 matched transplant,<br />
while three had an 8/10 matched donor. The highest number<br />
of mismatches was found at the HLA-C locus (9 patients).<br />
However, the most interesting finding regarding the matching<br />
at the HLA loci was observed among our patients positive<br />
for the HLA-DRB1*11 specificity. Namely, patients<br />
with HLA-DRB1*11:04 allele were more difficult to match<br />
than those with HLA-DRB1*11:01 allele. This was the case<br />
for four patients in the group of patients mismatched for one<br />
DRB1 allele (N=6), <strong>and</strong> one patient who received an 8/10<br />
matched transplant <strong>and</strong> in addition to a r<strong>are</strong> DRB1 allele<br />
also had the HLA-DRB1*11:04 allele. All those patients ultimately<br />
received a DRB1*11:01 positive transplant. The<br />
explanation for this finding lies in the almost equal frequency<br />
of DRB1*11:01 <strong>and</strong> DRB1*11:04 alleles in the Croatian<br />
population as opposed to the predominance of DRB1*11:01<br />
elsewhere. The mismatches in other cases were mainly due<br />
to the either a r<strong>are</strong> allele or an unusual haplotype of the patient.<br />
In conclusion, results of the study revealed some specific<br />
characteristics of the Croatian population which should be<br />
taken into account while performing the donor search. The<br />
finding regarding the HLA-DRB1*11 alleles is an important<br />
example of how the differences in allele distribution<br />
between Croatian population <strong>and</strong> populations with potential<br />
donors can influence the search outcome.<br />
PP60 Following the Chimerism Status of Patients<br />
after Hematopoietic Stem Cell<br />
Transplantation – Ten Years Experience<br />
Stingl K 1 , Grubic Z 1 , Serventi Seiwerth R 2 , Labar B 2 ,<br />
Rajic Lj 3 , Vrhovac R 4 , Zunec R 1 . 1 Tissue Typing Centre,<br />
2 Department of Medicine, 3 Clinic of pediatrics, Clinical<br />
Hospital Centre, 4 Department of Medicine, Clinical<br />
Hospital Merkur, Zagreb, Croatia<br />
The analysis of the patient’s chimerism status following<br />
the hematopoietic stem cell transplantation (HSCT) has<br />
been accepted in the last decade as a valuable tool in the<br />
post-HSCT treatment <strong>and</strong> prediction of the transplantation<br />
outcome. The aim of this retrospective study was to evaluate<br />
the current protocol used for this purpose in our centre.<br />
In the period from 2001–2011, the peripheral blood or<br />
bone marrow samples of 273 patients have been received<br />
for the chimerism analysis. The protocol consisted out of<br />
DNA isolation using the commercial kit, PCR amplification<br />
of the chosen microsatellite loci <strong>and</strong> electrophoresis on a<br />
6% polyacrilamide gel. Microsatellite loci tested were<br />
HUMTH01, HUMVWFA31, HUMFES/FPS, HUMF13A01,<br />
SE33, D1S80 <strong>and</strong> D22S683. In cases when two or less tested<br />
loci were informative (both recipient <strong>and</strong> donor specific<br />
alleles could be identified), additional microsatellites were<br />
analysed (D1S549, D1S1656, D12S391, D18S535).<br />
The number of informative loci ranged from 2 (7.3%) to<br />
7 (2.6%) with the highest percentage of patients having 4<br />
informative loci (32.2%). The most informative locus was<br />
SE33 (61.1%). Additional loci had to be tested for 68 pa-<br />
116<br />
tients. In this period, the analysis could not be performed<br />
only once, in a case when patient <strong>and</strong> donor were identical<br />
twins. The number of times the patient underwent the chimerism<br />
analysis varied, depending on the conditioning regimen,<br />
diagnosis <strong>and</strong> the clinical status of the patient. This<br />
number ranged from one to 25. The majority of the patients<br />
had a full donor chimerism (FDC) status for the entire time<br />
of the follow-up (69.2%). However, various other situations<br />
have been encountered: patients who reached FDC after a<br />
period of decreasing mixed chimerism (MC, 10.3%), patients<br />
with a transient MC (5.9%), patients who had a stable<br />
or decreasing MC (2.6%), patients with an increasing proportion<br />
of recipient cells either after a period of FDC status<br />
or without ever reaching FDC (5.1%), patients who, after a<br />
FDC status, showed MC in the last performed analysis<br />
(3.7%), <strong>and</strong> patients who never achieved engraftment with<br />
only recipient cells detectable (4.0%). A good correlation<br />
between the clinical status <strong>and</strong> the results of the chimerism<br />
analysis has been observed, especially in the cases of increasing<br />
MC.<br />
In conclusion, the protocol for chimerism analysis established<br />
in our centre has proven to be a reliable <strong>and</strong> useful<br />
tool in the patient treatment after transplantation. Regular,<br />
consecutive analyses enable the determination of the chimerism<br />
dynamics <strong>and</strong> thus provide necessary data for timely<br />
interventions <strong>and</strong> improvement of the transplantation outcome.<br />
PP61 Venous access for Apheresis <strong>and</strong><br />
Photopheresis procedures<br />
Babic A. Istituto Europeo di Oncologia, Divisione di<br />
Ematologia, Milan, Italy<br />
Background: Our Clinical Transplantation Program consists<br />
in a process performed by a multidisciplinary team<br />
working with common staff training, programs, protocols,<br />
<strong>and</strong> quality management systems, according to JACIE <strong>and</strong><br />
ISO guidelines. Peripheral blood stem cells represent the<br />
most used source of hematopoietic cells <strong>and</strong> apheresis is a<br />
routinary technique applied to collect them. In our Collection<br />
Unit we use Cobe Spectra System for apheresis procedures<br />
<strong>and</strong> also perform photopheresis procedures with<br />
UVA-PIT off line system for GvHD treatment.<br />
Aims: To perform the apheresis pocedures, single or<br />
multiple, we need the presence of good vascular access,<br />
able to provide constant blood flow pressure of 40–90 ml/h<br />
during the whole procedure time (3 hours approximately)<br />
with minor complication risks, due to the procedure itself or<br />
to a long time presence of central venous catheter.<br />
Methods: For apheresis procedures to collect CD34+<br />
cells or lymphocytes, where possible, usually with healthy<br />
donors, we prefer to use the peripheral veins (cephalic or<br />
basilical) for the procedure. On the contrary, in patients the<br />
peripheral veins <strong>are</strong> often insufficient or severely compromised<br />
by multiple chemotherapy cycles, therefore we need<br />
to use central veins to perform the procedure. Frequently<br />
our patients <strong>are</strong> provided with a Porth-a-Cath Catheter<br />
which can be used as a return way during the procedure so<br />
it becomes easier to find only one peripheral access rather
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations<br />
than two. In case of complete absence of peripheral access<br />
we put another central venous catheter preferably in femoral<br />
vein. On the other h<strong>and</strong>, when we perform the extracorporeal<br />
photopheresis procedure with off line system we first<br />
need to execute the lympho+monocytes collection by Cobe<br />
Spectra; therefore we need two good venous access available<br />
during the whole program of cure. There <strong>are</strong> a variety<br />
of schedules depending on disease but usually the treatment<br />
takes 5–6 months to be completed. The choice of the central<br />
venous catheter to be used also depends on the psychophysical<br />
conditions of each patients <strong>and</strong> it needs to be evaluated<br />
c<strong>are</strong>fully <strong>and</strong> on a one-to-one basis.<br />
Results: Depending on the situation, the choice of the<br />
catheters to be used for procedures is personalised. Venous<br />
access, risks of infections <strong>and</strong> thrombosis <strong>are</strong> evaluated by<br />
the apheresis team while the nurse is dedicated to perform<br />
the procedure <strong>and</strong> to schedule catheter’s medications. Complications<br />
due to catheters used for apheresis procedure <strong>are</strong><br />
usually r<strong>are</strong> , mostly those linked to thrombotic or infection<br />
complications. (Bern MM e coll.,1990)<br />
Conclusions: Choosing the right venous access we can<br />
guarantee the optimum blood flow able to collect in less<br />
time the selected cell types with low contamination of unwanted<br />
cells, minor risks due to the platelet loose, minor<br />
stress to the patient <strong>and</strong> major security to patient <strong>and</strong> to operator.<br />
PP62 Pure red cell aplasia preceding a DLBCL<br />
with 6 years<br />
Barca G, Marin S, Nada S, Dragan C, Barbu D,<br />
Angelescu S, Tevet M, Saguna C, Bizu I, Lupu AR,<br />
Coltea Clinical Hospital, Hematology Clinic, Buch<strong>are</strong>st,<br />
Romania<br />
Background: Pure red cell aplasia (PRCA) is one of the<br />
autoimmune diseases seen during the course of lymphomas.<br />
However, the relation of PRCA with the underlying lymphomas<br />
remains unclear, <strong>and</strong> cases were reported in which<br />
PRCA occurred concomitantly, preceded, or followed the<br />
diagnosis of lymphoma.<br />
Aims <strong>and</strong> case description: we report the case of a 49<br />
