LEUKEMIA AND LYMPHOMA East and West are Together

LEUKEMIA AND LYMPHOMA
East and West are Together
September 17–21, 2011
Dubrovnik, Croatia
Organizers:
The University of Texas, MD Anderson Cancer Center
and
Clinical Hospital Center Zagreb, School of Medicine
University of Zagreb
SUPLEMENT
LIJE^ VJESN 133:1–130 4 ZAGREB, 2011.

Utemeljen 1877. Founded 1877
SAVJET / ADVISORY BOARD
PREDSJEDNIK / PRESIDENT
Mladen Belicza
TAJNIK / SECRETARY
Miroslav Hromadko
^LANOVI / MEMBERS
Ivan Bakran (Zagreb) – Tomislav Dasovi} (Zagreb) – Hedviga Hricak (New York) – Miroslav Hromadko (Zagreb) – Mirko Jung
(Zürich) – Ivica Kostovi} (Zagreb) – Mladen Kri` (Rijeka) – Ante Padjen (Montreal) – Marko Pe}ina (Zagreb) – Dinko Podrug
(New York) – Miljenko Pukani} (Sydney) – Smiljan Pulji} (Upper Saddle River, New Jersey) – Petar Rei} (Split) – Berislav Tomac
(Hagen) – Marko Turina (Zürich) – Ljiljana Zergollern-^upak (Zagreb) – @ivojin @agar (Zagreb)
UREDNI^KI ODBOR / EDITORIAL BOARD
Branimir Ani} (Zagreb) – Darko Anti~evi} (Zagreb) – Alen Babacanli (Zagreb) – @elimir Bradamante (Zagreb) – Nada ^ike{
(Zagreb) – Vladimir Duga~ki (Zagreb) – @eljko Feren~i} (Zagreb) – Rudolf Gre gurek (Zagreb) – Smilja Kaleni} (Zagreb) – Ni kola
Mandi} (Osijek) – August Miji} (Zagreb) – Davor Mili~i} (Zagreb) – Stojan Poli} (Split) – @eljko Reiner (Zagreb) – Darko Richter
(Zagreb) – Zvonko Rumboldt (Split) – Juraj Sep~i} (Rijeka) – Zdenko Sonicki (Zagreb) – Davor [timac (Rijeka)
GLAVNI I ODGOVORNI UREDNIK / EDITOR-IN-CHIEF
Branimir Ani}
TAJNIK UREDNI^KOG ODBORA / SECRETARY OF THE EDITORIAL BOARD
@eljko Feren~i}
Osniva~ i izdava~ / Founder and Publisher
HRVATSKI LIJE^NI^KI ZBOR
Glavni i odgovorni urednik / Editor-in-Chief
BRANIMIR ANI]
Tajnica redakcije / Secretary of the Editorial Offi ce
DRA@ENKA KONTEK
Rje{enje naslovne stranice / Front Page Design
BRANKO VUJANOVI]
Tehni~ki urednik / Technical Editor
JOSIP VLAHOVI]
Slog / Typesetting
»GREDICE« – Zagreb, Horva}anska 67
Tisak / Printed by
PRINTERA GRUPA – Zagreb
Web stranica / Web page
ALEN BABACANLI
Zagreb 2011.
Naklada 200 primjeraka
Rukopis i svi ~lanci {alju se Uredni{tvu Lije~ni~kog vjesnika, Zagreb, [ubi}eva ul. 9, tel. (01) 46-93-300. ^lanarina,
pretplata i sve nov~ane po{iljke {alju se Hrvatskomu lije~ni~kom zboru, Zagreb, [ubi}eva ulica 9, odnosno na `irora~un
br. 2360000-1101214818 ili devizni ra~un br. 2100060384, Zagreba~ka banka d.d., Savska c. 60, Zagreb, Swift:
Zaba HR 2X, IBAN HR7423600001101214818, OIB 60192951611. ^lanarina Hrvatskoga lije~ni~kog zbora iznosi
200 kuna; za lije~nike pripravnike i obiteljska ~lanarina iznosi 100 kuna. Pretplata za Lije~ni~ki vjesnik je 270 kuna.
Radi redovitog primanja potrebno je odmah svaku promjenu adrese i boravka javiti Uredni{tvu. ^asopis se {alje
svim ~lanovima besplatno. Svaki ~lan Hrvatskoga lije~ni~kog zbora ima pravo besplatno objaviti ~lanak u Lije~ni~kom
vjesniku; autori koji nisu ~lanovi Zbora moraju platiti naknadu u iznosu od 150 kuna.
Lije~ni~ki vjesnik citiraju: MEDLINE/Index Medicus i EMBASE/Excerpta Medica.

MEETING CHAIRMAN:
Emil Freireich (USA)
Hagop Kantarjian (USA)
Boris Labar (Croatia)
Ranka Serventi Seiwerth (Croatia)
Srdjan Verstovsek (USA)
SCIENTIFIC SECRETARY:
Sandra Basic Kinda (Croatia)
Mirta Mikulic (Croatia)
MEETING VENUE:
Hotel Palace, Dubrovnik
September 17–21, 2011
Dear Colleagues,
It is our pleasure to welcome you for 2nd Leukemia and Lymphoma Meeting to Dubrovnik,
Croatia, September 17–21, 2011. The organizers are MD Anderson Cancer
Center, Houston, TX, USA and University Hospital Center, Zagreb, School of Medicine
University of Zagreb, Croatia.
During this 5-day meeting, we will explore the most relevant and recent evidencebased
data on treatment of hematological neoplasms. We will discuss the same topics as
in the 1st Leukemia and Lymphoma Meeting; however, in order to encourage audience
participation and interaction, we added new sessions:
Meet the professor and Lunch with Experts which will break into informal discussion
groups.
End of the Day debate to discuss controversies in the treatment of hematological
malignancies.
Many distinguished invited speakers from Europe and USA will participate again.
Welcome to Dubrovnik!
ORGANIZERS

Golden sponsor
Sponsors
Contributors

Contents
Scientific program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
SA01 State of the art I.: Acute leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
OP01-73 Symposia/Special Lectures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
OP01-04 Presidential Symposium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
OP05-10 Symposium: AML – Risk adapted therapy I. . . . . . . . . . . . . . . . . . . . . . . . . . 20
OP11-13 Symposium: AML – Risk adapted therapy II. . . . . . . . . . . . . . . . . . . . . . . . . . 23
OP14-19 Symposium: MDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
OP20-25 Symposium: Myeloproliferative Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . 31
OP26-31 Symposium: CML . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
OP32-35 Symposium: Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
OP36-43 Symposium: ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
OP44-48 Symposium: CLL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
OP49-57 Symposium: Stem Cell Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
OP58 Special Lecture I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
OP59-66 Symposium: Non- Hodgkin Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
OP67-73 Symposium: Hodgkin Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
MP01-10 Meet the Professor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
SA02 State of the art II.: Diagnostic and Treatment Approach
for Acute Myeloblastic Leukemia - Report from Central and Eastern European
Leukemia Group (CELG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
PP01-64 Poster Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
PP01-07 Acute leukemia I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
PP08-13 Ph + Chronic Myeloid Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
PP14-20 Stem Cell Transplantation I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
PP21-27 Lymphoma I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
PP28-34 Myeloproliferative neoplasm and miscelaneus . . . . . . . . . . . . . . . . . . . . . . . . 101
PP35-40 Multiple myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

PP41-47 Acute Leukemia II. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
PP48-54 Lymphoma II. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
PP55-60 Stem Cell Transplantation II. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
PP61-64 Miscelaneus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
SP01-13 Satellite Symposia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Scientific Program
Friday, 16. September 2011
LEUKEMIA AND LYMPHOMA
East and West are Together
Dubrovnik, Croatia, September 17–21, 2011
Organizers:
The University of Texas, MD Anderson Cancer Center
and
Clinical Hospital Center Zagreb, School of Medicine
University of Zagreb
Meeting Venue: Hotel Palace, Dubrovnik
15.00 – 19.00 Meeting: Central and Eastern European Leukemia Group
15.00 – 15.45 Registration of the CELG Group
15.45 – 16.30 Acute Leukemia
16.30 – 17.00 Coffee break
17.00 – 17.45 CML
17.45 – 18.30 Myelofibrosis
18.30 – 19.00 New proposals for CELG Activity
Saturday, 17. September 2011.
13.30 – 15.30 Lunch Satellite Symposium: Therapy of fungal infections in immunocompromised patients
Chair: Boris Labar (Croatia)
14.00 – 14.05 Boris Labar (Croatia)
Welcome and introduction
14.05 – 14.30 Lubos Drgona (Slovakia)
Hematologic patients dying of IFI? Trends in IFI epidemiology (SP01)
14.30 – 14.55 Michael Girschikofsky (Austria)
Invasive aspergillosis in hematological patients – from empirical to early pre-emptive therapy (SP02)
14.55 – 15.20 Ben De Pauw (The Netherlands)
Management of Invasive aspergillosis:guidelines at the bedside (SP03)
15.20 – 15.30 Boris Labar (Croatia)
Panel discussion and meeting close
16.15 – 17.45 Satellite Symposium: Iron chelation therapy for MDS
Chair: Ranka Serventi Seiwerth (Croatia)
16.15 – 16.40 Heather A. Leitch (Canada)
Role of Iron Chelation in Myelodysplastic Syndrome (SP04)
16.40 – 17.05 Aristoteles Giagounidis (Germany)
Which MDS patients are eligible for iron chelation therapy? (SP05)
17.05 – 17.30 Theo De Witte (The Netherlands)
Deferasirox in iron-overloaded patients with transfusion-dependent MDS (SP06)
17.30 – 17.45 Panel discussion and closing of the Symposium
vii

Scientific Program Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
18.00 – 20.00 OPENING CEREMONY and PRESIDENTIAL SYMPOSIUM
18.00 – 18.20 Opening Ceremony
18.20 – 20.00 Presidential Symposium
Chair: Hagop Kantarjian (USA), Boris Labar (Croatia), Srdjan Verstovsek (USA),
Ranka Serventi-Seiwerth (Croatia)
18.20 – 18.45 Emil Freireich (USA)
White blood cell transfusion and leukemia therapy (OP01)
18.45 – 19.10 Roel Willemze (The Netherlands)
Presence and future of treatment of acute myeloid leukemia in patients under the age of 60 (OP02)
19.10 – 19.35 Michael Keating (USA)
CLL: how close is the cure? (OP03)
19.35 – 20.00 Hans-Jochem Kolb (Germany)
From donor »Buffy Coat« to vaccination (OP04)
20.30 – 23.00 CONCERT AND WELCOME COCKTAIL
Sunday 18.09. 2011.
08.30 – 12.30 SYMPOSIUM AML – Risk adapted therapy
Chair: Hagop Kantarjian (USA) Sergio Amadori (Italy)
08.30 – 08.45 Torsten Haferlach (Germany)
AML in adults – what we need for diagnosis (OP05)
08.45 – 09.00 Joop Jansen (The Netherlands)
Mutation of epigenetic regulators in AML and MDS (OP06)
09.00 – 09.15 Alan Burnett (United Kingdom)
Therapy for younger adults with AML (OP07)
09.15 – 09.30 Sergio Amadori (Italy)
Therapy for elderly AML (OP08)
09.30 – 09.45 Miguel Angel Sanz (Spain)
Do we need chemotherapy for APL treatment? (OP09)
09.45 – 10.00 Farhad Ravandi (USA)
FLT3 inhibitors – too much expectations?! (OP10, SA01)
10.00 – 10.30 Coffee break
Chair: Ranka Serventi-Seiwerth (Croatia), Steven Z. Pavletic (USA)
10.30 – 10.45 Marry Horowitz (USA)
Allogeneic SCT for AML – when to treat (OP11)
10.45 – 11.00 Didier Blaise (France)
Allogeneic SCT for AML with reduced intensity conditioning (OP12)
11.00 – 11.15 Hagop Kantarjian (USA)
Novel drugs for AML (OP13, SA01)
11.15 – 11.45 Questions and Answers
12.15 – 13.45 Lunch Satellite Symposium Recent innovations in leukemia and lymphoma treatment
– new hope?!
Chair: Arnold Ganser (Germany)
12.15 – 12.35 Raphael Duarte (Spain)
More patients for autologous transplantation
12.35 – 12.55 Kai Huebel (Germany)
Further development in Stem Cell Mobilization and transplantation
12.55 – 13.15 Arnold Ganser (Germany)
Future Perspectives for Adult Myeloid Leukemia
viii

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Scientific Program
13.15 – 13.35 Rupert Handgretinger (Germany)
Allogeneic Transplant Strategies for the Treatment of Pediatric Acute Leukemias
13.35 – 13.45 Panel Discussion and Closing of the Symposium
14.00 – 15.15 Lunch/Poster Session
Poster presentation: Session 1. Acute leukemia I.
Chair: Drago Batinic (Croatia)
14.00 – 14.10 Rapamycin enhances dimethyl sulfoxide-mediated growth arrest in human myelogenous
leukemia cells (PP01)
Lalic H, Lukinovic-Skudar V, Banfic H, Visnjic D. Department of Physiology & CIBR,
School of Medicine, University of Zagreb
14.10 – 14.20 Ikaros transcription factors expression in cell differentiation (PP02)
Antica M1 , Paradzik M1 , Matulic M2 , Batinic D3 , Labar B3 . 1Division of Molecular Biology,
Ru|er Bo{kovi} Institute, Zagreb, 2Department of Molecular Biology, Faculty of Science, Zagreb,
3University Hospital Center Zagreb and School of Medicine University of Zagreb, Croatia.
14.20 – 14.30 Multicenter Perforomance Evaluation of the Multifrugquant Assay Kit (PP03)
Márki-Zay J1 , Tauber Jakab K1 , Sipka S2 , Nagy G2 , Baráth S2 , Gyimesi E2 , Hevessy Zs3 , Sziráki Kiss V3 ,
Szabó P5 , Tõkés-Füzesi M5 , Nagy É7 , Trucza É7 , Udvardy M4 , Borbényi Z8 , Dávid M6 , Kappelmayer J3 .
1 2 3 Solvo Biotechnology, Szeged, Hungary; Regional Immunological Laboratory, Department of Clinical
Biochemistry and Molecular Pathology, 42nd Department of Internal Medicine, University of Debrecen-
Medical and Health Science Center, Debrecen, Hungary; 5Department of Laboratory Medicine,
University of Pécs-Medical School, 61st Department of Internal Medicine, Pécs, Hungary; 7Department of Laboratory Medicine, 82nd Department of Medicine and Cardiology, University of Szeged – Albert
Szent-Györgyi Clinical Center, Szeged, Hungary
14.30 – 14.40 NPM1 mutations in AML detected by fragment analysis and Sanger sequencing (PP04)
Crncec I, Musani V, Marusic Vrsalovic M, Livun A, Pejsa V, Jaksic O, Haris V, Ajdukovic R,
Stoos Veic T, Kusec R. Departments of Hematology, Divison of molecular diagnostics and genetics
and Cytology, Universtiy hospital Dubrava and Zagreb School of Medicine, Division of molecular
medicine, Institute Rudjer Boskovic, Zagreb, Croatia.
14.40 – 14.50 NPM1 mutation A and FLT3/ITD in AML with myelodysplasia-related changes (PP05)
Radic Antolic M1 , Ries S2 , Zadro R1 , Davidovic S3 , Labar B4 . 1Department of Clinical Laboratory,
2 3 4 Department of Pathology, Deaprtment of Pediatric, Department of Medicine, Clinical Hospital Center
and School of Medicine, University of Zagreb, Croatia
14.50 – 15.00 Prognostic Significance of CD56 Antigen Expression in Patients with Acute Myeloid
Leukemia (PP06)
Djunic I, Virijevic M, Djurasinovic V, Novkovic A, Colovic N, Kraguljac-Kurtovic N, Vidovic A,
Suvajdzic-Vukovic N, Tomin D. Clinic of hematology, Clinical Center Serbia, Belgrade, Serbia
15.00 – 15.10 FLT3 internal tandem duplication is a poor risk factor in patients with AML with diverse
cytogenetic features (PP07)
Mikulic M1 , Zadro R2 , Davidovic S3 , Serventi Seiwerth R1 , Sertic D1 , Nemet D1 , Batinic J1 , Batinic D2 ,
Gjadrov K4 , Ries S4 , Labar B1 . 1Division of Hematology, 1Department of Medicine, 2Department of
Clinical Laboratory, 3Department of Pediatric, 4Department of Pathology, Clinical Hospital Center
and School of Medicine, University of Zagreb, Croatia
Poster presentation: Session 2. Ph+ Chronic Myeloid Leukemia
Chair: Martin Mistrik (Slovakia)
14.00 – 14.10 A Philadelphia-negative Chronic Myeloid Leukemia with a BCR/ABL Fusion Gene (PP08)
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 ,
Begovic D 1 . 1 Division of Medical Genetics, Department of Paediatrics Univesity Hospital Center
Zagreb, Zagreb, Croatia. 2 Division of Hematology, Department of Internal Medicine, Clinical Hospital
Merkur, Zagreb, Croatia. 3 Division of Hematology Departmrnt of Internal Medicine, Clinical Hospital
Dubrava, Zagreb, Croatia. 4 Clinical Laboratory Diagnostics, University Hospital Center Zagreb,
Zagreb, Croatia 5 Division of Hematology, Department of Internal Medicine Univesity Hospital Center
Zagreb, Zagreb, Croatia
ix

Scientific Program Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
14.10 – 14.20 Croatian CML Registry based on European LeukemiaNet CML Registry (PP09)
Sertic D1 , Peric Z1 , Sincic-Petricevic J2 , Lozic D3 , Mandac-Rogulj I4 , Duletic-Nacinovic A5 ,
Gveric-Krecak V6 , Corovic-Arneri E7 , Pejsa V8 , Suvic-Krizanic V9 , Skunca Z10 , Babok-Flegaric R11 ,
Krmek-Zupanic D12 , Carzavec D13 , Lazic-Prodan V14 , Coha B15 , Ajdukovic R8 , Romic I7 , Zadro R1 ,
Davidovic S1 , Lasan-Trcic R1 , Labar B1 . Croatian Cooperative Group for Hematologic Diseases-CML
Group: 1University Hospital Center Zagreb, 2University Hospital Center Osijek, 3University Hospital
Center Split, 4Clinical Hospital Merkur Zagreb, 5University Hospital Center Rijeka, 6General Hospital
[ibenik, 7General Hospital Dubrovnik, 8Clinical Hospital Dubrava-Zagreb, 9General Hospital Sisak,
10 11 12 13 General Hospital Zadar, General Hospital Vara`din, General Hospital Sv.Duh-Zagreb, Clinical
Hospital Center Sestre milosrdnice-Zagreb, 14General Hospital Pula, 15General Hospital Slavonski Brod
14.20 – 14.30 Use of Imatinib mesylate in Chronic Phase CML in Clinical Practice – Our Experience (PP10)
Miljkovic E, Markovic D, Cojbasic I, Nikolic V, Marjanovic G, Govedarovic N,
Macukanovic-Golubovic L, Vucic M, Pavlovic M, Vukicevic T, Tijanic I, Simonovic O. Clinic of
hematology, Clinical Center Nis, Serbia
14.30 – 14.40 Imatinib for CML as a frontline therapy – Zagreb Experience (PP11)
Sertic D1 , Zadro R2 , Nemet D1 , Davidovic S3 , Lasan-Trcis R3 , Radic Antolic M2 , Horvat I2 ,
Frani} Simic I3 , Roncevic P1 , Radman I1 , Basic-Kinda S1 , Aurer I1 , Labar B1. 1Division of Hematolofy
Department of Medicine, 2Department of Clinical Laboratory, 3Department of Pediatric, Clinical
Hospitral Center and School od Medicine, University of Zagreb, Croatia
14.40 – 14.50 Frequency of 4 bcr-abl1 kinase domain mutations in chronic myeloid leukemia patients resistant
to imatinib mesylate therapy (PP12)
Horvat I1 , Radic Antolic M1, Zadro R1 , Sertic D2 , Labar B2 . 1Department of Clinical Laboratory,
2Department of Medicine, Clinical Hospital Center and School of Medicine, University of Zagreb,
Croatia
14.50 – 15.00 Imatinib mesylate in Patients with CML Relapse after Allogeneic Transplantation (PP13)
Serventi Seiwerth R1 , Sertic D1 , Radic Antolic M2 , Mrsic M1 , Zadro R2 , Davidovic S3 , Grubic Z2 ,
Mikulic M1 , Labar B1 . 1Department of Medicine, 2Department of Clinical Laboratory, 3Department of
Pediatric, Clinical Hospital Center and School of Medicine, University of Zagreb, Croatia
Poster presentation: Session 3. Stem Cell Transplantation I.
Chair: Alois Gratwohl (Switzerland)
14.00 – 14.10 Long-term survival and late-onset complications after reduced-intensity conditioning (RIC)
allogeneic stem cell transplantation (allo-SCT) (PP14)
Peric Z, Clavert A, Chevallier P, Brissot E, Malard F, Guillaume T, Delaunay J, Ayari S, Dubruille V,
Le Gouill S, Mahe B, Gastinne T, Blin N, Harousseau JL, Moreau P, Milpied N, Mohty M. Service
d’Hématologie Clinique, Centre Hospitalier et Universitaire (CHU) de Nantes, Nantes, France
14.10 – 14.20 Factors predicting overall survival in patients with advanced chronic graft versus host disease
diagnosed by NIH consensus criteria (PP15)
Grkovic L1,2 , Steinberg SM1 , Baird K1 , Williams KM1 , Cowen EW1 , Mitchell SA1 , Pulanic D1,2 ,
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
Hospital Center Zagreb, Croatia
14.20 – 14.30 Secondary Systemic Immunosuppressants (SSI) after Myeloablative HLA Matched Related
and Unrelated Bone Marrow Transplantation (BMT) using High Dose Cyclophosphamide (Hi Cy)
as sole GVHD prophylaxis (PP16)
Durakovic N1 , Bolaños Meade J1 , Zahurak M2 , Kowalski J2 , Fuchs EJ1 , Jones RJ1 , Luznik L1 . 1Oncology, Johns Hopkins University, Baltimore, Maryland, United States and 2Oncology Biostatistics, Johns
Hopkins University, Baltimore, Maryland, United States
14.30 – 14.40 Allogeneic transplantation from HLA matched unrelated donor – single Center experience (PP17)
Serventi Seiwerth R1 , Mikulic M1 , Mrsic M1 , Grubic Z2 , Bojanic I3 , Durakovic N1 , Stingl K2 , Labar B1 .
1 2 3 Division of Hematology, Department of Medicine, Department of Clinical Laboratory, Department of
Transfusiology, Clinical Hospital Center and School of Medicine, University of Zagreb, Croatia
14.40 – 14.50 Extracorporeal Photochemotherapy in Treatment of Chronic Graft-versus-Host Disease (PP18)
Bojanic I1 , Serventi Seiwerth R2 , Golubic Cepulic B1 , Mazic S1 , Lukic M1 , Raos M1 , Plenkovic F1 ,
Golemovic M1 , Dubravcic K3 , Perkovic S3 , Batinic D3 , Labar B2 . 1Department of Transfusiology,
2 3 Division of Hematology, Department of Medicine, Department of Clinical Laboratory, Clinical
Hospital Center and School of Medicine University of Zagreb, Croatia.
x

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Scientific Program
14.50 – 15.00 Wernicke’s encephalopathy in an adolescent after allogeneic hematopoietic stem cell
transplantation: a case report (PP19)
Rajic Lj1 , Pavlovic M1 , Femenic R1 , Bilic E1 , Krnic N1 , Barisic N1 , Ozretic D1 , Tesovic G4 , Dusek D4 ,
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
for Infectious Diseases, 1,2,3,4School of Medicine University of Zagreb, Croatia
15.00 – 15.10 Need + Information + Satisfaction (PP20)
Vieira S, Monroe D, Librojo M, London, United Kingdom
Poster presentation: Session 4. Lymphoma
Chair: Vlatko Pejsa (Croatia)
14.00 – 14.10 CD43 expression is associated with inferior survival within activated B-cell group of diffuse large
B-cell lymphoma (PP21)
Mitrovic Z1,4 , Iqbal J1 , Fu K1 , Smith LM2 , Weisenburger DD1 , Greiner T1 , Auon P1 , Bast M3 , Armitage
JO3 , Vose JM3 , Chan WC1 . Departments of 1Pathology/Microbiology and 3Hematology/Oncology, 2 4 College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA, School of
Medicine University of Zagreb, Croatia
14.10 – 14.20 Association of Interleukin-10,TNF-Alpha and TGF-Beta Gene Polymorphisms on The Outcome
of Diffuse Large B-cell Lymphoma (PP22)
Tarabar O, Tukic Lj, Cikota B, Milanovic N, Aleksic A, Magic Z. Military Medical Academy, Belgrade,
Serbia
14.20 – 14.30 Dose Adjusted EPOCH – Rituximab as First Line Treatment for High Risk Diffuse Large B-Cell
Lymphoma: A Single Center Experience (PP23)
Pejsa V, Prka Z, Lucijanic M, Jaksic O, Pirsic M, Ajdukovic R, Kusec R. Division of Hematolofy,
Department of Medicine, Universiti Hospital Dubrava and School of Medicine, University of Zagreb,
Croatia
14.30 – 14.40 Immunoblastic Morphology as a Possible Prognostic Indicator for the Outcome of the Patients
with Diffuse Large B cell Lymphoma in Era of the Rituximab Based Treatment: Single Centre
Experience (PP24)
Trajkova S, Panovska-Stavridis I, Stojanovik A, Petrusevska G, Dukovski D, Cevreska L. Department of
Hematology, Medical Faculty, Skopje, Republic of Macedonia
14.40 – 14.50 Primary Mediastinal Large B-Cell Lymphoma – Results of our Center (PP25)
Miljkovic E, Marjanovic G, Cojbasic I, Tijanic I, Markovic D, Nikolic V, Macukanovic-Golubovic L,
Govedarovic N, Vucic M. Clinic of hematology, Clinical Center Nis, Serbia
14.50 – 15.00 Dose-Intense BACOP for Treatment of High-Risk Peripheral T-Cell NHL (PP26)
Aurer I, Dujmovic D, Basic-Kinda S, Nemet D, Radman I, Ilic I, Stern-Padovan R, Santek F, Sertic D,
Cigrovski N, Labar B. Departments of Internal Medicine, Pathology, Radiology and Oncology,
University Hospital Center Zagreb, Zagreb, Croatia
15.00 – 15.10 Oral lomustine, chlorambucil, etoposide and prednisolone (CCEP) for treatment of patients
with advanced lymphoma (PP27)
Radman I, Vodanovic M, Mitrovic Z, Aurer I, Basic-Kinda S, Labar B. Division of Hematology,
Department of Medicine, Clinical Hospital Center and School of Medicine, University of Zagreb,
Croatia
Poster presentation Session 5. Myeloproliferative neoplasm and miscelaneous
Chair: Rajko Kusec (Croatia)
14.00 – 14.10 Efficacy and Safety of Ruxolitinib, a JAK1 and JAK2 Inhibitor, in Patients With Myelofibrosis:
Results From a Randomized, Double-Blind, Placebo-Controlled, Phase III Trial (COMFORT-I)
(PP28)
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 ,
Silver R 10 , Talpaz M 11 , Winton E 12 , Harvey J 13 , Arcasoy M 14 , Hexner E 15 , Lyons R 16 , Paquette R 17 ,
Raza A 18 , Vaddi K 4 , Erickson-Viitanen S 4 , Koumenis I 4 , Sun W 4 , Sandor V 4 , Kantarjian H 1 . 1 The
University of Texas MD Anderson Cancer Center, Houston, TX, USA; 2 Mayo Clinic, Scottsdale, AZ,
USA; 3 Stanford Cancer Center, Stanford, CA, USA; 4 Incyte Corporation, Wilmington, DE, USA;
5 Princess Margaret Hospital, Toronto, Canada; 6 Washington University School of Medicine, St. Louis,
MO, USA; 7 Frankston Hospital, Frankston, Australia; 8 University of Utah Huntsman Cancer Institute,
Salt Lake City, UT, USA; 9 Saint Agnes Cancer Institute, Baltimore, MD, USA; 10 Weill Cornell Medical
xi

Scientific Program Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
College, New York, NY, USA; 11 University of Michigan, Ann Arbor, MI, USA; 12 Emory University School
of Medicine, Atlanta, GA, USA; 13 Birmingham Hematology & Oncology, Birmingham, AL, USA; 14 Duke
University Health System, Durham, NC, USA; 15 University of Pennsylvania Health System, Philadelphia,
PA, USA; 16 Cancer Care Center of South Texas, San Antonio, TX, USA; 17 UCLA Medical Hematology &
Oncology, Los Angeles, CA, USA; 18 Columbia Presbyterian Medical Center, New York, NY, USA.
14.10 – 14.20 Prevalence of the JAK2 V617F Mutation in Croatian Patients with Classic Ph-Negative
Myeloproliferative neoplasm (PP29)
Duletic Nacinovic A, Dekanic A, Hadzisejdic I, Seili I, Grahovac B, Grohovac D, Valkovic T, Host I,
Petranovic D, Jonjic N. Department of Medicine and Deppartment of Pathology, Clinical Hospital
Center and School of Medicine, University of Rijeka, Croatia
14.20 – 14.30 Frequency and Clinical Correlates of JAK2 46/1 Haplotype in Essential Thrombocythemia:
Single Center Experience (PP30)
Panovska-Stavridis I, Matevska N, Ivanovski M, Trajkova S, Dukovski D, Pivkova-Veljanovska A,
Cevreska L, Dimovski A. Department of Hematology, Medical Faculty, Skopje, Republic of Macedonia
14.30 – 14.40 Myeloid sarcoma – diagnostic and therapeutic pitfals (PP31)
Antic D, Elezovic I, Perunicic Jovanovic M, Suvajdzic N, Djunic I, Mitrovic M, Tomin D.
Clinic of hematology, Clinical Center Serbia, Belgrade, Serbia
14.40 – 14.50 The Risk of Hematopoetic Malignancy in Children Born after in vitro Fertilization (PP32)
Bilic E, Stemberger L, Slipac J, Stojsavljevic S, Bilic E, Konjevoda P, Konja J, Femenic R, Rajic Lj.
Department of Pediatrics and Departmen of Neurology, Clinical Hospital Center and School of
Medicine, University of Zagreb, Croatia
14.50 – 15.00 H1N1 Influenza pneumonia in patient with chronic lymphocytic leukemia – case report (PP33)
Vince A 1 , Barsic B 1 , Dusek D 1 , Vrhovac R 2 , Kutlesa M 1 , Santini M 1 . 1 University Hospital for Infectious
Diseases »Dr. Fran Mihaljevic«, Zagreb, Croatia, 2 Department of Medicine, Division of Hematology.
University Hospital »Merkur« Zagreb Croatia.
15.00 – 15.10 Treatment of paroxismal nocturnal hemoglobinuria – a case report (PP34)
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
of Hematology, Department of Medicine, 2 Department of Clinical Laboratory, Clinical Hospital Center
and School of Medicine, University of Zagreb, Croatia
15.30 – 17.15 SYMPOSIUM MDS
Chair: David Steensma (USA), Pierre Wijermans (The Netherlands)
15.30 – 15.45 Ross Levine (USA)
Molecular pathogenesis of myelodysplastic syndromes (OP14)
15.45 – 16.00 David Steensma (USA)
Risk models in MDS (OP15)
16.00 – 16.15 Luca Malcovati (Italy)
Transfusion iron overload and iron chelation therapy in MDS (OP16)
16.15 – 16.30 Pierre Wijermans (The Netherlands)
Progress with epigenetic therapy in MDS (OP17)
16.30 – 16.45 Theo de Witte (The Netherlands)
Hematopoietic cell transplantation for MDS: New Developments (OP18)
16.45 – 17.00 Hagop Kantarjian (USA)
Novel Agents in MDS (OP19)
17.00 – 17.15 Questions and Answers
17.15 – 17.45 Coffee Break
17.45 – 19.15 MEET THE PROFESSOR
Martin Mistik (Slovakia)
Chronic myeloid leukemia (MP01)
Petro Petrides (Germany)
Essential Thrombocythaemia (MP02)
17.45 – 19.15 END OF THE DAY DEBATE
Moderator: Theo de Witte (The Netherlands)
AML vs MDS – what is similar
Participants: Luca Malcovati (Italy)
David Steensma (USA)
xii

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Scientific Program
Monday 19.09. 2011.
08.30 – 10.30 MYELOPROLIFERATIVE NEOPLASM
Chair: Srdjan Verstovsek (USA), Lidija Cevreska (Macedonia)
08.30 – 08.45 Richard Van Etten (USA)
Pathophysiology of MPNs and role of JAK2 mutations (OP20)
08.45 – 09.00 Srdjan Verstovsek (USA)
JAK2 inhibitors (OP21)
09.00 – 09.15 Petro E. Petrides (Germany)
Individualized MPN management–long term experience with anagrelide (OP22)
09.15 – 09.30 Richard Silver (USA)
Interferon as therapy for PV (OP23)
09.30 – 09.45 Nicolaus Kröger (Germany)
Allogeneic Hematopoietic Stem Cell Transplantation for Myelofibrosis (OP24)
09.45 – 10.00 Vesna Najfeld (USA)
Jumping 1q Translocations are Clonal Markers of Myeloid Malignancies Associated
with Transformation to AML. (OP25)
10.00 – 10.30 Question and Answers
10.30 – 11.00 Coffee Break
11.00 – 13.00 SYMPOSIUM CML
Chair: Dubravka Sertic (Croatia), Elias Jabbour (USA)
11.00 – 11.15 Rudiger Hehlmann (Germany)
Prognostic tools in CML (OP26)
11.15 – 11.30 David Marin (United Kingdom)
Imatinib, still the best first line therapy?(OP27)
11.30 – 11.45 Elias Jabbour (USA)
Second line TKI – when, which one? (OP28)
11.45 – 12.00 Gianantonio Rosti (Italy)
Second line TKI – the best first line therapy? (OP29)
12.00 – 12.15 Elias Jabbour (USA)
How to monitor CML therapy (OP30)
12.15 – 12.30 Alois Gratwohl (Switzerland)
Stem cell transplants for chronic phase CML (OP31)
12.30 – 13.00 Questions and Answers
13.15 – 14.45 Lunch Satellite Symposium: The optimal management of CML
Chair: Gianantonio Rosti (Italy) Boris Labar (Croatia)
13.15 – 13.25 Gianantonio Rosti (Italy)
Introduction
13.25 – 13.45 Giuseppe Saglio (Italy)
Nilotinib versus Imatinib for Newly Diagnosed CML patients: ENESTnd study results (SP07)
13.45 – 14.05 Francis Giles (Ireland)
Optimal 1st line treatment for CML (SP08)
14.05 – 14.25 Martin M. Mueller (Germany)
The importance of molecular monitoring in CML patients (SP09)
14.25 – 14.45 Boris Labar (Croatia)
Panel discussion and conclusion
xiii