years-old women with pure red cell aplasia diagnosed in<br />
2003 <strong>and</strong> confirmed by bone marrow biopsy with immunohistochemical<br />
analysis. After 6 years of treatment with red<br />
blood cell mass transfusion, erythropoietin <strong>and</strong> iron chelation<br />
therapy she developed a left supraclavicular tumor. The<br />
biopsy followed by imunohistochemical analysis showed a<br />
diffuse large B cell lymphoma <strong>and</strong> the initial workup established<br />
stage IIIB disease. She received 8 R-CHOP cycles of<br />
chemotherapy, with PET/CT confirming complete remission<br />
at the end. During chemotherapy the hemoglobin concentration<br />
started rising, despite the grim expectations. At<br />
the time this report was written, she does not need transfusions<br />
any more.<br />
Discussion <strong>and</strong> conclusions: Immunotherapy with<br />
Rituximab <strong>and</strong> immunosuppressive medication, including<br />
ciclofosfamide <strong>are</strong> mentioned in the literature as viable<br />
treatments for PRCA. Both Rituximab <strong>and</strong> the immunosuppressive<br />
effects of the CHOP regimen could be responsible<br />
for the favorable response seen in this case. The peculiarity<br />
of the case consists in the the occurence of lymphoma at a<br />
considerable interval from the diagnosis of PRCA <strong>and</strong> the<br />
prompt response of PRCA to the R-CHOP therapy for lymphoma.<br />
PP63 Can Platelet be Unnecessary<br />
Vieira S, Monroe D, Librojo M. London, United Kingdom<br />
Blood transfusion continues to be an essential part of<br />
modern practise but not without risks. During the last decade<br />
there has been an increase interest in national level<br />
across the United Kingdom (UK) <strong>and</strong> Europe for collecting<br />
data on the hazards of transfusion of blood components.<br />
Therefore avoiding unnecessary transfusion is accepted as<br />
one way of reducing the risk which is associated with blood<br />
transfusion. In our stem cell transplant unit we have audited<br />
platelet transfusion (PT) frequency <strong>and</strong> reason for it.<br />
Patients <strong>and</strong> methods: The audit was carried out prospectively.<br />
A log in book was kept in unit for recording the<br />
red cell transfusion orders. The data was validated with<br />
cross check retrospectively all inpatient episodes record on<br />
monthly basis. The audit was carried over 6 months of period<br />
form May 2010 till end of October 2010.<br />
Results: Unit policy is to keep platelet count above 10<br />
with the exception of 20 if the patient is febrile. It is also<br />
aimed to keep plt above 50 if pat is receiving anticoagulant<br />
or bleeding for various reasons.<br />
In six months period, total of 105 episodes platelet transfusion<br />
occurred. Only 10% of these were routine transfusion<br />
<strong>and</strong> they were below 10 X109/L. <strong>and</strong> 26% of plt was<br />
given due to bleeding. However 10% of routine transfusion<br />
was given when platelet count was higher than 31 X 109/L.<br />
In overall 36% of the total platelet transfusion was given<br />
when platelet count was higher than 31 x109/L. 26% of the<br />
PT was given due to bleeding <strong>and</strong> 19% was given as unit<br />
policy i.e. anticoagulant treatment.<br />
Conclusion: Our organisation recognises the importance<br />
of risk associated in unnecessary blood product transfusion.<br />
Our 6 moths audit has shown interesting figures.<br />
In six months period total of 105 platelet transfusion carried<br />
out, only 36.5% of these transfusion was fitting the unit<br />
policy. 9.5% of these were given when platelet count was<br />
higher than 31 x109/L. There were various reason to transfuse<br />
platelet even though count was reasonable for haematology<br />
patient group such as bleeding <strong>and</strong> anticoagulant<br />
use.<br />
PP64 Transfuse or Not to Transfuse?<br />
Vieira S, Monroe D, Librojo M. London, United Kingdom<br />
Blood transfusion continues to be an essential part of<br />
modern practise but not without risks. During the last decade<br />
there has been an increase INTEREST in national<br />
level across the United Kingdom (UK) <strong>and</strong> Europe for collecting<br />
data on the hazards of transfusion of blood components.<br />
Therefore avoiding unnecessary transfusion is ac-<br />
117
Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
cepted as one way of reducing the risk which is associated<br />
with blood transfusion. In our stem cell transplant unit we<br />
have audited red cell transfusion frequency <strong>and</strong> reason for<br />
it. Unit policy is to keep Haemoglobin level above 8gr/dl,<br />
this may change time to time to 8.5 mg/dl depends on patient<br />
symptoms or if post chemo.<br />
Patients <strong>and</strong> methods: The audit was carried out prospectively.<br />
A log in book was kept in unit for recording the<br />
red cell transfusion orders. The data was validated with<br />
cross check retrospectively all inpatient record on monthly<br />
basis. The audit was carried over 6 months of period form<br />
May 2010 till end of October 2010.<br />
Results: During this 6 months period total of 90 episodes<br />
RCT performed in our unit. Haemoglobin level was 8.5 gr/L<br />
or below in 75.5% episodes, where as only 11% of the trans-<br />
118<br />
fusion performed when haemoglobin level was 9.1 gr/L or<br />
above.<br />
The reason for transfusion was categorised as routine as<br />
unit protocol, bleeding, pre procedure <strong>and</strong> on doctor’s instruction<br />
due to patient symptoms or keeping high trash<br />
hold haemoglobin level. Routine RCT was 87% of total<br />
episodes <strong>and</strong> 76% of this was 8.5 gr/L or below. However<br />
10% of the RCT transfusion was done when haemoglobin<br />
level is 9.1 gr/L or higher.<br />
Conclusion: Our organisation recognises the importance<br />
of risk associated in unnecessary blood product transfusion.<br />
Our 6 moths audit has shown interesting figures. 10% of<br />
total episodes RCT was given as routine were above 9.1 gr/<br />
L where as 70% of routine RCT was performed due to low<br />
haemoglobin level according to our unit policy.
Satellite Symposia<br />
Satellite Symposium:<br />
Therapy of fungal infections<br />
in immunocompromised patients<br />
SP01 Hematologic patients dying of IFI? Trends<br />
in IFI epidemiology<br />
Lubos Drgona, Slovakia<br />
Invasive fungal infections/diseases (IFD) <strong>are</strong> life threatening<br />
infectious complications in the population of immunocompromised<br />
patients. Patients with acute acute leukemia<br />
<strong>and</strong> patients undergoing hematopoietic stem cell transplantation<br />
(HSCT) <strong>are</strong> considered as the high risk group for<br />
development of IFD. During the last years of previous millenium<br />
an increase of incidence of invasive aspergillosis<br />
(IA) <strong>and</strong> decrease of invasive c<strong>and</strong>ida infection were observed<br />
at hematological departments. Today, invasive c<strong>and</strong>idaemia<br />
(IC) in high-risk haematological patient is quite r<strong>are</strong><br />
fungal infection when comp<strong>are</strong>d with IA but IC is still associated<br />
with high mortality (40–50%). Incidence of IC<br />
started to decline after the introduction of fluconazole to<br />
profylaxis of high risk patients during the 90-ties. But, results<br />
from our consecutive, prospective studies documented<br />
that the incidence of c<strong>and</strong>ideamia in Slovakia during the recent<br />
5 years is increasing. The population at risk is situated<br />
at ICUs <strong>and</strong> hematology-oncology departments <strong>and</strong> the<br />
most common pathogen is C.albicans in 38–50% of all episodes<br />
followed by C. parapsilosis in 26–29%. Infections<br />
caused by non-albicans species dominated at our hematooncology<br />
wards. The resistance of some non-albicans strains<br />
to fluconazole <strong>and</strong> voriconazole is slightly increasing. The<br />
local epidemiological data <strong>are</strong> important <strong>and</strong> they should<br />
help to guide the therapy for the patients with c<strong>and</strong>idaemia.<br />
The incidence of IA is 5–15% among the patients after<br />
allogeneic HSCT; the incidence in AML patients after induction<br />
therapy can reach 5–10%. Autopsy surveys identifyied<br />
the high prevalence of IA (30%) in patients with AML<br />
or after allogeneic HSCT but only about 1/3 of them were<br />
diagnosed before the death. Unfortunately, autopsy rate is<br />
very low in some countries. Several factors <strong>are</strong> associated<br />
with the increased risk for invasive fungal disease <strong>and</strong> higher<br />
mortality. Many studies have confirmed that good performance<br />
status, controlled malignancy, rapid neutropenia recovery,<br />
other than allogeneic transplantation <strong>and</strong> localized<br />
infection <strong>are</strong> factors associated with the higher probability<br />
of successfull outcome. The ascent of novel therapies for<br />
lymphoid malignancies (e.g. fludarabine, alemtuzumab) is<br />
associated with the higher incidence of opportunistic infections,<br />
including the IA. Despite the better knowledge of risk<br />
factors, useful diagnostic tools (e.g.GM, HRCT) <strong>and</strong> appropriate<br />
use of antifungal drugs – which <strong>are</strong> able to decrease<br />
mortality – the overall <strong>and</strong> infection-related mortality is still<br />
a problem. Mortality of high-risk haematological patients<br />
with IA is still high (40–80%) but there is a trend to decrease<br />
of mortality of IA confirmed by recently published<br />
studies. Our data from Czech <strong>and</strong> Slovak Fungal Infection<br />
Database (FIND) showed the overall mortality of 59% at 1<br />
year after the diagnosis of IA. The long-term overall survival<br />
of patients patients with IA who failed on the 1.line<br />
therapy was only 30% according to our observation in another<br />
survey. Genetic <strong>and</strong> prognostic risk factors <strong>are</strong> more<br />
widely studied now to better define the high-risk population<br />
<strong>and</strong> to improve the selection of appropriate antifungal strategy.<br />
A better knowledge about the epidemiology <strong>and</strong> risk factors<br />
is one of the key issues in the complex management of<br />
haematologic patients with IFD <strong>and</strong> may help to decrease<br />
mortality.<br />
SP02 Invasive aspergillosis in hematological<br />
patients – from empirical to early<br />
pre-emptive therapy<br />
Michael Girschikofsky, Austria<br />
The management of invasive fungal infection (IFI) is still<br />
a major challenge in patients with hematological malignancies<br />
or undergoing allogeneic stem cell transplantation. The<br />
incidence depends on the severity <strong>and</strong> duration of neutropenia,<br />
co-morbidity <strong>and</strong> co-medication, as well as local hospital<br />
factors like reconstruction works. Despite development<br />
of novel agents the mortality of proven invasive aspergillosis<br />
remains about 50%, which is mainly attributed to a delayed<br />
onset of antifungal therapy.<br />
Several guidelines support the decision finding for a prophylactic<br />
use of antimycotics in this high risk population.<br />
Nevertheless about 30% of patients develop neutropenic fever<br />
<strong>and</strong> 72–96 hours after failure of broad spectrum antibiotics<br />
the use of empirical antifungal therapy is considered as<br />
st<strong>and</strong>ard of c<strong>are</strong>. Overtreatment und drug related toxicity is<br />
a well known problem of this approach. Targeting the time<br />
frame between the first evidence of pathogens <strong>and</strong> manifest<br />
clinically signs of IFI, the pre-emptive strategy which is<br />
based on regularly screening with non-culture microbiological<br />
techniques (aspergillus galactomannan <strong>and</strong> PCR)<br />
<strong>and</strong> early CT-scanning may lead to a more effective use of<br />
antimycotic therapy.<br />
The detection of fungal associated signs in computed tomography<br />
scan (CT) is helpful but never pathognomonic.<br />
Thus, if clinically justifiable invasive diagnostic procedures,<br />
like CT guided biopsy <strong>are</strong> recommended to exclude other<br />
diseases or to determine the fungal species.<br />
119
Satellite Symposia Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
SP03 Management of Invasive aspergillosis:<br />
guidelines at the bedside<br />
Ben De Pauw (The Netherl<strong>and</strong>s)<br />
The relative incidence of the various fungal infections depends<br />
on geography as well as on local medical practices in<br />
a given hospital. In general, the number of patients at risk of<br />
invasive fungal infections has increased over the last decennium<br />
with the introduction of modern immunosuppressive<br />
<strong>and</strong> monoclonal antibodies for the treatment of both malignant<br />
<strong>and</strong> immune-mediated diseases. The problems in the<br />
management of invasive fungal disease hinge around three<br />
pivotal factors: 1) Difficulty to establish the diagnosis in an<br />
early stage of development; 2) Availability of safe, efficacious<br />
<strong>and</strong> affordable antifungal agents; 3) Impact of the<br />
evolvement of the underlying immune deficiency on the<br />
outcome of the infection.<br />
Diagnostic tools, notably serological tests <strong>and</strong> imaging<br />
techniques have improved over the last decade but their still<br />
doubts about their potency to detect an invasive fungal infection<br />
in an early stage of disease, partly because the required<br />
knowledge <strong>and</strong> facilities <strong>are</strong> only available at specialized<br />
centers where only a minority of the patients is being<br />
treated. As to avoid the confrontation with a stage of<br />
infection beyond a chance of cure, strategies based on early<br />
intervention became very popular. However, after having<br />
r<strong>and</strong>omized more than 7000 patients in clinical trials there<br />
is still no convincing scientific evidence to support a theoretically<br />
attractive prophylactic strategy. Using fluconazole<br />
as prophylaxis against c<strong>and</strong>idiasis in reasonably well defined<br />
risk groups appe<strong>are</strong>d effective but the story is different<br />
for mould infections. Even the most recent trials on posaconazole<br />
in the prevention of aspergillosis failed to provide a<br />
definite answer. Moreover, the risk of inducing resistance of<br />
selection of resistant stains is the price to be paid for intensive<br />
use of antifungals as has been witnessed after the introduction<br />
of fluconazole. Empirical treatment, i.e. institution<br />
of systemically active antifungals for fever not responding<br />
to adequate antibacterial therapy, was originally designed to<br />
eliminate life-threatening c<strong>and</strong>idosis but gained general recognition<br />
as an anti-aspergillosis strategy as well. As there<br />
<strong>are</strong> myriad causes of fever, it is inevitable that, following an<br />
empirical strategy, many patients will receive antifungals<br />
without actually requiring them. Improved diagnostics<br />
might help to reduce the number of c<strong>and</strong>idates for antifungals<br />
substantially; it is expected that such an pre-emptive<br />
strategy will become more popular.<br />
Systemically active antifungal compounds from four different<br />
classes of drugs <strong>are</strong> regularly used to treat invasive<br />
fungal infections. Amphotericin B was the drug of choice<br />
for all invasive fungal infections for more than 30 years.<br />
Presently, fluconazole is prescribed mainly to treat new infections<br />
by C<strong>and</strong>ida species <strong>and</strong> Cryptococcus neoformans.<br />
Recommendations on the management of aspergillosis for<br />
high-risk patients is now confusing since posaconazole<br />
would appear the drug of choice for prophylaxis, while voriconazole<br />
remains the drug of choice for the treatment of<br />
proven <strong>and</strong> probable aspergillosis leaving caspofungin <strong>and</strong><br />
liposomal amphotericin B the preferred drugs for empirical<br />
120<br />
therapy. This is the unfortunate consequence of mixing efficacy<br />
studies that ought to be designed to explore the options<br />
<strong>and</strong> limitations of a given drug with strategy trials.<br />
It has become customary to issue guidelines for the management<br />
of life-threatening diseases such as invasive fungal<br />
infections. These guidelines <strong>are</strong> supposed to offer the clinician<br />
easy access to the overwhelming amount of sometimes<br />
confusing data assuming that the assorted information will<br />
help to select the most suitable treatment for the seriously ill<br />
patient. Moreover, patients <strong>and</strong> authorities alike dem<strong>and</strong><br />
clear regulations to provide insight in the medical procedures<br />
<strong>and</strong> an objective benchmark for quality control, repectively.<br />
It is obvious that administrative people <strong>and</strong> clinician<br />
appreciate treatment guidelines in a different way. The individual<br />
patient occupies the central position in the vision of<br />
the clinician, while administrators see a group of patients<br />
with a similar disease who require a particular therapy.<br />
Guidelines for its treatment have been published in English<br />
by working parties from various countries <strong>and</strong> as all<br />
committees had the same data set at their disposal, great<br />
congruency amongst the various documents could be expected.<br />
The differences, however, <strong>are</strong> considerable. Most<br />
discrepancies <strong>are</strong> related to a different interpretation of the<br />
clinical trials. Empirical trials <strong>and</strong> salvage studies, which<br />
<strong>are</strong> rather strategic than drug-efficacy studies <strong>are</strong> of no value<br />
at all. The value of clinical trials for this purpose is largely<br />
overestimated, especially by unexperienced practitioners<br />
<strong>and</strong> regulatory authories. Therefore the published guidelines<br />
for the treatment of invasive fungal disease have to be<br />
taken into consideration but applied in clinical practice with<br />
prudence. They <strong>are</strong> provided for groups but there <strong>are</strong> frequently<br />
good reasons to deviate from the recommendations<br />
in individual cases.<br />
Satellite Symposium:<br />
Iron chelation therapy for MDS<br />
SP04 The Role of Iron Chelation Therapy in MDS<br />
Heather A. Leitch (Canada)<br />