Scientific Program Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
15.00 – 16.15 Poster Session
Poster presentation: Session 6. Multiple myeloma
Chair: Joan Bladé (Spain)
15.00 – 15.10 Anti-proliferative and pro-apoptotic action of the combined cytostatic/immunosuppressive
treatment of myeloma cell lines in vitro (PP35)
Zelic A1 , Ivcevic S1 , Kovacic N1 , Kusec R2 , Grcevi} D1 . 1Zagreb University School of Medicine;
2Dubrava University Hospital; Zagreb, Croatia
15.10 – 15.20 Tandem Transplantation in Multiple Myeloma – Single Center Experience (PP36)
Batinic J1 , Durakovic N1 , Sertic D1 , Bojanic I2 , Batinic D3 , Golubic-Cepulic B2 ,
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
Laboratory, Clinical Hospital Center and School of Medicine, University of Zagreb, Croatia
15.20 – 15.30 The Role of Thalidomide as Maintenance Therapy in Multiple Myeloma (PP37)
Bila J1,2 , Bodrozic J2 , Todorovic M1,2 , Sefer D2 , Kraguljac N2 , Antic D2 , Andjelic B2 , Elezovic I1,2 ,
Tomin D1,2 , Gotic M1,2 , Mihaljevic B1,2 . 1Medical Faculty, University of Belgrade, 2Clinic of Hematology,
CCS, Belgrade
15.30 – 15.40 Modificated dosing of the VMP /Velcade + melphalan + prednisone/ regime in multiple myeloma
/MM/ patients (PP38)
Masarova K, Stefanikova Z, Mistrik M. Department of Hematology and Transfusiology, University
Hospital, Bratislava, Slovakia
15.40 – 15.50 Tevagrastim and Plerixafor as first line mobilizing regimen in patients with lymphoma
and Multiple Myeloma (PP39)
Andreola G, Babic A, Negri M, Drera M, Martinelli G, Laszlo D. Department of Haematology,
European Institute of Oncology, Milan, Italy
15.50 – 16.00 Does Prelixafor do the trick in mobilising Stem Cells? (PP40)
Vieira S, Monroe D, Librojo M. London, United Kingdom
Poster presentation: Session 7. Acute leukemia
Chair: Dragica Tomin (Serbia)
15.00 – 15.10 Multidrug Resistance: From Research to Clinics (PP41)
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-
Medical and Health Science Center, Debrecen, Hungary; 32nd Department of Medicine and Cardiology,
University of Szeged – Albert Szent-Györgyi Clinical Center, Szeged, Hungary; 41st Department of
Internal Medicine, Pécs, Hungary
15.10 – 15.20 P-glycoprotein activity and Flt3 internal tandem duplication in 39 patients with acute myeloid
leukemia (PP42)
Batinic D1 , Perkovic S1 , Zadro R1 , Labar B2 . 1Department of Clinical Laboratory, 2Division of Hematology, Clinical Hospital Center and School of Medicine, University of Zagreb, Croatia
15.20 – 15.30 The pretreatment risk factors and importance of comorbidity index for overall survival,
complete remission and early death in patients with acute myeloid leukemia (PP43)
Djunic I, Virijevic M, Novkovic A, Djurasinovic V, Colovic N, Vidovic A, Suvajdzic-Vukovic N,
Tomin D, Clinic of hematology, Clinical Center Serbia, Belgrade, Serbia
15.30 – 15.40 Treatment of Adolescents with Acute Lymphoblastic Leukemia (PP44)
Konja J, Rajic Lj, Bilic E, Femenic R, Anicic M. Department of Pediatric, Clinical Hospital Center
and School of Medicine, University of Zagreb, Croatia
15.40 – 15.50 FLAG-IDA as the Salvage Regime for Relapsed and Refractory Acute Leukemias (PP45)
Virijevic M, Suvajdzic N, Djunic I, Novkovic A, Djurasinovic V, Colovic N, Vidovic A, Tomin D.
Clinic for hematology, Clinical Center Serbia, Belgrade, Serbia
15.50 – 16.00 Clinical outcome and prognosis related factor in acute promyelocytic leukemia patients treating
with PETHEMA LPA 099 protocol (PP46)
Mitrovic M, Suvajdzic N, Bogdanovic A, Novkovic A, Kraguljac N, Sretenovic A, Antic D, Djunic I,
Vidovic A, Colovic N, Virijevic M, Djurasinovic V, Elezovic I, Tomin D. Clinic of hematology,
Clinical Center Serbia, Belgrade, Serbia
xiv

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Scientific Program
16.00 – 16.10 Acute myeloid leukemia with t(8;21)(q22;q22); RUNX1-RUNX1T1 – case report (PP47)
Radic Antolic M, Rajic Lj, Femenic R, Bilic E, Pavlovic M, Perkovic S, Lasan R,
Markovic-Glamocak M, Zadro R. Department of Clinical Laboratory and Department of Pediatrics,
Clinical Hospital Center and School of Medicine, University of Zagreb, Croatia
Poster presentation: Session 8. Lymphoma
Chair: Igor Aurer (Croatia)
15.00 – 15.10 Successful treatment of B-cell prolymphocytic leukemia (B-PLL) with FCR-Lite protocol (PP48)
Batar P, Telek B, Udvardy M. Department of Hematology, University of Debrecen Health Sciences
Center, Debrecen, Hungary
15.10 – 15.20 Combination of rituximab and high-dose chlorambucil in therapy of small lymphocyte lymphoma
/ chronic lymphocytic leukemia (PP49)
Aurer I, Hude I, Basic Kinda S, Dujmovi} D, Nemet D, Radman I, Ilic I, Stern-Padovan R, Santek F,
Sertic D, Labar B. Departments of Internal Medicine, Pathology, Radiology and Oncology, University
Hospital Center Zagreb, Zagreb, Croatia
15.20 – 15.30 Atypical Blastoid Variant of Hairy Cell Leukemia: a Case Report (PP50)
Hadji-Pecova L, Petrusevska G, Panovska I, Stojanovski Z, Stojanovic A. Department of Hematology,
Medical Faculty, Skopje, Republic of Macedonia
15.30 – 15.40 Intravascular T-cell lymphoma presented as a subcutaneous panniculitis-like lymphoma:
A case report (PP51)
Ilic I(1), Basic Kinda S (2), Bosnic D (2), Aurer I 2(2), Dotlic S (2), Gasparovic V (1).
1 2 Department of Pathology, Department of Medicine, Clinical Hospital Center and School of Medicine,
University of Zagreb, Croatia
15.40 – 15.50 Primarily Localized non Hodgkin Lymphoma of Testes with Relapse Localized in Buccal Area
– Case Report (PP52)
Hotic-Lazarevic S, Kezic Lj, Mandic D, Stojcic B, Malinovic J, Mrdja J. Division of Hematology,
Department of Internal Medicine, Clinical Center Banja Luka, Banja Luka, Bosnia and Herzegovina
15.50 – 16.00 A 48 Year Old Woman with a Rare Case of a Midline Destructive Disease Presenting
as Having both Midline and Nonmidline Lesions – a Case Report (PP53)
Fernandez S, Lapus F, Barez MY. Davao Medical Center, Davao City, Philippines
16.00 – 16.10 Successful mobilisation with Plerixafor – clinical report (PP54)
Babic A. Istituto Europeo di Oncologie, Divisione di Ematologia, Milan, Italy
Poster presentation: Session 9. Stem Cell Transplantation II.
Chair: Mirta Mikulic (Croatia)
15.00 – 15.10 Isolation and in vitro cell culture of mesenchymal stem cells from human umbilical cord
blood (PP55)
Mazic S (1), Golemovic M (1), Skific M (1), Bojanic I (1), Humar I (2), Golubic Cepulic B (1).
1 2 Department of Transfusiology, Deaprtment of Clinical Laboratory, Cliniacal Hospital Center, Zagreb,
Croatia
15.10 – 15.20 Biological properties of human mesenchymal stem cells expanded in vitro in media supplemented
with human platelet lysate (PP56)
Skific M (1), Golemovic M (1), Mazic S (1), Bojanic I (1), Humar I (2), Davidovic S (3),
Crkvenac Gornik K (3), Ilic I (4), Durakovic N (5), Mikulic M (5), Serventi-Seiwerth R (5), Labar B (5),
Golubic Cepulic B (1). 1Department of Transfusiology, 2Department of Clinical Laboratory, 3Department of Pediatric, 4Department of Pathology, 5Department of Medicine, Clinical Hospital Center and School of
Medicine, Universiuty of Zagreb, Croatia
15.20 – 15.30 Croatian Cord Blood Bank: the first 4 years (PP57)
Mazic S (1), Bojanic I (1), Zlopasa G (2), Mrsic M (3), Plenkovic F (1), Lukic M (1), Raos M (1),
Gojceta K (1), Golemovic M (1), Skific M (1), Tomac G (1), Burnac IL (1), Novoselac J (1), Vidovic I
(1), Biskup M (1), Labar B (3), Golubic Cepulic B (1). 1Department of Transfusiology, 2Department of
Gynecology and Obstetrics, 3Department of Medicine, Clinical Hospital Center and School of Medicine,
Universiuty of Zagreb, Croatia
15.30 – 15.40 Italian nurses group in mobilisation and apheresis (GIIMA): ideation and activity (PP58)
Babic A, Laszlo D, Galgano L, Marchi E, Orlando L, Martinelli G. Istituto Europeo di Oncologia,
Divisione di Ematologia, Milan, Italy
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Scientific Program Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
15.40 – 15.50 Unrelated Donor Search Experience in the Croatian Hematopoietic Stem Cell Transplantation
Program (PP59)
Grubic Z1 , Stingl K1 , Serventi Seiwerth R2 , Labar B2 , Zunec R1 . 1Tissue Typing Centre, 2Department of
hematology, Clinical Hospital Centre Zagreb, Croatia
15.50 – 16.00 Following the Chimerism Status of Patients after Hematopoietic Stem Cell Transplantation
– Ten Years Experience (PP60)
Stingl K1 , Grubic Z1 , Serventi Seiwerth R2 , Labar B2 , Rajic Lj3 , Vrhovac R4 , Zunec R1 . 1Tissue Typing
Centre, 2Department of Medicine, 3Clinic of pediatrics, Clinical Hospital Centre, 4Department of
Medicine, Clinical Hospital Merkur, Zagreb, Croatia
Poster presentation: Session 10. Miscalenous
Chair: Ivo Radman (Croatia)
15.00 – 15.10 Venous access for Apheresis and Photopheresis procedures (PP61)
Babic A. Istituto Europeo di Oncologia, Divisione di Ematologia, Milan, Italy
15.10 – 15.20 Pure red cell aplasia preceding a DLBCL with 6 years (PP62)
Barca G, Marin S, Nada S, Dragan C, Barbu D, Angelescu S, Tevet M, Saguna C, Bizu I, Lupu AR.
Coltea Clinical Hospital, Hematology Clinic, Bucharest, Romania
15.20 – 15.30 Can Platelet be Unnecessary (PP63)
Vieira S, Monroe D, Librojo M, London, United Kingdom
15.30 – 15.40 Transfuse or Not to Transfuse? (PP64)
Vieira S, Monroe D, Librojo M, London, United Kingdom
16.15 – 17.30 SYMPOSIUM MULTIPLE MYELOMA AND RELATED DISORDERS
Chair: Bart Barlogie (USA), Damir Nemet (Croatia),
16.15 – 16.30 Christoph J. Heuck (USA)
Pathophysiology of Myeloma (OP32)
16.30 – 16.45 Joan Blade (Spain)
Bortezomib in the Treatment of Multiple Myeloma (OP33)
16.45 – 17.00 Robert P. Gale (USA)
IMIDs in Myeloma (OP34)
17.00 – 17.15 Bart Barlogie (USA)
Curing Multiple myeloma – the facts behind the claim (OP 35)
17.15 – 17.30 Questions and Answers
17.45 – 19.15 End of the Day Debate
Moderator: Damir Nemet (Croatia)
SCT in Myeloma – for all young patients?
Participants: Bart Barlogie (USA)
Joan Blade (Spain)
Tuesday 20. 09. 2011.
07.00 – 08.15 Satellite Symposium: Optimal management of PNH
Chair: Peter Hillmen (United Kingdom) Boris Labar (Croatia)
07.00 – 07.15 Boris Labar (Croatia)
PNH – Morbidities & Mortality (SP10)
07.15 – 07.40 Peter Hillmen (United Kingdom)
Shifting the Paradigm in PNH Management (SP11)
07.40 – 07.50 Jaroslav Cermak
Acute renal failure and PNH – Case report (SP12)
07.50 – 08.00 Ana Boban (Croatia)
Treatment of Paroxismal nocturnal hemoglobinuria – a case report (SP13)
08.00 – 08.15 Q & A and Summary
xvi

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Scientific Program
08.30 – 10.30 SYMPOSIUM ALL
Chair: Jean Pierre Marie (France), Susan O’Brien (USA)
08.30 – 08.45 Dieter Hoelzer (Germany)
Adult ALL treatment approach for B-ALL (OP36)
08.45 – 09.00 Stefan Faderl (USA)
T-ALL current treatment (OP37, SA01)
09.00 – 09.15 Jean Pierre Marie (France)
Young adult with ALL – how to treat (OP38)
09.15 – 09.30 Oliver Ottman (Germany)
Ph+ALL – Current treatment options (OP39)
09.30 – 09.45 Deborah Thomas (USA)
MRD – criteria for postremission therapy (OP40)
09.45 – 10.00 Mohamad Mohty (France)
SCT for ALL: standard vs mini-allo (OP41)
10.00 – 10.15 Sebastian Giebel (Poland)
Autologous SCT for ALL – stil the chalange (OP42)
10.15 – 10.30 Susan O’Brien (USA)
Novel drugs for ALL (OP43, SA01)
10.30 – 11.00 Questions and Answers
11.00 – 11.30 Coffee Break
11.30 – 13.15 SYMPOSIUM CLL
Chair: Alessandra Ferrajoli (USA) Branimir Jaksic (Croatia)
11.30 – 11.45 William Wierda (USA)
Prognostic impact of Biologic factors in CLL (OP44)
11.45 – 12.00 Susan O’Brien
Frontline therapy for CLL (OP45)
12.00 – 12.15 Alessandra Ferrajoli (USA)
Antibodies for CLL – alone or in combinations (OP46)
12.15 – 12. 30 Peter Hillmen (United Kingdom)
New and old drugs in CLL – we can do better (OP47)
12.30 – 12.45 Issa Khouri (USA)
SCT for CLL – when? (OP48)
12.45 – 13.15 Questions and Answers
13.30 – 15.00 Meet the Professor
– Jiri Hollowiecki (Poland) Acute myeloid leukemia (MP03)
– Boris Labar (Croatia) Stem cell transplantation (MP04)
– Deborah Thomas (USA) Acute lymphoblastic leukemia (MP05)
– Petra Muus (The Netherlands) Myelodysplastic syndrome (MP06)
– Branimir Jaksic (Croatia) Chronic lymphocytic leukemia (MP07)
– Srdjan Verstovsek (USA) Myelofibrosis (MP08)
– Igor Aurer (Croatia) Non-Hodgkin Lymphoma (MP09)
– Damir Nemet (Croatia) Multiple Myeloma (MP10)
13.30 – 15.00 Lunch with Experts (1 expert on 10 registered particip.)
Hagop Kantarijan (USA) Acute Myeloid Leukemia
Dieter Hoelzer (Germany) Acute lymphoblastic Leukemia
David Steensma (USA) Myelodysplastic Syndrome
Rudiger Hehlmann (Germany) Chronic myeloid leukemia
Peter Hillmen (United Kingdom) Chronic lymphocytic leukemia
Bart Barlogie (USA) Multiple myeloma
Patrice Carde (France) Hodgkin lymphoma
xvii

Scientific Program Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
15.15 – 18.45 SYMPOSIUM STEM CELL TRANSPLANTATION
Moderator: Boris Labar (Croatia)
15.15 – 15.30 Introduction
15.30 – 15.45 Alois Gratwohl (Switzerland)
Prognostic score for SCT (OP49)
15.45 – 16.00 Mary Horowitz (USA)
Consideration in choosing the optimal stem cell source (OP50)
16.00 – 16.15 Mohamad Mohty (France)
Source of stem cells in the allogeneic transplant setting: bone marrow versus peripheral blood stem
cells (OP51)
16.15 – 16.45 Dietger Niederwieser (Germany), John Barrett (USA)
Conditioning for SCT – the impact of disease?! (OP52) (OP53)
16.45 – 17.15 Coffee break
17.15 – 18.15 Complications – anything new in prevention/treatment
17.15 – 17.30 Finn Bo Petersen (USA)
Infectious Complications of Stem Cell Transplantation (OP54)
17.30 – 17.45 Leo Luznik (USA)
Old drug, new tricks in prevention of graft-versus-host disease (GVHD): Development and clinical
applicability of high-dose cyclophosphamide (OP55)
17.45 – 18.00 Steven Z. Pavletic (USA)
Chronic Graft-versus-Host Disease – Anything New in Prevention and Treatment? (OP56)
18.00 – 18.15 Michael Bishop (USA)
Relapse after Allogeneic Hematopoietic Stem Cell Transplantation – The Necessity for New Strategies
and Treatments (OP57)
18.15 – 18.45 Round table Discussion and Conclusion:
Perspective of SCT
19.00 – 19.20 SPECIAL LECTURE:
Chair: Roel Willemze (The Netherlands)
19.00 – 19.20 Stefan Suciu (Belgium)
Design, conduct and analysis of clinical trials in acute leukemia: the keys of success (OP58)
20.30 – 24.00 Farewell Dinner
Wednesday 21. 09. 2011.
08.30 – 11.45 SYMPOSIUM NON-HODGKIN LYMPHOMA
Chair: Nathan H. Fowler (USA) Igor Aurer (Croatia)
08.30 – 08.45 Nathan H. Fowler (USA)
Front line therapy for indolent B-cell lymphoma (OP59)
08.45 – 09.00 Ofer Sphilberg (Israel)
Rituximab maintenance treatment in indolent lymphoma (OP60)
09.00 – 09.15 Marek Trneny (Czech Republic)
Risk adapted treatment for patients with B-DLBCL (OP61)
09.15 – 09.30 Piere Luiggi Zinzani
Therapy for peripheral T-cell lymphoma (OP62)
09.30 – 09.45 Christian H. Geisler (Denmark)
Therapy of Mantle cell Lymphoma (OP63)
19.45 – 10.00 Piere Luiggi Zinzani (Italy)
Is there a role of radioimmunotherapy in NHL (OP64)
10.00 – 10.30 Coffee Break
10.30 – 10.45 Anas Younes (USA)
Therapy for relapsed/refractory aggressive NHL (OP65)
xviii

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Scientific Program
10.45 – 11.00 Luis Fayad (USA)
Alternative monoclonal antibodies for the treatment of NHL (OP66)
11.00 – 11.30 Questions and Answers
12.00 – 14.30 Symposium/Central and Eastern European Leukemia Group
CELG-AML-1 Study
Chair: Zita Borbenyi (Hungary), Agnieszka Wierzbowska (Poland), Georgi Mihajlov (Bulgaria)
12.00 – 12.15 Boris Labar (Croatia)
Design and Objective of the CELG-AML-1 Study
12.15 – 12.30 Dragica Tomin (Serbia)
Cytomorphology for diagnosis of AML (CELG-AML-1 Study)
12.30 – 12.45 Zita Borbenyi (Hungary)
Immunophenotyping for diagnosis of AML (CELG-AML-1 Study)
12.45 – 13.05 Agnieszka Wierzbowska (Poland)
Cytogenetic and Molecular diagnostic for diagnosis of AML (CELG-AML-1 Study)
13.05 – 13.25 Georgi Mihajlov (Bulgaria)
CELG-AML-1 Study – Induction therapy and Consolidation
13.25 – 13.40 Lidija Cevreska (Macedonia), Irina Panovska (Macedonia)
CELG-AML-1 Study – Autologous SCT
13.40 – 13.55 Labar B. (Croatia)
CELG-AML-1 Study – Allogeneic SCT
13.55 – 14.10 Panel Discussion and Conclusion
Plerixafor for Stem Cell Mobilization
Chair: Ines Bojanic (Croatia)
14.10 – 14.30 Grzegorz Wladyslaw Basak
Novel aspects of stem cell mobilization with plerixafor and G-CSF based on CELG data
15.00 – 17.15 SYMPOSIUM HODGKIN LYMPHOMA
Patrice Carde (France), Sandra Basic-Kinda (Croatia)
15.00 – 15.15 Patrice Carde (France)
Early favorable and unfavorable Hodgkin lymphoma in adults, standards and directions (OP67)
15.15 – 15.30 Berthe Aleman (The Netherlands)
Radiation therapy for Hodgkin’s lymphoma (OP68)
15.30 – 15.45 Bastian von Tresckow (Germany)
Improving Outcome in High Risk Hodgkin’s lymphoma (OP69)
15.45 – 16.00 Martin Hutchings (Denmark)
What is the role of PET in Hodgkin’s lymphoma (OP70)
16.00 – 16.15 Igor Aurer (Croatia)
Treatment of Relapsed/Refractory Hodgkin’s lymphoma (OP71)
16.15 – 16.30 Ana Sureda (Spain)
Allogeneic SCT for Hodkin’s lymphoma (OP72)
16.30 – 16.45 Anas Younes (USA)
New Drugs in the treatment of Hodkin’s lymphoma (OP73)
16.45 – 17.15 Questions and Answers
17.15 – 17.30 Adjourn
xix

LEUKEMIA AND LYMPHOMA
East and West are Together

State of the Art I.
SA01 Acute Leukemias
Elias Jabbour, Susan O’Brien, Stefan Faderl,
Farhad Ravandi, Jorge Cortes, Hagop Kantarjian,
Department of Leukemia, U.T. M.D. Anderson Cancer
Center, Houston, TX, USA
Abstract: Acute leukemias are clonal malignant hematopoietic
disorders resulting from genetic alterations in normal
hematopoietic stem cells. These alterations induce differentiation
arrest and/or excessive proliferation of abnormal
»leukemic« cells or »blasts«. Acute leukemias are classified
as those of myeloid or lymphoid lineage. Over the
past several decades, improvements in chemotherapeutic
regimens have improved outcomes in both acute myeloid
leukemia (AML) and acute lymphoblastic leukemia (ALL).
Better understanding of the biology of both AML and ALL
has resulted in the identification of new therapeutic targets.
Despite current optimism, most patients with AML still die
of their disease, and only about 30–40% of adults achieve
long-term disease-free survival in ALL. With better molecular
definition and elucidation of the physiopathology of
AML and ALL subtypes, and development of new and targeted
therapies, a better outcome for acute leukemias may
be achievable in the future.
Epidemiology and Etiology
The incidence of acute myeloid leukemia (AML) is 2.7 per
100,000 while acute lymphoblastic leukemia (ALL) occurs
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
with its precursor myelodysplasia, AML appears to be rising,
particularly in the population over the age of 60 and represents
the most common type of acute leukemia in adults. ALL
exhibits a bimodal distribution, with an early peak in children
4 to 5 years old (4 to 5 per 100,000 persons), followed
by a second peak at approximately 50 years of age (2 per
100,000 persons). 4 ALL represents the most common childhood
acute leukemia representing about 80% of acute leukemias,
while it comprises only 20% of adult leukemias. 4,5
The incidence of AML is slightly higher in males and in
populations of European descent. Acute promyelocytic leukemia
(APL), a distinct subtype of AML, is more common
among populations of Latino or Hispanic background. 6,7 An
increased incidence of AML is seen in patients with disorders
associated with excessive chromatin fragility such as
Bloom’s syndrome, Fanconi’s anemia, Kostmann’s syndrome,
and with Wiskott-Aldrich syndrome or ataxia-telangiectasia.
Other syndromes like Down’s (trisomy of chromosome
21), Klinefelter (XXY and variants) and Patau
(trisomy of chromosome 13) have also been associated with
a higher incidence of AML. 8–11
Survivors of the atomic bombs in Japan had an increased
incidence of myeloid leukemias that peaked 5 to 7 years
following exposure. 8 Therapeutic radiation increases AML
risk, particularly if given with alkylating agents. There are
two main types of therapy-related AML. The »classic« alkylating-agent
type (e.g. cyclophosphamide, melphalan,
nitrogen mustard) has a latency period of 4 to 8 years, and is
often associated with abnormalities of chromosome 5 and/
or 7. Exposure to agents that inhibit the DNA repair enzyme
topoisomerase II (e.g. etoposide, teniposide) are associated
with secondary AML with a shorter latency period, usually
1 to 3 years, with chromosome 11q23 at the location of the
MLL gene, and with an M4 or M5 morphology. 8,12,13 Drugs
such as chloramphenicol, phenylbutazone, chloroquine, and
methoxypsoralen can induce marrow damage that may later
evolve into AML. Benzene, smoking, dyes, herbicides and
pesticides have been implicated as potential risk factors for
development of AML. 9,10
AML may also be secondary to progression of a myelodysplastic
process or of a chronic bone marrow »stem cell«
disorder, such as polycythemia vera, chronic myelogenous
leukemia, primary thrombocytosis, or paroxysmal nocturnal
hemoglobinuria. 10–14
The etiology of ALL remains unknown. Chromosomal
translocations occurring in utero during fetal hematopoiesis
have been suggested as the primary cause for pediatric ALL,
while postnatal genetic events are suggested as secondary
contributors. A higher incidence of ALL is noted among
mono and di-zygotic twins of patients with ALL, reflecting
possible genetic predisposition. 5 Patients with trisomy 21,
Klinefelter’s syndrome and inherited diseases with excessive
chromosomal fragility such as Fanconi’s anemia,
Bloom’s syndrome, and ataxia-telangiectasia have a higher
risk of developing ALL. Implications have also been made
towards infectious etiologies. 15–17 Associations between human
T-cell lymphotrophic virus type 1 and adult T-cell
leukemia/lymphoma, as well as HIV and lymphoproliferative
disorders have been established. In addition, associations
with varicella and influenza viruses have also been
suggested.
Clinical Presentation
Fatigue, bruising or bleeding, fever and infection, reflecting
a state of bone marrow failure, are common in both
AML and ALL. Only 10% of AML patients present with
white blood cell (WBC) counts greater than 100 x 109 /L. 2,18
These patients are at higher risk of tumor lysis syndrome
and leukostasis, both of which are considered oncologic
emergencies and require prompt recognition and management.
Tumor lysis syndrome can be due to spontaneous or
treatment-mediated cell destruction and is characterized by
hyperuricemia, renal failure, acidosis, hypocalcemia and
3

State of the Art Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
hyperphosphatemia. 19 Manifestations of leukostasis include
dyspnea, chest pain, headache, altered mental status, cranial
nerve palsies, and/or priapism. In addition, physical findings
in AML may include organomegaly, lymphadenopathy,
sternal tenderness, and retinal hemorrhages. Monocytic
variants, M4 or M5, commonly display infiltration of gingivae,
skin, soft tissues or meninges. 3 Disseminated intravascular
coagulopathy (DIC) with bleeding diathesis is a common
presentation in APL
Whereas symptoms related to hyperleukocytosis can occur
in AML, they are rare in ALL, even in the presence of
high white cell counts. »B-symptoms« such as fever, night
sweats, or weight loss can occur in ALL. Central nervous
system (CNS) involvement (cranial neuropathies, meningeal
infiltration) at presentation, common in mature B-ALL
(Burkitt leukemia) occurs in 5% to 8% of patients. 20 Abdominal
masses and significant spontaneous tumor lysis
syndrome are more likely with mature B ALL. Lymphadenopathy
and hepatosplenomegaly, rarely symptomatic, are
noted in 20% of the patients, with a higher incidence in T
and mature B cell ALL. The combination of hypercalcemia
and lytic bone lesions are suggestive of adult T cell leukemia/lymphoma
(ATLL). Chin numbness (mental nerve involvement),
when elicited in the history or exam, is suggestive
or mature B-cell ALL (Burkitt’s).
Diagnosis and Classification
The diagnosis of leukemia is often demonstrated by increased
number of blasts in the bone marrow, or peripheral
blood. By the French-American-British (FAB) Cooperative
Group criteria, acute leukemia is diagnosed when a
200-cell differential reveals the presence of 30% or more
blasts in a marrow aspirate. 21 The minimal criterion has
recently been changed to 20% by the World Health Organization
(WHO). 22 Patients with the cytogenetic abnormalities
t(8;21)(q22;q22), inversion(16)(p13q22) or
t(16;16)(p13;q22), and t(15;17)(q22;q12) should be considered
to have AML regardless of the blast percentage. After
establishing the diagnosis, the blasts lineage (myeloid,
lymphoid, or undifferentiated) is determined. The distinction
is important and dictates specific therapy. Lineage determination
is made using cytochemical stains (Figure 1). If
3% or more blasts stain positive for myeloperoxidase (MPO)
or Sudan Black B, the diagnosis is AML. If the blasts are
peroxidase negative, but stain for butyrate or non-specific
esterase, acute monocytic leukemia is diagnosed. 1 If not,
lineage determination is based on the blasts expressing surface
antigens associated with the myeloid (equivalently
monocytic, erythroid, or megakaryocytic), or lymphoid immunophenotype.
Myeloid antigens are CD13, CD33, c-kit,
CD 14, CD64 (the latter 2 are monocytic markers), glycophorin
A (an erythroid marker), and CD41 (a megakaryocytic
marker). Lymphoid markers are CD10, CD19, CD20
(pre-B or B cells) and CD2, CD3, CD4, CD5, and CD8
(T-cells). 23,24 A minority of MPO negative and Sudan Black
B-negative cases are AML, and may include minimally differentiated
(M0), and megakaryocytic leukemias (M7) that
require flow cytometry for characterization. 1,25,26
If the blasts are peroxidase and butyrate negative and express
none of the myeloid or lymphoid antigens noted
4
Figure 1. Acute leukemia diagnostic algorithm
above, the diagnosis is acute undifferentiated leukemia,
which is treated like AML. The initial marrow aspirate may
be a »dry tap«, reflecting marrow fibrosis. In this case, a
biopsy is needed to exclude acute megakaryocytic leukemia
or hairy cell leukemia. 26,27 If the marrow contains >50% normoblasts
and pronormoblasts, the blast percent is based
only on the non-erythroid cells; in these cases, the diagnosis
is typically acute erythroid leukemia (M6), which can be
confirmed if glycophorin A expression on the surface of the
blasts.
The WHO classification incorporates molecular, cytogenetic,
and clinical features (prior hematological disorder) to
the morphologic characteristics to better recognize the diversity
of the disease, and its response to therapy. For example,
AML with multilineage dysplasia by the WHO classification
has no exact counterpart in the FAB classification.
Several chromosomal abnormalities and mutations have
been identified: The t (8;21), t(16;16) and inv 16 mutations
are associated with a better prognosis, while alterations of
11q23, leading to the MLL rearrangement. (mixed-lineage
leukemia) portends a worse outcome (Table 1). The mutation
in FLT3 (tyrosine kinase receptor) is the most common
mutation in AML and is associated with poor clinical outcome
(Table 2). T(15;17) is always associated with acute
promyelocytic leukemia (APL), and leads to a mutation in
retinoic acid receptor implicated in hematopoeitic differentiation.
The FAB Cooperative Group distinguishes three ALL
groups (L1 to L3) based on morphologic criteria (cell size,
cytoplasm, nucleoli, basophilia, vacuolation). 21 The morphologic
distinction between L1 and L2 has lost its prognostic
significance. L3 morphology is associated with mature
B-cell ALL (Burkitt’s leukemia). The WHO proposed
new guidelines for the diagnosis of Neoplastic Diseases of
Hematopoietic and Lymphoid Tissues or Lymphomas. 28 In
addition to lowering the blast count to ≥20% as sufficient
for an ALL diagnosis, the morphologic distinction of L1,
L2, and L3 morphologies is abandoned as no longer relevant.
Both FAB and WHO classification systems continue
to rely heavily on morphological assessment. 29 Identification
of the immunophenotype has become a major part of

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) State of the Art
Karyotype % Frequency
Table 1. AML cytogenetic risk group.
% Complete
Remission
% Event-free
Survival
Favorable
t(8;21) 5–10 90 60–70
inv(16) 5–10 90 60–70
t(15;17)
Intermediate
5–10 80–90 70
Diploid, -Y
Unfavorable
40–50 70–80 30–40
–5 / –7 20–30 50 5–10
+8 10 60 10–20
11q23, 20q- , other 10–20 60 10
Table 2. Prognostic factors in AML.
Relapse Rate Survival
↑ BAACL NS ↓
FLT3 ITD/mutation ↑ ↓
MLL PTD ↑ NS
↑ BCL2 and WT1 mRNA ↑ ↓
↑ EVI1 mRNA ↑ ↓
p53 mutation NS ↓
CEBPA mutation ↓ ↑
c-kit mutation ↑ ↓
BAACL: Brain And Acute Leukemia Cytoplasmic; FLT3: Fms-like tyrosine
kinase 3; MLL: Mixed lineage leukemia; BCL2: B-cell CLL lymphoma 2;
WT1: Wilms tumor 1;
EVI1: Ecotropic viral integration site 1; CEBPA: CCAAT/enhancer binding
protein-alpha; NS: Not significant.
Table 3. Immunophenotypic classification of ALL 30,33
B Lineage T Lineage
CD19/CD79a/CD22 CD3 (surface/cytoplasmic)
Pre-pre-B ALL – Precursor T ALL CD1a, CD2, CD5,
CD7, CD8, cCD3
Common ALL CD10 (CALLA) Mature T ALL Surface CD3
(plus any other
T cell markers)
Pre-B ALL Cytoplasmic IgM
Mature B ALL Cytoplasmic or
surface Igκ or λ
ALL diagnosis (Table 3). 30–33 Three broad groups can be distinguished:
precursor B-cell, mature B-cell, and T-cell ALL.
Treatment (AML)
Achievement of a complete remission (CR) significantly
improves survival in AML, therefore the objective of therapy
is to produce and maintain CR. 34 Criteria for CR include:
platelet count ≥100 x 109 /l, neutrophil count ≥1 x
109 /l, and ≤5% blasts present in the bone marrow. 35 The
probability of AML recurrence sharply declines to less than
10% after 3 years in CR, and patients in continuous CR for
3 or more years can be considered »potentially cured«. 36 In
recent years additional response criteria have been proposed,
such as »CR with incomplete platelet recovery«
(CRp), defined as CR with platelet count greater than 30 x
109 /l, but less than 100 x 109 /l. 37
Once AML is diagnosed and the decision to treat is made,
the need for emergency therapy must be assessed. Emergency
treatment is required in cases of APL, if the circulating
blast count is > 50–100 x 10 9 /l, in the presence of DIC
or organ dysfunction (especially pulmonary) attributed to
leukemic infiltration (most seen in patients with > 10 x 10 9 /l
circulating blasts and/or M4 or M5 FAB morphology). In
the latter situation, it is important to initiate immediate chemotherapy.
Leukapheresis for severe leukocytosis and/or
leukostasis should be considered.
Conventional treatment for AML, divided into remission
induction and post-remission therapy, has been with combinations
of anthracyclines and cytarabine. Traditionally, the
anthracycline (i.e. idarubicin, daunorubicin) is usually administered
daily for 3 days, and cytarabine is given at 100–
200 mg/ m 2 daily for 7 days by continuous infusion (3+7
regimen). In clinical practice, a bone marrow aspirate is
usually obtained 2–3 weeks after beginning therapy. A biopsy
is only needed if the quality of the aspirate does not
permit determination of cellularity. If the marrow continues
to show blasts and is cellular, a second course of the same
therapy is often given, sometimes at a reduced total dose (2
days anthracycline + 5 days cytarabine). If the day 14 or 21
marrow is hypoplastic, therapy is usually delayed until it is
clear that leukemia has reappeared, at which time the second
course begins. A second repeated course of therapy can
produce remissions, but these are usually of shorter duration
than remissions produced after one course of therapy, although
this is controversial. 38 The timing of a second course
with persistent AML is controversial. Several cooperative
group studies advocated starting a second course if there is
persistent AML on day 10–15 of chemotherapy. With highdose
cytarabine (HDAC), a delay of a second course with
persistent disease on day 21–28 may be indicated if the
blasts are decreasing because most (90%) CRs are obtained
after the first course, and response to a second course is
poor. It is important to recognize that the initial marrow obtained
after a period of hypoplasia may demonstrate up to
30–50% blasts as a reflection of the regeneration of normal,
not »leukemic,« marrow recovery. In this circumstance, follow-up
(e.g. at 1–2 week intervals) marrows show reduction
in blast percentages concomitant with a rise in neutrophils
and platelets. Administration of a colony-stimulating factor
may have an impact on the bone marrow findings.
Three types of post-remission therapy can be distinguished.
Maintenance therapy is usually defined as therapy
less myelosuppressive than that used to produce remission.
The doses used in consolidation therapy usually approach,
whereas those in intensification therapy may surpass, the
doses used during induction. Typically, once in remission
after treatment with the »3 + 7« regimen, patients receive
maintenance therapy, with the same drugs given during induction
administered at approximately monthly intervals
for 4–12 months. The need for a prolonged duration of
maintenance therapy may depend on the intensity of induction
and post-remission therapy. 39,40 For example, a randomized
German AML Cooperative Group (AMLCG) trial noted
that addition of 3 years of maintenance improved the
probability of 3-year relapse-free survival (RFS) from 7%
to 30%. However, a similarly randomized trial by the same
5

State of the Art Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
group found no difference in RFS or survival when patients
in the no maintenance arm received a more intensive induction
treatment and one intense post-remission course .41–43
Some maintenance therapy may be needed if intensive postremission
therapy is not contemplated. However, any benefit
from traditional maintenance after the administration of
3–4 months of consolidation is relatively small, and perhaps
nonexistent, with respect to survival. 44
Randomized trials have attempted to identify which anthracycline
(e.g. idarubicin [IDA], daunorubicin [DNR],
mitoxantrone [MTZ], aclarubicin) is better. 45–47 Based on
several such randomized studies, IDA (12 mg/m 2 daily days
1 through 3) has been proposed as the anthracycline of
choice. 48 However, this may be misleading since the anthracyclines
(IDA versus DNR) were not administered at equally
toxic doses. 46 In several studies, standard-dose cytarabine
plus MTZ 12 mg/m 2 daily x 3 has been compared with cytarabine
plus DNR at 45 mg/m 2 daily x 3. Overall, the CR
rates with the two regimens were similar, and there were no
significant differences in the incidence or the severity of
toxicities. In a three-arm randomized study, there was no
advantage when comparing DNR, IDA, and MTZ as part of
the induction regimen for patients over 55 years of age. 49 In
contrast, the three-arm randomized trial, conducted by the
EORTC and GIMEMA, comparing DNR to MTZ and IDA,
reported that 5-year disease free survival (DFS) and overall
survival (OS) were significantly better for patients receiving
IDA and MTZ (p=0.03 and 0.02, respectively). Of note, the
recovery time was longer with IDA and MTZ (p

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) State of the Art
appear to be intrinsically more resistant to standard chemotherapy
and the presence of comorbid conditions and decreased
marrow reserve contribute to the poor outcomes.
The approximate CR rate of 45% in patients over age 60 is
considerably lower than younger patients. In addition, elderly
patients experience shorter remissions, minimal longterm
and overall survival, and considerable treatment related
mortality. Factors contributing to worse outcome in elderly
AML are: age > 75 years, unfavorable karyotype (mostly
complex), poor performance status and organ dysfunction,
and longer duration of AHD. Treatment should be individualized
and may include standard intensive therapy for patients
with none or at most one adverse factor, or low-intensity
investigational therapies for those with multiple adverse
factors. Targeted therapies, low dose cytarabine, nucleoside
analogs, and palliative regimens may be considered as lowintensity
options. Investigational treatment or palliative care
options become more plausible in poorer-prognosis elderly
AML.
Relapsed/Refractory AML
Recurrent AML is common with approximately 10–50%
of newly-diagnosed patients not achieving CR (»primary
refractory«). The most important predictive factor for outcome
of therapy in relapsed/refractory AML (salvage therapy)
is duration of first CR. 64 Salvage therapy produces CR
rates of 40% to 60% in patients with duration of first CR of
one year or longer, but only 10% to 15% in those with shorter
first CR duration. Allogeneic transplant appears superior
to HDAC or idarubicin and cytarabine containing regimens
in patients with first CR duration less than 1 year; the great
majority of these transplants were from HLA-matched sibling
donor. 65–68 However, since very few patients are cured
with conventional therapy, all patients with relapsed or refractory
AML should be treated in clinical trials.
Mechanisms to lengthen remission duration require further
evaluation. Beneficial effects of T-cells and natural
killer cells on preventing relapse of AML have been recognized.
69,70 However, the addition of recombinant interleukin-
2 (rIL-2) during maintenance therapy has not led to improved
outcomes. 54
Investigational Agents
Investigational therapies should be considered when expectations
with standard therapy are low, either because of
high mortality or high relapse rates. These include: 1) poor
performance status 3–4; 2) age 80 years or older; 3) poor
risk cytogenetics; or 4) intermediate prognosis cytogenetic
group, but with an AHD, FLT3 mutation or (MDR)1 positivity.
If investigational therapy is not feasible, palliative
care or low-dose cytarabine alone or with hydroxyurea may
be considered in patients age 65 or older with poor performance
status 3–4, or in patients 80 years or older regardless
of performance status.
Current investigational approaches include targeted therapy
against surface antigens with monoclonal antibodies
such as GO, signal transduction targeting (FLT3, farnesyl
transferase inhibitors [FTIs], methylation, angiogenesis,
inhibition of bcl-2 with antisense therapy) and new formu-
lations of established drugs (e.g. liposomal formulations,
pegylated formulations). Multidrug resistance (MDR)-reversing
agents or nucleoside analogs like clofarabine, decitabine
and azacitidine in different regimens are also of
interest. 71–73
Clofarabine, a nucleoside analog, has demonstrated activity
with acceptable toxicity in elderly patients. 74 In newly
diagnosed patients with 2 or more poor prognostic factors,
39% of patients 70 years of age or older achieved CR with
clofarabine 30 mg/m 2 administered intravenously daily for
5 days. 75 Induction related mortality was reduced to 10%
with clofarabine in comparison to conventional chemotherapy
regimens for older AML patients that report 30 and 60
day mortality ranging from 27% to above 60%. 76,77 In another
study, a lower dose of clofarabine (20 mg/m 2 administered
intravenously daily for 5 days) in combination with
subcutaneously administered cytarabine led to higher rates
of CR (59%), with similar induction mortality (9%). 78 Survival
was longer with this combination (11.3 months) versus
idarubicin and cytarabine (8.7 months), though this did
not reach statistical significance. 79
Decitabine, a pyrimidine analogue with significant antileukemic
activity, induced an overall response rate of 32%
(9 CRs and 7 PRs) among 50 patients with recurrent-refractory
hematologic malignancies treated in a phase I study. 80
In combination with valproic acid, the response rate was
22%. 81 Decitabine has also displayed favorable response
when used in combination with vorinostat. 82 A similar agent,
azacitidine, has also been evaluated for elderly patients unfit
for intensive chemotherapy. In a front-line investigation
with or without valproic acid, CR of 17% and improvements
in cytopenias were reported with azacitidine, both translating
to survival benefit. 83
Early clinical trials have demonstrated the activity of
FLT3 inhibitors, particularly in patients who harbor FLT3
mutations in their leukemic blasts. 84 Their role in combination
with other agents is undergoing further investigation.
CR was achieved in 88% (22/25) of newly diagnosed AML
patients under the age of 65 years with the addition of
sorafenib, an oral multi-kinase inhibitor, to idarubicin and
cytarabine. 85 A second generation FLT3 inhibitor, AC220,
has demonstrated responses in a Phase 1 study, with phase
II investigations ongoing. 86
Another novel treatment for AML is the nucleoside analogue,
sapacitabine, which displayed activity against AML
and MDS patients in phase I study. Current evaluations have
targeted the drug for patients 70 years of age or older with
newly diagnosed AML or in first relapse. 87 Different dosing
regimens have led to overall response rates ranging from
25–45%, with mild to moderate toxicities reported that include
fatigue, nausea, diarrhea, anemia, febrile neutropenia,
thrombocytopenia, and peripheral edema.
Acute promyelocytic leukemia (AML)
This is a distinct subtype of AML accounting for 5% to
15% of cases, with unique clinical, morphologic, and cytogenetic
features. APL results from translocations between
the retinoic acid α (RARα) locus on chromosome 17 and
the »promyelocytic leukemia« protein (PML) locus located
7

State of the Art Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
on chromosome 15, demonstrable in 95–100% of cases. 88,89
Independent risk factors for a diagnosis of APL in a patient
with AML are younger age, Hispanic background, and obesity.
7 The main clinical presentation is bleeding diathesis
resulting both from plasmin-dependent primary fibrinolysis
and disseminated intravascular coagulation. 90 Cognition of
APL is crucial because appropriate treatment is different
than for other types of AML and is curative in most patients
with APL. 91,92
Anthracyclines were historically the first effective treatment
inducing a cure rate of 30–40% in APL. Addition of
ATRA, 45 mg/m 2 daily, to chemotherapy (idarubicin) increases
CR rate, and more dramatically the cure rate from
40% to 70%. 93–95 Data suggests ATRA should be used together
with anthracyclines during induction and, probably,
during post-remission therapy. The major toxicity of ATRA
is a potentially fatal leukocytosis syndrome (APL differentiation
syndrome) characterized by fever and leakage of
fluid into the extravascular space producing fluid retention,
effusions, dyspnea, and hypotension. It is effectively treated
with dexamethasone. 96 Use of frequent transfusions of platelets,
cryoprecipitate, and fresh frozen plasma makes the use
of heparin (historically recommended) unnecessary. The
comparison of ATRA, arsenic trioxide (As 2 O 3 ) , and ATRA +
As 2 O 3 in 61 patients with untreated APL (all patients also
received consolidation chemotherapy and maintenance) displayed
favorable response with combination therapy. 97
ATRA and As 2 O 3 for induction and consolidation (without
chemotherapy) induced a CR rate of 86%, molecular remission
rate of 94% and 2-year event-free survival of 85%
among 37 newly diagnosed APL patients. 98 The results of
several studies support the role of As 2 O 3 in front-line therapy.
99,100
A stratification system has been developed that distinguishes
newly-diagnosed patients with APL into low, intermediate,
or high risk. Low risk patients present with WBC
count less than 10 x 10 9 /l and platelet count above 40 x 10 9 /
l; a WBC count above 10 x 10 9 /l identifies high-risk patients.
Others are at intermediate risk. Anticipated cure rates
are close to 100%, 90%, and 70%, respectively. Low-risk
patients may only require 3–4 courses of post-remission
therapy, following which PCR tests can be done every 3
months for 1 year. Intermediate risk patients may require a
longer duration of post-remission treatment (e.g. 6 months).
High-risk patients have both a higher early death rate from
hemorrhage and a higher risk of relapse. These patients may
benefit from more intense post-remission therapy. More frequent
PCR testing (e.g. monthly in CR) may also be advisable.
Treatment (ALL)
Therapy of ALL remains among the most complex therapies
of anticancer programs. Multiple drugs are molded into
regimen-specific sequences of dose- and time-intensity with
the goal to reconstitute normal hematopoiesis, prevent
emergence of resistant subclones, provide adequate prophylaxis
of sanctuary sites (e.g. central nervous system (CNS),
testicles), and eliminate minimal residual disease through
post-remission consolidation and maintenance. 5 Three dis-
8
tinct phases and 4 components are distinguished: induction,
intensified consolidation, maintenance, and CNS prophylaxis
in the fourth component that accompanies induction
and consolidation.
The combination of vincristine, corticosteroids, and anthracyclines
represents the backbone of ALL induction regimens.
This combination achieves complete remission (CR)
rates of 72% to 92% with a median remission duration of
around 18 months. 101 Dexamethasone is often substituted
for prednisone because of better in vitro antileukemic activity
and achievement of higher drug levels in the cerebrospinal
fluid (CSF). 102,103 While L-asparaginase is an important
agent in the treatment of pediatric ALL, its role in adult
ALL is not entirely well defined. Hematopoietic growth factors
during induction accelerate recovery from myelosuppression
and allow timely administration of dose-intense
treatment regimens. 104 Consolidation represents a repetition
of a modified induction schedule, rotational consolidation
programs, or stem cell transplantation. Novel strategies try
to emphasize subtype- and risk-oriented approaches of consolidation
programs.
Daily 6-mercaptopurine, weekly methotrexate, and monthly
pulses of vincristine and prednisone, given over 2 to 3
years are the mainstay of maintenance therapy. Extension of
maintenance beyond 3 years, as well as omission or shortening
of therapy is not beneficial. No maintenance therapy
is given in mature B-cell ALL as these patients have a high
cure rate with short-term dose-intense regimens, and relapses
beyond the first year in remission are rare. The best maintenance
for patients with Ph-positive ALL remains disputed,
but should incorporate effective BCR-ABL tyrosine kinase
inhibitors.
Although CNS disease is uncommon at diagnosis (

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) State of the Art
liposomal cytarabine, and thiotepa. In the absence of IT
therapy, isolated CNS recurrence can account for 10% to
16% of relapses, warranting the inclusion of IT chemotherapy
in CNS prophylactic regimens. The use of IT chemotherapy
in combination with the hyper-CVAD regimen (hyperfractionated
cyclophosphamide, vincristine, doxorubicin,
dexamethasone alternating with methotrexate and highdose
cytarabine), reduced the incidence of CNS relapse to
4%. 105 The number of IT injections depend on the risk of
CNS relapse (two IT treatments per course). Mature B-cell
ALL, serum lactate dehydrogenase (LDH) levels, and a high
proportion of bone marrow cells in a proliferative state
(>14% of cells in S+G2M phase of the cell cycle) have been
associated with a higher risk of CNS disease in adults. 118
Patients with low-risk CNS disease receive six IT treatments,
those with undetermined risk eight, and those with
high-risk disease 16 IT treatments including all patients
with mature B cell ALL. 119
Philadelphia (Ph) chromosome-positive ALL
Philadelphia chromosome (Ph) positivity is the most
common cytogenetic abnormality in adults with ALL, occurring
in 20–30% of patients. The outcome of patients with
Ph-positive ALL with conventional chemotherapy remains
poor with long-term disease-free survival (DFS) rates of

State of the Art Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
Minimal residual disease (MRD) in adult ALL
MRD describes the presence of disease below the threshold
of detection by conventional methods (light microscopy
and cytochemical stains). Different methodologies are available
to detect and monitor MRD, including fluorescence in
situ hybridization (FISH), multicolor flow cytometry, and
polymerase chain reaction (PCR) assays, especially real
time quantitative (RQ) PCR. Multicolor flow cytometry and
PCR techniques take advantage of either fusion transcripts
resulting from chromosome abnormalities (e.g. BCR-ABL,
MLL-AF4, TEL-AML1) or patient-specific junctional regions
of rearranged immunoglobulin and T cell receptor
genes.
Measurement of MRD in ALL has become an increasingly
important prognostic factor for assessing risk of relapse.
To which extent MRD needs to be controlled or eliminated
remains uncertain. Several questions remain: i) what
are the most appropriate time points for measurement of
MRD. Persistence of MRD early in CR does typically not
have the same significance as detection of residual disease
in later stages of therapy; ii) Is there a definable threshold of
residual disease by quantitative assays that would predict
high relapse probability; iii) is it necessary to revise response
criteria and introduce the concept of a »molecular
relapse«. It should be emphasized that molecular relapse
does not always predict clinical relapse, and intensification
of therapy under these circumstances may not be appropriate;
iv) can quantitation of MRD over time lead to a new
risk classification with impact on choice of consolidation
and maintenance strategies. Most of our current knowledge
about MRD and its kinetics derive from studies in childhood
ALL and differences in pattern and dynamics of clearance
of MRD between adult and childhood ALL. Marrow
samples from 33 adults and 21 children were analyzed by
PCR for immunoglobulin heavy chain gene rearrangements
at specific time points after diagnosis. 131 Among patients
who remained in CR, a decrease in the MRD positivity occurred
during the first 12 months. The proportion of positive
tests decreased faster in children than in adults, suggesting
more rapid resolution of MRD, particularly in the first 6
months of CR.
Salvage therapy
Outcome of salvage therapy in adult ALL remains poor.
CR rates rarely exceed 50% and long-term DSF is rare. Independent
prognostic factors associated with achieving CR
include duration of first CR and platelet count. 132 Short duration
of first CR, thrombocytopenia, elevated percent bone
marrow blasts, and low albumin level represent factors associated
with poor survival rates (Table 4). Salvage regimens
are structured according to outcomes from frontline
therapy. Newer agents have been approved in the relapsed
setting, while the role of novel formulations of conventional
active agents are being further investigated.
Clofarabine demonstrates activity in acute leukemias. In
phase 2 trials of clofarabine in relapsed or refractory pediatric
leukemias, 31% of patients with ALL responded including
12% CR, 8% CRp, and 10% partial response. 133 Based
on the response rate in pediatric relapsed ALL, clofarabine
10
Table 4. Prognostic factors in relapsed ALL 123
Poor prognostic factors for CR Poor prognostic factors for survival
Albumin level < 3 g/L* Albumin level < 3 g/L*
Duration of first CR < 36 months* Duration of first CR < 36 months*
Hemoglobin level < 10 g/dL Hemoglobin level < 10 g/dL
Platelet count ≤ 50 x 109 /L* Platelet count ≤ 50 x 109 /L*
Percent bone marrow blasts > 50 % Percent bone marrow blasts > 50%*
Peripheral blood blasts ≥ 1% Percent peripheral blood blasts ≥ 1%
White blood cell count > 20 x 109 /L
All prognostic factors listed significantly reduced rate of CR and survival.
*Independent prognostic factors identified by multivariate analysis.
was FDA approved for this indication. The maximum tolerated
dose in adults with leukemia is 40 mg/m 2 /day for 5
days, 20 times the MTD studied in solid tumors. 133 Unlike
other purine analogs, clofarabine is not associated with neurotoxicity.
Hepatotoxicity, skin rashes, drug fever, and palmoplantar
erythrodyethseia have been reported. 133–136 Studies
exploring the combinations of clofarabine with known
active agents for ALL are ongoing.
Nelarabine, an araguanosine analogue, has been shown to
be very active as a single agent in recurrent T-cell ALL with
a response rate more than 50% in first bone marrow relapse.
When administered on an alternate day schedule of 1.5 mg/
m 2 /day (day 1, 3, and 5) to relapsed/refractory T-cell ALL,
31% of patients achieved CR. 129 Neurotoxicity with nelarabine
has been of concern since initial studies. Concurrent
intrathecal chemotherapy should be cautioned as the combination
may compound the risk of neurotoxicity. Nelarabine
in combination with hyper-CVAD is currently under investigation
in newly diagnosed T-Cell ALL. Nelarabine given
at 650 mg/m 2 daily x 5 days every 28 days for two courses
as consolidation following completion of the hyper-CVAD
sequence was feasible, however the true impact on survival
has yet to be determined. 137
Vincristine, a key component to the backbone of ALL
therapy, causes peripheral neuropathy necessitating dose reductions
or omission from the chemotherapy regimens. Liposomal
formulations of chemotherapeutic agents generally
produced reduced toxicity and increased efficacy. Activity
has been observed in relapsed ALL with use of sphingosomal
vincristine with minimal neurotoxicity compared
with the conventional formulation. 138 While capping doses
of conventional vincristine at 2 mg has become common
practice, sphingosomal vincristine may be administered
without dose capping. 139 Preliminary results are encouraging,
with further studies planned.
The role of pegaspargase in adult ALL requires further
exploration. Although critical to DNA and RNA synthesis,
asparagine can not be produced by ALL cells and it’s depletion
through break down by asparaginase results in death of
leukemic calls. Applying variations of pediatric regimens to
adults may improve outcomes. Pegaspargase, E-Coli asparaginase
liked to polyethylene glycol, minimizes reactions
while maintaining the enzymatic activity of asparaginase.
Combinations with pegaspargase are critical to determine
the efficacy in adult ALL. When substituted for L-asparaginase
in the BFM regimen (prednisone, vincristine, daunoru-

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) State of the Art
bicin, L-asparaginase followed by cyclophosphamide, cytarabine,
mercaptopurine and IT methotrexate), CR was reported
at 96%. 140,141
Modifications to the hyper-CVAD regimen mimicking
approaches from pediatric regimens improve the outcomes
in relapsed/refractory ALL. The design of the »augmented«
hyper-CVAD regimen intensified the dosages of vincristine
and dexamethasone, with the addition of L-asparaginase.
With each course of »augmented« hyper-CVAD, vincristine
dosed at 2 mg and L-asparaginase dosed at 20,000 units
were administered on day 1, 8 and 15. 142,143 Additionally,
dexamethasone was increased from the standard hyper-
CVAD regimen to 80 mg daily on days 1–4 and days 15–18.
Of 49 patients treated, 45% achieved CR with a median remission
duration of 4.75 months. 143 L-asparaginase related
toxicities were frequent with 5% of patients removed from
study due to intolerance. The role of pegaspargase in combination
with this regimen is currently under investigation.
Specific sequencing of medications enhances antileukemic
effect. For example, asparaginase increases the sensitivity
of leukemic cells to methotrexate and administration
24 hours after methotrexate reduces the toxicity of methotrexate.
144 In previously treated ALL, combining sequential
moderate-dose methotrexate (100–225 mg/m 2 ) and asparaginase
with vincristine and dexamethasone (MOAD) proved
beneficial in attaining remission. CR was achieved in 11 of
14 (79%) previously treated patients. The median duration
of CR was 7.5 months and the median survival was 11.2
month.
Stem cell transplant is recommended for all patients with
Ph-chromosome positive ALL in first CR. For Ph-chromosome
positive patients not eligible for transplant, survival is
minimal. Acquired resistance to imatinib results from mutations
in the kinase domain of ABL and BCR-ABL amplification.
Second generation tyrosine kinase inhibitors appear
promising in the management of imatinib resistant ALL.
While imatinib only binds to BCR-ABL in the closed conformation,
dasatinib binds in both the open and closed conformation,
resulting in an increased affinity to BCR-ABL.
The ability of dasatinib to inhibit src activity may provide
advantage over imatinib by blocking BCR-ABL activity
through a separate mechanism. Dasatinib, in combination
with chemotherapy (hyper-CVAD) was evaluated in 14 patients
with relapsed Ph-chromosome positive ALL or CML
with lymphoid blast crisis. 145 Seventy-one percent of patients
achieved CR while 29% attained complete response
without platelet recovery (CRp). Major molecular response
was achieved in 64%. Of four patients that had relapsed,
two acquired the T315I mutation, resistant to currently
available tyrosine kinase inhibitors.
Stem Cell Transplant (SCT)
High-dose chemotherapy with or without radiation followed
by hematopoietic stem cell transplantation (SCT) is
increasingly used as therapy for acute leukemia. AML in
first CR, particularly in patients with poor-risk factors such
as deletion of 5q and 7q, trisomy 8, t(6;9), t(9;22), and a
history of myelodysplasia or AHD are candidates for SCT.
With a possible advantage of allogeneic transplantation in
patients with poor-risk cytogenetic features, there are no
subgroups identified in whom there is a clear advantage to a
particular modality. 146 An exception is patients with inversion
16, or t(8;21) who do better with chemotherapy. 147 Two
other exceptions are patients younger than 20 years in whom
transplant-related mortality is relatively low and who may
do better with allogeneic stem cell transplantation, and patients
older than 60 years in whom excessive mortality excludes
the possibility of conventional myeloablative transplant.
148,149 If allogeneic transplant is proposed, data suggest
there is no advantage in giving consolidation chemotherapy
before transplantation. 150
The outcome with SCT versus continuation of chemotherapy
in ALL has been debated. Although SCT is superior
to chemotherapy with long-term disease-free survival rates
of 20% to 40% in salvage, only 30% to 40% of patients who
achieve a second CR are eligible for SCT and fewer than
half have enough time prior to relapse to undergo SCT. Traditionally,
SCT has been reserved for patients with Ph-positive
ALL or in patients considered high risk (age greater
than 35 years, B lineage with white blood cell count ≥ 100 x
10 9 /L, T lineage with white blood cell count ≥ 30 x 10 9 /L). 151
However, survival at 5 years was not significantly different
between patients treated with a matched related donor SCT
and those treated with continued chemotherapy or autologous
SCT in high-risk patients. Improvements in survival at
5 years were significantly greater in patients treated with a
matched related donor SCT in patients not considered highrisk.
SCT reduced the rate of relapse compared with chemotherapy
or autologous SCT in both risk groups of patients.
The use of chemotherapy is favored over autologous SCT
for patients without a suitable donor.
Conclusion
The biology of both AML and ALL is now better understood.
Following a period of paucity in discoveries, new
strategies are finally evolving that may help patients with
AML. Better definition of the complex process initiating
and sustaining the leukemic process will lead to a better
definition of targets for therapeutic intervention that may
translate into improved cure rates. Specific attention must
be given to prognostic factors that identify subsets of AML.
Progress in the understanding of the biology and pathogenesis
of adult ALL has helped improve outcome and prognosis.
More intensive regimens combined with targeted therapy
are being evaluated with encouraging results. As in other
leukemias, the key to further improving prognosis of adult
ALL lies in an appreciation and recognition of the heterogeneity
of ALL. Novel strategies under investigation as monotherapy
or in combination with chemotherapy provide improvements
in the treatment of relapsed disease. Development
of new drugs and agents tailored to subset-specific
cytogenetic-molecular characteristics remains vital to the
success in adult ALL. Progress in adults has been marked by
utilization of intensive regimens proven beneficial in pediatric
patients as well as the inclusion of new targeted therapy.
Treatment remains highly successful in pediatric ALL and
with continuous investigation, adults may soon achieve
comparable long term-survival.
11

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15

Oral Presentations
OP01 White blood cell transfusion and leukemia
therapy
Emil Freireich, The University of Texas MD Anderson
Cancer Center, Houston, Texas, USA
The leading cause of morbidity and mortality in leukemia
patients results from uncontrolled infection. Since the late
50s, it has been clear that leucopenia is a major contributing
factor to the occurrence of infection. Both the severity and
duration of leucopenia result in increased incidence of infection.
Similarly, thrombocytopenia is the major contributing
cause to hemorrhage. Transfusion of allogeneic platelets
has been very effective in controlling hemorrhage, and decreasing
hemorrhage as a cause of morbidity and mortality.
However, for infections, replacement of leucocytes by transfusion
has been frustrated by inability to technically collect
a sufficient number of leucocytes to increase the number of
leucocytes in the circulation, and the physiology of the leucocytes
where a great majority of the cells (over 95%) are
located outside of the vasculature. Thus, the volume of distribution
is at least 20 fold that of red cells. First efforts to
overcome this limitation were the studies of the transfusion
of allogeneic leucocytes collected from donors with uncontrolled
chronic myeloid leukemia (CML), which allowed
transfusion of between 10 and 100 billion cells to leucopenic
children with acute leukemia. These studies demonstrated
that with an adequate dose of these cells, even abnormal
granulocytes from CML patients, doses of 50–100 billion
cells was uniformly effective in controlling established infection.
To reach these concentrations of normal cells required
the development of an efficient and semi-automated
continuous blood flow cell separator; the application of a
safe and largely degradable macromolecule to increase separation
efficiency of the granulocytes; and the discovery of
the granulocytes stimulating colony factors to mobilize myeloid
cells from the bone marrow into the blood to allow
collection. With these advances, it became possible to regularly
collect 30–50 billion leucocytes from a single volunteer
donor and transfusion of these cells into severely leucopenic
patients with existing infection resulted in significant
reversal of infection in 40% of patients who received a minimum
of 4 consecutive daily transfusions. These data were
reported in the late 1970s, and in several centers leucocyte
transfusion was practiced. In the mid 80s, following several
anecdotal reports of a syndrome resembling Graft vs Host
Disease (GVHD) were reported in literature. These were
single or two patient reports. However, these reports result
in radiating all leucocyte transfusion products from the mid
80s to 2008. It is important to recognize that several metaanalyses
of all the published reports of transfusion associated
GVHD did not support the conclusion that such a syndrome
resulted from leucocyte transfusion.
While radiation of the transfusion product did not have a
major effect on neutrophil function in vitro, it completely
eliminated lymphoid cells and thus was considered to be
free of any possibility of transfusion associated Graft vs
Host Disease (TAGVHD). In vitro studies subsequently demonstrated
that in addition to the effect on lymphoid cells,
the mononuclear monocytes and macrophages were completely
inactivated by doses of radiation administered. But
perhaps most importantly since the GCSF mobilized leucocytes
collections were demonstrated to have myeloid hemapoietic
stem cells and a large number of undifferential
myeloid cells which, in the recipient, were able to continue
to mature into granulocytes. The consequence was that the
half life of measured granulocytes post non-radiated transfusions
was approximately 24 hours, whereas the half life of
the radiated products was approximately 6 hours. In 2008
we undertook a prospective randomized double-blind study
comparing unradiated granulocytes with the same product
which has been radiated in vitro. The goal of this study was
primarily to determine the risk of TAGVHD was, and secondly,
to quantitatively measure the effect of radiation on
post transfusion increments and granulocyte levels in patients.
The study was closed on July 14 th 2011 and we found,
after the study of 109 patients, that in the 49 patients who
received irradiated granulocytes transfusion, there were no
patients who developed any syndrome resembling GVHD.
While the 30 day survival and the response rates and overall
survival were not significantly different, the increments
measured post transfusion were more than twice in the recipients
of non irradiated transfusions than those in the radiated
transfusions. This study led to two conclusions – first,
the unradiated leucocytes transfusions have the potential of
being effective in helping control infectious complications
in leucopenic patients and secondly, that such transfusions
are demonstrated to be safe.
OP02 Presence and future of treatment of acute
myeloid leukemia in patients under the age
of 60
Roel Willemze 1 , Stefan Suciu S, Giovanna Meloni, Boris
Labar, Halkes S, Petra Muus, David Selleslag D, Marko
Vignetti, Sergio Amadori, Theo de Witte T, Jean-Pierre
Marie, on behalf of the EORTC and GIMEMA Leukemia
Groups, 1 Department of Hematology, Leiden University
Medical Center, the Netherlands
The age of the patient still determines the choice of treatment
and outcome in acute myeloid leukemia (AML). In
patients, younger than 60 years, 65% to 80% enter complete
remission after several anthracycline-cytarabine-based combinations.
Dosing of these drugs influences the prognosis of
17

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
the patients. Intermediate high dose cytarabine is recently
reported to lead to the same results as standard dose cytarabine,
while high dose cytarabine may improve results compared
to standard dose cytarabine. A similar phenomenon is
true for different kinds of anthracyclines or dosages of anthracyclines.
Although much is still unclear, it still looks
like more antileukemic drug, in addition to improvements in
supportive care (new antibiotics and bloodbank support),
leads to a better outcome. One consolidation course consisting
of high-dose cytarabine is considered necessary although
firm proof is lacking. The intensity of the induction
schedule appears to influence the duration of the hematological
recovery phase and the number of autologous stem
cell that can be harvested after consolidation, and the relapse
risk after this consolidation course. These findings
may indicate that in certain patients the sensitivity of normal
hematopoietic stem cells for certain antileukemic drugs
parallels the sensitivity of leukemic stem cells. Further consolidation
of the remission status using repeated high-dose
cytarabine courses or a stem cell transplantation decreases
relapse rate and increases remission duration, allogeneic
stem cell transplantation in the younger patients being superior
to autologous stem cell transplantation or high-dose
cytarabine. Although the administration of IL-2 after autologous
stem cell transplantation or intensive consolidation
therapy did not affect the duration of remission in most
studies, the combination of low-dose of interleukin-2 and
histamine as maintenance prolonged remission in one study.
Outcome improved by allogeneic stem cell transplantation
using sibling donors, especially in patients under the age of
50 with intermediate or bad risk AML. Currently, due to
improved HLA-matching techniques, the outcome of allogeneic
stem cell transplantation using matched unrelated
donors equals the results obtained by sibling donors. Adoptive
cellular immunotherapy after allogeneic stem cell transplantation
using donor lymphocytes or in vitro cultured T
cells are under investigation but preliminary results look
promising with respect to the control of molecular or cytogenetic
relapses. Acute myeloid leukemia appears to be a
high heterogenous disease where an increasing number of
cytogenetic and molecular aberrations of the leukemic cells
determines the prognosis. These differences led already to a
subdivision of AML in good, intermediate and bad or very
bad risk subgroups where different treatment strategies need
to be applied. However some molecular aberrations may be
present across these prognostic subtypes, complicating the
study of the value of drugs specifically designed against
these aberrations. Relatively few new drugs have been approved
for AML in the last two decades. Gemtuzumab ozogamicin
is the first example of antibody directed chemotherapy
targeting the CD33 epitope. Its use in combination
with chemotherapy has been denied in Europe due to the
lack of benefit in overall survival. Studies targeting the
FLT3 mutation have shown limited activity as monotherapy
but randomized trials in combination are underway. Targeting
RAS and other farnesylated peptides and P-glycoprotein
has been disappointing. Demethylating agents such as
decitabine, have shown superior antileukemic activity in the
past, appear useful in the management of patients with myelodysplasia,
and are currently reintroduced in the treatment
18
of AML. A new agent, clofarabine, shows increased hematological
toxicity and a high complete remission rate at the
maximum tolerated dose in phase I/II trials but requires randomized
evidence to evaluate its real impact on duration of
remission and overall survival.
In conclusion, the outcome of AML under the age of 60
has improved considerably during the last 25 years due to
the use of more intensive chemotherapy and stem cell transplantation
and improvements in supportive care. Currently
and in the next future the improved knowledge on tumor
immunology and on molecular aberrations of leukemic cells
will lead to an extreme subdivision of AML in subgroups
with specific treatment requirements. In this personalised
treatment era, patients available to enter into a phase III trial
will become quite limited. This development necessitates
worldwide cooperation of Leukemia Groups in order to collect
sufficient patients of a specific subgroup of AML.
OP03 CLL: how close is the cure?
Michael Keating, The University of Texas M. D. Anderson
Cancer Center, Houston, Texas, USA
Dramatic changes have occurred in the outcome of patients
with chronic lymphocytic leukemia (CLL) over the
last 25 years. Using modern day criteria for response, the
complete remission (CR) rate with alkylating agent regimens
was approximately 5%. As fludarabine entered into
frontline treatment, the CR rate increased to 20–25%, going
to 30–35% for fludarabine plus cyclophsomide (F+C), and
more recently with the FCR regimen, adding rituximab to
FC, the CR rate is 50–70%. An important part of the development
of evaluation criteria were provided by the NCI
working group guidelines 1 and more recently the iwCLL
guidelines 2 for indications for treatment and response evaluation
in CLL. In most tumors when the complete remission
rate gets above 50% there is a fraction of patients who are
cured of their disease. This question is increasingly being
asked in chronic lymphocytic leukemia.
It is clear that there is a close correlation of the time to
progression (TTP) of complete and partial responders (CR
+ PR) according to the quality of the remission and other
parameters such as the mutation status and FISH genetics.
Patients who achieve CR using NCI WG criteria have a significantly
longer time to progression than nodular partial
remissions (NPR) who again have a longer remission duration
than other partial responders. An analysis of 300 patients
treated with the FCR regimen (FCR300) previously
published 3 has demonstrated that there is a clear association
of time to progression with the mutation status of the immunoglobulin
variable sequence of the heavy chain (IgVH) 4 .
The mutated patients have a very significantly greater likelihood
of being 5 and 10 years in remission than patients who
are unmutated. There is also evidence that patients that
achieve minimal residual disease (MRD) negativity have a
greater probability of being long term remissions. The technology
for measuring MRD has evolved over time so that
the more recent strict criteria of flow cytometry identifying
1 in 10 4 cells has only recently been applied. Most of these