Most patients with MDS develop RBC transfusion dependence<br />
<strong>and</strong> resulting iron overload (IOL) impacts negatively<br />
on survival. 1 Mechanisms of toxicity may include<br />
non-transferrin-bound iron (NTBI) resulting in oxidative<br />
stress, damaging lipids, proteins, <strong>and</strong> nucleic acids, <strong>and</strong> potentially<br />
leading to apoptosis or mutagenesis <strong>and</strong> malignant<br />
progression, both features of MDS. Guidelines recommend<br />
iron chelation therapy in lower-risk MDS with reasonable<br />
life expectancy, where retrospective studies show a survival<br />
benefit; these data will be reviewed. 2–4<br />
Chelation is also considered for patients eligible for stem<br />
cell transplantation (SCT), where decreased survival <strong>and</strong><br />
increased treatment-related mortality with IOL is seen, a<br />
sharp increase in NTBI occurs, <strong>and</strong> lower infection risk, delayed<br />
leukaemic transformation <strong>and</strong> improved outcome<br />
with chelation <strong>are</strong> suggested. 5,6<br />
While awaiting results of phase 3 trials of chelation in<br />
MDS, treatment should be individualized <strong>and</strong> monitored ac-
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Satellite Symposia<br />
cording to guidelines. If observations that chelation could<br />
improve outcome in higher-risk MDS <strong>are</strong> confirmed, future<br />
expansion in the role for iron-lowering therapy may be<br />
seen.<br />
R E F E R E N C E S<br />
1. Sanz G, Nomdedeu B, Such E, Bernal T, Belkaid M, Ardanaz MT, et al.<br />
Independent impact of iron overload <strong>and</strong> transfusion dependency on survival<br />
<strong>and</strong> leukemic evolution in patients with myelodysplastic syndrome.<br />
Blood 2008;112:[abstract 640].<br />
2. Leitch HA, Leger CS, Goodman TA, Wong KK, Wong DHC, Ramadan<br />
KM, et al. Improved survival in patients with myelodysplastic syndrome<br />
receiving iron chelation therapy. Clin Leuk 2008;2:205–11.<br />
3. Fox F, Kündgen A, Nachtkamp K, Strupp C, Haas R, Germing U, Gattermann<br />
N. Matched-pair analysis of 186 MDS patients receiving iron<br />
chelation therapy or transfusion therapy only. Blood 2009;114:[abstract<br />
1747].<br />
4. Rose C, Brechignac S, Vassilief D, Pascal L, Stamatoullas A, Guerci A,<br />
et al. Does iron chelation therapy improve survival in regularly transfused<br />
lower risk MDS patients? A multicenter study by the GFM. Leuk<br />
Res. [Epub ahead of print 2010 Feb 1].<br />
5. Pullarkat V, Blanchard S, Tegtmeier B, Dagis A, Patane K, Ito J, Forman<br />
SJ. Iron overload adversely affects outcome of allogeneic hematopoietic<br />
cell transplantation. Bone Marrow Transplant 2008;42:799–805.<br />
6. Sorror ML, Storer BE, Schoch G, S<strong>and</strong>maier BM, Martin PJ, Scott BL,<br />
et al. Low albumin, high ferritin, <strong>and</strong> thrombocytopenia before transplant<br />
predict non-relapse mortality (NRM) independent of the hematopoietic<br />
cell transplantation comorbidity index (HCT-CI). Blood 2009;<br />
114:[abstract 651].<br />
SP05 Which MDS patients <strong>are</strong> eligible for iron<br />
chelation therapy?<br />
Aristoteles Giagounidis (Germany)<br />
SP06 Deferasirox in iron-overloaded patients<br />
with transfusion-dependent MDS<br />
de Witte T, de Swart L, Swinkels D, MacKenzie M<br />
(The Netherl<strong>and</strong>s)<br />
Myelodysplastic syndromes (MDS) <strong>are</strong> a heterogeneous<br />
group of clonal hematopoietic stem cell disorders. They <strong>are</strong><br />
characterized by abnormal differentiation <strong>and</strong> maturation of<br />
myeloid cells, bone marrow failure <strong>and</strong> genetic instability<br />
with an enhanced risk of progression to secondary leukaemia.<br />
The International Prognostic Scoring System (IPSS)<br />
for MDS is based on the percentage of marrow blasts, the<br />
number of cytopenias <strong>and</strong> cytogenetic characteristics <strong>and</strong><br />
has shown to be effective in predicting outcome mainly for<br />
MDS patients treated with supportive c<strong>are</strong> 1 . A new scoring<br />
system, the WHO Prognostic Scoring System (WPSS), is<br />
based on the WHO classification, transfusion dependency<br />
<strong>and</strong> cytogenetic abnormalities.<br />
Diagnosis <strong>and</strong> treatment of iron overload <strong>and</strong> iron toxicity<br />
is of great importance in the clinical management of<br />
MDS patients, because iron overload is likely an important<br />
predictor of morbidity <strong>and</strong> mortality. In a retrospective<br />
study 2 , heart failure was the most important non-leukemic<br />
cause of death (50%), followed by infection (31%) <strong>and</strong> liver<br />
cirrhosis (8%). These causes can be the result of iron overload.<br />
Iron overload in MDS is mainly caused by red blood cell<br />
transfusions 3 . Transfused iron probably accumulates initially<br />
in the liver before it is loaded into the heart as is described<br />
in β-thalassemia patients 4 . In a study with transfusion-dependent<br />
MDS patients, iron accumulation of the heart occurred<br />
after 75–100 blood transfusions when patients did<br />
not receive iron chelation therapy 6 .<br />
Ineffective erythropoiesis may also play an important<br />
role in iron accumulation in MDS patients in addition to red<br />
blood cell transfusions associated iron overload. Similar to<br />
β-thalassemia patients, ineffective erythropoiesis may lead<br />
to an increased growth differentiation factor (GDF)15 level,<br />
which subsequently lowers the hepcidin levels <strong>and</strong> results in<br />
an increased iron absorption from the intestinal tract 7 . Until<br />
now, only small studies have been performed in MDS patients<br />
to evaluate the hepcidin level 8–10 , but GDF15 has<br />
shown to be increased in RARS patients 11 . It is not clear if<br />
ineffective erythropoiesis itself leads to significant symptomatic<br />
iron overload. However, serum ferritin levels can be<br />
elevated before blood transfusions <strong>are</strong> given, especially in<br />
patients with RARS 12 , suggesting that iron overload is already<br />
present.<br />
Besides iron accumulation, iron toxicity probably plays<br />
an important role in MDS. Free iron in the plasma becomes<br />
available when the capacity of transferrin to carry iron is<br />
exceeded. This non-transferrin-bound iron (NTBI) is even<br />
elevated in MDS patients who did not yet receive any blood<br />
cell transfusions <strong>and</strong> is associated with a higher level of<br />
apoptosis 13 . In a recent study with thalassemia patients,<br />
NTBI was correlated with transferrin saturation but not with<br />
serum ferritin level. Patients with heart diseases had significantly<br />
higher NTBI levels than those without heart disease,<br />
suggesting that NTBI will be responsible for functional organ<br />
damage 14 . The presence of NTBI will be reflected in a<br />
rise of labile plasma iron (LPI) <strong>and</strong> reactive oxygen species<br />
(ROS) that causes cell <strong>and</strong> tissue damage 15,16 . LPI is the<br />
fraction of NTBI that is redox active <strong>and</strong> eliminated by iron<br />
chelators 17 . The determination of NTBI remains difficult<br />
<strong>and</strong> new methods <strong>are</strong> under investigation to improve the reliability<br />
of this important iron toxicity parameter. In the near<br />
future a more reliable assessment of NTBI in combination<br />
with LPI will be most valuable to determine iron toxicity in<br />
MDS patients.<br />
Recently new oral iron chelation therapy has become<br />
available (deferasirox), which makes iron chelation therapy<br />
more feasible <strong>and</strong> effective despite possible side effects.<br />
Several prospective studies have demonstrated that oral<br />
iron chelation therapy is effective in the reduction of the<br />
iron accumulation, but it is not yet clear which patients benefit<br />
most of this treatment 18–21 . Iron chelation therapy will<br />
probably reduce iron accumulation in end target organs as<br />
well as decrease iron toxicity by reducing potentially toxic<br />
iron 19,22 . Some studies have shown benefit of iron chelation<br />
therapy for survival in MDS patients 23,24 .<br />
Several guidelines for iron chelation therapy in MDS patients<br />
have been published the last years, without clear evidence<br />
for the optimum treatment of iron overload 25 . By<br />
gaining more insight into the pathophysiology <strong>and</strong> toxicity<br />
of iron overload in MDS patients, the guidelines for iron<br />
121
Satellite Symposia Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
chelation therapy can be optimized to reduce iron related<br />
morbidity <strong>and</strong> mortality.<br />
An ongoing registry study organized by the MDS Working<br />
Package of the European LeukemiaNet has collected<br />
prospectively demographic <strong>and</strong> treatment data on more than<br />
1,000 patients with lower risk MDS from 15 European<br />
countries. An interim analysis presented at the most recent<br />
EHA meeting showed that transfusions dependent patients<br />
had a 4.1 times higher chance of dying during a short observation<br />
period of 18 months only. This registry consortium<br />
will continue to collect data, including data on the impact of<br />
iron chelation on outcome.<br />