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
clinical trials evaluating FCR regimens or other regimens
combining purine analogs with monoclonal antibodies such
as rituximab are too immature to evaluate true long term
remissions.
We now have complete follow-up of patients treated with
FCR (300). The percent of patients who are free of recurrence
at 10 years are 46% for CR, 26% for NPR and 17%
for other PR.
The FISH evaluation was not available for the FCR 300
patients and we cannot make such projections. However, it
is clear that more recent CR + PR patients who are mutated
have a 61% likelihood of being free of relapse at seven years
but only 18% if unmutated. Within the unmated group of
patients it is apparent that shorter times to remission occur
in patients with deletion of chromosome 11q.22-23 (del
11q). Older patients have not fared as well, but in the small
proportion of patients 70 years of age or older who were CR
or PR in the first FCR study, 36% are still alive. 53% have
relapsed and 17% have died in remission. A substantial
number of patients are dying of other illnesses while still in
remission of their disease which is functionally a cure of
their disorder.
Now that subsets of patients who are at high risk of relapse
can be more readily identified, post remission strategies
with monoclonal antibodies, lenalidomide and stem
cell transplantation are being applied. The prospects for
long term survival of patients with 17p deletion or p53 mutation
is still grim with stem cell transplantation the only
reasonable option to give long term control. The 11q group
of patients have a very high propensity of relapse, but they
have a good second remission rate so that opportunities are
present to prolong remission by intervention during their
first and later remissions. All other subsets including trisomy
chromosome 12, 13q deletion and negative patients have
the same likelihood of being free of disease. With the development
of new therapies such as the B cell Receptor signaling
antagonists such as CAL-101 and PCI-32765, improved
transplant options for patients up to 75 years of age and immune
modulating agents such as lenalidomide, prospects
for all subsets of patients is improving.
R E F E R E N C E S
1. Cheson BD, Bennett JM, Grever M, Kay N, Keating MJ, O’Brien S, Rai
KR. National Cancer Institute-sponsored Working Group guidelines for
chronic lymphocytic leukemia: revised guidelines for diagnosis and
treatment. Blood 1996;87(12):4990–7.
2. Hallek M, Cheson BD, Catovsky D, Caligaris-Cappio F, Dighiero G,
Döhner H, Hillmen P, Keating MJ, Montserrat E, Rai KR, Kipps TJ.
Guidelines for the diagnosis and treatment of chronic lymphocytic leukemia:
a report from the International Workshop on Chronic Lymphocytic
Leukemia updating the National Cancer Institute-Working Group
1996 guidelines. Blood 2008;111(12):5446–56.
3. Tam CS, O’Brien S, Wierda W, Kantarjian H, Wen S, Do KA, Thomas
DA, Cortes J, Lerner S, Keating MJ. Long-term results of the fludarabine,
cyclophosphamide, and rituximab regimen as initial therapy of
chronic lymphocytic leukemia. Blood 2008;112(4):975–80.
4. Lin KI, Tam CS, Keating MJ, Wierda WG, O’Brien S, Lerner S,
Coombes KR, Schlette E, Ferrajoli A, Barron LL, Kipps TJ, Rassenti L,
Faderl S, Kantarjian H, Abruzzo LV. Relevance of the immunoglobulin
VH somatic mutation status in patients with chronic lymphocytic leukemia
treated with fludarabine, cyclophosphamide, and rituximab
(FCR) or related chemoimmunotherapy regimens. Blood 2009;113(14):
3168–71.
OP04 From donor buffy coat to vaccination
Hans-Jochem Kolb 1 , Helga Schmetzer 2 , Arndt Borckhardt 3 .
1 3. Med. Klinik, Techn. Universitaet Muenchen,
1 Helmholtz Zentrum München, National Reserch Center
for Environmental Health, 2 3. Med. Klinik, Universitaet
München, Germany, 3 Kinderklinik Univ. Düsseldorf,
Germany
Chimerism and transplantation tolerance can be achieved
with allogeneic stem cell transplantation. The state of chimerism
provides the chance for adoptive immunotherapy
using donor lymphocytes exerting strong immune effects on
leukemia and other malignancies of the host without being
rejected. The risks of allogeneic lymphocytes are development
of graft-versus-host disease (GVHD) as well as tolerance
toward the malignant disease. Delay of donor lymphocyte
transfusions after cessation of the cytokine storm of
conditioning treatment and establishment of some form of
peripheral tolerance and careful treatment in escalating doses
starting at a low dose has facilitated the treatment of relapse
of chronic myeloid leukemia and prevention of acute
myeloid leukemia without severe GVHD. However, preemptive
transfusion of donor lymphocytes has been limited
to a minority of patients because of early relapses and acute
GVHD. The hypothesis that myeloid leukemia respond better
to donor lymphocytes because of their differentiation to
dendritic cells has been supported by the demonstration of
dendritic cells with the karyotype of the leukemia and the
improved response following treatment with interferon-a
and GM-CSF. However in the case of rapidly progressive
relapse cytotoxic therapy may be necessary and subsequently
donor lymphocytes may produce GVHD. Therefore we
and others have studied lymphocytes of treated patients for
the recognition of antigens that are overexpressed in leukemia
blasts like WT-1, PR-1 and PRAME. We found overexpression
of these proteins in acute myeloid leukemia. Moreover
we found 4 new antigens overexpressed inAML coded
by the Y-chromosome. Unfortunately the number of CD8cells
with multimer staining for peptides of these antigens
were few and gamma-interferon release low. We also studied
splice variants of a Y-chromosome associated antigen
UTY for tissue restriction. We could demonstrate a multitude
of splice variants, but no specific tissue restriction.
These findings are in contrast to the selection of T cells using
antigenic peptides of EBV covering more than 90% of
HLA-antigens; these cells could be selected and transfused
inducing rapid remissions in patients with EBV-associated
post-transplant lymphoma. This has been proven as a life
saving cost effective procedure that would be ideal for the
treatment of leukemia, if an antigen of similar strength
could be defined for leukemia. Genome wide screening for
SNPs using T-cells of stem cell transplant patients has
shown a few new minor histocompatibility antigens. The
cumulative frequency of genes for minor H-antigens may
thus increase and more patients could benefit of immunotherapy
directed against mHA. We have tried to test the generation
of T cells in vitro against dendritic cells of leukemic
origin, and we found two results: first patients with blasts
differentiating into DC have a better chance to respond to
19

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
door lymphocytes, secondly cytotoxic T cells generated to
dendritic cells of leukemia origin in vitro have T cell receptors
( Vß-chain) found in the patients post transplantation.
Several Vß chain clones are represented in more than 1 sample;
they may represent dominant clones that can be recognized
in vitro and sometimes even in the donor. There is a
good chance that they can be selected and used for immunotherapy
without further analysis of the antigens against
which they are directed.
Major histocompatibility antigen may cause more vigorous
reactions including early cellular reactions and antibody
production. Of particular interest is NK reactivity against
hematopoietic cells missing own HLA-antigens, transplantation
across cross-reactive HLA-C groups sharing killer
inhibitor receptors have a strong graft-versus-leukemia effect
in acute leukemia, not in lymphoma. Maternal transplants
have a superior GVL effect to paternal grafts indicating
immune memory against paternal antigens. For alternate
donor transplants we prefer HLA-haploidentical transplants
for younger patients and cord blood transplants for elderly
patients. Double cord transplants have a strong GVL activity
for as yet unknown reasons. Non-inherited maternal antigens
and graft-versus-graft reactions may play a role. Major
histocompatibility antigens may not only be a strong
target for alloimmune reactions, they may as well present
peptide of autologous antigens in an immunogenic way and
provide a major activating stimulus to reactions against minor
HA. Several recent observations support the necessity
of strong costimulation in order to prevent tolerance toward
leukemia-associated antigens and minor HA. Repeat vaccination
with WT1 and PR1 peptides induced non-reactivity
(Rezvani et al. 2011) even in the presence of memory T
cells (Pospori et al, 2011). We discuss mechanisms of immune
escape in leukemia and possible ways to overcome it
with interferon-a, GM-CSF and bispecific antibody treatment.
Future donors have not only to selected according to
histocompatibility, but also according to their immune repertoire.
In future immunotherapy not only target antigens
and effector cells have to be considered, but also immune
escape and mechanisms to maintain immune tolerance.
OP05 AML in adults – what we need for diagnosis
Torsten Haferlach, MLL Munich Leukemia Laboratory,
Munich, Germany
The diagnosis of AML is getting more and more comprehensive
but also complicated. First of all, making the diagnosis
does not always mean to classify AML: according to
the WHO classification as published in 2008 1 , several hierarchical
steps have to be fulfilled:
To make it easier for application, one could first discriminate
between »treatment-related AML« following radiation
and/or chemotherapy and »de novo AML«. Thus, the history
of the patient has to be known to the physician but also to
the diagnostic laboratory.
As a second step, »AML with recurrent cytogenetic aberrations«
are defined by the WHO. This for sure needs chromosomal
banding analysis, even if in some cases molecular
techniques such as PCR screening may be helpful. But not
20
all entities subcategorized in this »AML with recurrent genetic
abnormalities« can be detected by PCR, as such standard
chromosomal banding analysis accompanied by FISH
and/or PCR are necessary. As a matter of fact, these techniques
have a turn around time of three to ten days in experienced
laboratories. Therefore, the diagnosis cannot rely
only and primarily on this classification aspects, chromosomal
banding analysis.
In the next step of the hierarchy, »AML with myelodysplasia-related
changes« have to be taken into account.
Again, these cases are based on their respective history of
the patient (AML following MDS or MDS/MPN overlap)
but also include in addition or only cytogenetic changes,
mostly known from MDS, and/or dysplastic features, socalled
multilineage dysplasia. Also in this category, as it is a
combination of different methods, turn around time and
availability make it not easy to get this category implemented
into a daily routine diagnostic workflow.
Finally, those cases not fulfilling the above-mentioned
criteria are classified according to the formally known morphologic
criteria as defined in the FAB classification. In
these cases, at least cytomorphology is important.
In addition, several other aspects are included today more
and more in standard approaches to AML diagnostics: molecular
markers such as NPM1 and CEBPA have been suggested
to be »provisional entities« according to WHO classification,
especially within a normal karyotype, other genes
should be investigated as well such as FLT3-ITD, MLL-
PTD and newer markers my also be implemented in the near
future such as DNMT3A. In addition, the expression of several
genes such as EVI1, WT1 and BAALC have to be taken
into account, which makes it even more difficult to follow
up with the complete WHO scenario for diagnosis of AML
in a routine setting 2 .
Therefore, several guidelines have been suggested or different
scenarios, the most important one was published by a
cooperating initiative of the ELN 3 . The authors clearly elaborate
on the specific diagnostic algorithms in AML in adults,
discriminating between standard diagnostic approaches in
general and clinical studies:
From clinical perspective it seems mandatory that for patients
who may undergo standard treatment approaches,
cytomorphology (leading to the diagnosis at the same day)
accompanied by immunophenotyping (same turn around
time) is mandatory. This has to be performed together with
standard cytogenetic analysis, as cytogenetic results still
provide the most important prognostic factor in AML 4 . In
addition, cytogenetic results are mandatory to fulfil baseline
diagnostic criteria according to the WHO classification
2008.
If allogeneic transplantation may be an option, also the
investigation of molecular markers such as NPM1, FLT3-
ITD and CEBPA, especially in the normal karyotype AML
subset, seems important 5 . It further has to be discussed that
minimal residual disease studies in AML with molecular
markers such as PML-RARA, CBFB/MYH11 but also NPM1
may help to further subclassify and guide treatment in the
individual AML patient.
The next future will also demonstrate that new molecular
markers such as DNMT3A 6 , TET2 and others may not only

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
add important diagnostic value for AML but also will guide
treatment and define prognosis. However, it has to be admitted
that the diagnosis of AML is still getting more complicated,
labour intensive and expensive. The next few years
will demonstrate, if techniques such as next-generation sequencing
(NGS) will help us to better characterize AML
patients not only in clinical studies but also in the daily routine
setting.
We have to realize that many patients still die with the
diagnosis of AML and it is highly appreciated that any new
diagnostic and therapeutic approach has be followed to be
investigated within clinical studies and to be implemented
for all patients after validation in a short timeframe.
R E F E R E N C E S
1. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues.
Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H
et al., editors. 4th. 2008. Lyon, International Agency for Research on
Cancer (IARC).
2. Marcucci G, Haferlach T, Döhner H. Molecular genetics of adult acute
myeloid leukemia: prognostic and therapeutic implications. J Clin Oncol
2011;29:475–486.
3. Döhner H, Estey EH, Amadori S, Appelbaum FR, Buchner T, Burnett
AK, et al. Diagnosis and management of acute myeloid leukemia in
adults: recommendations from an international expert panel, on behalf
of the European LeukemiaNet. Blood 2010;115:453–474.
4. Grimwade D, Hills RK, Moorman AV, Walker H, Chatters S, Goldstone
AH, et al. Refinement of cytogenetic classification in acute myeloid leukemia:
determination of prognostic significance of rare recurring chromosomal
abnormalities among 5876 younger adult patients treated in
the United Kingdom Medical Research Council trials. Blood 2010;116:
354–365.
5. Schlenk RF, Dohner K, Krauter J, Frohling S, Corbacioglu A, Bullinger
L, et al. Mutations and treatment outcome in cytogenetically normal
acute myeloid leukemia. N Engl J Med 2008;358:1909–1918.
6. Ley TJ, Ding L, Walter MJ, McLellan MD, Lamprecht T, Larson DE, et
al. DNMT3A mutations in acute myeloid leukemia. N Engl J Med 2010;
363:2424–2433.
OP06 Mutation of epigenetic regulators in AML
and MDS
Joop Jansen, Laboratory of Hematology, Radboud
University Nijmegen Medical Centre St. Radboud and
Nijmegen Centre for Molecular Life Sciences, Nijmegen,
The Netherlands
Aberrant epigenetic modifications have been described in
many types of cancer. In myeloid malignancies aberrant
methylation patterns may be observed, and it has been proposed
that repression of genes that are crucial for the cessation
of the cell cycle and the induction of differentiation
may contribute to the malignant transformation of normal
hematopoietic cells. In the past years, various genes were
shown to be mutated in AML and MDS, and this has been
accelerated by the application of novel technologies like
high-resolution SNP-array analysis and next generation sequencing.
Strikingly, several of the newly identified genes
(ASXL1, UTX, TET2, EZH2, DNMT3A) function to regulate
gene expression by epigenetically changing chromatin. The
TET2 gene is currently the most frequently mutated gene in
MDS known so far (20–25% of the cases), and is also mutated
in AML (10% of the cases) and various types of MPN
(including CMML, where it is mutated in 30–40% of the
cases). It was shown to convert methylated cytosines (correlating
with repression of gene expression) into 5-hydroxymethyl
cytosine, of which the functional consequences are
under investigation. Mutations of the DNA-methyltransferase
3A gene (DNMT3A) were found both in AML and in
MDS, which also provides a direct link between gene mutations
and DNA methylation. Furthermore, mutations in
genes that regulate the epigenetic modifications of histones
have been found, such as the polycomb-repressor complex-
2 (PRC2) component EZH2. It will be interesting to see
whether the patients who carry mutations in the genes that
regulate epigenetic chromatin changes are responding differently
to the novel epigenetic therapies (like hypomethylating
agents) that are currently being investigated.
OP07 Therapy for younger adults with AML
Alan Burnett, Department of Haematology, Cardiff
University School of Medicine, Heath Park, Cardiff,
United Kingdom
Survival in younger patients (arbitrarily defined as patients
less than 60 years) has improved in the last 20 years
such that 45 to 50% can now be cured, but may have reached
the limit of the potential with »standard chemotherapy.
Standard of care comprises 7+3 Ara-C + Daunorubicin for
induction followed by high dose Ara-C (3 g/m 2 ) for consolidation
or allogeneic transplant for non-favourable cases
for who a donor is available. However higher remission
rates have been consistently shown with alternative inductions
such as a 10 day Ara-C schedule, but intensification of
Ara-c in induction has not been consistently of benefit. Similarly
comparisons of different anthracylcine or anthracyline-like
agents have not shown consistent superiority over
Daunorubicin once dose equivalence has been taken into
account. Recently a Daunorubicin dose of 90 mg/m 2 has
been shown to have improved induction and in some cases
survival. However the comparator are only produced a 57%
CR rate. However Idarubicin is equivalent to Daunorubicin
80 mg/m 2 . Many consider that a 60 mg/m 2 the optimum
dose. The addition of mylotarg to a Daunorubicin dose of
45 mg was equivalent to a 60 mg dose, however in the largest
trial testing the addition of mylotarg to a 3+10 schedule
significantly improved survival by 10% in 70% of patients
with high risk disease. Inclusion of other nucleoside analogues
such as Fludarabine/ Cladrabine or clofarabine has
potential to be more effective induction.
High dose Ara-C is standard of care in consolidation but
what dose and how many courses is still under study. The
MRC AML15 trial compared 3 g vs a 1.5 g dose and found
no overall difference. Three consolidation courses was not
superior to two. In this trial, two courses of FLAG-Ida in
induction did not improve overall survival, although it significantly
reduced the risk of relapse, but because of more
myelosuppression there was less compliance with consolidation
therapy. However the survival of patients who received
2 courses of FLAG-Ida only was the same as for patients
who received all planned four courses. The survival
21

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
for patients who received FLAG-Ida X 2 and Ara-C consolidation
X 2 was 64%.
Stem cell transplantation is clearly superior to chemotherapy
in high risk disease, although far from satisfactory
for this difficult subgroup in which there has been no improvement
in the last 30 years.There is continuing controversy
concerning which intermediate risk patients should
have SCT in CR1. This is usually initially defined by cytogenetics,
however of other important prognostic factors are
used to identify further high risk groups (inadequate marrow
response to course 1/secondary disease/ high white
count/ male gender) the remaining patients may not need
transplantation. Younger patients ( 10 x 10 9 /L) seem
to benefit from treatments including cytarabine in the ATRA
plus chemotherapy scheme, whereas standard risk patients
can be successfully managed with less intensive regimens
containing ATRA and anthracycline-based chemotherapy.
More recently, arsenic trioxide (ATO), which as a single
agent is the most effective drug for APL, has unquestionably
emerged as the most exciting »new drug« to be included
in the treatment strategy for this disease. Following the
outstanding results with ATO in the treatment of APL relapse,
several clinical trials have been reported by single
institutions in relatively small and non-comparative studies.
Although published studies are lacking, there are currently
at least two ongoing randomized trials comparing ATObased
versus chemotherapy-based approaches. One conducted
by the Italian GIMEMA group for patients with WBC
count < 10 x 10 9 /L and another by the British NCRI for all
patients with APL Further to explore the role of ATO in
front-line therapy with the aim of minimizing or even eliminating
the use of chemotherapy, other clinical trials have
been designed to assess the use of ATO to reinforce standard
ATRA plus chemotherapy regimens and further improve the
outcome of APL. In this regard, a recent report of a large
randomized study by the US Intergroup showed significantly
better outcomes in patients receiving two courses of ATO
immediately after achieving complete remission and before
the standard consolidation with ATRA and chemotherapy.
Currently other major cooperative groups, such as the
French-Belgian-Swiss group and the PETHEMA-HOVON
group, are also conducting studies to assess the role of ATO
in consolidation therapy of ATRA plus chemotherapy regimens.
The opportunities offered by the incorporation of
ATO into the therapeutic armamentarium of APL, not only
to minimize or even eliminate the use of chemotherapy, but
also to optimize the standard approach, will be discussed in
this presentation.
OP10 FLT3 inhibitors – too much expectations?!
Farhad Ravandi, University of Texas – MD Anderson
Cancer Center, Houston, Texas, USA [see SA01]
The FLT3 receptor kinase is highly expressed in acute
leukemias. FLT3 gene mutations are among the most com-

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
mon molecular abnormalities in AML occurring in about a
third of patients particularly those with diploid cytogenetics
and acute promyelocytic leukemia. Available evidence suggests
that these molecular lesions confer a shorter diseasefree
survival and overall survival in patients with intermediate-risk
cytogenetics. As a result, there is substantial interest
in inhibition of the FLT3 kibase as a therapeutic target and
several promising inhibitors that target this tyrosine kinase
are in clinical development.
Several reported trials of these kinase inhibitors as a single
agent and incombination with traditional cytotoxic
agents have clearly demonstrated their activity. However,
future trials involving perhaps more potent are likely to shed
further insights on the relevance of FLT3 kinase as a target,
the population most likely to derive benefit, the most appropriate
agents for combination, and the clinical and biological
correlates predicting a benefit.
OP11 Allogeneic SCT for AML – when to treat
OP12 Allogeneic SCT with reduced intensity
conditioning for AML
Didier Blaise, Unité de Transplantation et de Thérapie
Cellulaire (UTTC), département d’hématologie, Institut
Paoli-Calmettes, Marseille and Université de la
Méditerranée, Marseille, France.
Allogeneic stem cell transplantation (allo-SCT) is the
treatment exerting the most efficient antileukemic effect in
acute myeloblastic leukemia (AML). In selected subset of
patients, this conducts into a survival benefit as compared to
chemotherapy strategies. However, the oldest patients can
rarely benefit from intensive treatment including standard
myeloablative allo-SCT because of an unacceptable high
risk of procedure-related toxicity. This point is especially
critical when considering AML patients in first CR (CR1).
Finally, most of the patients lack a human lymphocyte antigen
(HLA)-identical donor further precluding an allo-SCT
strategy.
The development of the so-called non-ablative, or reduced-intensity
conditioning (RIC) regimens appears to decrease
allo-SCT-related toxicities, as promising results have
already been reported in different series of patients with
various hematological malignancies. In contrast to standard-dosed
myeloablative allo-SCT, and although long term
follow-up is still needed in many studies, RIC allo-SCT is
relatively well tolerated by patients with high-risk clinical
features such as advanced age or associated co-morbidities.
Nevertheless, toxicity might represent only one face of the
problem, since AML encompasses a group of chemo-sensitive
diseases, raising concerns that significant reduction of
the intensity of the standard conditioning regimens may
negatively impact long-term leukemic control. This concern
might be particularly apparent in patients with high-risk
leukemic features. Indeed, the importance of dose intensity
has been already shown in myeloablative allo-SCT. However,
the beneficial effect of more intensive conditioning
that is associated with a reduced risk for relapse was offset
by an increased transplant-related toxicity. The latter figures
may be even more complex since the relative benefit of myeloablation
as part of the conditioning regimen, may also
depend on patient and disease status at time of allo-SCT
(e.g. CR1 vs. beyond CR1 or advanced disease). Thus, investigators
are currently faced with a dilemma on how to
optimize the potential role of RIC allo-SCT in patients with
AML, while delivering minimal myeloablation and maximizing
allogeneic immunotherapy. To add to this debate we
will review present knowledge on reduced intensity regimen
approach in AML and report our experience.
OP13 Novel drugs for AML
Hagop Kantarjian, Department of Leukemia, U.T. M.D.
Anderson Cancer Center, Houston, TX, USA [see SA01]
OP14 Molecular Pathogenesis of Myelodysplastic
Syndromes
Omar Abdel-Wahab, Alan Shih, Ross L. Levine, Leukemia
Service, Department of Medicine, Human Oncology and
Pathogenesis Program, Memorial Sloan Kettering Cancer
Center
Myelodysplastic syndromes represent one of the most
common myeloid malignancies, and are associated with poor
outcome overall due to progressive cytopenias/bone marrow
failure and progression to acute myeloid leukemia. Importantly,
clinical and cytogenetic parameters have been
used to improve prognostication for MDS patients, however
little insight into the molecular pathogenesis of MDS
had been elucidated until recently when a series of candidate
gene and whole genome studies have identified recurrent
somatic mutations in MDS patients including TET2,
ASXL1, DNMT3A, EZH2, and TP53 mutations. Importantly,
a subset of these genes including ASXL1, EZH2, and
TP53 have been associated with poor outcome, and recent
studies have shown that these mutations can be used to supplement
the IPSS and improve prognostication in MDS.
These data will be reviewed.
In addition recent functional studies have begun to elucidate
how these disease alleles contribute to MDS pathogenesis.
Specifically, the TET family of proteins have been
shown to place a hydroxyl mark on methylated DNA and
lead to DNA demethylation. We have shown that TET2 mutations
leads to loss of DNA hydroxymethylation and a hypermethylation
phenotype in leukemia patients. In addition,
in vitro and in vivo studies show that TET2 loss leads to
impaired hematopoietic differentiation, increased stem cell
self-renewal, and myeloid transformation in vivo. These
data will be presented in detail.
Finally, more recent studies have revealed a role of mutations
in chromatin modifying enzymes in MDS pathogenesis,
including ASXL1 and EZH2 mutations. The effects of
these mutations on chromatin state, gene expression, and
hematopoietic function have begun to be elucidated, sug-
23

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
gesting mutations in chromatin modifying enzymes coopt
the epigenetic state of hematopoietic stem/progenitor cells
to contribute to transformation. Data from recent in vitro
and in vivo studies including novel MDS models will be
presented in detail.
OP15 Risk models in MDS
David Steensma, Dana-Farber Cancer Institute, Harvard
Medical School, Boston, MA, USA
In recent years, investigators have proposed several novel
risk models for the purpose of forecasting the clinical course
of patients with myelodysplastic syndromes (MDS). The
most widely used MDS prognostic system in clinical practice
continues to be the 4-strata 1997 International Prognostic
Scoring System (IPSS), but clinicians have recognized
for many years that the IPSS has a number of critical limitations.
These limitations include unsatisfactory applicability
of the IPSS to a variety of clinical situations such as secondary,
therapy-related MDS or previously treated patients;
lack of sensitivity to the degree of patients’ peripheral blood
cytopenias, especially severe thrombocytopenia; excessive
emphasis on elevated marrow blast proportion compared to
high-risk cytogenetics; a restricted number of included
karyotypes; and failure to account for either comorbid conditions,
or newer biomarkers of demonstrated prognostic
value such as the presence of high-grade marrow fibrosis or
elevated serum ferritin level. Collectively, these limitations
make the original IPSS a less accurate and helpful tool than
it might otherwise be, and have prompted other investigators
to derive and propose newer risk stratification tools.
The 5-strata Word Health Organization (WHO) classification-based
Prognostic Scoring System (WPSS), proposed
by Malcovati and colleagues initially in 2007 and since
modified to include marrow fibrosis, attempted to improve
on the IPSS by including transfusion dependence as well as
bringing the prognostic classification in line with the WHO
Classification of Tumors of Haematopoietic and Lymphoid
tissues as updated in 2001 and again in 2008. In 2008, Kantarjian
and colleagues from the MD Anderson Cancer Center
proposed a 4-strata generalized risk model for patients
with MDS that is both sensitive to the degree of cytopenias
and emphasizes the importance of high risk karyotype,
which several analyses have suggested is a more powerful
marker of a negative outcome than increased marrow myeloblast
proportion. A review of 1,503 Mayo Clinic patients
comparing the 1997 IPSS, the WPSS, and the MD Anderson
Cancer Center general risk model found that while all 3
prognostic systems were useful, the MD Anderson classification
scoring system accurately classified the broadest
range of patients and also achieved the greatest separation
between lower risk and higher risk groups.
In May 2011, Greenberg discussed a revised/updated version
of the IPSS, IPSS-R, at the 11th MDS Foundation International
Symposium in Edinburgh, Scotland. The IPSS-
R includes a much broader range of karyotypes than the
initial IPSS (based on the German-Austrian consortium data
24
of Haase and colleagues), has 5 stratification groups instead
of 4, and rebalances the relative risk of cytogenetic abnormalities
compared to marrow blast proportion, as well as
introducing a graduated system for cytopenias that allows at
least some sensitivity to the degree of cytopenia rather than
just the number of cytopenias. Work on extending and validating
the IPSS-R is ongoing.
In addition to inclusion of comorbidities and other patient
features, new disease-associated biomarkers that might be
incorporated in future versions of the IPSS include results
of flow cytometric panels, array-based measurement of loss
of heterozygosity and gene copy number, and assessment
specific molecular abnormalities. The MDS-associated somatic
gene mutation landscape continues to expand, and
none of the existing risk models incorporates mutational
analysis. For example, Bejar and colleagues in the Benjamin
Ebert laboratory in Boston assessed 439 samples from
patients with MDS stratified using the IPSS, and found that
mutations in EZH2, ASXL1, TP53, or RUNX1 all conferred
an IPSS-independent adverse prognosis in terms of overall
survival. None of the other mutations tested – ETV6, CBL,
NRAS/KRAS, IDH1/2, TET2, NPM1, or JAK2 – had an
IPSS-independent effect on survival. Since the publication
of Bejar’s paper in the New England Journal of Medicine,
the Washington University in St. Louis group have described
DNMT3A mutations, which are associated with a strikingly
adverse negative IPSS- and karyotype-independent prognostic
effect, both in MDS and in acute myeloid leukemia.
Finally, somatic SF3B1 mutations, recently described in
MDS by the Cancer Genome Project of the Wellcome Trust
Sanger Institute – represent a class of mutation that appears
to be particularly strongly associated with MDS subtype refractory
anemia with ring sideroblasts and associated with
lower-risk disease. Incorporation of these and other novel
prognostic markers will continue to require revision of risk
stratification schemes in the years to come.
OP16 Iron Chelation Therapy in MDS
Luca Malcovati, Department of Hematology Oncology,
S. Matteo Hospital Foundation, University of Pavia
Medical School, Pavia, Italy
Anemia is the most frequent peripheral cytopenia observed
in myelodysplastic syndromes (MDS), and is an established
negative prognostic factor in patients with MDS.
Most patients with MDS eventually become dependent on
regular red cell transfusions.The onset of a transfusion-dependency
is associated with a worsening of survival and an
increased risk of progression into acute myeloid leukemia. 1
Transfusion-dependent patients invariably develop secondary
iron overload. Transfusion iron is primarily taken up
by the reticuloendothelial cells, but later redistributed to parenchymal
cells. This process is modulated by several factors,
including ineffective erythropoiesis through suppression
of hepcidin production. Parenchymal iron overload
from transfusions is responsible for morbidity and mortality
in patients with thalassemia major, but clinical consequences
have been reported also in patients with MDS.