R E F E R E N C E S<br />
1. Greenberg P, Cox C, LeBeau MM et al. International scoring system<br />
for evaluating prognosis in myelodysplastic syndromes. Blood 1997;89<br />
(6):2079–2088.<br />
2. Malcovati L, Porta MG, Pascutto C et al. Prognostic factors <strong>and</strong> life<br />
expectancy in myelodysplastic syndromes classified according to WHO<br />
criteria: a basis for clinical decision making. J Clin Oncol 2005;23<br />
(30):7594–7603.<br />
3. Porter JB. Practical management of iron overload. Br J Haematol<br />
2001;115(2):239–252.<br />
4. Chacko J, Pennell DJ, Tanner MA et al. Myocardial iron loading by<br />
magnetic resonance imaging T2* in good prognostic myelodysplastic<br />
syndrome patients on long-term blood transfusions. Br J Haematol<br />
2007;138(5):587–593.<br />
5. Jensen PD, Jensen FT, Christensen T, Eiskjaer H, Ba<strong>and</strong>rup U, Nielsen<br />
JL. Evaluation of myocardial iron by magnetic resonance imaging during<br />
iron chelation therapy with deferrioxamine: indication of close relation<br />
between myocardial iron content <strong>and</strong> chelatable iron pool. Blood<br />
2003;101(11):4632–4639.<br />
7. Tanno T, Bhanu NV, Oneal PA et al. High levels of GDF15 in thalassemia<br />
suppress expression of the iron regulatory protein hepcidin. Nat<br />
Med 2007;13(9):1096–1101.<br />
8. Murphy PT, Mitra S, Gleeson M, Desmond R, Swinkels DW. Urinary<br />
hepcidin excretion in patients with low grade myelodysplastic syndrome.<br />
Br J Haematol 2009;144(3):451–452.<br />
9. Tanno T, Bhanu NV, Oneal PA et al. High levels of GDF15 in thalassemia<br />
suppress expression of the iron regulatory protein hepcidin. Nat<br />
Med 2007;13(9):1096–1101.<br />
10. Winder A, Lefkowitz R, Ghoti H et al. Urinary hepcidin excretion in<br />
patients with myelodysplastic syndrome <strong>and</strong> myelofibrosis. Br J Haematol<br />
2008;142(4):669–671.<br />
11. Ramirez JM, Schaad O, Durual S et al. Growth differentiation factor 15<br />
production is necessary for normal erythroid differentiation <strong>and</strong> is increased<br />
in refractory anaemia with ring-sideroblasts. Br J Haematol<br />
2009;144(2):251–262.<br />
12. Gattermann N. Clinical consequences of iron overload in myelodysplastic<br />
syndromes <strong>and</strong> treatment with chelators. Hematology/Oncology<br />
Clinics 2005;19:13–17.<br />
13. Cortelezzi A, Cattaneo C, Cristiani S et al. Non-transferrin-bound iron<br />
in myelodysplastic syndromes: a marker of ineffective erythropoiesis?<br />
Hematol J 2000;1(3):153–158.<br />
14. Piga A, Longo F, Duca L et al. High nontransferrin bound iron levels <strong>and</strong><br />
heart disease in thalassemia major. Am J Hematol 2009;84(1):29–33.<br />
15. Esposito BP, Breuer W, Sirankapracha P, Pootrakul P, Hershko C, Cabantchik<br />
ZI. Labile plasma iron in iron overload: redox activity <strong>and</strong><br />
susceptibility to chelation. Blood 2003;102(7):2670–2677.<br />
16. Ghoti H, Amer J, Winder A, Rachmilewitz E, Fibach E. Oxidative<br />
stress in red blood cells, platelets <strong>and</strong> polymorphonuclear leukocytes<br />
from patients with myelodysplastic syndrome. Eur J Haematol 2007;<br />
79(6):463–467.<br />
17. Pootrakul P, Breuer W, Sametb<strong>and</strong> M, Sirankapracha P, Hershko C,<br />
Cabantchik ZI. Labile plasma iron (LPI) as an indicator of chelatable<br />
plasma redox activity in iron-overloaded beta-thalassemia/HbE patients<br />
treated with an oral chelator. Blood 2004;104(5):1504–1510.<br />
18. Gattermann N, Schmid M, Della PM, et al. Efficacy <strong>and</strong> safety of deferasirox<br />
during 1 year of treatment in transfusion-dependent patients<br />
122<br />
with myelodysplastic syndromes: results from EPIC trial. ASH Annual<br />
Meeting Abstracts 633. 2008. Ref Type: Abstract<br />
19. List AF, Baer MR, Steensma DP, et al. Iron chelation with Deferasirox<br />
improves iron burden in patients with myelodysplastic syndromes<br />
(MDS). ASH Annual Meeting Abstracts 634. 2008. Ref Type: Abstract<br />
20. Porter J, Galanello R, Saglio G et al. Relative response of patients with<br />
myelodysplastic syndromes <strong>and</strong> other transfusion-dependent anaemias<br />
to deferasirox (ICL670): a 1-yr prospective study. Eur J Haematol<br />
2008;80(2):168–176.<br />
21. Wood JC, Kang BP, Thompson A et al. The effect of deferasirox on<br />
cardiac iron in thalassemia major: impact of total body iron stores.<br />
Blood 2010;116(4):537–543.<br />
22. Ghoti H, Amer J, Winder A, Rachmilewitz E, Fibach E. Oxidative<br />
stress in red blood cells, platelets <strong>and</strong> polymorphonuclear leukocytes<br />
from patients with myelodysplastic syndrome. Eur J Haematol 2007;<br />
79(6):463–467.<br />
23. Rose C, Brechignac S, Vassilief D et al. Does iron chelation therapy<br />
improve survival in regularly transfused lower risk MDS patients? A<br />
multicenter study by the GFM (Groupe Francophone des Myelodysplasies).<br />
Leuk Res 2010;34(7):864–870.<br />
24. Leitch HA, Leger CS, Goodman TA et al. Improved survival in patients<br />
with myelodysplastic syndrome receiving iron chelation therapy. Clinical<br />
Leukemia 2008;2(3):205–211.<br />
25. Messa E, Cilloni D, Saglio G. Iron chelation therapy in myelodysplastic<br />
syndromes. Adv Hematol 2010;2010:756289.<br />
Satellite Symposium<br />
The Optimal Management of CML<br />
SP07 Nilotinib versus Imatinib for Newly<br />
Diagnosed CML patients: ENESTnd study<br />
results<br />
Giuseppe Saglio (Italy)<br />
Patients with newly diagnosed chronic phase (CP) chronic<br />
myeloid leukemia (CML) have a high probability of longterm<br />
survival, which is mainly due to the efficacy of imatinib,<br />
the first targeted inhibitor of the oncogenic BCR-<br />
ABL1 kinase to be registered. In a recent report from IRIS<br />
study, patients in the imatinib arm had a 8-year rate of overall<br />
survival (OS) of 85% <strong>and</strong> freedom from progression to<br />
accelerated- (AP) or blast-phase (BP) disease of 93%. Cumulative<br />
rates of complete cytogenetic response (CCyR)<br />
were 69% at 1 year, 87% at 5 years, <strong>and</strong> 89% at 8 years.<br />
These data highlight that for at least one-third of patients,<br />
the potential exists to improve on what can be achieved with<br />
st<strong>and</strong>ard imatinib 400 mg/d treatment. After imatinib failure,<br />
current treatment recommendations include dose escalation<br />
to 600–800 mg/d, or switch to an approved next-generation<br />
tyrosine kinase inhibitor (TKI. Although stem cell<br />
transplant (SCT) remains an important <strong>and</strong> potentially curative<br />
option, favorable response rates <strong>and</strong> tolerability achieved<br />
with TKIs have resulted in SCT being increasingly reserved<br />
for patients who have failed on TKIs <strong>and</strong> for those who have<br />
progressed to advanced phases. The results from ENESTnd<br />
trial testing nilotinib at two different dosages, 300mg BID<br />
<strong>and</strong> 400 BID, clearly indicate a superior efficacy of the more<br />
potent second-generation TKI nilotinib with respect to imatinib,<br />
particularly in terms of higher rates of major molecular<br />
responses (MMR), of complete cytogenetic responses<br />
(CCyR) that, more importantly, lead to a decreased number<br />
of progressions to more advances phases of the disease.
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Satellite Symposia<br />
These results will probably modify imatinib-based strategies<br />
in the first-line therapy of CML <strong>and</strong> <strong>are</strong> becoming a key<br />
<strong>are</strong>a of clinical research during the next few years.<br />
REFERENCES<br />
1. Saglio G, Kim DW, Issaragrisil S, et al. Nilotinib versus Imatinib for<br />
Newly Diagnosed Chronic Myeloid Leukemia. N Engl J Med 2010;362:<br />
2251–2259.<br />
2. Kantarjian H, Shah NP, Hochhaus A, et al. Dasatinib versus Imatinib in<br />
Newly Diagnosed Chronic-Phase Chronic Myeloid Leukemia. N Engl J<br />
Med 2010;362:2260–2270.<br />
SP08 Optimal treatment for newly diagnosed<br />
CML patients<br />
Francis Giles (Irel<strong>and</strong>)<br />
Nilotinib (Tasigna ® ) is a much more potent <strong>and</strong> selective<br />
BCR-ABL inhibitor than imatinib <strong>and</strong> was designed to<br />
overcome imatinib’s deficiencies. Nilotinib has very significant<br />
efficacy in patients with CML in chronic (CP) <strong>and</strong><br />
accelerated (AP) following imatinib failure. Based on the<br />
results of the Evaluating Nilotinib Efficacy <strong>and</strong> Safety in<br />
Clinical Trials-Newly Diagnosed Patients (ENESTnd) study,<br />
the Food <strong>and</strong> Drug Administration (FDA) on June 17 th 2010<br />
granted approval of nilotinib for the treatment of adult patients<br />
with newly diagnosed Philadelphia-chromosome positive<br />
CML in CP. Imatinib changed our perceptions of the<br />
therapeutic power of targeted inhibition of a pathologically<br />
active kinase. Nilotinib, a designer agent built on the imatinib<br />
scaffold, has proven superior to its template agent by<br />
every significant surrogate marker used in monitoring CML.<br />
The largest CML-related threat to life on imatinib therapy is<br />
development of AP/BP within the first 3 years of imatinib<br />
therapy. In terms of both the clinically relevant surrogate<br />
markers, CCyR <strong>and</strong> MMR, <strong>and</strong> of the clinically vital endpoints<br />