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
The reference method for determining body iron stores is
the assessment of hepatic iron concentration. Although percutaneous
liver biopsy is difficult to implement in MDS because
of neutropenia and thrombocytopenia, data have been
reported in these patients. Schafer and coworkers demonstrated
an increased liver iron concentration with signs of
portal fibrosis in a high proportion of transfusion-dependent
adults patients with refractory and sideroblastic anemia. 2
In MDS patients, body iron status is routinely assessed by
serum ferritin; although its level can be affected by inflammation
or liver disease, sequential measurements were proven
to be of value in monitoring iron overload. In transfusion-dependent
MDS patients retrospective studies showed
that elevated serum ferritin was associated with worse survival,
3 and poor outcome after allogeneic hematopoietic
stem cell transplantation. 4
Magnetic resonance imaging T2* provides a non-invasive
method for detecting and quantifying both liver and
myocardial iron overload. Preliminary studies adopting this
approach showed both hepatic and myocardial iron accumulation
can be observed in heavily transfused MDS patients.
5
According to the available evidence- and consensus-based
guidelines, patients with refractory anemia with ring
sideroblasts or other forms of refractory anemia, in whom
long-term transfusion therapy is likely, are recognized as
the best candidates to receive iron chelation therapy. In addition,
patients who are candidates for allogeneic stem cell
transplantation may also benefit from chelation therapy,
since iron overload is associated with increased transplantrelated
mortality. 6,7
In conclusion, the available evidence allows to identify
subsets of MDS patients that at risk of developing parenchymal
iron overload and might benefit from iron chelation
therapy. Nevertheless, a more accurate information on the
impact of iron-mediated organ damage on the outcome of
patients with MDS is warranted in order to support clinical
decision with evidence-based criteria.
R E F E R E N C E S
1. Cazzola M, Malcovati L. Myelodysplastic syndromes-coping with ineffective
hematopoiesis. N Engl J Med 2005;352(6):536–8.
2. Schafer AI, Cheron RG, Dluhy R, et al. Clinical consequences of acquired
transfusional iron overload in adults. N Engl J Med 1981;304
(6):319–24.
3. Malcovati L, Della Porta M, Pascutto C, et al. Prognostic factors and life
expectancy in myelodysplastic syndromes classified according to WHO
criteria. A basis for clinical decision-making. J Clin Oncol 2005;23:
7594–603.
4. Armand P, Kim HT, Cutler CS, et al. Prognostic impact of elevated pretransplant
serum ferritin in patients undergoing myeloablative stem cell
transplantation. Blood 2007;109(10)4586–8.
5. Di Tucci AA, Matta G, Deplano S, et al. Myocardial iron overload assessment
by T2* magnetic resonance imaging in adult transfusion dependent
patients with acquired anemias. Haematologica 2008;93(9):
1385–8.
6. Alessandrino EP, Amadori S, Barosi G, et al. Evidence- and consensusbased
practice guidelines for the therapy of primary myelodysplastic
syndromes. A statement from the Italian Society of Hematology. Haematologica
2002;87(12):1286–306.
7. Bowen D, Culligan D, Jowitt S, et al. Guidelines for the diagnosis and
therapy of adult myelodysplastic syndromes. Br J Haematol 2003;120
(2):187–200.
OP17 Progress with epigenetic therapy
in MDS
Pierre Wijermans, Haga Hospital, The Hague,
The Netherlands
Epigenetic therapy with demethylating agents for intermediate
and high risk MDS was developed over the last 10
years. We now know that up to almost 50% of the patients
can reach a response when treated properly. Many problems
in the treatment of these patients however are not solved yet
as for instance who should be treated, what is the most efficient
drug, what is the best dosing scheme and how long
should we give therapy in case of response.
There are some answer to give on the basis of new information
that are relevant to the treating physicians.
Who should be treated?
The Italian study with Azacytidine in low risk en intermediate
risk patients confirmed earlier 5-aza-2-deoxycytidine
(Decitabine) experience that treating some of these patients
is helpful. Longer duration of the treatment with probably
also maintenance in case of good response seems appropriate.
Also some of the more high risk patients especially with
adversed cytogenetic abnormalities might be good candidates.
The first results come available that also some of AML
patients may benefit.
Which drugs should we use
Azacytidine and Decitabine probably do differ in their effect
on the tumor cell therefore combination therapy seems
an interesting option.
HDAC inhibitors are used in multiple phase II trials and
although potentially very interesting have not showed major
clinical inpact in the treatment of MDS patients yet. However
combination therapy is an option based upon the working
mechanism of the two drugs.
Which dosing scheme
Alternative more convenient dosing schemes with lower
dose both for Azacytidine and Decitabine are presented.
Some of them are using lower doses. How low can we go
with the dose? Prelininary results of studies to intracellular
drug levels revealed that an intra-individual metabolism
might important.
How long should we treat
Complete cure of the MDS is with epigenetic therapy not
possible. We know that often soon after stopping (even in de
cases of a CR) the disease will relapse. Individual experience
of physicians showed us that long term maintenance
treatment might a good option.
The option to treat fit patients with a donor with an allotransplantation
after reaching a CR with epigenetic therapy
has been explored with some success.
25

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
OP18 Hematopoietic cell transplantation
for MDS: New developments
Theo J.M. de Witte, Department of Tumor Immunology,
Radboud University Medical Centre, Nijmegen,
The Netherlands
The spectrum of myelodysplastic syndromes (MDS) varies
from an indolent course over several years to a rapid
progression to acute myeloid leukemia (AML) 1 . MDS classification
systems have been modified recently, leading to
the WHO classifications and WHO-based prognostic scoring
system (WPSS) 2, 3 . The new classifications have improved
the accuracy of prognosis by incorporating the impact
of cytogenetic characteristics and transfusion dependency.
WHO classifications and WPSS showed prognostic
relevance after allo-SCT 4 . According to WPSS criteria, low
risk patients have the highest overall survival rate (80%) and
the lowest relapse probability (9%) 5 years after transpalntation
5 , but most patients with these low risk criteria do not
require treatment with allo-SCT.
Currently, the most effective curative treatment is allogeneic
stem cell transplantation (alloSCT), with long-term
survival rates between 25% and 70%. However, treatmentrelated
mortality continues to be a limiting factor 6 . The most
important factors influencing outcome after alloSCT are not
recipient age or intensity of conditioning, but disease stage
at the time of transplantation 7 .
Several large studies in de-novo AML have assessed the
role of allogeneic SCT by a donor versus no donor comparison
8–10 . In these studies the advantage of the presence of
a histocompatible sibling donor was mainly restricted to patients
younger than 40 years. In the MDS Criant study the
average age was considerably higher than 40 years and only
28% (38/135) of the patients who reached CR and ≤55 years
old, were younger than 40 years 11 . In the Criant study only
patients with unfavorable or intermediate cytogenetic characteristics
appeared to benefit from allogeneic stem cell
transplantation 11 . Whether patients with advanced stages
of MDS should receive remission-induction chemotherapy
prior to the transplant conditioning remains a point for discussion
11 . Retrospective analyses showed conflicting data.
Interpretation of the data is hampered by various selection
biases in the two treatment approaches and by lacking details
about the administered chemotherapy prior to the transplant
conditioning 6,12 . The Criant study shows that the great
majority of patients with an identified donor received the
transplant (94%). The 4-year DFS rate of the donor-group
of 46% is encouraging compared to large registry data. 13
In conclusion: these data suggest that allogeneic SCT
may be the treatment of choice for the young patients (age
≤55 years) with MDS, characterized by poor risk or intermediate
risk cytogenetics, who have a histocompatible donor.
For patients lacking an HLA-compatible sibling donor,
the outcome with autologous SCT or chemotherapy may be
good alternatives for MDS patients with good-risk cytogenetic
characteristics. Until now, no study has proven superiority
of autologous SCT compared to intensive chemotherapy
11 .
26
Reduced intensity conditioning regimens (RIC) for alloSCT
in MDS has dramatically expanded the scope of allografting
to many previously ineligible older patients, or
patients with multiple co-morbidities. The heterogeneity
amongst conditioning regimens between centers is considerable,
but usually the procedure appears to be associated
with durable hematopoietic engraftment amongst both sibling
and unrelated HLA-matched donor allografts, together
with an acceptable level of transplant-related mortality. The
question whether RIC regimens result in better outcome
when compared to marrow ablative conditioning has been
addressed in several studies. EBMT performed a retrospective
study of 836 patients with MDS undergoing allogeneic
HSCT with HLA matched siblings, comparing 215 patients
receiving reduced intensity conditioning with 621 patients
receiving standard myeloablative conditioning (SMC). Patients
receiving RIC were older (age > 50 years in 73% RIC
vs. 28% in SMC, P

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
iron absorption and increased iron toxicity. Infections occur
frequently in patients with AML and MDS, especially after
during and after intensive antileukemic therapy. Infections
are associated with increased levels of cytokines, such as
IL6, which also blocks Hepcidin production and increased
iron absorption in the gut with its associated iron toxicity.
Finally, every unit of erythrocytes adds 200 mg of iron to
the total iron store of 5 gm in an individual of 75 kg, Several
studies 16 indicate that pre-conditioning ferritin levels
are associated with post-transplant complications, such as
mucositis, bacteremia, and fever episodes 4, 18 . This association
was apparent in autologous 19 , but more importantly in
the large retrospective analysis performed by the Dana Farber
Institute Group on 543 recipients of allogeneic HSCT 20 .
This study showed a strong association between pretransplantation
serum ferritin level and a lower overall survival,
especially in patients with MDS and acute leukemia (AL) 20 .
Strikingly, the median ferritin level in this group was 930
mg/l. The percentage of patients with elevated ferritin levels
varied greatly from 25% in chronic myeloid leukemia
(CML) to 70% in lymphoma, 81% in MDS and 97% in AL.
The question is what to do to prevent this iron overload
related toxicity? The approach should be multifactorial because
iron overload and toxicity cannot be solely contributed
to the number of transfused units of erythrocytes 21 . In
a postmortem study of 10 patients who died early after
HSCT 21 the iron content was in the range of hemachromatosis
patients while the average number of transfusions given
from diagnosis to death was only 48 units. In the pretransplant
period vigorous iron chelation may be important, but
prospective studies should prove a survival benefit. During
the transplant period anti-oxidant therapy, including various
iron chelators, glutamine or the angiotensin-converting enzyme
(ACE)-inhibitor Captopril may be considered, but
clinical experience is limited to anecdotal observations 16 .
During the conditioning and the early post-transplant period,
innocuous glutathione-depleting agents like acetaminophen
should be avoided 16 . Finally, in the post-transplant
period phlebotomy, sometimes combined with erythropoietin,
has been successfully applied after HSCT in thalassemic
patients. For those patients who cannot be phlebotomized
iron chelation can be considered as well.
In conclusion: iron toxicity is likely to be an underestimated
cause of HSCT treatment-related mortality. We need
to know more on the pathogenesis, the diagnosis and the
monitoring of iron induced organ damage. Prevention of
iron-induced toxicity will require a multidisciplinary approach
of biochemists, pathologists, transfusionists and clinicians.
It is clear we do need well-designed prospective
studies both with interventions prior to HSCT and after
HSCT.
Several new drugs have now been approved for the treatment
of MDS. The question often arises, especially in older
patients, whether patients should be treated with those (less
toxic) drugs and be transplanted only if they do not or no
longer respond or should undergo HSCT at the time of optimum
response. In addition, these new treatment modalities
may be used to reduce more efficiently the MDS clone prior
to the HSCT conditioning. Weighing the pros and cons in
view of the potential post-HSCT complications, especially
GVHD, provides a challenging task. GVHD, particularly in
its chronic form, occurs in 50%–60% of patients. Ongoing
trials are directed at optimizing pre-HSCT therapy, conditioning
and GVHD prophylactic regimens to minimize toxicity
while maintaining a potent cytotoxic effect with low
GVHD incidence. These efforts include various approaches
of pre HSCT therapy, incorporation of ATG, use of antibody-conjugated
radioisotopes and post- HSCT administration
of chemotherapy, primarily hypomethylating agents.
R E F E R E N C E S
1. Bennett JM, Catovsky D, Daniel MT et al. Proposals for the classification
of the myelodysplastic syndromes. Br J Haematol 1982;51(2):
189–199.
2. Malcovati L, Porta MG, Pascutto C et al. Prognostic factors and life
expectancy in myelodysplastic syndromes classified according to WHO
criteria: a basis for clinical decision making. J Clin Oncol 2005;23
(30):7594–7603.
3. Malcovati L, Germing U, Kuendgen A et al. Time-dependent prognostic
scoring system for predicting survival and leukemic evolution in
myelodysplastic syndromes. J Clin Oncol 2007;25(23):3503–3510.
4. Alessandrino EP, la Porta MG, Bacigalupo A et al. Prognostic impact
of pre-transplantation transfusion history and secondary iron overload
in patients with myelodysplastic syndrome undergoing allogeneic stem
cell transplantation: a GITMO study. Haematologica 2010;95(3):
476–484.
5. Alessandrino EP, la Porta MG, Bacigalupo A et al. WHO classification
and WPSS predict posttransplantation outcome in patients with myelodysplastic
syndrome: a study from the Gruppo Italiano Trapianto di
Midollo Osseo (GITMO). Blood 2008;112(3):895–902.
6. de Witte T, Hermans J, Vossen J et al. Haematopoietic stem cell transplantation
for patients with myelo-dysplastic syndromes and secondary
acute myeloid leukaemias: a report on behalf of the Chronic Leukaemia
Working Party of the European Group for Blood and Marrow Transplantation
(EBMT). Br J Haematol 2000;110(3):620–630.
7. Lim Z, Brand R, Martino R et al. Allogeneic hematopoietic stem-cell
transplantation for patients 50 years or older with myelodysplastic syndromes
or secondary acute myeloid leukemia. J Clin Oncol 2010;28(3):
405–411.
8. Suciu S, Mandelli F, de Witte T et al. Allogeneic compared with autologous
stem cell transplantation in the treatment of patients younger than
46 years with acute myeloid leukemia (AML) in first complete remission
(CR1): an intention-to-treat analysis of the EORTC/GIME-
MAAML-10 trial. Blood 2003;102(4):1232–1240.
9. Cornelissen JJ, van Putten WL, Verdonck LF et al. Results of a HOV-
ON/SAKK donor versus no-donor analysis of myeloablative HLAidentical
sibling stem cell transplantation in first remission acute myeloid
leukemia in young and middle-aged adults: benefits for whom?
Blood 2007;109(9):3658–3666.
10. Burnett AK, Wheatley K, Goldstone AH et al. The value of allogeneic
bone marrow transplant in patients with acute myeloid leukaemia at
differing risk of relapse: results of the UK MRC AML 10 trial. Br J
Haematol 2002;118(2):385–400.
11. de Witte T, Hagemeijer A, Suciu S et al. Value of allogeneic versus autologous
stem cell transplantation and chemotherapy in patients with
myelodysplastic syndromes and secondary acute myeloid leukemia.
Final results of a prospective randomized European Intergroup Trial.
Haematologica 2010;95(10):1754–1761.
12. Nakai K, Kanda Y, Fukuhara S et al. Value of chemotherapy before allogeneic
hematopoietic stem cell transplantation from an HLA-identical
sibling donor for myelodysplastic syndrome. Leukemia 2005;19(3):
396–401.
13. Sierra J, Perez WS, Rozman C et al. Bone marrow transplantation from
HLA-identical siblings as treatment for myelodysplasia. Blood 2002;
100(6):1997–2004.
14. Martino R, Iacobelli S, Brand R et al. Retrospective comparison of reduced-intensity
conditioning and conventional high-dose conditioning
for allogeneic hematopoietic stem cell transplantation using HLA-identical
sibling donors in myelodysplastic syndromes. Blood 2006;108
(3):836–846.
27

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
15. Sorror ML, Maris MB, Storb R et al. Hematopoietic cell transplantation
(HCT)-specific comorbidity index: a new tool for risk assessment before
allogeneic HCT. Blood 2005;106(8):2912–2919.
16. Evens AM, Mehta J, Gordon LI. Rust and corrosion in hematopoietic
stem cell transplantation: the problem of iron and oxidative stress.
Bone Marrow Transplant 2004;34(7):561–571.
17. Tanno T, Bhanu NV, Oneal PA et al. High levels of GDF15 in thalassemia
suppress expression of the iron regulatory protein hepcidin. Nat
Med 2007;13(9):1096–1101.
18. Pullarkat V. Objectives of iron chelation therapy in myelodysplastic syndromes:
more than meets the eye? Blood 2009;114(26):5251–5255.
19. Altes A, Ruiz A, Martinez C et al. The relationship between iron
overload and clinical characteristics in a Spanish cohort of 100 C282Y
homozygous hemochromatosis patients. Ann Hematol 2007;86(11):
831–835.
20. Armand P, Kim HT, Cutler CS et al. Prognostic impact of elevated pretransplantation
serum ferritin in patients undergoing myeloablative
stem cell transplantation. Blood 2007;109(10):4586–4588.
21. Strasser SI, Kowdley KV, Sale GE, McDonald GB. Iron overload in
bone marrow transplant recipients. Bone Marrow Transplant 1998;22
(2):167–173.
OP19 Treatment Options for Myelodysplastic
Syndromes
Elias Jabbour, Guillermo Garcia-Manero, Hagop
Kantarjian, Department of Leukemia, The University of
Texas M.D. Anderson Cancer Center, Houston, Texas
Abstract: Myelodysplastic syndromes are a group of
heterogeneous hematopoietic stem cell disorders characterized
by peripheral blood cytopenias and a risk of transformation
to acute myeloid leukemia. Until recently, treatment
of MDS predominately consisted of supportive care measures.
However, three agents for the treatment of MDS have
recently been approved: lenalidomide, decitabine and azacitidine.
These agents have dramatically improved the outcomes
for patients with MDS. To date, azacitidine is the
only agent that has demonstrated a survival advantage when
compared to conventional care. Novel agents and combination
regimens including lenalidomide, decitabine and azacitidine
are being explored in an effort to further improve
patient outcomes.
Introduction
Myelodysplastic syndromes (MDS) are a heterogeneous
group of clonal hematopoietic stem cell disorders that impair
normal hematopoiesis, resulting in a variable number
of cytopenias and a potential to evolve into acute myeloid
leukemia (AML). 1 With a median age at diagnosis around
70 years, MDS typically affects the elderly. 1,2 Hence, there
is much morbidity and mortality associated with this patient
population, as patients frequently suffer from complications
due to cytopenias as well as other comorbidities. The two
systems used for classifying MDS are the French American
and British (FAB) criteria and the more recently revised
World Health Organization (WHO) classification system. A
third system, the International Prognostic Scoring System
(IPSS) can predict survival based on percentage of bone
marrow blasts, karyotype, and number of peripheral blood
cytopenias3 and is the most widely used prognostic tool for
assisting with treatment decisions.
For many years, supportive care with blood products (red
blood cell (RBC) and platelet transfusions), hematopoietic
28
growth factors, and antibiotics remained the only treatment
modality for MDS patients, until the development of three
novel agents that may alter the natural history of this disease.
Within the past decade, the United States (U.S.) Food
and Drug Administration (FDA) has approved an immunomodulatory
agent, lenalidomide (Revlimid, Celgene) and
two hypomethylating agents, decitabine (Dacogen, Eisai,
Inc.) and azacitidine (Vidaza, Celgene) for the treatment
of patients with MDS. In simple practice, therapy is tailored
to IPSS score with an emphasis on supportive care therapies
or lenalidomide for lower-risk patients (IPSS low-or intermediate
[int]-1) and more intensive therapies such as conventional
chemotherapy, allogeneic hematopoietic stem cell
transplant (HST) and clinical trials, as well as hypomethylating
agents, for patients with higher-risk disease (IPSS int-
2 or high) or lower-risk patients with progressive disease. 3
Treatment of Lower-risk MDS
Supportive Care
Initial clinical management of lower-risk MDS patients
with symptomatic anemia includes the use of erythropoiesis
stimulating agents (ESA), such as epoetin alpha (Epogen,
Amgen; Procrit,Ortho Biotech) or darbepoetin alfa (Aranesp,
Amgen). ESAs have been shown to reduce RBC
transfusion needs in MDS patients and when given with
granulocyte colony-stimulating factor (G-CSF), ESAs have
been shown to confer a survival advantage. 4 The likelihood
of response to ESAs has been correlated with RBC transfusion
needs and serum erythropoietin levels. Patients with
low transfusion requirements (500 mU/mL are least likely to respond to ESAs. 5,6 Demonstrated
in a recent prospective, randomized study by the
Eastern Cooperative Oncology Group (ECOG), patients
with low-risk MDS and low serum EPO levels experienced
higher erythroid response rates when given ESAs with or
without G-CSF compared to patients with high-risk disease.
7
Immunosuppressive therapy (IST)
A subset of MDS patients with bone marrow failure responds
to IST, which suggests that an immune-mediated
pathogenesis is responsible for the cytopenias. In these patients
with hypocellular bone marrows, IST with antithymocyte
globulin (ATG), cyclosporine or both can be utilized.
In patients with MDS, ATG alone has been shown to decrease
red blood cell transfusion requirements as well as
improve neutropenia and thrombocytopenia. 8 Likewise,
long term outcomes in low risk MDS patients have shown
higher response rates with ATG and cyclosporine (54%)
than ATG alone (29%)(P=0.004). 9 Factors that have been
shown to favor response to ATG include age, 8–10 HLA-DR15
positivity, 8–10 and shorter duration of red blood cell transfusion
requirements. 8,9 In general, patients will respond to IST
within 3 to 4 months and will remain clinically stable for
years, but many eventually relapse with return of cytopeni-

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
as. Recently, a phase I/II pilot study demonstrated alemtuzumab,
an anti-CD52 monoclonal antibody, to produce durable
responses in patients with intermediate-risk MDS who
fit criteria to respond to IST. Ninety-seven percent of int-1
risk patients and 57% of int-2 patients responded to alemtuzumab
by 3 months, which was superior to response rates
reported with ATG alone 9 . Furthermore, at 12 months follow-up,
56% of responding patients had normal blood
counts and 78% of patients were transfusion independent. 11
Immunomodulating Therapy (IMID)
Lenalidomide
Lenalidomide was FDA approved in 2005 for the treatment
of patients with transfusion-dependent anemia due to
low- and int-1 risk MDS associated with deletion 5q karyotype
(del(5q)). The approval of lenalidomide was based on
two phase II studies demonstrating a high frequency of erythroid
responses in patients with an isolated del(5q) or
del(5q) with other abnormalities. 12,13 The majority of patients
in these studies were IPSS low- or int-1 risk patients
with transfusion-dependent anemia. The majority of patients
achieved a hematologic response (reduced transfusion
needs) and became transfusion independent. Of note, responses
occurred despite karyotype complexity and patients
with thrombocytopenia at baseline were less likely to respond
to lenalidomide compared to patients with platelets
>100,000 per cubic milliliter at baseline. Furthermore, a
majority of patients had cytogenetic improvement, and 45%
had a complete cytogenetic response. Hence, these responses
illustrate lenalidomide’s effect on the biology of the disease
by reversing the cytogenetic abnormalities associated
with the 5q13 deletion. 13 Following these studies, Raza et al
evaluated the safety and efficacy of lenalidomide in 214 patients
with transfusion-dependent anemia due to lower-risk
MDS without del(5q). Hematologic responses were lower
than those observed in patients with del(5q), but the rate of
transfusion independence was 26% and the median duration
of transfusion independence was 41 weeks. 14 Lenalidomide
demonstrated a potential benefit for low risk patients without
del(5q) who remain transfusion dependent after supportive
care measures or for patients who are not candidates
for ESAs or more intensive therapy. Although lenalidomide
is generally well tolerated, it induces significant cytopenias
resulting in dose reduction or interruption in a majority of
patients.
Treatment of Higher-risk MDS
Hypomethylating Agents
Azacitidine and Decitabine
Azacitidine and decitabine are both hypomethylating
agents that irreversibly inhibit DNA methyltransferase, resulting
in progressive loss of methylation and reactivation
of tumor suppressor genes. Azacitidine was the first DNA
methyltransferase inhibitor approved by the U.S. FDA in
2004 for the treatment of all FAB subtypes of MDS. This
approval was based on the results of three CALGB studies
which evaluated the efficacy and safety of azacitidine 75
mg/m2 IV or SQ x 7 days every 28 days in MDS patients. A
pooled analysis of the CALGB trials (8421, 8921, and 9221)
reported overall response rates (ORR) between 40 and 47%
(CR 10–17%, PR 1%, HI 23–36%) for azacitidine and 17%
(HI only) for BSC by IWG 2000 criteria 15 . 16
Subsequently, the AZA-001 trial established an improved
overall survival in patients with higher-risk MDS. In this
phase III trial, 358 patients with IPSS int-2 or high-risk
MDS were randomized to receive azacitidine (75 mg/m 2 SQ
daily x 7 days, every 28 days) or conventional care (BSC,
low-dose cytarabine, or intensive chemotherapy). The overall
survival was significantly longer with azacitidine compared
to conventional care (24.5 vs. 15 months, HR 0.58;
95% CI 0.43–0.77, p=0.0001) and was present regardless of
MDS subtype and IPSS subgroup. The median time to AML
transformation was reduced with azacitidine compared to
conventional care (17.8 vs. 11.5 months; HR 0.5; 95% CI
0.35–0.7, p

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
mg/m 2 IV x 5 days every 4 weeks. By modified IWG criteria
21 , the ORR was 51% and the median survival was 19.4
months. Patients received a median of five cycles of treatment
and 82% of the responses were seen by the second
cycle. 22 Furthermore, the efficacy of low-dose decitabine
and intensive chemotherapy was compared in a historical
comparison of patients with higher-risk MDS at the MD
Anderson Cancer Center. This study showed a similar CR
rate, but significantly lower 6-week and 3-month mortality
rates and improved survival with decitabine. 23
Patients require several courses of azacitidine and decitabine
(3–6 cycles) before demonstrating a response, so
drug- and disease-induced myelosuppression can be common
during this time period. Therefore, treatment should
continue with both agents for a minimum of 3–4 cycles before
declaring therapy a failure. Although azacitidine is an
outpatient regimen, it is complicated by a 7- consecutive
day regimen, necessitating weekend administration. More
convenient regimens (i.e. 5 day, 5 days followed by 2 additional
weekdays) have been explored in predominately lower-risk
patients and response rates appear similar among the
three regimens. 24,25 However, it is not certain that these regimens
will lead to a survival advantage in higher-risk MDS
patients.
Stem Cell Transplant
The only potential curative option for MDS is allogeneic
stem cell transplant (HSCT), but is restricted to patients
with a donor and those free from co-morbidities that may
preclude them from this option. For patients older than 55
years, the mortality rate is approximately 38%. For patients
that are eligible for HSCT, the timing of transplantation is
important. Published data identifying the optimal timing of
HSCT is scant. However, a retrospective analysis of patients
younger than 60 years of age who received a myeloablative
conditioning regimen from a sibling donor transplant suggests
that survival is better for low- and int-1 risk patients
receiving a transplant at the time of disease progression
rather than at diagnosis. Outcomes for int-2 and high-risk
patients are better when transplantation is done as early as
possible. 26 Therefore, donor screening for younger patients
should begin as soon as possible regardless of the IPSS
score at diagnosis. This sheds some light on the timing for
younger patients. For elderly patients, reduced intensity
transplants may be an option.
Conclusion
Patients with MDS are predominately elderly and have
multiple comorbidities that preclude them of curative therapies.
For many years, supportive care measures remained
the only treatment modality for MDS patients, until the development
of three novel agents that may alter the biology
of this disease. The recent development of three FDA-approved
agents, lenalidomide, azacitidine and decitabine,
have dramatically changed the MDS landscape. Lenalidomide
is remarkably effective in lower-risk patients, producing
complete transfusion independence in the majority of
del(5q) and some non-del(5q) patients. The hypomethylating
agents, azacitidine and decitabine, are effective in the
30
setting of higher-risk MDS patients, producing responses in
nearly half the treated patients. Compared to conventional
care regimens, azacitidine has significantly improved the
median survival of higher-risk patients. Despite these therapeutic
advances, the responses in higher-risk patients are
not durable, making the search for other novel agents necessary.
R E F E R E N C E S
1. Heaney M, Golde D. Myelodysplasia. N Engl J Med 1999;340:
1649–60.
2. Sekeres MA, Schoonen WM, Kantarjian H, et al. Characteristics of US
patients with myelodysplastic syndromes: results of six cross-sectional
physician surveys. J Natl Cancer Inst 2008;100:1542–51.
3. Greenberg P, Cox C, LeBeau MM, et al. International scoring system
for evaluating prognosis in myelodysplastic syndromes. Blood 1997;
89:2079–88.
4. Jadersten M, Malcovati L, Dybedal I, et al. Erythropoietin and granulocyte-colony
stimulating factor treatment associated with improved
survival in myelodysplastic syndrome. J Clin Oncol 2008;26:3607–13.
5. Hellstrom-Lindberg E. Efficacy of erythropoietin in the myelodysplastic
syndromes: a meta-analysis of 205 patients from 17 studies. Brit J
Haemat 1995;89:67–71.
6. Hellstrom-Lindberg E, Gulbrandsen N, Lindberg G, et al. A validated
decision model for treating the anaemia of myelodysplastic syndromes
with erythropoietin + granulocyte colony-stimulating factor: significant
effects on quality of life. Br J Haematol 2003;120:1037–46.
7. Greenburg PL, Sun Z, Miller KB, et al. Treatment of myelodysplastic
syndrome patients with erythropoietin with or without granulocyte
colony-stimulating factor: results of a prospective randomized phase 3
trial by Eastern Cooperative Oncology Group (E1996). Blood 2009;
114:2393–2400.
8. Molldrem JJ, Leifer E, Bahceci E, et al. Antithymocyte globulin for
treatment of the bone marrow failure associated with myelodysplastic
syndromes, Ann Intern Med, 2002;137:156–63.
9. Sloand EM, Wu CO, Greenberg P, et al. Factors affecting response and
survival in patients with myelodysplasia treated with immunosuppressive
therapy. J Clinical Oncol 2008;26:2505–11.
10. Saunthararajah Y, Nakamura R, Wesley R, et al. A simple method to
predict response to immunosuppressive therapy in patients with myelodysplastic
syndrome. Blood 2003;102:3025–7.
11. Sloand EM, Olnes MJ, Shenoy A, et al. Alemtuzumab treatment of intermediate-1
myelodysplasia patients is associated with sustained improvement
in blood counts and cytogenetic remissions. J Clin Oncol
2010;28:5166–73.
12. List A, Kurtin S, Roe DJ, et al. Efficacy of lenalidomide in myelodysplastic
syndromes. N Engl J Med 2005;352: 549–57.
13. List A, Dewald G, Bennett J, et al. Lenalidomide in the myelodysplastic
syndrome with chromosome 5q deletion. New Engl J Med 2006;355:
1456–65.
14. Raza A, Reeves JA, Feldman EJ, et al. Phase 2 study of lenalidomide in
transfusion-dependent, low-risk, and intermediate-1- risk myelodysplastic
syndromes with karyotypes other than deletion 5q. Blood 2008;
111:86–93.
15. Cheson BD, Bennett JM, Kantarjian H, et al. Report of an international
working group to standardize response criteria for myelodysplastic
syndromes. Blood 2000;96:3671–4.
16. Silverman LR, McKenzie DR, Peterson BL, et al. Further analysis of
trials with azacitidine in patients with myelodysplastic syndrome: studies
8421, 8921, and 9221 by the Cancer and Leukemia Group B. J Clin
Oncol 2006;24:3895–3903.
17. Fenaux P, Mufti GJ, Hellstrom-Lindberg E, et al. Efficacy of azacitidine
compared with that of conventional care regimens in the treatment
of higher-risk myelodysplastic syndromes: a randomized, open-label,
phase III study. Lancet Oncol 2009;10:223–32.
18. Kantarjian H, Issa JP, Rosenfeld CS, et al. Decitabine improves patient
outcomes in myelodysplastic syndromes: results of a phase III randomized
study. Cancer 2006;106:1794–803.
19. WijerMans P, Suciu S, Liliana Baila L, et al. Low dose decitabine versus
best supportive care in elderly patients with intermediate or high
risk MDS not eligible for intensive chemotherapy: final results of the

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
randomized phase III study (06011) of the EORTC Leukemia and German
MDS Study Groups. Blood 2008;112: abstract 226.
20. Kantarjian H, Oki Y, Garcia-Manero G, et al. Results of a randomized
study of 3 schedules of low-dose decitabine in higher-risk myelodysplastic
syndrome and chronic myelomonocytic leukemia. Blood 2007;
109:52–7.
21. Cheson BD, Greenberg PL, Bennett JM, et al. Clinical application and
proposal for modification of the International Working Group (IWG)
response criteria in myelodysplasia. Blood 2006;108:419–25.
22. Steensma DP, Baer MR, Slack JL, et al. Multicenter study of decitabine
administered daily for 5 days every 4 weeks to adults with myelodysplastic
syndromes: the alternative dosing for outpatient treatment
(ADOPT) trial. J Clin Oncol 2009;27: 3842–8.
23. Kantarjian HM, O’Brien S, Huang X, et al. Survival advantage with
decitabine versus intensive chemotherapy in patients with higher risk
myelodysplastic syndrome: comparison with historical experience.
Cancer 2007;109:1133–7.
24. Lyons RM, Cosgriff TM, Modi SS, et al. Hematologic response to three
alternative dosing schedules of azacitidine in patients with myelodysplastic
syndromes. J Clin Oncol 2009; 27:1850–6.
25. Martin MG, Walgren RA, Procknow E, et al. A phase II study of 5-day
intravenous azacitidine in patients with myelodysplastic syndromes.
Am J Hematol 2009;84: 560–4.
26. Cutler CS, Lee SJ, Greenberg P, et al. A decision analysis of allogeneic
bone marrow transplantation for the myelodysplastic syndromes: delayed
transplantation for low-risk myelodysplasia is associated with
improved outcome. Blood 2004;104:579–85.
OP20 Pathophysiology of MPNs and role of JAK2
mutations
Richard A Van Etten, Molecular Oncology Research
Institute & Division of Hematology/Oncology, Tufts
Medical Center, Boston, MA, USA
Since the discovery of the somatic JAK2 V617F mutation in
myeloproliferative neoplasms (MPNs) in 2005, there have
been dramatic advances in our understanding of the molecular
pathogenesis of the non-CML MPNs. We now appreciate
that JAK2 mutations (either JAK2 V617F or mutations in
exon 12 of JAK2) are found in virtually all patients with
polycythemia vera, and JAK2 mutation testing has become
a central part of the diagnostic evaluation of patients with
suspected MPN. Yet, there are still significant gaps in our
knowledge and several central questions that remain unanswered.
One unresolved issue is how one mutation
(JAK2 V617F ) can cause distinct MPN phenotypes (PV, ET,
and PMF) in different patients. A partial answer to this question
has been provided by transgenic and retroviral mouse
models wherein the JAK2 V617F kinase is expressed in mouse
hematopoietic cells. These models lend experimental support
for the concept that expression of JAK2 V617F at levels
similar to or higher than endogenous JAK2 causes erythrocytosis
whereas lower expression favors thrombocytosis,
but several variables, including origin of JAK2 and mouse
strain, confound the picture. Contributions from other somatic
mutations and possible germline disease-modifying
alleles are other potential mechanisms for phenotypic heterogeneity.
Another question is whether there are cooperating
mutations that complement or precede the acquisition of
a JAK2 mutation. Several lines of evidence point to the existence
of one or more predisposing mutations in MPNs:
families with occurrence of several different MPNs in multiple
members, patients (mainly ET) with clonal hematopoiesis
whose JAK2 V617F allele burden is less than 50%,
JAK2 V617F patients with other somatic mutations (eg, del20q)
in JAK2 +/+ cells, and JAK2 V617F patients who progress to
AML where the blasts lack the JAK2 V617F mutation. Candidate
gene and genome-wide SNP analyses have identified
correlations with disease phenotype and discovered a remarkable
association of an intronic JAK2 allele (rs10974944 or
46/1) that significantly predisposes carriers to develop
JAK2 V617F –positive MPN, where the mutation arises preferentially
on the same JAK2 gene as the SNP. The mechanism
(»hypermutability« vs »fertile ground«) through which this
occurs is unclear, but the same haplotype predisposes to
MPL mutations in PMF. Recent studies have also identified
somatic mutations that can occur in concert with JAK2/
MPL mutations: TET2 loss-of-function mutations in 10%,
ASXL1 mutations in 8–10%, IDH1/2 mutations in 3–5%,
and EZH2 mutations in 10–15% of MPN patients. The same
mutations can be found in MDS and AML patients, indicating
that these alleles can be associated with other myeloid
neoplasms. Clonal analysis of malignant hematopoietic
colonies demonstrates that these mutations can either precede
or develop after a JAK2 mutation; in some cases
(TET2, IDH1/2) they occur most commonly at time of progression
to AML. Emerging functional data and genetic
studies in mice suggest these mutations affect the epigenetic
state of the leukemic cells. Results from ongoing genomic
deep sequencing of MPN patient genomes are expected to
shed additional light on the pathogenesis of JAK2 V617F –negative
MPN. Finally, the question remains as to the overall
utility of JAK2 as a target for therapy in the MPNs. Clinical
results with small molecule JAK2 inhibitors (summarized
by Dr. Verstovsek in this Symposium) demonstrate that all
six of the inhibitors in clinical trials are effective at reducing
spleen size, reversing elevated proinflammatory cytokines,
and improving quality of life and performance status in
MPN patients, independent of JAK2 mutation status. However,
the effects of these agents on JAK2 allele burden, myelofibrosis,
cytopenias and transfusion requirements, thrombohemorrhagic
complications, and risk of progression to
AML in MPN are less clear. There appears to be a fundamental
difference between JAK2 and ABL1 as therapeutic
targets in MPN and CML, respectively. Recent translational
research has begun to identify some of the mechanisms involved,
including Epo-dependent sensitivity of malignant
JAK2 V617F –positive hematopoietic progenitors to JAK2 inhibitors,
and a possible compensatory role of other JAK
family members.
OP21 JAK2 inhibitors
Srdjan Verstovsek, MD Anderson Cancer Center, Leukemia
Department, Houston, Texas, USA
Myelofibrosis: Myelofibrosis (MF) is a Philadelphia chromosome-negative
myeloproliferative neoplasm (MPN) of
the bone marrow. This life-threatening disease is characterized
by splenomegaly and burdensome symptoms, including
fatigue, night sweats, pruritus, abdominal pain, and
cachexia. 1 The annual incidence of MF is about 1.0 per
100,000 population, and patients have a median life expectancy
of 2 to 11 years due to complications of progressive
31