of early transformation events <strong>and</strong> overall survival,<br />
nilotinib has proved superior to imatinib as first line therapy<br />
in CML. Nilotinib has a low incidence of grade 3/4 extramedullary<br />
adverse events, predominantly transient biochemical<br />
abnormalities, which tend to occur early in therapy.<br />
Nilotinib in the frontline setting is associated with less<br />
myelosuppression than imatinib. The ENEST1st study, a<br />
pan-European study, will further examine the efficacy of nilotinib<br />
300mg BID in newly diagnosed patients with CML<br />
using CMR as the primary study endpoint. The ENEST1st<br />
study has a range of integral international collaborative biology<br />
studies which include a focus on CML stem cells,<br />
indices of genomic instability, very sensitive mutated bcrabl<br />
phenotype clone detection <strong>and</strong> quantitation, <strong>and</strong> genomic<br />
analyses. Nilotinib PK <strong>and</strong> patient adherence to therapy<br />
will also be focused on in this study.<br />
R E F E R E N C E S<br />
1. Hochhaus A, Saglio G, le Coutre PD, et al. Superior efficacy of nilotinib<br />
comp<strong>are</strong>d with imatinib in newly-diagnosed patients with chronic myeloid<br />
leukemia in chronic phase (CML-CP): ENESTnd minimum 24month<br />
follow-up. Paper presented at: 16th Annual Congress of the European<br />
Hematology Association; June 9–12, 2011; London, UK.<br />
2. Saglio G, Hochhaus A, Guilhot F, et al. Nilotinib is associated with<br />
fewer treatment failures <strong>and</strong> suboptimal responses vs imatinib in pa-<br />
tients with newly diagnosed chronic myeloid leukemia in chronic phase<br />
(CML-CP): results from ENESTnd. Paper presented at: 16th Annual<br />
Congress of the European Hematology Association; June 9–12, 2011;<br />
London, UK.<br />
3. Weisberg E, Manley PW, Cowan-Jacob SW, Hochhaus A, Griffin JD.<br />
Second generation inhibitors of BCR-ABL for the treatment of imatinib-resistant<br />
chronic myeloid leukaemia. Nat Rev Cancer. 2007;7(5):<br />
345–356.<br />
4. Hughes TP, Hochhaus A, Saglio G, et al; for the ENESTnd investigators.<br />
ENESTnd 24-month update: continued superiority of nilotinib versus<br />
imatinib in patients with newly diagnosed chronic myeloid leukemia<br />
in chronic phase (CML-CP). Slides presented at: 52nd Annual Meeting<br />
of the American Society of Hematology; December 4–7, 2010; Orl<strong>and</strong>o,<br />
FL. Abstract 207.<br />
5. Saglio G, Kim D-W, Issaragrisil S, et al; for the ENESTnd investigators.<br />
Nilotinib versus imatinib for newly diagnosed chronic myeloid leukemia.<br />
N Engl J Med. 2010;362(24):2251–2259<br />
6. Pinilla-Ibarz J, Cortes J, Mauro MJ. Intolerance to tyrosine kinase inhibitors<br />
in chronic myeloid leukemia: definitions <strong>and</strong> clinical implications.<br />
Cancer. 2011;117(4):688–697.<br />
7. Kantarjian HM, Giles FJ, Bhalla KN, et al. Nilotinib is effective in patients<br />
with chronic myeloid leukemia in chronic phase following imatinib<br />
resistance or intolerance: 24-month follow-up results. Blood. 2010;<br />
117(4):1141–1145.<br />
SP09 The importance of molecular monitoring<br />
in CML patients<br />
Martin M. Mueller (Germany)<br />
Topic: The importance of molecular monitoring in CML<br />
patients<br />
Abstract: Molecular characterization of diseases has<br />
been implemented in routine work-up of hematologic patients<br />
in many countries. Molecular monitoring of CML patients<br />
represents one of the most advanced fields applying<br />
qualitative <strong>and</strong> quantitative RT-PCR using peripheral blood<br />
samples. Besides mentioning the advantages <strong>and</strong> disadvantages<br />
of the techniques, the differences comp<strong>are</strong>d to cytogenetic<br />
assessment as the current gold-st<strong>and</strong>ard will be highlighted.<br />
Quantification of BCR-ABL mRNA transcripts<br />
represents the most sensitive tool of monitoring CML patients<br />
allowing to predict for future response at early timepoints<br />
<strong>and</strong> to find suboptimal treatment outcomes triggering<br />
mutation analysis. Further, current European efforts of harmonizing<br />
laboratories for BCR-ABL quantification will be<br />
discussed.<br />
Satellite Symposium:<br />
Optimal Management of PNH<br />
SP10 PNH – Morbidities & Mortality<br />
Boris Labar (Croatia)<br />
Paroxysmal nocturnal hemoglobinuria (PNH) is a r<strong>are</strong>,<br />
chronic, life-threatening disorder caused by the somatic<br />
mutation of the PIG A gene in hematopoetic stem cells (1).<br />
Because of this mutation PNH cells <strong>are</strong> missing glycosilphosphatidylinositol<br />
(GPI) So GPI anchored proteins <strong>are</strong><br />
not bind <strong>and</strong> present on the cell surface. For PNH it is important<br />
that CD59 (1)(forms a defensive shield for erythrocytes<br />
from complement-mediated lysis) <strong>and</strong> CD55 (2) (pre-<br />
123
Satellite Symposia Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
vents formation <strong>and</strong> augments the instability of the C3 convertases,<br />
attenuating the complement cascades) <strong>are</strong> not<br />
present at the surface of red cells. Such cells underwent hemolysis<br />
because of uncontrolled complement activation (3).<br />
As a consequence of chronic hemolysis, progressive morbidities<br />
could develop such as thrombotic events (TEs),<br />
chronic kidney disease (CKD), <strong>and</strong> pulmonary hypertension.<br />
These <strong>and</strong> other PNH-associated symptoms (ie, abdominal<br />
pain, dyspnea, dysphagia, fatigue, hemoglobinuria,<br />
<strong>and</strong> erectile dysfunction) have a significant effect on patient<br />
quality of life (QoL). The 5-year mortality rate for patients<br />
with PNH is ∼35%,(4) <strong>and</strong> the leading cause of death is<br />
TE.(5) As many as 29% to 44% of patients with PNH suffer<br />
from at least one TE during their disease,(6) <strong>and</strong> TE may<br />
occur regardless of transfusion history. Many patients with<br />
PNH have impaired renal function, with up to 64% having<br />
CKD; renal failure is a common (8% to 18%) cause of death<br />
among patients with PNH.(7, 8) Nearly 50% of patients<br />
have some evidence of pulmonary hypertension.(9) Although<br />
not life-threatening, fatigue <strong>and</strong> pain <strong>are</strong> common in<br />
patients with PNH <strong>and</strong> can substantially impair QoL.<br />
Historically, PNH has been managed with transfusions,<br />
red blood cell supplements, anticoagulants, <strong>and</strong> steroids,(5,<br />
10) none of which have reduced the risks of disease progression<br />
or severe morbidity. Hematopoeitic stem cell transplant<br />
is associated with a high risk of morbidity <strong>and</strong> mortality;<br />
thus, for most patients, the associated risks preclude this option.<br />
As such, recent studies in PNH have focused on inhibiting<br />
the complement system to reduce the chronic hemolysis<br />
underlying the progressive morbidities <strong>and</strong> mortality.<br />
Treatment with eculizumab, a fully humanized monoclonal<br />
antibody that inhibits terminal complement activity, can<br />
normalize the survival of patients with PNH(11).<br />
R E F E R E N C E S<br />
1. Johnson JR et al. J Clin Pathol Mol Pathol. 2002;55:145–52<br />
2. Brodsky RA. In Hematology, Basic Principles <strong>and</strong> Practices, 4th ed. R<br />
Hoffman, EJ et al. Eds Philadelphia, Elsevier Churchil Livingstone,<br />
2005, pp 419–27.<br />
3. Rother RP et al. Nat Biotechnol. 2007;25:1256–1264.<br />
4. Hillmen P et al. N Engl J Med. 1995;25:1253–1258<br />
5. Parker C et al. Blood. 2005;106:3699–3709<br />
6. Hillmen P et al. Blood. 2007;110:4123–4128.<br />
7. Hillmen P et al. Am J Hematol. 2010;85:553–559.<br />
8. Nishimura J et al. Medicine (Baltimore). 2004;83:193–207.<br />
9. Hill A. et al. Br J Haematol. 2007;137:181–192<br />
10. Rachidi S et al. Eur J Intern Med. 2010;21:260–267.<br />
11. Kelly RJ et al. Blood. 2011;117:6786–6792<br />
SP11 Shifting the Paradigm in PNH Management<br />
Peter Hillmen (United Kingdom)<br />
Paroxysmal nocturnal hemoglobinuria (PNH) is a r<strong>are</strong>,<br />
acquired, chronic <strong>and</strong> life-threatening hematopoietic stem<br />
cell disorder characterized by chronic uncontrolled activation<br />
of the complement system. 1–3<br />
The primary clinical manifestation of PNH is chronic hemolysis,<br />
which is associated with severe morbidities, including<br />
thromboembolism (TE), chronic kidney disease<br />
(CKD), anemia, <strong>and</strong> fatigue. 4 For patients with PNH, treatment<br />
with eculizumab, a fully humanized monoclonal anti-<br />
124<br />
body that inhibits terminal complement activity, has represented<br />
a major paradigm shift.<br />
The clinical program of eculizumab in patients with PNH<br />
consists of 195 patients in total, <strong>and</strong> 4 trials [Pilot study<br />
(N=11), TRIUMPH (phase III, placebo-controlled trial)<br />
(N=87), SHEPHERD (broader patient population) (N=97)]<br />
<strong>and</strong> a subsequent long-term extension trial evaluating longterm<br />
efficacy <strong>and</strong> safety. 5 In the long-term trial, following<br />
eculizumab treatment, the reduction in lactate dehydrogenase<br />
(LDH) was sustained after 36 months follow-up (P <<br />
.0001), TE events were significantly reduced from 52 pretreatment<br />