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
splenomegaly, hepatomegaly with liver failure, portal hypertension,
gastrointestinal bleeding, pulmonary hypertension,
infections, and malnutrition. 3 Allogeneic stem cell
transplantation (alloSCT) offers the only potentially cure
for MF, but is associated with a high rate of transplant-related
mortality. 4 Other treatments for MF provide only temporary
and/or suboptimal relief of constitutional symptoms,
anemia, and splenomegaly, and do not generally change the
natural progression of the disease.
JAK2 as a Therapeutic Target in MF: Dysregulation of
the JAK2-STAT pathway is a central pathogenic component
in MF. Some clinical features of MF (anemia, splenomegaly,
risk of transformation to acute myeloid leukemia) have
been related to JAK2 V617F mutation or allele burden; 5–7 however,
the gain-of-function JAK2 V617F mutation is found in
only about 50% of MF patients. Other mutations that result
in activation of JAK-STAT signaling have been detected,
including mutations in exon 12 of the JAK2 gene 8 and the
MPL515 mutation in the thrombopoietin receptor. 9
JAK2 Inhibitors in MF: The initial reports of the JAK2 V617F
mutation in MPNs led to the development of ruxolitinib as
the first potent, selective, oral JAK1 and JAK2 inhibitor for
clinical use in MF patients. Currently, there are several
JAK2 inhibitors in development. Ruxolitinib is currently the
only JAK inhibitor to complete phase III trials in MF.
The safety and efficacy of ruxolitinib were evaluated in a
phase I/II study in 153 high- or intermediate-risk patients
with primary MF, post-polycythemia vera (PV) MF, or postessential
thrombocythemia (ET) MF. The median duration
of follow-up was 14.7 months. 11 Phase I results established
25 mg twice daily as the maximum tolerated dose (MTD),
with thrombocytopenia as the dose-limiting toxicity (DLT).
Phase II data established an optimized dose of 15 mg twice
daily (10 mg twice daily if platelets were 100–200 x 10 9 /L)
with monthly dose escalations up to 25 mg twice daily (if no
response and no toxicity were observed). Approximately
half of the patients achieved a ≥ 50% reduction in splenomegaly
by palpation. Magnetic resonance imaging (MRI)
confirmed reductions in spleen size. A 50% reduction in
spleen size by palpation was consistent with a 35% reduction
in volume by MRI. In addition, ruxolitinib improved
debilitating MF-related symptoms, including fatigue, night
sweats, and pruritus as assessed by the Myelofibrosis Symptom
Assessment Form (MFSAF). 12 Among biomolecular
parameters associated with disease activity, there was a reduction
in plasma levels of proinflammatory cytokines (IL-
6, TNF-α), an increase in plasma levels of leptin and erythropoietin,
and a dose- and time-dependent reduction in constitutively
phosphorylated STAT3 and/or STAT5.
COMFORT-I is a randomized, double-blind, placebocontrolled
phase III trial of ruxolitinib in patients with MF. 13
The primary endpoint was the proportion of patients achieving
a ≥ 35% reduction in spleen volume at 24 weeks of
treatment as assessed by MRI. The study met this endpoint:
41.9% of patients had a ≥ 35% reduction in spleen volume
versus 0.7% in the placebo group (P

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
has been confirmed by long term analysis of a subgroup of
the study group who have now been followed up to 91
months (4). Earlier studies had shown safety and efficacy of
anagrelide in younger patients (5,6). Meanwhile, long term
data from registries also covering older patients in Austria
(7), Spain (8), Czech Republic (9) or Germany (10) confirm
that anagrelide is well tolerated and effective in reducing
platelets to target levels in patients with ET. Addressing the
special issue of cardiovascular adverse events a recent Italian
study has demonstrated a low impact of this concern (11). In
some patients deterioration of renal function is observed under
long term anagrelide treatment: in such patients comedication
or evidence for transformation into myelofibrosis
have to be checked since CMPN can cause glomerulopathy
(12). Progression of bone marrow fibrosis (which is not present
in patients diagnosed according to the WHO classification)
cannot be halted with anagrelide (13).
Taken together, anagrelide is a valuable drug for the treatment
of patients with ET.
R E F E R E N C E S
1. Tefferi A. Polycythemia vera and essential thrombocythemia: 2011 update
on diagnosis, risk stratification and management. Amer J Hematol
2011;86:293–301.
2. Petrides PE. Anagrelide: What was new in 2005 and 2006? Sem Thrombosis
Research 2006;32:399–408.
3. Petrides PE et al. ANAHYDRET: A European multicenter prospective
phase 3 study: Noninferiority of anagrelide compared to hydroxyurea
in newly WHO diagnosed ET patients.Haematologica 2009;94:440.
4. Gisslinger H et al., in preparation.
5. Storen EC, Tefferi A. Long term use of anagrelide in young patients
with essential thrombocythemia. Blood 2001;97:863–866.
6. Mazzucconi MG et al. A long term study of young patients with essential
thrombocythemia treated with anagrelide. Haematologica 2004;
89:1306–1313.
7. Steurer M et al. Longterm experience with anagrelide (Thromboreductin®)
in the treatment of essential thrombocythemia: data from an international
regsitry. Blood, ASH abstract 2010;32828.
8. Giralt M et al. Retrospective analysis of the efficacy and tolerability of
anagrelide in patients with essential thrombocythemia: Spanish registry
of essential thrombocythemia. Med Clin (Barc) 2009;133:86–90.
9. Penka P et al. Essential thrombocythemia and other myeloproliferative
disorders treated with thromboreductin: a report from the data base registry.
Vnitr Lek 2010;56:503–512.
10. Petrides PE, Siegel P. Unpublished.
11. Gugliotta L et al. Low impact of cardiovascular adverse events on
anagrelide treatment discontinuation in a cohort of 232 patients with
essential thrombocythemia. Leukemia Research 2011, online.
12. Siad SM et al. Myeloproliferative neoplasms cause glomerulopathy.
Kidney Int 2011, online.
13. Hultdin M et al. Progression of bone marrow fibrosis in patients with
essential thrombocythemia and polycythemia vera during anagrelide
treatment. Med Oncol 2007;24:63–70.
OP23 Treatment of Polycythemia Vera
With Interferon
Richard T. Silver, Weill Cornell Medical College, USA
Certain diseases deserve intense medical scrutiny because
the abnormalities encountered stimulate investigation,
which greatly enhance our understanding of physiologic
mechanisms. The myeloproliferative disorders, including
polycythemia vera (PV), fall into this category. Two recent
major advances have been made in PV: the discovery of the
JAK2 V617F mutation which is useful for diagnosis and as a
marker for treatment effect, and the use of interferons as a
therapeutic modality.
Although hydroxyurea remains the most commonly used
cytoreductive treatment for PV, limitations of its use have
not received adequate attention. These include its leukemogenic
effect after 10–15 years of use, development of squamous
cell carcinoma of the skin, skin ulcers, and other
forms of oral, hepatic and renal toxicity. For the younger
patient, hydroxyurea is not appropriate because of its effect
on embryogenesis.
The use of recombinant interferon (rIFN) as a therapeutic
measure has led to significant improvement in the treatment
of all myeloprolifetrative diseases in the past 20 years, and
especially polycythemia vera. This has been based on appreciation
that a low dose of rIFN used over a prolonged
period may have a significant therapeutic effect. In our presentation,
we will review some of the salient features pertaining
to clinical use of interferon in PV.
Of the two types of interferon, type I (which includes alpha
and beta interferon) and type II (which includes gamma
interferon), it is alpha interferon which is primarily used in
hematologic practice. Interferon has a wide range of effects
of interest to the hematologist: It augments the functional
activity of T-cells, macrophages, and natural killer cells; it
induces dendritic differentiation; it promotes apoptosis of a
variety of tumor cell types; it suppresses the ability of normal
hematopoietic progenitor cells to form colonies in vitro;
it may stimulate dormant hematopoietic cells to cycle, thus
making them more susceptible to the effect of chemotherapeutic
agents. Interferon also inhibits erythroid progenitors
and erythroid burst-forming units in vitro and produces
morphologic and biochemical changes in megakaryocytes
including megakaryocytic proliferation and thrombopoeitin-induced
TPO receptor signaling. Interferon alpha antagonizes
platelet derived growth factor. These reasons provide
a physiologic basis for its use in PV.
Two general types of interferons have been clinically
used. In the past, the largest experience has been with interferon
alpha 2b, but more recently with pegylated interferon
alpha 2a (Peg A). More than 350 patients with PV have been
reported with interferon, the largest number (55) treated
with interferon (rIFN) alpha-2b by Silver. 1 Reduction in
phlebotomy rate occurred in 100% of patients and freedom
from phlebotomy in 96%. 1 Kiladjian reported on the effects
of Peg A in 37 patients also with a 100% reduction in phlebotomy
rate and 97% freedom from phlebotomy. 2 Qualitative
side effects in general have been the same with either
type of interferon – i.e. headache, malaise, fever, chills, fatigue,
myalgia being the most common but less severe with
Peg A than with rIFNα2b. With Peg A, significant reduction
in JAK2 V617F median allele burden at 24 months has been reported
by Kiladjian (45% to 5%) 2 and by Quintás-Cardama
(64% to 12%) 3 but not by Silver who reported that hematologic
response, both complete and partial, did not correlate
with the molecular response with either Peg A or rIFNα2b
treated patients. 4 However, drop out rates for the three investigations
related to toxicity were 24%, 10%, and 6% respectively.
2,3 Thus, it remains to be determined whether or
33

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
not over the long-term there will be significant difference in
the course of disease between a higher discontinuation rate
and a lower JAK2 V617F burden compared to lower discontinuation
rate and a higher molecular burden.
In the interferon trials reported by both Silver and Kiladjian,
there was a striking decrease in the number of CNS
vascular events compared to other published data. Whether
this represents a stricter attention to hematocrit levels as
practiced by both the French and American groups or some
unique biologic effect of interferon remains to be determined.
Noteworthy are two international trials of the Myeloproliferative
Disease Research Consortium with PEG-interferon
alpha 2a which will open soon. One study compares Peg
A to hydroxyurea in high risk PV and ET patients. The other
uses Peg A as a salvage therapy for PV and ET in patients
resistant or intolerant to hydroxyurea. Hopefully, these studies
will provide answers to some of the questions raised in
this presentation.
R E F E R E N C E S
1. Silver RT. Long-term effects of the treatment of polycythemia vera with
recombinant interferon-alpha. Cancer 2006;107:451–458.
2. Kiladjian JJ, Cassinat B, Chevret S, Turlure P, Cambier N, Roussel M, et
al. Pegylated interferon-alfa-2a induces complete hematologic and molecular
responses with low toxicity in polycythemia vera. Blood 2008;
112:3065–3072.
3. Quintas-Cardama A, Kantarjian H, Manshouri T, Manshouri T, Luthra
R, Estrov Z, et al. Pegylated interferon alfa-2a yields high rates of hematologic
and molecular response in patients with advanced essential
thrombocythemia and polycythemia vera. J Clin Oncol. 2009;27:5418–
5424.
4. Silver RT, Vandris K, Wang YL, Adriano F, Jones AV, Christos PJ, et al.
JAK2(V617F) allele burden in polycythemia vera correlates with grade
of myelofibrosis, but is not substantially affected by therapy. Leuk Res
2011;35:177–182.
OP24 Allogeneic Hematopoietic Stem Cell
Transplantation for Myelofi brosis
Nicolaus Kröger, Department of Stem Cell
Transplantation, University Hospital Hamburg-Eppendorf,
Hamburg, Germany
Hematopoietic stem cell transplantation offers a curative
therapy for patients with myelofibrosis. Due to toxicity, allografting
following myeloablative regimens is mainly applicable
to young patients. Two larger studies reported a 1
year non-relapse mortality of 27% and 31%, resulting in a 5
year estimated survival of 47% and 58%. (Guardiola et al.
1999 and Deeg et al. 2003). The major risk factors in the
myeloablative studies were advanced age, advanced disease
status according to Lille-score, and mismatched unrelated
donors.
With the introduction of dose-reduced conditioning using
busulfan or melphalan with fludarabin, transplantation became
tolerable also in older patients. Improvement in management
of transplant-related complications as well as increasing
numbers of volunteer stem cell donors lead to an
increased use of alternative donors. In the so far largest prospective
multicenter study of the Chronic Leukemia Working
Party of the European Group for Blood and Marrow
34
Transplantation (EBMT)103 patients were included and
transplanted after a dose reduced conditioning consisting of
busulfan (10mg/kg) /fludarabin and in vivo T-cell depletion
with ATG. All but 2 patients showed leukocyte and platelets
engraftment, and the cumulative incidence of TRM at 1 year
was 16% which was significantly higher with HLA-mismatched
donors. At 3 years, the cumulative incidence of
relapse was 22% and significantly influenced by the risk
status according to Lille. After a median follow up of 33
months (range, 12–76), five-year estimated OS and DFS
was 67% and 51% respectively. In the multivariate analysis,
age>55 years and HLA-mismatched transplantation significantly
predicted inferior overall survival (Kröger et al.
2009).
At the histomorphological level, a complete or near complete
resolution of bone marrow fibrosis resolution was seen
in 59% of patients by day 100, 90% by day 180, and 100%
by one year post-AHSCT
Considering the sufficient evidence available that even in
the case of massive splenomegaly donor cells engraftment
and full donor chimerism are achievable, together with the
significant risks associated with splenectomy pre-transplant
such as surgical risk, delayed immunreconstitution after
AHSCT and possibly the reported increased relapse, splenectomy
is not generally recommended in transplant-eligible
patients.
Through the discovery of new disease specific mutations,
such as JAK2V617F or MPL, close monitoring of residual
disease became feasible in many patients and can be used a
guide for adoptive immunotherapy such as donor lymphocyte
infusion (Achalby et al 2010) achieving of new transplant-derived
models to estimate risk status and possible
outcome in every individual patient and help in therapy decision
and determine optimal timing of stem cell transplantation.
Such a tool may optimally include not only clinicomorphological
characteristics but also other potentially relevant
factors such as cytogenetics and novel molecular
markers.
R E F E R E N C E S
1. Alchalby H, Badbaran A, Zabelina T et al. (2010) Impact of JAK2V617F
mutation status, allele burden, and clearance after allogeneic stem cell
transplantation for myelofibrosis. Blood 116:3572–3581.
2. Deeg HJ, Gooley TA, Flowers ME et al. (2003) Allogeneic hematopoietic
stem cell transplantation for myelofibrosis. Blood 102:3912–3918.
3. Guardiola P, Anderson JE, Bandini GW et al. (1999) Allogeneic stem
cell transplantation for agnogenic myeloid metaplasia: a European
Group for Blood and Marrow Transplantation, Societe Francaise de
Greffe de Moelle, Gruppo Italiano per il Trapianto del Midollo Osseo,
and Fred Hutchinson Cancer Research Center Collaborative Study.
Blood 93:2831–2838.
4. Kröger N, Alchalby H, Klyuchnikov E (2009a) et al. JAK2-V617F-triggered
preemptive and salvage adoptive immunotherapy with donor-lymphocyte
infusion in patients with myelofibrosis after allogeneic stem
cell transplantation. Blood 113:1866–1868.
5. Kröger N, Holler E, Kobbe G et al. (2009 b) Allogeneic stem cell transplantation
after reduced-intensity conditioning in patients with myelofibrosis:
a prospective, multicenter study of the Chronic Leukemia Working
Party of the European Group for Blood and Marrow Transplantation
(EBMT). Blood 114:5264–5270.
6. Kröger N, Badbaran A, Holler E et al. (2007 a) Monitoring of the JAK2-
V617F mutation by highly sensitive quantitative real-time PCR after allogeneic
stem cell transplantation in patients with myelofibrosis. Blood
109:1316–1321.

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
OP25 Jumping 1q Translocations are Clonal
Markers of Myeloid Malignancies
Associated with Transformation to AML
Vesna Najfeld, J. Tripodi, A. Scalise, L. Silverman, R.T.
Silver, S. Fruchtman, R. Hoffman, Tumor Cytogenetics
Laboratory, Departments of Pathology and Medicine, The
Myeloproliferative Disorders Program, The Tisch Cancer
Institute, The Mount Sinai School of Medicine, New York,
NY, Department of Med., Cornell-Weill School of
Medicine, New York, USA
Jumping translocations (JT) are rare cytogenetic phenomenon
resulting from a part of one chromosome translocating
to several recipient chromosomes, creating multiple
related clones within a single patient. Due to their rarity in
myeloid malignancies it is uncertain whether this abnormality
contributes to disease progression. We retrospectively
investigated 1qJT in 23 patients with myeloproliferative neoplasm
(MPN) and myelodysplastic syndrome (MDS) who
were evaluated in the Tumor Cytogenetics Laboratory at the
Mount Sinai School of Medicine between 1984 and 2009.
Diagnoses were made according to the World Health Organization
classification criteria. Table1 outlines the characteristics
of the 23 patients with 1qJT. Among 512 studied
patients with MPN (polycythemia vera [PV]=361, primary
myelofibrosis [PMF]=151), 3 (PV=2, PMF=1) were identified
who had 1qJT at diagnosis.
Table 1. Characteristics of 23 patients with Jumping 1q translocations
MPN
No. (%)
MDS
No. (%)
Baseline Analysis
Patients 7 16
Patients with 1qJT 3 5
Normal Karyotype 0 (0) 8 (50)
Abnormal Karyotype 7 (100) 8 (50)
Transformation to AML
Sequential Analysis
2 (29) 4 (25)
Patients 5* 12**
Specimens 24 101
Normal Karyotype 0 (0) 7 (67)
Transformation to AML 4 10
Mean Time from 1qJT to AML in Months (Range) 8 (0–16) 9 (0–42)
Mean Follow up in Months (Range) 65 (2–132) 34 (8–78)
Mean Time (Months) to develop 1qJT (Range) 47 (0–109) 21 (0–58)
* One patient (#3) had 1qJT at diagnosis and had one follow-up study
** One patient (#20) had 1qJT at diagnosis and 4 sequential studies up to 18
months after the intial study
Additionally four of 165 (PV=96, PMF=69) patients with
MPN-acquired 1qJT over a period of 11 years (the overall
incidence was 1.3% or 4.2% among cytogenetically abnormal).
The mean follow up of the five patients was 65 months
and the mean time from diagnosis to the development of
1qJT was 47 months. Four of these five patients transformed
to acute myeloid leukemia (AML) within 8 months of acquiring
1qJT. Patient 6 is particularly informative, he ini-
tially had i(9)(p10) but developed a der(6)t(1;6)(q21;q27)
subclone in two of 18 cells after 6 years. Over time the subclone
involved 100% of cells. The patient was treated solely
with interferon. The most recent analysis revealed 1qJT to
chromosomes 6, 7, Y as well as dup(1)(q21). The initial cytogenetic
analysis of 16 patients with MDS/AML revealed a
normal karyotype in 8 patients and an abnormal karyotype
in the other eight patients. Out of 532 studied between 1986
and 2009 we identified five patients who had 1qJT at diagnosis.
Four of these five patients presented at the time of
transformation of MDS to AML and the fifth patient was
studied after autologous stem cell transplantation. Follow
up studies revealed 11 patients developed 1qJT (the overall
incidence was 3%, or 6% among cytogenetically abnormal).
The mean time to develop 1qJT was 34 months. Among
eight patients with an initial normal karyotype the average
time to acquire 1qJT was 27 months. Once 1qJT were documented
they persisted for an average 9 months in 14 of
(88%) before evolving into AML. Our data do not provide
any common pattern as to the role of the partner chromosomes
in 1qJT. However, 81% of recipient breakpoints
were localized in pericentric regions while the remaining
19% were telomeric fusions. The presence of 1qJT at diagnosis
or the subsequent acquisition of 1qJT appears to be
associated with imminent transformation to AML in patients
with MPN and MDS after an average of 8 and 9
months, respectively. Once acquired, the prognosis tended
to be dependent on a copy number of 1q indicating that
1qJT was associated with both disease progression and poor
prognosis.This work was supported in part by the grant P01
CA1 108671 from the National Institutes of Health.
OP26 Prognostic Tools in CML
Rudiger Hehlmann, Universität Heidelberg, Germany
Prognosis of CML has improved due to the availability of
several new first-line treatment options (optimized imatinib,
2 nd generation TKI first-line). Prediction of prognosis in
CML is currently estimated by criteria at diagnosis and by
response to treatment.
At diagnosis, Sokal and EUTO scores have been commonly
used for prognostic prediction in the pre-imatinib
era. Since imatinib has changed the natural course of the
disease, a new score (EUTOS score) has been developed
from imatinib treated patients which uses only two variables
(spleen size and percentage of basophils in the peripheral
blood) and separates a high from a low risk group. The
EUTOS score has a predictive value which is about 1. 4
times more powerful than that of the Sokal score (Hasford
et al, Blood prepublished May 2, 2011).
Under therapy, the gold standard for prognostic prediction
has been complete cytogenetic remission (CCR). Recently
also major molecular remission (MMR) at 12 months
after start of treatment has been associated with better
survival (Hehlmann et al., JCO 29: 1634–1642, 2011).
MMR is a prerequisite for complete molecular remission
which is considered a necessary step on the path to cure and
for discontinuation of imatinib. Molecular analysis can be
35

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
performed with peripheral blood and avoids bone marrow
puncture.
A further advance in prognostic prediction is early molecular
response at the 10% level (international scale, IS)
after 3 months of treatment (Hanfstein et al., Blood 116,
2010, ASH, abstr. 360). Patients with a BCR-ABL level less
than 10% (IS) after 3 months have a significantly better progression
free survival (96% vs. 83% after 8 years).
It is concluded that molecular analyses performed by harmonized
laboratories with standardized methods might replace
cytogenetics as the new method of choice for prognostic
prediction at least partially in the future (Müller at al.,
Leukemia 23: 1957–1963, 2009).
OP27 Imatinib, still the best fi rst line therapy?
David Marin, Department of Hematology, Imperial College
London, London, United Kingdom
Rarely in the history of medicine has any new drug constituted
such a radical advance in the therapy of a particular
disease as has imatinib for chronic myeloid leukemia
(CML). Imatinib has been the standard front line therapy for
CML for nearly 10 years and although it may still be too
early to appreciate the full extent to which imatinib improves
the survival of CML patients. However at 5 years
more than one third of the patients have abandoned the medication
on account of side effects, lack of efficacy or progression.
Furthermore, imatinib may soon be displaced as
front line therapy by nilotinib, dasatinib or bosutinib. Small
phase II studies using nilotinib or dasatinib as initial therapy
in CML patients have shown that these drugs induce very
deep responses in the majority of patients with virtually nobody
failing to achieve complete cytogenetic response.
Three large phase III studies comparing nilotinib, dasatinib
and bosutinib with imatinib are ongoing with very promising
early results. It is likely that at least two of these drugs
will prove to be superior to imatinib; if that is the case, it
will be difficult to decide what the initial therapy for CML
patients should be as the there are no ongoing studies comparing
the three new drugs between each other.
OP28 Outcome of Treatment of CML with 2 nd
Generation Tyrosine Kinase Inhibitors
After Imatinib Failure
Elias Jabbour, Jorge Cortes, Hagop Kantarjian,
Department of Leukemia, The University of Texas MD
Anderson Cancer Center, Houston, Texas
Abstract: Although imatinib revolutionized the management
of chronic myeloid leukemia (CML), recent data indicate
a transformation in the treatment approach likely in the
near future. For patients who fail with standard-dose imatinib
therapy, imatinib dose escalation is a second-line option.
However, high-dose imatinib is not an appropriate approach
for patients experiencing drug toxicity, and there
remain questions over the durability of responses achieved
with this strategy. Alternative second-line options include
36
the newer tyrosine kinase inhibitors (TKIs) like dasatinib
and nilotinib. A substantial amount of long-term data for
these agents is available. Although both are potent and specific
BCR-ABL TKIs, dasatinib and nilotinib exhibit unique
pharmacological profiles and response patterns relative to
different patient characteristics, such as disease stage and
BCR-ABL mutational status. The superiority of second
generation TKIs over imatinib in newly diagnosed disease
has been recognized as well. They induce high and rapid
rates of cytogenetic and molecular response, with less progression
to advanced forms of disease in comparison with
imatinib. Several investigational agents specific for those
patients with the T315I mutation remain under evaluation.
The future of CML therapy may include early use of these
potent agents to help more patients achieve molecular remission
and potentially be a path to a CML cure.
Introduction
Chronic myelogenous leukemia (CML) is a myeloproliferative
neoplasm with an incidence of 1–2 cases per 100,000
adults, with increasing incidence with age and a slight male
predominance of 1.3:1. Thirty percent of patients are 60
years old or older, with the median age at presentation being
45–50 years old1 . The pathogenesis of CML involves a specific
genetic abnormality involving the fusion of the Abelson
murine leukemia (ABL) gene on chromosome 9 with
the breakpoint cluster region (BCR) gene on chromosome
222 . In 95% of cases, this fusion is the result of a balanced
translocation between chromosomes 9 and 22 [t(9;22)(q34;
q11)], termed the Philadelphia chromosome3,4 . The remaining
5% of cases are a result of other genetic abnormalities
that result in the fusion of these same genes4 . The resultant
BCR-ABL fusion protein contains the constitutively active
tyrosine kinase region of ABL that produces a proliferative
signal that regulates growth and replication through downstream
pathways such as RAS5 , RAF6 , JUN kinase7 , MYC8 ,
and STAT 9–11 . This contributes to leukemogenesis by creating
a cytokine-independent cell cycle with aberrant apoptotic
signals in response to cytokine withdrawal2 .
The causal role played by BCR-ABL in leukemogenesis,
specifically as it relates to CML, has led to the development
of tyrosine kinase inhibitors (TKIs) and represents the bulk
of pharmaceutical research performed in this arena within
the last decade. TKIs mitigate the oncogenic activity of the
BCR-ABL protein through competitive inhibition at the
ATP-binding site, leading to the inhibition of phosphorylation
of proteins involved in BCR-ABL mediated intracellular
signal transduction, and thereby causing the arrest of
growth and apoptosis in CML cells12–14 .
Imatinib mesylate (Gleevec; Novartis Pharmaceuticals
Corporation, NJ, USA) was the first of these drugs to receive
the approval by the United States Food and Drug Administration
(FDA) in 2001 for the treatment of patients
with CML-CP at a dose of 400 mg/day; as well as for advanced
phase (CML-AP) and blast phase (CML-BP) diease
at a higher dose of 600 mg/day15–17 . The advent of imatinib
revolutionized the treatment of CML and represented improved
outcome over the previously well established gold
standard of interferon-alpha (IFN-a) based treatments18 . As

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
a result, patients with CML in the chronic phase (CML-CP)
can expect a lifespan of approximately 25 years and even
beyond, transforming CML from a disease which was once
fatal, with a 40% 7-year survival to one that is chronic, with
a 90% 7-year survival.
Outcome with imatinib
The landmark phase III IRIS trial (International Randomized
Study of Interferon versus STI571) was the first to
clearly demonstrate the superiority of imatinib treatment in
CML-CP as compared to IFN-a. Complete cytogenetic response
(CCyR) rates were increased in the imatinib group
over the IFN group (68% vs. 7% at 12 months; and 76.2%
vs. 14.5% at 18 months) 19,20 . Imatinib produced durable
CCyR with rates of 87% and 85% at 5 years and 8 years
respectively21,22 . Major molecular response (MMR) rates,
defined as a 3 log reduction in BCR-ABL transcripts19 , or
BCR-ABL:control gene ratio of 0.10 or less23 , were also improved
(39% vs. 2% at 12 months; p

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
of patients who appear to have rising levels of BCR-ABL
transcripts while maintaining a cytogenetic response. This
may indicate an increased risk for development of mutations
or failure to therapy, however, this value should be
considered with caution. It is inherently variable due to the
fact that it is an international normalized ratio, and there is
significant variability in values reported from different laboratories.
Thus, a small increase in BCR-ABL transcript
levels does not necessarily indicate treatment failure or loss
of response. This is supported by the 3-year follow up of the
IRIS trial in which CCyR, regardless of MMR, was associated
with improved OS 25 . If a patient who has previously
achieved a MMR is noted to have a 1 log, or 5 fold increase
in BCR-ABL transcripts, the value should be repeated and
confirmed in 1–3 months to evaluate for loss of cytogenetic
response. Patient compliance should be evaluated in both
cases, and mutation analysis should be considered if the patient
has been identified as having a suboptimal response
within the first year of therapy or has had a loss of response
at any time 29 .
Resistance to imatinib
Despite the success of imatinib, a substantial proportion,
33%, of patients have been shown to be resistant to therapy30,31
. This resistance can be classified into two types: primary
and secondary. Failure to achieve any of the ELN outlined
criteria for response in accordance with the duration of
therapy is considered primarily resistant; those who have
previously achieved and subsequently lost their response in
accordance with those guidelines are considered secondarily
resistant18,29,30 . Primary resistance can be further divided
into primary hematologic resistance, which occurs in 2%–
4% of cases who fail to normalize peripheral counts; or primary
cytogenetic resistance, which is more common and
occurs in approximately 15%–25% of patients who fail to
reduce their Ph+ cells to 35% or fewer of those sampled32 .
Causal factors in imatinib resistance can be classified as
either BCR-ABL dependent, or BCR-ABL independent.
Point mutations are the most well-characterized BCR-ABL
dependent factors and are responsible for 35–75% of cases
of resistance30,33–38 . A key component to imatinib resistance
centers around its ability to bind only to the closed, or inactive,
conformation of the ABL kinase, and requires a very
specific structural arrangement for entry and binding. Point
mutations can cause steric hindrance as well as elimination
of critical molecules required for hydrogen bonding between
imatinib and ABL kinase, thus mitigating imatinib’s
efficacy30,38–40 . Examples of such mutations include T315I,
Y253H, and F255K, among others38 .
BCR-ABL independent mechanisms of resistance include
amplification of the ABL kinase oncogene in response
to high plasma imatinib levels30,41–44 ; increased efflux of the
drug by increased expression of P-glycoprotein (Pgp) efflux
pumps30,45–47 ; decreased drug uptake secondary to decreased
expression of the drug uptake transporter, hOCT130,48–51 ;
cytoplasmic sequestration of imatinib by increased serum
protein alfa1-acid glycoprotein (AGP) which binds imatinib
and impairs subsequent binding to ABL kinase30,52,53,54 ;
low serum drug concentration30 ; and alternative signaling
38
pathway activation, including Ras/Raf/MEK kinase, STAT,
Erk2, and SFK phosphorylation of BCR-ABL, all of which
decrease susceptibility to imatinib 30 .
Adherence is another BCR-ABL independent factor that
has been shown to affect outcome. Rates of daily imatinib
adherence have been estimated to range from 75% to
90% 55–57 with higher adherence rates correlated to improved
outcome. In one study of 87 patients with CML-CP treated
with imatinib 400 mg daily, adherence was shown to correlate
with MMR and CMR at 6 years. An adherence rate of
90% or less resulted in MMR in only 28.4% as compared to
94.5% in patients with greater than 90% adherence rates
(P

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
In another study assessing 84 patients over 61 months
with failure to standard-dose imatinib, doses were escalated
to 600–800 mg daily. In 21 patients with hematologic failure,
48% achieved a CHR, with only 14% achieving a cytogenetic
response. In 63 patients with cytogenetic failure,
75% responded with CCyR. Two and 3-year EFS rates were
57% and 47%, respectively; with OS rates of 84% and 76%,
respectively 59 . Thus, while dose escalation after failure of
standard-dose imatinib is an important and viable treatment
option, it is likely to be effective only in the subset of patients
with previous cytogenetic responses and is not indicated
for patients with intolerance to the drug. Thus, clinical
consideration should be given to 2 nd generation TKIs.
Second generation tyrosine kinase inhibitors
[Table2]
Dasatinib
Dasatinib was approved by the US FDA in 2006 for the
2nd line treatment of CML-CP, -AP, -BP, and Philadelphiapositive
acute lymphoblastic leukemia [Ph (+) ALL] with
resistance or intolerance to prior therapy with imatinib60,61 .
Dasatinib is 325 times more potent than imatinib38,62 . Unlike
imatinib, dasatinib binds to both the active and inactive
forms of BCR-ABL30 .
Several studies have shown that dasatinib is highly effective
in CML-CP In the START-C trial, an international, multicenter,
phase II trial assessing 387 patients with CML-CP
who had demonstrated imatinib intolerance (n= 99) or resistance
(n=288), patients were treated with dasatinib at an
initial dose of 70 mg BID. Twenty four-month follow-up
data showed overall rates of CyR 62%, CCyR 53%, CHR
91%, and MMR 47%. Two-year PFS was 80% and OS was
94%. Adverse events included grade 3 neutropenia (50%),
grade 3 thromboyctopenia (49%), and grade 3 pleural effusions
(9%). Nine percent of all adverse events were considered
»severe62 .« In another study assessed the efficacy of
dasatinib in 445 imatinib-resistant or intolerant patients
with CML-CP (n=186), CML-AP (n=107), CML-myeloid
blast crisis (n=74), CML-lymphoid blast crisis (n=42), or
Ph (+) ALL (n=36). Dasatinib produced MCyR rates of
45% and CCyR rates of 33% in patients with CML-CP, and
major hematologic response rates in advanced stages of disease,
including 59% in CML-AP; 39% in CML myeloid
blast crisis; 31% in lymphoid blast crisis; and 42% in Ph (+)
ALL 61 .
The dose optimization study CA180034 randomized 622
patients with imatinib resistant or intolerant CML-CP to 4
dasatinib treatment arms, including 100 mg daily, 50 mg
BID, 140 mg daily, and 70 mg BID. Dasatinib dosed at 100
mg daily produced similar CyR and PFS rates as other dosing
schedules, with significantly fewer occurrences of grade
3–4 neutropenia, thrombocytopenia, anemia, and pleural effusions.
There were also fewer treatment interruptions, reductions,
and discontinuations at 100 mg daily as compared
to the other treatment groups 63 .
Further evaluation of dasatinib therapy in imatinib-resistant
patients with mutations by meta-analysis of 3 dasatinib
studies, including the START-C, START-R, and CA180-034
dose optimization study, revealed that rates of response with
dasatinib are favorable in a variety of genetic mutations including
E255K/V (CCyR 38%), L248V (CCyR 40%), and
G250E (CCyR 33%). CCyR rates were lower in F317L(7%),
Q252H (17%), L384M(0%), and V299L (0%). Patients with
T315I mutations did not respond to dasatinib 64 .
Dasatinib has also been evaluated in patients with imatinib-resistant
or intolerant CML-AP. One study assessed
174 such patients treated with dasatinib 70 mg BID. Major
hematologic response rates were 64%, CHR rates were
45%; MCyR rates were 39% and CCyRrates were 32%.
PFS at 12 months was 66% and OS was 82%. Adverse
events included grade 3–4 thrombocytopenia (82%), neutropenia
(76%), and diarrhea (52%, grade 3 or 4 in 8%) 65 .
Appropriate dosing in CML-AP was evaluated in another
study, in which 317 patients were randomized to receive dasatinib
at 140 mg daily or 70 mg BID. The results at 2 years
after initiation of treatment demonstrated similar efficancy
in rates of hematologic and cytogenetic responses, as well
as in PFS and OS rates. Dasatinib 140 mg once daily did
demonstrate an improved safety profile with statistically
Table 2. Response to second generation tyrosine kinase inhibitors (dasatinib, nilotinib and bosutinib) in patients who are imatinib-resistant or intolerant
in chronic phase, accelerated phase and blast phase
Response
Dasatinib
Percent Response
Nilotinib Bosutinib
CP
N=387
AP
n=174
MyBP
n=109
LyBP
n=48
CP
n=321
AP
N=137
MyBP
N=105
LyBP
N=31
CP N=146
AP
N=51
BP
N=38
Median follow-up (mo) 15 14 12+ 12+ 24 9 3 3 7 6 3
% Resistant to imatinib 74 93 91 88 70 80 82 82 69 NR* NR*
% Hematologic Response – 79 50 40 94 56 22 19 85 54 36
CHR 91 45 27 29 76 31 11 13 81 54 36
NEL – 19 7 6 – 12 1 0 – 0 0
% Cytogenetic Response NR 44 36 52 NR NR NR NR – NR NR
Complete 49 32 26 46 46 20 29 32 34 27 35
Partial 11 7 7 6 15 12 10 16 13 20 18
% 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)
Legend: CP: chronic phase; AP: accelerated phase; MyBP: myeloid blast phase; LyBP: lymphoid blast phase, mo: months; CHR: complete hematologic response;
NEL: no evidence of leukemia
39

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
fewer patients experiencing pleural effusions (20% vs. 39%;
P