to 10 trial events by matched time analysis (P <<br />
.0005), <strong>and</strong> CKD stage (stages 1–5) was reduced from 69%<br />
of patients at baseline to 31% at 36 months. 5 Hemoglobin<br />
increased significantly <strong>and</strong> was sustained over 36 months<br />
(mean increase over baseline 9.5 g/L; range, –31 to 68; P <<br />
.0001). Among patients receiving ≥ 36 months of eculizumab<br />
(n=87), 29% became transfusion independent <strong>and</strong> remained<br />
so throughout treatment. Eculizumab was well tolerated;<br />
most adverse events (AEs) were mild-to-moderate.<br />
Of the 10% of patients who discontinued (n=20), 9 were the<br />
result of an AE. In 16-weeks of follow-up, 3 of the 20 discontinuing<br />
patients had TE, including 1 death. Two cases of<br />
meningococcal sepsis were successfully treated without sequelae.<br />
Four patients died during study; 3 were considered<br />
unrelated <strong>and</strong> 1 possibly related to eculizumab. Per Kaplan<br />
Meier estimation, overall survival was 97.6% at 3 years <strong>and</strong><br />
maintained through 5.5 years of treatment; this comp<strong>are</strong>s<br />
favorably to a survival rate previously reported in historical<br />
controls (65% at 5 years).<br />
In another analysis of survival (N=79), the efficacy of<br />
eculizumab was sustained over 8 years of therapy <strong>and</strong> was<br />
not different to that in an age-, sex-matched normal control<br />
population 6 .<br />
In conclusion, eculizumab significantly reduces chronic<br />
hemolysis <strong>and</strong> TE, improves CKD <strong>and</strong> PNH-associated<br />
symptoms, <strong>and</strong> improves probability of survival. These effects<br />
<strong>are</strong> sustained during long-term treatment. Thus, eculizumab<br />
inhibition of terminal complement activity is an effective<br />
treatment approach for patients with PNH.<br />
Alexion Pharmaceuticals, Inc: Consultancy, Honoraria,<br />
Membership on an entity’s Board of Directors or advisory<br />
committees, Research Funding.<br />
R E F E R E N C E S<br />
1. Brodsky R, Schrezenmeier H, Muus P et al. Blood [ASH]. 2009;114:<br />
Abstract 3007.<br />
2. Brodsky RA. Blood. 2009;113(26):6522–6527.<br />
3. Hillmen P, Elebute M, Kelly R et al. Am J Hematol. 2010;85(8):553–<br />
559.<br />
4. Parker C, Omine M, Richards S et al. Blood. 2005;106(12):3699–3709.<br />
5. Hillmen P, Risitano A, Schrezenmeier H et al. Haematologica [EHA]<br />
2011;96(s2):105. Abstract 0254.<br />
6. Kelly RJ, Hill A, Arnold LM et al. Blood. 2011;117(25):6786–6792.<br />
SP12 Acute renal failure <strong>and</strong> PNH – Case report<br />
Jaroslav Cermak (Czech Republic)<br />
Diagnosis <strong>and</strong> management of patients with PNH can be<br />
challenging. This case-based presentation provides a real-
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Satellite Symposia<br />
world context for PNH treatment <strong>and</strong> clinical trial data <strong>and</strong><br />
provides a forum for discussion of their application to evidence-based<br />
medicine in day-to-day practice.<br />
Patients with PNH often experience increased rates of infection,<br />
fatigue, insomnia, pain in the joints <strong>and</strong> abdomen,<br />
dyspnea, <strong>and</strong> dysuria, each of which can undermine quality<br />
of life <strong>and</strong> can also lead to an increased risk of thrombotic<br />
events <strong>and</strong> mortality. 1,2 In patients who present with these<br />
symptoms, a differential diagnosis based on histologic <strong>and</strong><br />
flow cytometry analyses is essential. 3 With only supportive<br />
c<strong>are</strong>, PNH is invariably progressive. 4 In later stages, renal<br />
failure, infections, <strong>and</strong> cardiopulmonary <strong>and</strong> hematologic<br />
complications can become life-limiting. 1,3<br />
Historical therapies for PNH have included supportive<br />
c<strong>are</strong> with red blood cell transfusions <strong>and</strong> iron chelation as<br />
needed, steroids, antithrombotic prophylaxis, <strong>and</strong> dialysis. 1,4<br />
However, the introduction of eculizumab, a terminal complement<br />
inhibitor, has provided an option to treat the underlying<br />
disease rather than palliating disease symptoms <strong>and</strong><br />
end-organ damage. 4,5 Nonetheless, several questions remain:<br />
What is the role for stem cell transplant? Will antithrombosis<br />
prophylaxis be needed during eculizumab treatment?<br />
What is the role of eculizumab in patients with aplastic<br />
anemia/PNH syndrome <strong>and</strong> other PNH-related conditions?<br />
Generation of an international PHN registry may<br />
provide insight into these questions.<br />
R E F E R E N C E S<br />
1. Parker et al. Blood. 2005;106:3699–3709.<br />
2. Lee et al. Haematologica. 2010;95: Abstracts 505 <strong>and</strong> 506.<br />
2. Borowitz et al. Cytometry B Clin Cytom. 2010;78:211–230.<br />
3. Rachidi et al. Eur J Intern Med. 2010;21:260–267.<br />
4. Hill A et al. Haematologica. 2010;95:567–573.<br />
SP13 Treatment of Paroxismal nocturnal<br />
hemoglobinuria – a case report<br />
Ana Boban (Croatia)<br />
Paroxismal nocturnal hemoglobinuria (PNH) is clonal<br />
acquired disorder characterized by hemolytic anemia, thrombosis,<br />
fatigue <strong>and</strong> bone marrow failure. It is caused by acquired<br />
mutation of PIG-A gene in mutipotent hematopoietic<br />
stem cell. As a consequence, cells <strong>are</strong> lacking glycosil phos-<br />
phatidylinosiol (GPI) – anchored proteins, namely CD55<br />
<strong>and</strong> CG 59, which <strong>are</strong> complement regulatory proteins. The<br />
lack of complement regulatory proteins makes erythrocytes<br />
susceptible to both intravascular <strong>and</strong> extravascular hemolysis.<br />
Intravascular hemolysis is responsible for majority of<br />
morbidity form the disease. Eculizumab is a monoclonal<br />
antibody that inhibits terminal complement activation,<br />
which reduces intravascular hemolysis in PNH patients.<br />
Here we present the first PNH patient in our Center treated<br />
with eculizumab.<br />
The patient was diagnosed having aplastic anemia in<br />
2009, at the age of 21. The treatment started with corticosteroids,<br />
<strong>and</strong> later altered into cyclosporine. In 2005 the patient<br />
presented with severe headache <strong>and</strong> transitory ischemic attack.<br />
At that point PNH was suspected, <strong>and</strong> diagnostic procedure<br />
was carried out. Diagnose of PNH was made based<br />
on PNH clone on flow cytometry. In 2007, the progression<br />
of intravascular hemolysis was noted, with significant increase<br />
in bilirubin <strong>and</strong> lactate dehidrogenase levels, followed<br />
by the signs of bone marrow failure. The need for<br />
blood transfusions <strong>and</strong> fatigue increased, while quality of<br />
life decreased. Allogenic stem cell transplantation was indicated,<br />
but no related donor was found. The patient was eligible<br />
for eculizumab treatment.<br />
The treatment with eculizumab started in January 2010.<br />
Patient was vaccinated for Naisseria meningitides, <strong>and</strong> developed<br />
severe cellulitis with skin necrosis on the place of<br />
the puncture, hence the reconstructive surgery of the left upper<br />
arm was needed. At the time when eculizumab was<br />
started, patient had severe hemolysis, thrombocytopenia,<br />
<strong>and</strong> anemia with need of blood transfusions every 2–3 weeks<br />
<strong>and</strong> secondary hemochromatosis. Subjectively, she complained<br />
mostly on severe fatigue. The patient received induction<br />
treatment without side effects <strong>and</strong> continued with<br />
maintenance treatment for 19 months. A significant decrease<br />
of hemolysis was noted, <strong>and</strong> consequently reduced<br />
need for transfusions <strong>and</strong> disappearance of symptoms,<br />
mainly fatigue with dramatic improvement in her quality of<br />
life.<br />
Eculizumab treatment significantly improved quality of<br />
life of the PNH patient. Patient’s main symptom, fatigue,<br />
disappe<strong>are</strong>d almost completely, <strong>and</strong> rate of blood transfusion<br />
was reduced to once in 5–6 weeks. We found eculizumab<br />
effective in treatment of PNH patients.<br />
125
Author Index<br />
Abdel-Wahab, O., 23<br />
Ajdukovic, R., 88, 91, 98<br />
Aleksic, A., 98<br />
Amadori, S., 17, 22<br />
Andjelic, B., 105<br />
Andreola, G., 106<br />
Angelescu, S., 117<br />
Anicic, M., 108<br />
Antic, D., 102, 105, 109<br />
Antica, M., 87<br />
Arcasoy, M., 101<br />
Armitage, JO., 97<br />
Auon, P., 97<br />
Aurer, I., 65, 79, 92, 99, 100, 105,<br />
111, 112<br />
Avila, DN., 94<br />
Ayari, S., 93<br />
Babic, A., 106, 113, 115, 116<br />
Babok-Flegaric, R., 91<br />
Baird, K., 94<br />
Banfic, H., 87<br />
Baráth, S., 88<br />
Barbu, D., 117<br />
Barca, G., 117<br />
B<strong>are</strong>z, MY, 112<br />
Barisic, N., 96<br />
Barlogie, B., 48<br />
Barrett, J., 56<br />
Barsic, B., 103<br />
Basic-Kinda, S., 92, 99, 100, 104,<br />
105, 111, 112<br />
Bast, M., 97<br />
Batar, P., 110<br />
Batinic, D., 87, 90, 96, 104, 105, 107<br />
Batinic, J., 90, 105<br />
Begovic, D., 90<br />
Bijedic, V., 81<br />
Bila, J., 105<br />
Bilic, E., 96, 103, 108, 110<br />
Bishop, M. R., 60<br />
Biskup, M., 114<br />
Bizu, I., 117<br />
Bladé, J., 47<br />
Blaise, D., 23<br />
Blin, N., 93<br />