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
results show achievement of an 85% CHR rate, 28% CyR
rate, 15% MCyR rate, 15% MMR rate, and 57% reduction
in the T315I clone. OS was not met in this group of patients.
In CML-AP, 37.5% showed hematologic response with OS
of 18.8 months. In CML-BP, hematologic response was
demonstrated in 30% with OS of 1.8 months 78 .
An update combining both of the above study populations
was presented at ASH 2010. Thirty six of the 93 chronic
phase patients had been treated previously with 3 or more
TKIs. Over a median followup of 7.5 months, 27/36 (75%)
achieved or maintained a CHR and 7 (19%) achieved a
major CyR (4 complete and 3 partial) with omacetaxine,
with a median duration of at least 4 months. These findings
support the further investigation of this agent in patients
failing other TKI therapy 79 . Grade 3 to 4 hematologic adverse
events included thrombocytopenia (65%), neutropenia
(48%), and anemia (40%), febrile neutropenia (12%),
bone marrow failure (12%), pancytopenia (7%) and febrile
bone marrow aplasia (6%). Grade 3 to 4 nonhematologic
adverse events included fatigue (6%). Grade 1–2 adverse
events included diarrhea, fatigue, nausea, vomiting, fever,
headache, and asthenia 77,78,79 .
Predictors of outcome
The primary goal of therapy for patients with CML is still
achievement of CCyR. Those who achieve this goal, have a
low probability of eventually progressing. Achieving a major
molecular response is desirable as it further improves the
long-term outcome, but patients who have a CCyR are not
considered to have failure to imatinib if they do not have a
major molecular response. This is because the difference in
EFS probability is small, although significant. The timing of
this response is also important. Despite initial suggestions
form the IRIS trial that a MMR at 12 months improved
long-term outcome, compared to CCyR but no MMR, the
8-year follow-up data has shown no difference in outcome
using this hallmark. By 18 months, patients who have a
CCyR and MMR have a better probability of EFS than those
with CCyR but no MMR, but the difference is small (95%
vs. 86%), and even smaller if considering only transformation
to AP or BP or death as an event (99% vs 96%) 80 .
The recommendations by the ELN have provided a clear
framework for decision making and the significance of the
definitions of failure and suboptimal response have been
demonstrated in two independent series27,81 . Patients with
suboptimal response to therapy have an inferior outcome,
although the significance appears to be heterogeneous, with
a more profound adverse prognostic effect for patients with
suboptimal response to therapy at earlier time points (6
months) and than at later time points (18 months). It is however
reasonable to consider treatment modifications for patients
who have a suboptimal response to therapy. Treatment
guidelines recommend dose escalation of imatinib to 600 or
800 mg/day in cases of suboptimal response38,70 . However, it
should be acknowledged that there is minimal data available
regarding the effectiveness of this approach58,59 . For patients
with clear failure to imatinib therapy, the current approach
is to change therapy to a second generation TKI, although
ASCT is also an option following treatment failure17,82 .
Clinical trial data have confirmed the efficacy of dasatinib
and nilotinib in patients with imatinib resistance or intolerance
and the superiority of dasatinib versus imatinib dose
escalation following imatinib resistance 70,81,83 . It is possible
that earlier treatment switch to second-line agents, i.e. after
suboptimal response, could result in more favorable longterm
outcomes than with dose-escalated imatinib, but there
are currently no clinical data to support this hypothesis.
In addition to efficacy outcomes, mutational data should
be considered when selecting TKI therapy 84 . The BCR-ABL
genotype can be used to guide treatment decisions since it is
a prognostic factor for disease progression 84–86 . Patients with
T315A/I, F317I/L, and V299L mutations do not appear to
respond consistently to therapy with dasatinib 86–89 , whereas
patients with the F359C/V substitution do benefit from dasatinib
86 . In an analysis of 1043 patients who underwent
mutational assessment in phase II/III studies in CP CML, 14
patients had baseline F317L mutations, and just one patient
had a baseline V299L mutation 89 . It was found that patients
bearing F317L mutations achieved a high CHR rate (93%),
but cytogenetic response rates (MCyR, 14%; CCyR, 7%)
were lower than in patients without these mutations. Importantly,
in patients treated with dasatinib, high response rates
were obtained with the common imatinib-resistant mutations
in Y253, E255 and E359 residues.
Nilotinib resistance is associated with mutations in the
T315, Y253, and E255 residues 84–86 . Indeed, recently it was
shown that the presence of E255K/V, Y253H, or F359C/V
mutations at baseline are independent predictors of worsened
PFS in patients with CP CML 86 . Therefore, dasatinib
therapy may be more appropriate for patients with these
common mutations, whereas nilotinib may be better suited
for those patients with F317L mutations 88 . Although both
dasatinib and nilotinib are ineffective against T315I BCR-
ABL 85 , this mutation is more likely to affect patients in
the advanced phases of CML 85 . Patients with T315I may
achieve favorable outcomes with therapies other than the
available second-line TKIs, e.g AP24534, omacetaxine, and
others 90,91 .
A recent study has explored factors that may predict response
and outcome in patients with chronic-phase CML
receiving dasatinib or nilotinib after failing imatinib 92,93 .
The analysis included 123 patients in chronic phase post
imatinib failure: 78 treated with dasatinib and 45 treated
with nilotinib. Multivariate analysis for predictive factors
was performed for event-free survival, overall survival, and
12-month major cytogenetic response (MCyR). Investigators
found that event-free survival in response to a second
TKI in CML depends on achieving a prior cytogenetic response
to imatinib and on the patient’s performance status.
In the study, patients with performance status ≥ 1 and no
prior cytogenetic response to imatinib had a high likelihood
of responding to a second TKI with poor event-free survival
and overall survival. Patients with both risk factors had a
24-month overall survival of only 40% compared with 95%
for patients with neither risk factor. Therefore, patients with
no previous cytogenetic response to imatinib should be offered
additional treatment approaches including allogeneic
stem cell transplantation and clinical trials. However, the
41

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
achievement of MCyR with a second TKI by 12 months
may compensate for the presence unfavorable baseline factors
93 .
Safety and tolerability are also important considerations
in choosing a TKI. The potential impact of the drug’s AE
profile on any of the patient’s preexisting conditions should
be considered in choosing between second generation BCR-
ABL inhibitors. Since pleural effusion is more common for
patients receiving dasatinib therapy, patients with risk factors
for pleural effusion such as a prior cardiac history,
chronic obstructive pulmonary disease and hypertension are
at greater risk for developing these complications 67 . Risk
factors for developing pleural effusions while taking dasatinib
also include disease stage (BC > AP > CP), previous
lung problems such as smoking or infections and those patients
maintained on starting doses of dasatinib 94 .
Blood glucose elevations have been observed in 11% of
CML-CP, and 4% of CML-AP patients treated with nilotinib
72,95 . While no CML-CP or CML-AP patients required
dose adjustments, dose interruption or discontinued nilotinib
therapy due to elevated blood glucose, preexisting hyperglycemia
should be carefully monitored to ensure that
the condition is not exacerbated by nilotinib treatment. Prior
severe pancreatitis may also be a concern on nilotinib therapy,
and patients with a history should be closely monitored
on nilotinib therapy.
Cardiac events, including congestive heart failure, left
ventricular dysfunction and QT prolongation have all been
reported with dasatinib and nilotinib. Though they occurred
in

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
also significantly improved the rates of CCyR and MMR at
24 months. CCyR at 24 months was 87% with 400 mg twice
daily nilotinib compared with 77% with imatinib (P =
.0018). Likewise, MMR at 24 months was 59% with 400
mg nilotinib vs 37% with imatinib (P < .0001). There were
also significantly fewer progressions to advanced phase and
blast crisis with nilotinib. Based on these data, nilotinib has
been approved for the frontline therapy of CML. The gap in
efficacy in favor of nilotinib has persisted over time and it
appears that nilotinib may improve both short-term and
long-term outcomes compared with imatinib 100 .
In the ENESTnd trial, nilotinib was also shown to be safe
and well-tolerated with no increase in side-effects compared
with imatinib. By contrast, treatment-related gastrointestinal
toxicity and fluid retention of all grades were more frequent
with imatinib than they were in either nilotinib
arm 100 .
Dasatinib in the frontline setting [Table 4]
Cortes et al at MD Anderson Cancer Center published a
study in which 50 patients with newly diagnosed CML-CP
were randomized to dasatinib 100 mg once daily or 50 mg
twice daily in the frontline setting. Median follow up was 24
months. Of the 50 patients enrolled in the study, 49 (98%)
attained a CCyR and 41 (82%) attained a MMR. Ninety
four percent of patients attained CCyR by 6 months. There
was no difference in response rate by treatment arm. The
projected event-free survival rate at 24 months was 88%.
Grade 3/ 4 hematologic toxicities included neutropenia and
thrombocytopenia, and occurred in 21% and 10% of patients,
respectively. Nonhematologic toxicity was usually
grade 1 to 2. There was no significant difference in toxicity
between the two arms, and the actual median dose at 12
months was 100 mg (range, 20 to 100 mg). These results
lead to the conclusion that the management of CML-CP in
the frontline setting with dasatinib is an effective approach,
yielding high rates of CCyR and MMR101 .
The DASISION trial, an international, multicenter, randomized
phase III trial on frontline dasatinib therapy, randomized
519 patients to receive dasatinib 100 mg once
daily or imatinib 400 mg once daily. Findings from this trial
were recently published102 . The current data presented at
ASH 2010 represented an 18-month follow-up showing that
dasatinib was superior to imatinib with respect to the primary
endpoint, the rate of CCyR. The likelihood of achieving
a CCyR at any time was higher with dasatinib vs imatinib
(85% vs 80%; hazard ratio [HR] = 1.5; P < .0001) 103 .
Table 4. Response rates with frontline dasatinib.
Study
Number of
CCyR (%) MMR (%)
patients
PFS (%) OS (%)
MDACC 50 98 82 – –
DASISION 259 78 57
94.9
(18 months)
96
(18 months)
S0325 123 82 59
99
(12 months)
100
(12 months)
CCyR: complete cytogenetic response, MMR: major molecular response,
PFS: progression free survival, OS: overall survival, MDACC: MD Anderson
Cancer Center
*cCCyR (confirmed complete cytogenetic response) is reported for DASI-
SION study.
In addition, the secondary endpoint, the rate of MMR,
was also significantly improved with dasatinib compared
with imatinib. The likelihood of achieving MMR at any
time with dasatinib was significantly higher than with imatinib
(57% vs 41%; HR = 1.8; P < .0001). Based on these
data, dasatinib was approved by the US Food and Drug Administration
as a standard of care for CML patients. Dasatinib
was also shown to be well tolerated, with low rates of
grade 3/4 hematologic and nonhematologic toxicity, as well
as a low rate of discontinuation due to adverse events although,
pleural effusion occurred only in patients treated
with dasatinib (in 12% of 258 patients, nearly all grade 1
and 2) 102,103 .
Another study by the Southwest Oncology Group (S0325)
compared dasatinib 100 mg to imatinib 400 mg in newly
diagnosed CML in chronic phase. The study showed that
dasatinib was associated with greater MMR compared with
imatinib at 12 months. However, the 12-month rates of complete
hematologic response (CHR), CCyR, OS, or PFS were
comparable between treatment groups. The lack of statistical
significance in rates of CCyR was likely due to the fact
that patients who were not evaluable were considered nonresponders
104 .
Bosutinib in the frontline setting
The BELA trial, an international, mutlicenter, open-label
phase III trial, compares bosutinib with imatinib in the
frontline setting using CCyR as a primary endpoint and
MMR as a secondary endpoint105 . In this study, non-evaluable
patients were considered non-responders. Consequently,
bosutinib was associated with a similar rate of CCyR
compared with imatinib at 12 months (70% vs 68%; P =
.601), and the primary endpoint was not met. In evaluable
patients only, bosutinib did induce a significantly higher
rate of CCyR compared with imatinib (78% vs 68%; P =
.026). In addition, there was a significantly higher MMR
with bosutinib in both the intent-to-treat and evaluable populations
(intent-to-treat patients: 39% vs 26%, P = .002;
evaluable patients: 43% vs 27%, P < .001). More follow-up
on these studies is needed to determine whether these responses
are sustained and whether bosutinib is truly superior
to imatinib.
Conclusion
The treatment of CML has progressed significantly since
the approval of imatinib in 2001. With the advent of TKIs,
the focus of the scientific community has shifted to the molecular
management of disease, which has had a considerable
impact on the approach to cancer treatment to date.
Imatinib has transformed CML from an immediately lifethreatening
disease to one that is treatable with daily oral
medication that makes it possible to improve both overall
survival and maintain quality of life. However, increasing
incidence of imatinib-resistance and intolerance necessitates
the development of alternative therapies. There is a
substantial amount of data supporting the improvement in
outcome in long term follow up of the 2nd generation TKIs,
nilotinib and dasatinib. Improving outcome in the frontline
setting should be the direction of further scientific research,
43

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
including the implementation of 2 nd generation TKIs as
frontline therapy.
Despite extraordinary progress, a true cure for CML is
not generally achieved by Abl kinase inhibitors. TKIs are
potent inhibitors of Bcr-Abl kinases (among others), resulting
in rapid reduction of the majority of cells carrying the
Ph chromosomal marker. However, suppression of Abldriven
hematopoiesis may be insufficient to eradicate quiescent
stem cells. Studies assessing the combination of TKIs
with promising agents are ongoing. These combinations include
TKI and hedgehog inhibitors, omacetaxine, vaccines,
and hypomethylatings agents. If successful, this strategy
could lead to a safe and permanent discontinuation of therapy
in patients with a good response. The impact of using
more potent agents in the frontline setting on the potential to
discontinue TKI therapy remains to be determined. The future
of CML therapy may include early use of these potent
agents, perhaps in combination with new molecules, to help
more patients achieve CMR, which could lead to therapy
discontinuation and cure.
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chronic myeloid leukemia (CML) patients who harbor the Bcr-
Abl T315I mutation-results of an ongoing multicenter phase 2/3 study.
Blood 2009;114:Abstract 644.
92. Kantarjian HM, Jabbour E, Giles FJ, et al. Prognostic factors for progression-free
survival in patients with imatinib-resistant or –intolerant
chronic myeloid leukemia in chronic phase (CML-CP) treated with nilotinib
based on 24 month data. Blood 2009(D);113:3298.
93. Jabbour E, Kantarjian H, O’Brien S, et al. Predictive factors for response
and outcome in patients (pts) treated with second generation
tyrosine kinase inhibitors (2-TKI) for chronic myeloid leukemia in
chronic phase (CML-CP) post imatinib failure. Blood. 2009;114:210.
Abstract 509.
94. Lipton JH, Sriharsha L, Bogomilsky S, Casciaro L, Keating A, Messner
H, et al. Pleural effusions in patients treated with dasatinib: Results
from two institutions, risk factors and management. Journal of Clinical
Oncology 2007; 25: 680s.
95. Kantarjian H, Giles F, Bhalla K, et al. Update On Imatinib-Resistant
Chronic Myeloid Leukemia Patients in Chronic Phase (CML-CP) On
Nilotinib Therapy at 24 Months: Clinical Response, Safety, and Long-
Term Outcomes. Blood (ASH Annual Meeting Abstracts), Nov 2009;
114:1129.
96. Cortes JE, Baccarani M, Guilhot F, et al. Phase III, randomized, openlabel
study of daily imatinib mesylate 400 mg versus 800 mg in patients
with newly diagnosed, previously untreated chronic myeloid leukemia
in chronic phase using molecular end points: tyrosine kinase inhibitor
optimization and selectivity study J Clin Oncol. 2010 ;28:424–430.
97. Guilhot. Randomized Comparison of Imatinib Versus Imatinib Combination
Therapies in Newly Diagnosed Chronic Myeloid Leukaemia
(CML) Patients in Chronic Phase (CP): First Results of the Phase III
(SPIRIT) Trial from the French CML Group (FI LMC). Blood (ASH
Annual Meeting Abstracts) 2008 112: Abstract 183
46
98. Cortes JE, Jones D, O’Brien et al. Niltonib as front-line therapy for
patients with chronic myeloid lekemia in early chronic phase. J Clin
Oncol 28:392–397. 2010.
99. Rosti G, Castagnetti F, Gugliotta G. Excellent outcomes at 3 years
with Nilotinib 800 mg daily in early chronic phase, Ph(+) chronic
myeloid leukemia (CML): Results of a phase 2 GIMEMA CML WP
clinical trial. Blood (ASH Annual Meeting Abstracts) 2010 116: Abstract
359.
100. Hughes TP, Hochhaus A, Saglio G, et al. ENESTnd update: Continued
superiority of nilotinib versus imatinib in patients with newly diagnosed
chronic myeloid leukemia in chronic phase (CML-CP).
Blood (Annual abstract )Abstract 207
101. Cortes JE, Jones D, O’Brien S, et al. Results of dasatinib therapy in
patients with early chronic-phase chronic myeloid leukemia. J Clin
Oncol 28:398–404.2010.
102. Kantarjian H, Shah NP, Hochhaus A, et al. Dasatinib versus imatinib
in newly diagnosed chronic-phase chronic myeloid leukemia. N Engl
J Med. 2010;362:2260–2270.
103. Shah N, Kantarjian HM, Hochhaus A, et al. Dasatinib versus imatinib
in patients with newly diagnosed chronic myeloid leukemia in chronic
phase (CML-CP) in the DASISION trial: 18-month follow-up. Program
and abstracts of the 52nd American Society of Hematology Annual
Meeting and Exposition; December 4–7, 2010; Orlando, Florida.
Abstract 206.
104. Jerald P. Radich, Kenneth J. Kopecky, and Suzanne Kamel-Reid, et al.
A Randomized Phase II Trial of Dasatinib 100 Mg Vs Imatinib 400
Mg In Newly Diagnosed Chronic Myeloid Leukemia In Chronic
Phase (CML-CP): The S0325 Intergroup Trial. Blood (ASH Annual
Meeting Abstracts), Nov 2010; 116: LBA-6.
105. Gambacorti-Passerini C, Kim DW, Kantarjian HM, et al. An ongoing
phase 3 study of bosutinib (SKI-606) versus imatinib in patients with
newly diagnosed chronic phase chronic myeloid leukemia. Program
and abstracts of the 52nd American Society of Hematology Annual
Meeting and Exposition; December 4–7, 2010; Orlando, Florida. Abstract
208.
OP29 Second line TKI – the best fi rst line therapy?
Gianantonio Rosti, (Italy)
Abstract not submitted.
OP30 How to monitor CML therapy
Elias Jabbour, Department of Leukemia, The University
of Texas M. D. Anderson Cancer Center, Houston, Texas,
USA [see OP28]
OP31 Stem cell transplants for chronic phase
CML
OP32 Pathophysiology of Myeloma
Christoph J. Heuck, University of Arkansas for Medical
Sciences, Myeloma Institute for Research and Therapy,
Little Rock, AR, USA
Muchof the recent progress in the treatment of multiple
myeloma has been attributed to the introduction of several
novel agents which, when combined with standard cytotoxic
agents and each other, have imparted a high frequency of
clinical responses. We have previously reported on the superior
survival outcomes in Total Therapy 3A (TT3A), with
added bortezomib (Bz), compared with Total Therapy 2
(TT2),which randomized patients to a control arm or an ex-

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
perimental thalidomide arm of a multi-agent chemotherapy
and tandem autograft-supported high-dose melphalan program.
The major advance with TT3A was observed in the
85% of patients presenting with gene expression profiling
(GEP)-defined low-risk myeloma and. As part of TT3A,
pharmacogenomic investigations of Bz, using GEP analysis
pre- and post-48 hr test-dosing, were performed in an attempt
to further delineate low- versus high-risk disease.
Pharmacogenomic investigations after test-dose applications
of Bz have revealed that high expression levels of proteasome
genes are linked to inferior prognosis in both of our
TT3 protocols. The GEP80 model discriminated outcomes
whether applied to post-Bz or baseline samples. These findings,
observed in TT3A, were validated in TT3B and also
applied to both arms of TT2 (control and thalidomide).
Employing post-Bz and baseline samples in TT3, the
GEP80 model provided segregation of high-risk subsets of
9% and 3%, respectively, in the GEP70 low-risk group and
low-risk subsets of 41% and 55%, respectively, in the
GEP70 high-risk setting. In TT2, the GEP80 model failed to
discern a low-risk subset among the patients with GEP70
high-risk disease, and the GEP80 model discriminated only
one patient with high-risk status among those identified to
have GEP70 low-risk disease.
We found a significant upregulation in the expression of
proteasome genes following a 48-hour Bz test dose. PSMD4
was only one of three genes common to both GEP70 and
GEP80 models. PSMD4 and other proteasome genes were
uniquely upregulated by Bz but not by dexamethasone, immunomodulatory
agents, and melphalan. Prognostically,
GEP80(BL)-defined high-risk status was the sole genetic
parameter that survived multivariate PFS and OS models,
along with low albumin and high LDH, although all the
other standard and both cytogenetic and molecular genetic
variables also contributed when examined alone.
We have previously reported that both the copy number
and the percentage of cells with amp1q21 invariably increase
when comparing samples obtained at diagnosis and
at relapse. Genes residing on chromosome 1q21 contribute
critically to the high-risk designation in the GEP70 model.
Consistent with this, we have noted that the GEP70 score
inevitably increases at relapse and a shift from low to high
risk imparts a significantly shorter post-relapse survival.
OP33 Bortezomib in the Treatment of Multiple
Myeloma
Joan Bladé, Institut of Hematology and Oncology,
Department of Hematology Hospital Clinic, Barcelona,
Spain
Bortezomib is a first-in-class selective proteasome inhibitor
approved for the treatment of relapsed and refractory
multiple myeloma (MM) as well as in first-line therapy in
combination with melphalan and prednisone (MPV) for patients
not eligible for high-dose therapy/autologous stem
cell transplantation (ASCT). In vitro, bortezomib induces
apoptosis of myeloma cells and inhibits cell adhesion within
the bone marrow microenvironment. Preclinical and clinical
data have shown that bortezomib enhances sensitivity and
can reverse resistance to standard therapeutic agents used
in MM.
The first phase II trial of bortezomib (SUMMIT) in patients
with MM who had received at least 3 lines of therapy
showed an overall response rate of 35% including 10% of
CR or nCR. The second pivotal phase II trial (CREST), also
performed in patients with relapsed/refractory myeloma
showed that a reduced dose of 1 mg/m 2 instead of the usual
dose of 1.3 mg/m 2 induced a response rate of 33% with
lower toxicity. A randomized trial comparing bortezomib
versus high-dose dexamethasone (APEX) showed that bortezomib
was superior in RR, PFS and OS. A large phase 3
trial of bortezomib plus pegylated liposomal doxorubicin
versus bortezomib alone resulted in a significantly superior
CR plus VGPR rate, PFS and OS in favour of the combination.
The subcutaneous administration of bortezomib has
shown similar efficacy with less peripheral neuropathy than
the i.v. formulation. Bortezomib can be effective in patients
with extramedullary disease and can partially overcome the
poor prognosis of high-risk cytogenetics. Patients who have
responded to bortezomib with no significant peripheral neuropathy
and have been for longer than 6 months off therapy
should be re-treated with the same drug.
In a large phase III (VISTA) trial of newly diagnosed patients
non-eligible for ASCT the association of melphalanprednisone-bortezomib
(MPV) was superior to MP in RR
(71 vs. 36%), CR rate (30 vs. 4%), PFS (median, 24 vs.
16%) and OS (82.6 vs. 69.5%). For patients with renal failure
the best initial treatment regimen seems to be the association
of bortezomib/dexamethasone with or without doxorubicin.
In patients eligible for ASCT, the induction with
botezomib/dexamethasone results in pre-transplant RR of
65% including 12% of immunofixation negative CR. The
RR post-transplant is about 90% with 33% CR. The addition
of a third drug, either doxorubicin (PAD, VDD) or thalidomide
(VTD), results in an increased pre-transplant CR
rate from 20 to 35% and a post-transplant CR up to 50%. In
consequence, a pre-transplant induction regimen should today
include bortezomib and dexamethasone plus a third
agent, preferably an IMiD or a doxorubicin formulation.
It has been shown for the first time outside of the allogeneic
setting, that 18% of patients in at least VGPR after
ASCT achieved molecular remission by qualitative and
quantitative PCR with intensification therapy with VTD. In
addition, post-transplant intensification with bortezomib
alone significantly improved the CR rate. Finally, encouraging
results with bortezomib maintenance in the ASCT and
non-transplant setting are being reported and the possible
efficacy of maintenance with bortezomib is studies in a
number of ongoing clinical trials
OP34 IMIDs in Myeloma
Robert Peter Gale, Haematology Section, Division of
Experimental Medicine, Department of Medicine, Imperial
College, London, UK and Celgene Corp, Summit, NJ, USA
The pathophysiology of multiple myeloma is complex.
The initiating event is a mutational event in a B-cell. However,
there are important additional mechanisms including:
47

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
(1) additional mutational events within the myeloma clone;
(2) aberrancies of the bone marrow micro-environment; (3)
abnormalities of cytokines and hematopoietic growth factors;
and (4) immune-deficiency. For several decades myeloma-therapy
focused predominately on control of the myeloma
clone by cytotoxic DNA-alkylating drugs (like melphalan
and cyclophosphamide) and by drugs directly toxic
to B-cells (like dexamethasone). Recently, new classes of
anti-myeloma drugs were developed including proteosomeinhibitors
(like bortezomib) and so-called immune-modulating
drugs (IMiDs) (like thalidomide, lenalidomide and
pomalidomide). My talk focus on the mechanism(s) of action
of IMiDs in myeloma and clinical efficacy.
IMiDs are effective anti-myeloma drugs. Their mechanisms
of action are diverse and complex. They also differ
for different IMiDs. In general, IMiDs act on 4 targets in
myeloma: (1) direct cytotoxicity; (2) immune-modulation;
(3) effects on the bone marrow micro-environment; and (4)
modulation of cytokines and hematopoietic growth factors.
Exactly how IMiDs mediate these effects are complex. For
example, IMiDS cause cell-cycle arrest by increasing P21,
ERG1 and P15 expression, altering expression of cancer
suppressor genes CDK2 and RB1, decreasing interferon
regulatory factor-4 (IRF4), increasing caspase-3,-8 and -9
expression and apoptosis and by decrease expression of tumour
necrosis factor-alpha (TNFα). There are also stimulating
effects on T- and NKT-cells. These mechanisms will be
discussed in detail.
Substantial data support the important clinical activity of
IMiDs, alone or with other anti-myeloma drugs (like dexamethasone),
in myeloma-therapy. Randomized clinical trials
support the effectiveness of thalidomide and lenalidoime
in persons with newly-diagnosed and with advanced myeloma.
Interestingly, lenalidomide also prevents myelomarelapse
in recipients of high-dose therapy and hematopoietic
cell autotransplants. Pomalidomide, the newest IMiD, is active
in persons failing therapy with thalidomide and lenalidomide.
These data suggest different proportions of anti-myeloma
mechanisms of action and support sequencing of and
combinations of IMiDs in myeloma-therapy.
OP35 Curing Multiple myeloma – the facts behind
the claim
Bart Barlogie, Alan Mitchell, John D Shaughnessy Jr,
and John Crowley, Myeloma Institute for Research and
Therapy, University of Arkansas for Medical Sciences,
Little Rock, AR; and Cancer Research And Biostatistics,
Seattle, WA
Our Total Therapy (TT) approach for newly diagnosed
multiple myeloma (MM) was initiated in 1989 with the
stated goal of attempting MM cure by applying all known
MM-active agents up-front in order to overcome the genomic
chaos present in the majority of patients. We are reporting
on updates of TT1 (n=231), TT2 randomizing 668
patients between a control an thalidomide arm, and TT3 that
incorporated bortezomib up-front together with thalidomide
and applying VTD in maintenance (n=303). With median
follow-up times of 17.8 years in TT1, 9.4 years in TT2 and
48
6.1 years in TT3, patients alive at last contact include 44,
321, 214, respectively, of whom 24, 208, 194 remain progression-free
including 15, 156,149 in continuous complete
remission (CR). According to an exponential/plateau model,
significant cure fractions (CF) were estimated from overall
survival (OS), progression-free survival (PFS) and CR duration
(CRD) as 14.6%, 10.1% and 14.1% in TT1; 19.9%,
15.6% and 32.2% in TT2’s control arm; 22.5%, 24.7% and
40.3% in TT2’s thalidomide arm; and 61.6%, 58.2% and
77.2% in TT3. Data will be presented on age- and genderadjusted
comparisons of overall survival (OS) with the general
population along with the independent baseline features
linked to 5-yr PFS and CRD estimates, also in the context of
gene expression profiling (GEP), available in subsets of
TT2 and TT3 trials. Collectively our results support the conclusion
of curability in principle through increasing survival
plateaus especially for GEP-defined low-risk MM reaching
post-CR CF estimates of >80% in TT3 but also 33% in
high-risk MM treated with TT3.
OP36 Adult ALL treatment approach for B-ALL
Dieter Hoelzer, University of Frankfurt, Germany
Therapy of Burkitt leukemia (WHO classification 2008,
also mature B-ALL or L3 ALL) with conventional chemotherapy
resulted in an extremely overall survival of less then
10% in all published studies.
Short intensive sequential therapy
Improvement in outcome of Burkitt lymphoma/ leukemia
was first obtained in paediatric protocols e.g. (CODOX-M,
BFM, LMB). Important treatment elements were high-dose
fractionated alkylating agents, metabolites, high-dose Meth-

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
otrexate and high-dose Ara-C. When such protocols (e.g.
CODOX-M/IVAC, GMALL-B-NHL, Hyper-CVAD) were
applied in adult B-ALL and Burkitt-NHL, the CR rate increased
up to 80%, and the overall survival to 50–60%. Further
intensification, e.g. in HDMTX-dose, did not improve
results.
Stem cell transplantation
Autologous stem cell transplantation was considered as
an alternative option in Burkitt lymphoma/ leukemia. Survival
rates in retrospective analysis and prospective studies
ranged from 30–60%. A substantial proportion of patients
was not included because of CNS/ BM involvement or rapid
progress. Allogeneic transplant resulted in an overall survival
of 25–30%, most patients had high risk features or far
advanced disease. It was concluded that the allogeneic HCT
may exert a graft-versus-leukemia effect. Overall those SCT
results were not superior to those obtained with short intensive
sequential chemotherapy.
Immunochemotherapy
Burkitt-NHL/ leukemia cells express in >85% CD20.
Therefore some adult studies included the anti-CD20 monoclonal
antibody (MoAb) Rituximab. The response rate increased
and overall survival rate improved to 80–90% in
Burkitt lymphoma, in some studies somewhat inferior for
Burkitt leukemia.
Burkitt-NHL in HIV
20–40% of all NHL in HIV+ patients are Burkitt NHL.
When the short intensive treatment regimen were applied to
those patients, outcome was clearly superior to CHOP. CR
of approx. 60–70% and an overall survival rate of 50% were
achieved when the patients received an additional intensive
antiviral therapy (HAART).
In a recent attempt HIV+ Burkitt NHL patients received
also the MoAb Rituximab in addition to the intensive chemotherapy
and – despite the risk of increased immunosuppression
– the survival was improved to >60%.
Prognostic factors
With the improvement in outcome, it is not clear which
adverse prognostic factors for Burkitt-NHL/ BL remain.
Achievement of CR and probably stage of disease, but most
likely the double-hit lymphomas with a MYC/8q24 translocation
in combination with another recurrent translocation,
mainly t(14;18) with BCL2-IGH fusion are associated with
an unfavourable prognosis. For those patients an early SCT
might be indicated.
Future directions
A new strong adverse prognostic risk factor in Burkitt
leukemia is MRD, but is most unlikely relevant for Burkitt-
NHL.
For the remaining small fraction of non-responding or
relapsed patients it is difficult to find promising approaches,
this could be novel drugs including new antibodies, with the
aim to reduce the tumor load before a SCT.
Realising the rareness of the disease, joined efforts in
ALL study groups to identify risk populations and new promising
approaches should be considered.
OP37 T-ALL – Current Treatment
Stefan Faderl, Department of Leukemia, The University of
Texas MD Anderson Cancer Center Texas, USA [see SA01]
Patients with T ALL constitute about 25% of all adult
patients with ALL. The median age at diagnosis is about 30
years and it is seen more commonly in males. Not infrequently
do patients with T ALL present with high white
blood cell (WBC) counts and an anterior mediastinal mass
which may reach bulky proportions. Immunophenotyping
by flow cytometry is an essential part of the diagnostic work
up to confirm the diagnosis of an acute leukemia, assign the
correct lineage, an define the stage of maturation of the blast
cell population. Based on expression of various CD markers
T cell blasts are divided into early, cortical (thymic) and
meduallary (mature) subtypes. The most T cell lineage specific
marker is expression of surface CD3 (sCD3). This
marker is typically positive in the medullary type, negative
in the early stages and ambiguously expressed in the cortical
subtypes. Although less specific but of sufficient sensitivity,
CD1a is expressed in the cortical stages of T ALL but
not in early and medullary subtypes.
The prognosis of T ALL was poor in the past but has
improved substantially over recent decades and nowadays
surpasses that of patients with the more common precursor
B cell ALL. This evolution is due to changes in treatment
design and in particular based on 1) increased intensity; and
2) addition of other active drugs (eg, cytarabine, cyclophosphamide,
asparaginase). For example, whereas long-term
disease-free survival (DFS) was about 35% with conventional
Non-Hodgkin’s lymphoma (NHL) regimens, it increased
to about 50% when applying NHL regimens for
high-grade lymphomas and around 55% when using ALL
protocols. 1
An example for a current high-intensity ALL program is
Hyper-CVAD. 2 Hyper-CVAD consists of 8 intensive induction
/consolidation cycles where hyper-CVAD (hyperfractionated
cyclophosphamide, doxorubicin, vincristine, dexamethasone)
alternates with high-dose methotrexate and cytarabine.
This is followed by up to 32 months of the so
called POMP maintenance (vincristine, methotrexate, mercaptopurine,
prednisone). Central nervous system (CNS)
prophylaxis consists of intrathecal therapy with cytarabine
and methotrexate for a maximum of 8 injections. The experience
of patients with lymphoblastic lymphoma (T cell lineage
in 79% of the patients) was recently published. Fortynine
patients were included with a median age of 31 years
(range 17 to 59). The complete remission rate was 96% and
5-year survival 68%. Fourteen of the patients who achieved
CR relapsed at a median of 13 months. The joint study of
the MRC UKALL XII/ECOG E2993 trial included 356 patients
with T ALL with a median age of 29 years. 3 Patients
received 2 induction phases (daunorubicin, vincristine, asparaginase,
prednisone, methotrexate in phase 1 followed
by cyclophosphamide, cytarabine, mercaptopurine, and methotrexate
in phase 2). Patients were then either assigned to
an allogeneic stem cell transplant (SCT) arm (if they had an
HLA-compatible donor and were younger than 50 years) or
randomized between either an autologous SCT or chemo-
49