Boban, A., 104, 125<br />
Bodrozic, J., 105<br />
Bogdanovic, A., 109<br />
Bojanic, I., 95, 96, 105, 113, 114<br />
Bolaños Meade, J., 94<br />
Borbenyi, Z., 81, 88, 107<br />
Borckhardt, A., 19<br />
Bosnic, D., 112<br />
Brissot, E., 93<br />
Burnac, IL., 114<br />
Burnett, A., 21<br />
Carde, P., 63<br />
Carzavec, D., 91<br />
Catalano, J., 101<br />
Cermak, J., 124<br />
Cevreska, L., 81, 99, 102<br />
Chan, WC., 97<br />
Chevallier, P., 93<br />
Cigrovski, N., 99<br />
Cikota, B., 98<br />
Clavert, A., 93<br />
Coha, B., 91<br />
Cojbasic, I., 91, 99<br />
Colovic, N., 89, 108, 109<br />
Corovic-Arneri, E., 91<br />
Cortes, J., 3, 36<br />
Cowen, EW., 94<br />
Crkvenac Gornik, K., 114<br />
Crncec, I., 88<br />
Crowley, J., 48<br />
Dávid, M., 88, 107<br />
Davidovic, S., 89, 90, 91, 92,<br />
93, 114<br />
Deininger, M., 101<br />
Dekanic, A., 101<br />
Delaunay, J., 93<br />
De Marchi, E., 115<br />
De Pauw, B., 120<br />
de Swart, L., 121<br />
de Witte, T., 17, 26, 76, 121<br />
Dimovski, A., 102<br />
DiPersio, J., 101<br />
Djunic, I., 89, 102, 108, 109<br />
Djurasinovic, V., 89, 108, 109<br />
Dotlic, S., 112<br />
Dragan, C., 117<br />
Drera, M., 106<br />
Drgona, L., 119<br />
Dubravcic, K., 96, 104<br />
Dubruille, V., 93<br />
Dujmovic, D., 99, 111<br />
Dukovski, D., 99, 102<br />
Duletic Nacinovic, A., 91, 101<br />
Durakovic, N., 94, 95, 105,<br />
114<br />
Dusek, D., 96, 103<br />
Elezovic, I., 102, 105, 109<br />
Engert, A., 65<br />
Erickson-Viitanen, S., 101<br />
Faderl, S., 3, 49<br />
Fayad, L., 63<br />
Femenic, R., 96, 103, 108, 110<br />
Fern<strong>and</strong>ez, S., 112<br />
Ferrajoli, A., 53<br />
Fowler, N., 61<br />
Frani} Simic, I., 92<br />
Freireich, E., 17<br />
Fruchtman, S., 35<br />
Fu, K., 97<br />
Fuchs, EJ., 94<br />
Gale, R. P., 47<br />
Galgano, L., 115<br />
Garcia-Manero, G., 28<br />
Gasparovic, V., 112<br />
Gastinne, T., 93<br />
Geisler, C., 62<br />
Giagounidis, A., 121<br />
Giebel, S., 52<br />
Giles, F., 123<br />
Girinsky, T., 64<br />
Girschikofsky, M., 119<br />
Gjadrov, K., 90<br />
Gojceta, K., 114<br />
Golemovic, M., 96, 113, 114<br />
Golubic Cepulic, B., 96, 105, 113,<br />
114<br />
Gotic, M., 105<br />
Gotlib, J., 101<br />
Govedarovic, N., 91, 99<br />
Grahovac, B., 101<br />
Gratwohl, A., 54<br />
Grcevi}, D., 104<br />
Greiner, T., 97<br />
Gress, RE., 94<br />
Grkovic, L., 94<br />
Grohovac, D., 101<br />
Grubic, Z., 93, 95, 115, 116<br />
Guillaume, T., 93<br />
Gupta, V., 101<br />
Gveric-Krecak, V., 91<br />
Gyimesi, E., 88<br />
Hadji-Pecova, L., 111<br />
Hadzisejdic, I., 101<br />
Haferlach, T., 20<br />
Haïat, S., 50<br />
127
Author Index Lije~ Vjesn 2011; godi{te 133; (Supl. 4)<br />
Halkes, S., 17<br />
Haris, V., 88<br />
Harousseau, JL., 93<br />
Harvey, J., 101<br />
Hehlmann, R., 35<br />
Heuck, C. J., 46<br />
Hevessy, Zs., 88<br />
Hexner, E., 101<br />
Hillmen, P., 54, 124<br />
Hoelzer, D., 48<br />
Hoffman, R., 35<br />
Horowitz, M. M., 55<br />
Horvat, I., 92<br />
Host, I., 101<br />
Hotic-Laz<strong>are</strong>vic, S., 112<br />
Hude, I., 111<br />
Humar, I., 113, 114<br />
Hutchings, M., 65<br />
Ilic, I., 99, 111, 112, 114<br />
Indrak, K., 81<br />
Iqbal, J., 97<br />
Ivanovski, M., 102<br />
Ivcevic, S., 104<br />
Jabbour, E., 3, 28, 36, 46<br />
Jaksic, B., 78, 90<br />
Jaksic, O., 88, 90, 98<br />
Jansen, J., 21<br />
Jones, RJ., 94<br />
Jonjic, N., 101<br />
Kantarjian, H., 3, 23, 28, 36,<br />
101<br />
Kappelmayer, J., 88<br />
Kardum, I., 90<br />
Keating, M., 18<br />
Kezic, Lj., 112<br />
Khouri, I., 54<br />
Kis, E., 107<br />
Knopinska-Posluszny, W.,<br />
81<br />
Kolb, H.-J., 19<br />
Konja, J., 96, 103, 108<br />
Konjevoda, P., 103<br />
Koumenis, I., 101<br />
Kovacic, N., 104<br />
Kowalski, J., 94<br />
Kraguljac, N., 105, 109<br />
Kraguljac-Kurtovic, N., 89<br />
Krajcsi, P., 107<br />
Krmek-Zupanic, D., 91<br />
Krnic, N., 96<br />
Kröger, N., 34<br />
Kusec, R., 88, 90, 98, 104<br />
Kutlesa, M., 103<br />
Labar, B., 17, 72, 75, 81, 87, 89, 90,<br />
91, 92, 93, 95, 96, 99, 100, 104,<br />
105, 107, 111, 114, 115, 116, 123<br />
128<br />
Lalic, H., 87<br />
Lapus, F., 112<br />
Lasan-Trcic, R., 90, 91, 92, 110<br />
Laszlo, D., 106, 115<br />
Lazic-Prodan, V., 91<br />
Le Gouill, S., 93<br />
Legr<strong>and</strong>, O., 50<br />
Leitch, H. A., 120<br />
Levine, R. L., 23<br />
Levy, R., 101<br />
Librojo, M., 97, 106, 117<br />
Livun, A., 88<br />
Lozic, D., 91<br />
Lucijanic, M., 98<br />
Lukic, M., 96, 114<br />
Lukinovic-Skudar, V., 87<br />
Lupu, AR., 117<br />
Luznik, L., 58, 94<br />
Lyons, R., 101<br />
MacKenzie, M., 121<br />
Macukanovic-Golubovic, L., 91, 99<br />
Magic, Z., 98<br />
Mahe, B., 93<br />
Malard, F., 93<br />
Malcovati, L., 24<br />
Malinovic, J., 112<br />
M<strong>and</strong>ac-Rogulj, I., 91<br />
M<strong>and</strong>ic, D., 112<br />
Marie, J.-P., 17, 50<br />
Marin, D., 36<br />
Marin, S., 117<br />
Marjanovic, G., 91, 99<br />
Márki-Zay, J., 88, 107<br />
Markovic, D., 91, 99<br />
Markovic-Glamocak, M., 110<br />
Martinelli, G., 106, 115<br />
Marusic Vrsalovic, M., 88<br />
Masarova, K., 106<br />
Matevska, N., 102<br />
Matulic, M., 87<br />
Mazic, S., 96, 105, 113, 114<br />
Meloni, G., 17<br />
Mesa, R., 101<br />
Mihaljevic, B., 105<br />
Mihaylov, G., 81<br />
Mikulic, M., 90, 93, 95, 96, 114<br />
Milanovic, N., 98<br />
Miljkovic, E., 91, 99<br />
Miller, C., 101<br />
Milpied, N., 93<br />
Mistrik, M., 71, 81, 106<br />
Mitchell, A., 48<br />
Mitchell, SA., 94<br />
Mitrovic, M., 102, 109<br />
Mitrovic, Z., 97, 100<br />
Mohty, M., 52, 55, 93<br />
Moicean, A., 81<br />
Monroe, D., 97, 106, 117<br />
Moreau, P., 93<br />
Mrdja, J., 112<br />
Mrsic, M., 93, 95, 114<br />
Mueller, M. M., 123<br />
Musani, V., 88<br />
Muus, P., 17, 76<br />
Nada, S., 117<br />
Nagy, É., 88<br />
Nagy, G., 88<br />
Najfeld, V., 35<br />
Negri, M., 106<br />
Nemet, D., 79, 90, 92, 99, 105,<br />
111<br />
Niederwieser, D., 55<br />
Nikolic, V., 91, 99<br />
Novkovic, A., 89, 108, 109<br />
Novoselac, J., 114<br />
O’Brien, S., 3, 53<br />
Orl<strong>and</strong>o, L., 115<br />
Ottman, O., 51<br />
Ozretic, D., 96<br />
Panovska, I., 111<br />
Panovska-Stavridis, I., 99, 102<br />
Paquette, R., 101<br />
Paradzik, M., 87<br />
Pavletic, SZ., 59, 94<br />
Pavlovic, M., 91<br />
Pavlovic, Maja 96, 110<br />
Pejsa, V., 88, 90, 91, 98<br />
Peric, Z., 91, 93, 104<br />
Perkovic, S., 96, 107, 110<br />
Perunicic Jovanovic, M., 102<br />
Petersen, F. B., 57<br />
Petranovic, D., 101<br />
Petrides, P. E., 32, 72<br />
Petrusevska, G., 99, 111<br />
Pirsic, M., 98<br />
Pivkova Veljanovska, A., 102<br />
Plenkovic, F., 96, 114<br />
Prka, Z., 98<br />
Pulanic, D., 94<br />
Radic Antolic, M., 89, 92, 93, 110<br />
Radman, I., 92, 99, 100, 105, 111<br />
Rajic, Lj., 96, 103, 108, 110, 116<br />
Raos, M., 96, 114<br />
Rav<strong>and</strong>i, F., 3, 22<br />
Raza, A., 101<br />
Ries, S., 89, 90<br />
Romic, I., 91<br />
Roncevic, P., 92<br />
Rosti, G., 46<br />
Saglio, G., 122<br />
Saguna, C., 117<br />
S<strong>and</strong>or, V., 101<br />
Santek, F., 99, 111<br />
Santini, M., 103
Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Author Index<br />
Sanz, M. A., 22<br />
Scalise, A., 35<br />
Schmetzer, H., 19<br />
Sefer, D., 105<br />
Seili, I., 101<br />
Selleslag D, D., 17<br />
Sertic, D., 90, 91, 92, 93, 99,<br />
105, 111<br />
Serventi Seiwerth, R., 90, 93, 94, 95,<br />
96, 104, 114, 115, 116<br />
Shaughnessy, J. D., Jr, 48<br />
Shih, A., 23<br />
Silver, R. T., 33, 35, 101<br />
Silverman, L., 35<br />
Simonovic, O., 91<br />
Sincic-Petricevic, J., 91<br />
Sipka, S., 88<br />
Skific, M., 113, 114<br />
Skunca, Z., 91<br />
Slipac, J., 103<br />
Smith, LM., 97<br />
Sphilberg, O., 61<br />
Sretenovic, A., 109<br />
Steensma, D., 24<br />
Stefanikova, Z., 106<br />
Steinberg, SM., 94<br />
Stemberger, L., 103<br />
Stern-Padovan, R., 99, 111<br />
Stingl, K., 95, 115, 116<br />
Stojanovic, A., 99, 111<br />
Stojanovski, Z., 111<br />
Stojcic, B., 112<br />
Stojsavljevic, S., 103<br />
Stoos Veic, T., 88<br />
Suciu, S., 17, 60<br />
Sun, W., 101<br />
Sureda, A., 66<br />
Suvajdzic, N., 102, 109<br />
Suvajdzic-Vukovic, N., 89, 108<br />
Suvic-Krizanic, V., 91<br />
Swinkels, D., 121<br />
Szabó, P., 88<br />
Sziráki Kiss, V., 88<br />
Talpaz, M., 101<br />
Tarabar, O., 98<br />
Tauber Jakab, K., 88, 107<br />
Taylor, TN., 94<br />
Telek, B., 110<br />
Tesovic, G., 96<br />
Tevet, M., 117<br />
Thomas, D., 52, 76<br />
Tijanic, I., 91, 99<br />
Todorovic, M., 105<br />
Tõkés-Füzesi, M., 88<br />
Tomac, G., 114<br />
Tomin, D., 81, 89, 102, 105, 108,<br />
109<br />
Trajkova, S., 99, 102<br />
Tripodi, J., 35<br />
Trneny, M., 62<br />
Trucza, É., 88<br />
Tukic, Lj., 98<br />
Udvardy, M., 88, 107, 110<br />
Vaddi, K., 101<br />
Valkovic, T., 101<br />
Van Etten, R. A., 31<br />
Vekhoff, A., 50<br />
Verstovsek, S., 31, 79, 101<br />
Vidovic, A., 89, 108, 109<br />
Vidovic, I., 114<br />
Vieira, S., 97, 106, 117<br />
Vignetti, M., 17<br />
Vince, A., 103<br />
Virijevic, M., 89, 108, 109<br />
Visnjic, D., 87<br />
Vodanovic, M., 100<br />
Vose, JM., 97<br />
Vrhovac, R., 103, 116<br />
Vucic, M., 91, 99<br />
Vukicevic, T., 91<br />
Weisenburger, DD., 97<br />
Wierda, W., 53<br />
Wierzbovska, A., 81<br />
Wijermans, P., 25<br />
Willemze, R., 17<br />
Williams, KM., 94<br />
Winton, E., 101<br />
Wroblewski, SG., 94<br />
Younes, A., 62, 69<br />
Zadro, R., 89, 90, 91, 92, 93, 96,<br />
107, 110<br />
Zahurak, M., 94<br />
Zelic, A., 104<br />
Zinzani, P. L., 62<br />
Zlopasa, G., 114<br />
Zunec, R., 115, 116<br />
129