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
therapy (if they were at least 50 years old and had no donor).
Prior to their assigned or randomized treatment every patient
received high-dose methotrexate and asparaginase.
The complete remission rate was 94%; older patients (over
age 50 years) had a significantly lower remission probability
of 79%. The median 5-year survival probability was 48%
with significant differences based on age (38% for patients
over age 35), WBC (41% for patients with a WBC of
>100,000/mcl), immunophenotype (patients who expressed
CD13 and lacked CD1a expression did worse), and karyotype
(19% with complex karyotypes).
The German ALL Study Group (GMALL) evaluated outcome
of patients with T ALL based on immunophenotype:
early (sCD3 negative, CD1a negative), thymic (CD1a positive),
and mature/medullary (sCD3 positive). 4 Three different
studies included a total of 744 patients. Study GMALL
05/93 included 239 patients who all received multiagent
chemotherapy without provisions for SCT in first remission.
Studies GMALL 06/99 and 07/03 consisted of 505
patients. In these latter two studies patients received an intensified
treatment (pegaspargase, high-dose methotrexate)
and patients with early, mature and high-risk thymic T ALL
received SCT in first CR. Outcome was most favorable for
patients with thymic ALL where 10-year survival exceeded
60% with chemotherapy alone. Results were worst for patients
with early and mature T-ALL if they received chemotherapy
but were significantly better if these patients received
an allogeneic SCT in first remission.
Novel approaches aim to include additional drugs. In a
study by the MD Anderson group Hyper-CVAD is being
combined with nelarabine. Patients receive Hyper-CVAD as
detailed above. Prior to the POMP maintenance they receive
two cycles of nelarabine followed by one further cycle of
nelarabine later during the maintenance. Interim results
have recently been presented. 5 Of 23 patient with a median
age of 38 years (rate 21 to 76), the CR rate was 96%. With a
median follow up of 14 months, median overall and DFS
have not been reached. The survival probability at 3 years
was 65%. These data are in keeping with those reported by
other groups before. Longer follow up will be necessary to
determine the benefit if any of the addition of nelarabine
and in what sequence.
In summary, modern and intensive multiagent chemotherapy
regimens achieve remissions in most patients and
long-term DFS in about 50 to 60%. New markers of prognosis
(immunophenotype, genotype) are valid in determining
whether or not further intensification (SCT) in first remission
can improve outcome. Other markers (eg, mutations of
NOTCH1 or detection of the NUP214-ABL1 fusion gene)
are being explored as basis for applying targeted treatment
approaches (gamma secretase inhibitors in the former and
tyrosine kinase inhibitors in the latter example). New drugs
and combinations such as with nelarabine provide further
means to expand therapeutic options in the future.
R E F E R E N C E S
1. Cortelazzo S, Ponozoni M, Ferreri AJM, Hoelzer D. Lymphoblastic
lymphoma. Cri Rev Oncol/Hematol 2011 [epub]
2. Thomas DA, O’Brien S, Cortes J, et al. Outcome with the hyper-CVAD
regimens in lymhoblastic lymphoma. Blood 2004;104:1624–1630.
50
3. Marks DI, Paietta EM, Moorman AV, et al. T-cell acute lymphoblastic
leukemia in adults: clinical features, immunophenotype, cytogenetics,
and outcome from the large randomized prospective trial (UKALL XII/
ECOG E2993). Blood 2009;114:5136–5145.
4. Hoelzer D, Thiel E, Arnold R, et al. Successful subtype oriented treatment
strategies in adult T-ALL; Results of 744 patients treated in three
consecutive GMALL Studies. Blood 2009;114:abs 324.
5. Al-Ameri A, Thomas DA, Ravandi F, et al. Hyper-CVAD plus nelarabine
in the treatment of newly diagnosed patients with T cell acute lymphoblastic
leukemia/ lymphoblastic lymphoma (T-ALL/LL). J Clin Oncol
2011;29:432S.
OP38 Young adult with ALL – how to treat
Jean-Pierre Marie, Stéphanie Haïat, Anne Vekhoff
& Ollivier Legrand, Department of Hematology, Saint-
Antoine Hospital & Université Pierre et Marie Curie,
Paris, EORTC Leukemia Group
Survival for adult with ALL is lower than in children,
mainly due to the relapse rate. A pressing question is whether
the age-related differences in outcome are predicated by
the disease per see or whether they result from a different
approach to, or tolerance of, therapy. Boissel et al. (1) compared
the outcome of adolescents (15–20 years) with ALL
treated in France in either the pediatric FRALLE 93 or the
adult LALA-94 clinical trials. With a median follow up of
about 3.5 years, the CR rate (94% vs. 83%), event free survival
(EFS) at 5 years (67% vs.41%), and the DFS for the
CR patients (72% vs. 49%) were far superior in the pediatric
group and multivariate analysis confirmed the independent
effect of the treatment trial on outcome. The major differences
between the pediatric or adult approach were the actually
given dosages of asparaginase, corticosteroids and vinca-alkaloids.
Another difference was the strict discipline
with which the treatment courses were administered by the
pediatricians compared to the flexibility of the internists.
Analyses with similar outcome have been reported by comparing
ALL patients aged 15 till 21 years treated in different
countries (2,7). The recent GRAALL-2003 study suggests
that pediatric-inspired therapy markedly improves the outcome
in adult patients with ALL, at least until the age of 45
(8). We recently tested the feasibility of a pediatric regimen
(FRALLE 2000) (9) in 40 adult ALL patients (age 16–57
years), and compared the results to the EORTC ALL4 trial
(10). Median follow-up of alive patients was 1596 days for
patients treated in pediatric protocol and 1552 days for patients
treated in ALL4 protocol (p=NS). DFS and OS were
63%±9%, and 70%±7%, and were significantly longer in
patients under 40yo (86%±7% versus 30%±15%, p=0.003
[DFS] and 86%±7.8% vs 49%±12%, p=0.01 [OS], respectively)
or cortico/chemo-sensitive (71%±9% versus 36%±
15%, p=0.01 [DFS] and 86%±7%, versus 28%±13%, p=
0.0004 [OS]) than in other patients.
Ten patients had undetectable minimal residual disease
(MRD) and none of them experienced relapse. Grade 3 – 4
toxicities included a considerable number of severe infections,
liver function abnormalities, unexpected peripheral
neuropathies, osteonecrosis and denutrition. These toxicities
increased with age. The adherence discipline with respect
to time-lines of the treatment schedules was successful
in approximately 50% of the limited number of patients

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
studied so far. Similar experience was observed in the HO-
VON-70 study, which included 54 patients aged 18 to 39
years. Overall, it was concluded that results appeared very
encouraging, but that side effects necessitated prolongation
of the induction/consolidation/ intensification phase in a
considerable number of patients and that the protocol
seemed too intensive for older patients. The threshold, in
our experience but also in the GRAALL and the HOVON is
40 yo.
In conclusion, adolescents but also »young« adults (

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
ond generation ABL TK inhibitors. This provides the rationale
for the administration of TKI after SCT, although the
exact modalities, e.g. type of TKI, dose, starting timepoint
and duration of treatment remain to be resolved.
The importance of mutations in clinical resistance to
available TKI has promoted the search for novel inhibitors,
active particularly against the T315I gatekeeper mutation.
Interesting immunologic approaches are based on recently
developed bispecific T-cell-engager (BiTE) antibodies
that transiently engage cytotoxic T-cells for lysis of selected
target cells. The bispecific antibody construct called blinatumomab
links T cells with CD19-expressing target cells,
resulting in a non-restricted cytotoxic T-cell response and
T-cell activation. Preliminary results indicate that treatment
with blinatumomab is able to convert MRD positive ALL
into an MRD negative status, and that this is well tolerated.
Current efforts also involve the optimisation of molecular
techniques to quantitate minimal residual disease and identify
resistance mechanisms. Optimal treatment results necessitate
the integration of all available therapeutic and molecular
diagnostic approaches into predefined, long-term
strategies that take into account both patient and disease
characteristics.
OP40 MRD – criteria for postremission therapy
Deborah Thomas, (USA)
52
Abstract not submitted.
OP41 Allogeneic stem cell transplantation for
adult ALL: standard vs. Reduced-intensity
conditioning
Mohamad Mohty, Hematology Dpt., University-Hopsital
of Nantes, Centre de Recherche en Cancerologie de
Nantes-Angers (CRCNA), INSERM U892, F-44093
Nantes, France
Acute lymphoblastic leukemia (ALL) accounts for approximately
15 to 20% of all adult acute leukemias. Despite
the fact that 80 to 90% of adult patients with ALL succeed
in achieving complete remission (CR), most of them will
relapse and die of their disease. Among adults with ALL,
long-term leukemia-free survival (LFS) rates of 30 to 40%
have been obtained with the use of chemotherapy, as compared
with 45 to 75% with the use of conventional myeloablative
conditioning (MAC) allogeneic stem cell transplantation
(allo-SCT). The latter favorable effect is likely due to a
reduced risk of relapse, especially in those patients in first
CR. However, non-relapse mortality (NRM) may counterbalance
that favorable overall outcome observed after MAC
allo-SCT in those elderly patients and/or in patients with
comorbidities. Thus, the use of reduced intensity conditioning
(RIC) prior to allo-SCT may offer hitherto unavailable
opportunities to obtain a graft-vs.-leukemia effect without
the toxicities of intense preparative regimens. However, one
must acknowledge that the role of allo-SCT in adult ALL is
still controversial. In addition, ALL encompasses a group of
chemosensitive diseases, raising concerns that significant
reduction of the intensity of the preparative regimen prior to
allo-SCT may have a negative impact on long-term leukemic
control as it has been already shown in other settings.
Also, very few data is available analyzing RIC allo-SCT for
patients with ALL.
This report will discuss the available research evidence in
this field with a special focus on comparative studies which
assessed the outcomes of adult patients with ALL who underwent
allo-SCT, and were analyzed according to the type
of conditioning received prior to allo-SCT (RIC vs. MAC).
OP42 Autologous SCT for ALL – stil a chalange
Sebastian Giebel, Department of Bone Marrow
Transplantation, Maria Sklodowska-Curie Memorial
Cancer Centre and Institute of Oncology, Gliwice Branch,
Gliwice, Poland
First-line therapy of adults with Ph-negative acute lymphoblastic
leukemia (ALL) consists of remission induction
followed by intensive consolidation. Further treatment usually
depends on the presence of risk factors. Conventional
risk factors include initial tumor burden, age, immunophenotype,
karyotype, and time to achieve complete remission
(CR). In recent years, a number of studies demonstrated a
strong prognostic value of the status of minimal residual
disease (MRD) measured after induction and consolidation.
1–3 According to some authors MRD together with cytogenetics
may be sufficient for risk stratification. 4,5 Patients
allocated to standard risk (SR) group used to be treated with
long-term maintenance chemotherapy while those with high
risk (HR) features are usually offered allogeneic stem cell
transplantation (alloSCT).
The role of autologous SCT (autoSCT) in adults with
ALL has not been clearly defined. In the 1990ies a series of
studies have been conducted to evaluate whether high-dose
therapy followed by autoHSCT may improve the outcome
of HR patients lacking an HLA-identical sibling compared
to conventional-dose post-consolidation chemotherapy. 6–9
In the EORTC ALL3 study results of autoHSCT and maintenance
treatment appeared superimposable. 6 In the PETH-
EMA ALL93 study no significant difference between the
transplantation and chemotherapy arm could be demonstrated,
however, there was some tendency in favor of conventional-dose
treatment (disease-free survival, DFS, 44% vs.
35% at 5 years). 7 In contrast, results of the LALA-94 suggested
some advantage of autoHSCT (DFS 25% vs. 13% at
5 years) although the difference was not statistically significant.
8 A pooled analysis of three subsequent trials by the
French group (LALA-85/87/94) showed that autoHSCT may
contribute to decreased risk of relapse compared to conventional-dose
chemotherapy (66% vs. 78%, p=0.05) with mno
significant impact on survival. 10 Altogether, the above cited
studies did not provide clear evidence for neither the superiority
nor inferiority of autoHSCT over the maintenance.
In the largest so far MRC UKALLXII/ECOG 2993 study
investigators tested if autoHSCT may be administered instead
of consolidation + maintenance for patients lacking an
HLA-identical sibling, irrespective of the presence of risk
factors. 9 The overall survival was significantly worse in the

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
autoHSCT compared to chemotherapy arm (46% vs. 37% at
5 years, p=0.03) leading to conclusion that early autoHSCT
cannot substitute consolidation. In addition the donor vs. no
donor analysis revealed advantage of alloHSCT arm in SR
patients. In HR group the non-relapse mortality was 39%
among patients having a donor, overcoming advantage related
to reduced risk of relapse.
Disappointing results of prospective trials evaluating the
role of autoHSCT led to a general tendency to abandon this
treatment option in adults with ALL. It must be stressed,
however, that design of the studies could have been suboptimal.
First of all, the trials have been conducted before the
era of routine MRD assessment. Low tumor burden is prerequisite
of successful autotransplantation as in other conditions
the transplant material may be contaminated by residual
leukemic blasts leading to their re-transplantation and
early relapse. Evaluation of MRD status in bone marrow
reflecting the tumor load may therefore be crucial for selection
of patients who could benefit from autoHSCT. Indeed,
in a retrospective analysis by the European Working Group
for Adult ALL, the MRD level was demonstrated the most
important prognostic factor with DFS of 58% for patients
with MRD

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
mia (CLL) cells. The availability of these antibodies is making
a great impact in the treatment of CLL. Alemtuzumab, a
chimeric monoclonal antibody that targets the CD52 surface
antigen, was the first antibody approved for the treatment
of patients with CLL. It induces responses in one-third
of relapsed and refractory patients, and in more than 80% of
the patients when used as initial therapy. Alemtuzumab has
been used as single agent as well as in combination with the
monoclonal antibody rituximab or with chemotherapy in
combination with fludarabine, cyclophosphamide and alemtuzumab.
Treatment with alemtuzumab is associated with a
profound lymphocyte depletion and acquired immunosuppression;
therefore, opportunistic infections are often increased
following this therapy limiting its use. Rituximab,
a chimeric monoclonal antibody against CD20 has been
widely used in lymphoproliferative disorders. In CLL, rituximab
has limited activity when used as single agent, but has
significant synergism when used in combination with other
monoclonal antibodies or chemotherapy. The addition of
rituximab to the combination of fludarabine and cyclophosphamide
has been shown to improve response rate and prolong
survival in physically fit patients with CLL. Rituximab
has also shown activity in combination with numerous chemotherapeutic
agents such as bendamustine and pentostatin.
More recently developed, ofatumumab, is a fully humanized
anti-CD20 antibody with efficacy in patients whose
disease is refractory to both fludarabine and alemtuzumab.
Ofatumumab is currently undergoing evaluation in combination
with chemotherapy and other biological agents. Other
antibodies or related molecules currently in clinical trials
include GA101, a type II anti-CD20 antibody, lumiliximab,
an antibody targeting CD23, blinatumomab, a bi-specific
single-chain antibody targeting CD19 and Tru-016 a small
modular immunopharmaceutical (SMIP) targeting CD37.
These monoclonal antibodies and related agents use diverse
mechanisms of action, complement each other and when
used in combinations have the potential to enhance the activity
of chemotherapy and other biologic agents. Through
the ongoing and future development of such combinations,
effective therapeutic options for patients with CLL will continue
to increase.
OP47 New and old drugs in CLL – we can do
better
Peter Hillmen, (United Kingdom)
54
Abstract not submitted.
OP48 SCT for CLL – when?
Issa Khouri, Department of Stem Cell Transplantation
and Cellular Therapy, The University of Texas MD
Anderson Cancer Center, Houston, Texas, USA
In the past decade, the paradigm for allogeneic stem cell
transplantation (SCT) for chronic lymphocytic leukemia
(CLL) has changed. Confidence in the power of the graftversus-leukemia
effect has encouraged the use of transplan-
tation after low-intensity, nonmyeloablative preparative
regimens. This strategy has resulted in long-term remissions
in a subset of patients with advanced CLL who develop resistance
to conventional treatments. Nonmyeloablative SCT
(NST) can overcome adverse prognostic factors such as the
presence or absence of somatic mutations in the immunoglobulin
heavy chain variable region, Zeta-chain-associated
protein 70 kDa expression, and the presence of chromosomal
aberrations, including 17p13.1 deletion. Recent studies
suggested that patients’ hematopoietic SCT-comorbidity index,
tumor bulk, age, and disease refractoriness were important
determinants of survival. We review the results of
NST in CLL, discuss the evolution of the new nonmyeloablative
approaches, and make recommendations for when
SCT should be considered in patients with CLL.
OP49 Prognostic score for Hematopoietic Stem
Cell Transplantation
Alois Gratwohl, Hematology, Medical Faculty, University
of Basel, Basel, Switzerland
Hematopoietic stem cell transplantation (HSCT) has become
the treatment of choice for many patients with a congenital
or acquired severe disorder of the hematopoietic
system. Despite marked improvements over time, HSCT remains
inherently associated with morbidity and mortality.
Prior to any decision to proceed with HSCT an assessment
is warranted whether the potential benefits outweigh the
risks of the procedure. Risk assessment is complex, requires
specific skills and experience and includes risk of the disease
and risk of HSCT. Risk of HSCT includes pre-, peri-
and post transplant risk elements. Not all of them are known
at the time of decision making, pretransplant elements are.
The EBMT risk score provides a simple tool to assess instantly
pre-transplant risks for an individual patient. Five
factors, age of the patient (40 years 2 score points), stage of the disease (Early disease
stage 0; intermediate disease stage 1; late stage disease 2
score points), time from diagnosis to HSCT (1
year 1 score point. Note: time interval diagnosis to HSCT
does not apply for patients transplanted in 1 st CR, score is
always 0), donor type (HLA-identical sibling as donor 0;
other donor 1 score point) and donor recipient gender combination
(»all other combinations« 0; »female donor for a
male recipient« 1 score point) augment risk for an individual
patient with increasing score from 0 as best to 7 as worst.
Individual risks are additive! The score holds for all acquired
hematological disorders, for allogeneic and autologous
HSCT (for autologous HSCT consider only age, disease
stage and time interval; hence score 0–5). The score is
independent of the HSCT technology; eg, it is valid for standard
or reduced intensity conditioning, for bone marrow,
peripheral blood and cord blood transplants, for grafts with
or without T cell depletion. Survival is uniformly worse for
older patients, transplanted in more advanced disease stage
after a long time interval with a mismatched donor than for
younger patients, transplanted soon in early stage with a
well matched donor. Additional factors such as performance

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
score, comorbidities, CMV serostatus or cytokine polymorphisms
add to the risk and improve prediction. There impact
differs for low or high risk patients. Optimal donor recipient
gender combination or CMV serostatus improve outcome in
otherwise low risk patients whereas a low performance
score might be acceptable in low risk but detrimental in otherwise
high risk patients. Such comparative assessment of
disease risk and global pre-transplant risk can guide the decisions
for individual patients between HSCT and a non
transplant approach. The EBMT score forms the basis for a
risk adapted individualized strategy which should replace
the traditional »donor versus no donor« concept.
OP50 Consideration in Choosing the Optimal
Stem Cell Source
Mary M. Horowitz, Division of Hematology and Oncology,
Department of Medicine, Medical College of Wisconsin
and Scientific Director, Center for International Blood
and Marrow Transplantation (CIBMTR), USA
Considerations in selecting the optimal cell source for allogeneic
transplantation include donor relationship (related
versus unrelated), donor-recipient HLA-matching. and cell
source (bone marrow vs peripheral blood versus umbilical
cord blood). HLA-identical siblings are generally accepted
as the preferred donor unless donor co-morbidities preclude
donation. Whether to use bone marrow or peripheral blood
grafts from sibling donors depends, in part, on recipient factors.
Although peripheral blood grafts are associated with
higher risks of chronic graft-versus-host disease (GVHD),
patients with advanced disease may benefit from the higher
cell doses possible with such grafts. If an HLA-identical
sibling is not available, a search for an unrelated adult volunteer
donor may be done. Best results with unrelated donor
transplantation are obtained when donor and recipient are
matched at high-resolution for HLA A, B, C, and DRB1. In
the absence of a matched unrelated donor, a donor with a
single mismatch at these loci may be used. In such situations,
matching at low-expression alleles (DQ, DP, DRB3/
4/5) may be beneficial. CIBMTR data suggest that bone
marrow or peripheral blood grafts from unrelated donors
result in similar survival rates but with more GVHD; a large
randomized trial of unrelated donor blood versus bone marrow
grafts is in progress. Some data suggest that peripheral
blood transplantation may be more permissive of HLA mismatching
than bone marrow transplantation. If an adult unrelated
donor is not available in a timely manner, umbilical
cord blood mismatched at one or two loci may be used, with
current data suggesting results similar to results with unrelated
bone marrow or peripheral blood transplantation. The
limiting factor in cord blood transplantation is cell dose,
which may be circumvented by use of multiple units. The
choice of an adult donor versus cord blood is influenced by
graft factors such as HLA-match and cell dose but also by
patient factors such as age, weight, type of disease and urgency
of the clinical situation. Haploidentical peripheral
blood or bone marrow transplantation may also be effective
graft sources with a recent study suggesting results similar
to cord blood transplantation. With an increasing array of
graft source options, transplantation should be considered
early in the disease course of patients with diseases potentially
benefited by allografting to allow appropriate testing
of potential donors and to avoid undue delay when transplantation
becomes necessary. Decisions about when and
with which graft source to perform transplantation should
be based on a several factors, including donor and graft
characteristics but also patient age, performance status and
disease.
OP51 Source of stem cells in the allogeneic
transplant setting: bone marrow versus
peripheral blood stem cells
Mohamad Mohty, Hematology Dpt., University-Hopsital
of Nantes, Centre de Recherche en Cancerologie de
Nantes-Angers (CRCNA), INSERM U892, F-44093
Nantes, France
While peripheral blood stem cells (PBSC) are used almost
exclusively in autologous transplantation, recent surveys
indicate that PBSC are used in 50% to 70% of allogeneic
stem-cell transplants. Thus, large variation in practice
and considerable uncertainty exists with respect to the relative
effects of allogeneic PBSC transplantation (PBSCT)
versus bone marrow transplantation (BMT) on the outcomes
of patients with hematologic malignancies. Indeed, the use
of PBSCs for allogeneic transplantation is still not universally
accepted. This is in part due to unresolved concerns
about the long-term effects of growth factor treatment in
healthy volunteers and data suggesting that this stem cell
source is associated with more chronic graft-versus-host
disease (cGVHD). Compared with BM, PBSC grafts contain
significantly more total blood cells and more CD34+
cells. However, the most striking difference is the 10-fold
higher number of T cells in the PBSC graft. Other differences
include a higher number of monocytes and the absence
of mesenchymal stem cells.
In order to address the question of PBSCT versus BMT,
several randomized controlled trials have been conducted.
However, despite these well designed and executed clinical
trials, taken individually, most of these trials were relatively
small to draw definitive conclusions, and not surprisingly,
substantial controversy still remains regarding the impact
on mortality, disease control, and other important clinical
outcomes in relation with the type of donor.
This report will examine the differences in the outcomes
between HLA–matched, related and unrelated allogeneic PB-
SCT and BMT as therapy for hematologic malignancies.
OP52 Conditioning for SCT – the impact
of disease?!
Dietger Niederwieser, (Germany)
Abstract not submitted.
55

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
OP53 Conditioning for SCT – the impact
of disease?!
John Barrett, Hematology Branch, National Heart,
Lung and Blood Institute, National Institutes of Health.
Bethesda, MD, USA
Background
Bone marrow stem cell transplantation for hematological
malignancies was originally perceived as a necessary rescue
from bone marrow failure following the definitive treatment
of the malignant disease by high dose chemotherapy or radiation.
The earliest clinical studies from the mid 1950s involved
autologous bone marrow harvest, a single high dose
infusion of an alkylating agent followed by bone marrow
infusion rescue. Nevertheless, as early as 1956 Barnes and
Loutit demonstrated that in contradistinction to autologous
marrow grafts an allogeneic bone marrow could confer a
graft versus-leukemia (GVL) effect, albeit with an associated
lethal graft-versus-host reaction (GVH) 1 . Despite this
early recognition that the curative effect of a bone marrow
allograft lay not only in the strength of the conditioning
regimen but also in the alloreactivity of donor against recipient
leukemia it was generally considered that the GVL
effect was modest unless associated with such severe GVH
disease that it would be impracticable to pursue ways to select
and maximize GVL. In 1990 two papers changed our
perception by demonstrating that the GVL effect made a
major contribution to the curative effect of stem cell transplantation.
The first – a study by Horowitz, from the International
Bone Marrow Transplantation Registry revealed
the significantly lower relapse risk in survivors who had developed
acute and chronic GVHD with lowest relapse in
those who experienced both complications2 . The second,
from Kolb and colleagues, revealed the remarkable potential
of infusions of donor lymphocytes to achieve stable
cures of chronic myelogenous leuekemia (CML) relapsing
after bone marrow transplantation3 . The new perception that
GVL was a force to be recognized has underpinned the subsequent
evolution of SCT strategies. Here I will discuss the
interplay between the myelosuppression and immunosuppression
of the conditioning regimen, the stem cell graft
type, and post graft immunosuppression in the control of
malignant disease. The impact of various transplant approaches
on disease type and stage will then be considered
with the aim of identifying the best transplant strategy for
the individual patient.
The multifunctional role of the conditioning regimen
The agents used in conditioning regimens impact both
the hematopoietic and immune system as well as causing
off-target damage to other organ systems especially those
showing rapid cell turnover such as the gastrointestinal
tract. Figure 1 shows commonly used conditioning agents
classified by the spectrum of their properties. However it
should be noted that detailed characterization of the immunosuppressive
properties of many agents such as busulfan,
is lacking.
Nevertheless we now have enough understanding of the
relative actions of conditioning agents that regimens can be
56
Figure 1. Relative properties of common conditioning regimen agents
designed according to their intensity and myeolsuppressive
characteristics, as well as their ability to immunoablate.
Carefully selected combinations can minimize the unwanted
side effects. Currently used conditioning regimens are
classified as full intensity or reduced intensity which may or
may not be myeloablative.
Role of myelosuppressive intensity
There are now many studies comparing reduced intensity
and standard intensity regimens in specific malignancies.
Myeloablative intensity can be measured by myeloid cell
chimerism using CD15 as a marker. Lower intensity regimens
allow host hematopoietic recovery before their ultimate
rejection and replacement by donor myeloid cells
when the donor immunity transcends that of the host. Predictably
many studies show that relapse rates are higher in
recipients of reduced intensity transplants while recipients
of full intensity transplants are at greater risk of death from
non-relapse complications.
Role of immunosuppressive intensity
In a completely immunoablated recipient with no T cell
or NK cell function the SCT can rapidly engraft. Donor T
cell chimerism, measured in the CD3 fraction of peripheral
blood, reaches 100% by day 14 permitting the early establishment
of GVL effects accompanied by a risk of early
acute GVHD. The type of conditioning regimen affects the
degree to which residual host cells persist and thus affects
the pace of engraftment of the donor immune system.
Towards the selection of the best conditioning regimen
for the disease
While it is broadly true that more intensive conditioning
leads to greater antileukemic control as well as conferring
greater immunosuppression and permitting early donor immune
function, the relative merits of promoting GVL effects
or relying on direct suppression of malignancy by
chemoradiotherapy depend on the malignant disease in
question. The current challenge is to vary the conditioning
regimen to deliver the optimum conditions for cure for specific
disease subtypes.

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
Diseases where GVT effects predominate
The role of conditioning in promoting the GVT effect
transcends any anti-malignancy effect in two situations; In
solid tumors insensitive to chemotherapy such as renal cell
cancer the role of the conditioning is to establish the donor
immune system to initiate GVT activity. Fludarabine and
cyclophosphamide combinations function well in this regard
achieving rapid donor T cell chimerism without myeolablation.
Some hematological malignancies – CML,
chronic lymphocytic leukemia (CLL), and some non-hodgkin
lymphomas (NHL) are especially sensitive to GVL effects.
NHL regimens that avoid excessive immunosuppression
from conditioning using Campath (anti CD52) antibody
have a significantly lower relapse rate. In CML prior
to the imatinib era several studies began to explore the use
of non-myeloablative regimens or reduced intensity regimens
to achieve cure cure without complications from intensive
treatment. These studies showed that without the
contribution from some myelosuppression there was an increased
risk of persistent disease. CLL appears to be particularly
susceptible to GVL. As typically older patients
with CLL require transplants there has been much progress
in designing low intensity but effective regimens for such
patients.
Diseases requiring disease control as well as GVL/GVT
Despite a GVL effect being demonstrable most hematological
disorders (including myelodysplastic syndromes,
acute leukemias and multiple myeloma) require myeloablation
to maximize the chance of cure. The problem arises in
this group that there is a trade-off between curative potential
and risk of mortality from non-relapse causes. This has led
to careful titration of the dose intensity of the conditioning
especially in older or debilitated patients recognizing that
relapse risk increases with reduction in intensity.
Diseases without GVT
It seems likely that some solid tumors, neuroblastoma,
melanoma and breast cancer have minimal benefit from a
GVT effect. While GVT effects have been described in
breast cancer they appear to be in only a minority of patients.
Despite the potential for immunotherapy in this disease
allogeneic stem cell transplants for melanoma have not
been promising. After immunoablative conditioning the disease
appears to rapidly accelerate precluding any delayed
benefit from the GVT effect.
The future – disease control without excessive
conditioning intensity
Improvements in the present status of SCT for malignant
disease await developments in two areas; (1) Augmentation
of the GVT /GVL effect. Areas of investigation include
ways to generate tumor-specific or minor antigen-specific
CTL to prevent or treat relapse, use of tumor specific vaccines,
and augmentation of NK mediated GVL through NK
infusions and cytokines to boost NK function4,5 . Other promising
approaches are the use of demethylating agents to
upregulate presentation of cancer-testis antigens on malignant
cells and the use of cytokines and immunostimulatory
agents such as revlemid (upregulated CTL generation) 5 , and
bortezomib (upregulated TRAIL mediate killing) 6 .
(2) Delivering focused antimalignant therapy: The introduction
of »small molecules« – tyrosine kinase inhibitors
(TkI), and targeted therapy of malignancy while efficacious
as a stand alone treatment in CML may best be combined
with SCT. In Ph+ ALL, TkI with SCT may improve the
chances of disease-free survival 7 . Sirolimus appears to have
a unique double therapeutic effect of controlling GVHD
while having a direct anti-lymphoma effect 8 . Lastly the use
of radio-isotopes to target the bone marrow may be a promising
way to deliver high dose treatment to the areas where
leukemia resides while avoiding general organ toxicity 9 .
R E F E R E N C E S
1. Barnes DW, Corp MJ, Loutit, JF, Neal FE. Treatment of murine leukaemia
with X rays and homologous bone marrow; preliminary communication.
Br Med J 1956;2(4993):626–7.
2. Horowitz MM, Gale RP, Sondel PM, Goldman JM, Kersey J, Kolb HJ,
Rimm AA, Ringdén O, Rozman C, Speck B, et al. Graft-versus-leukemia
reactions after bone marrow transplantation. Blood 1990;75:555–62.
3. Kolb HJ, Mittermüller J, Clemm C, Holler E, Ledderose G, Brehm G,
Heim M, Wilmanns W Donor leukocyte transfusions for treatment of
recurrent chronic myelogenous leukemia in marrow transplant patients.
Blood 1990;76:2462–5.
4. Barrett J, Rezvani K. Immunotherapy: Can we include vaccines with
stem-cell transplantation? Nat Rev Clin Oncol 2009;6:503–5.
5. Parmar S, Fernandez-Vina M, de Lima M.Novel transplant strategies for
generating graft-versus-leukemia effect in acute myeloid leukemia. Curr
Opin Hematol 2011;18:98–104.
6. Yong AS, Keyvanfar K, Hensel N, Eniafe R, Savani BN, Berg M, Lundqvist
A, Adams S, Sloand EM, Goldman JM, Childs R, Barrett AJ.
Primitive quiescent CD34+ cells in chronic myeloid leukemia are targeted
by in vitro expanded natural killer cells, which are functionally
enhanced by bortezomib. Blood 2009;113:875–82.
7. Lee HJ, Thompson JE, Wang ES, Wetzler M. Philadelphia chromosomepositive
acute lymphoblastic leukemia: current treatment and future perspectives.
Cancer 2011;117:1583–94.
8. Armand P, Gannamaneni S, Kim HT, Cutler CS, Ho VT, Koreth J, Alyea
EP, LaCasce AS, Jacobsen ED, Fisher DC, Brown JR, Canellos GP,
Freedman AS, Soiffer RJ, Antin JH. Improved survival in lymphoma
patients receiving sirolimus for graft-versus-host disease prophylaxis
after allogeneic hematopoietic stem-cell transplantation with reducedintensity
conditioning. J Clin Oncol 2008;26:5767–74.
9. Pagel JM, Kenoyer AL, Bäck T, Hamlin DK, Wilbur DS, Fisher DR,
Park SI, Frayo S, Axtman A, Orgun N, Orozco J, Shenoi J, Lin Y, Gopal
AK, Green DJ, Appelbaum FR, Press OW. Anti-CD45 pretargeted radioimmunotherapy
using bismuth-213: high rates of complete remission
and long-term survival in a mouse myeloid leukemia xenograft model.
Blood 2011;118:703–1.
OP54 Infectious Complications of Stem Cell
Transplantation
Finn B. Petersen, Intermountain Blood and Marrow
Transplant Program, Salt Lake City, Utah, USA
Introduction
Despite major advances in detecting, preventing and treating
infections associated with any type of stem cell transplantation
(SCT), non-relapse mortality after SCT rarely
occurs without a direct or indirect contribution from an infectious
episode. Thus, by 2009, infections were reported as
a primary cause of mortality in up to 8% of autologous, and
up to 20% of allogeneic SCT recipients1 . For this reason,
ongoing focus on cost-effective means to detect, prevent
57

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
and treat SCT associated infections need to remain a major
focal point of SCT care.
Methods
5 complementary approaches are commonly used by SCT
clinicians to minimize the risk of morbidity and mortality
from infectious diseases: 1) prophylactic modalities, 2) empiric
modalities, 3) pre-emptive modalities, 4) therapeutic
modalities, and 5) salvage modalities. Which modality will
be most effective for a given situation or patient population
for prophylaxis depends solely on the severity of infection
to be prevented, the cost, and expected adverse events, for
empiric therapy on signs or symptoms of infection vs. the
inability of early detection, for pre-emptive therapy on the
ability for early detection vs. available effective therapy, for
therapy on having effective therapeutics available, and for
salvage on having effective second line therapies available
in case of primary treatment failure.
Major Advances
Since the beginning of clinical SCT, and the recognition
of the high morbidity and mortality from infections in this
patient population, infection prevention and control have
been a main area of clinical SCT research, already in the
1970’s documenting the benefit of protective environments,
prophylactic antimicrobials and rapid diagnosis of the most
serious infections.
The most significant advances over the past 25 years in
reducing the impact and threat of infectious diseases in SCT
are shown in table 1. However, these improvements have
most often been used to expand SCT treatments to older and
higher risk patients, or for permitting us of more potent immunesuppression
with the SCT, for a net stable treatment
related morbidity and mortality from infectious diseases
over time.
Future Directions
Aside from continuing to refine and adapt the modalities
listed in table 1 to the ever changing transplant and microbiological
environments, future improvements in reducing
the impact of infectious diseases associated with SCT may
Table 1. Modalities to reduce the impact of infectious diseases in stem
cell transplantation
Modality
Year
Introduced
Use
Broad Spectrum Systemic Antibiotics 1986 P, E, PE, T, S
Acyclovir 1983 P, E, PE, T
Post-transplant Filgrastim 1989 P, E, PE
Peripheral Blood Stem Cells 1990 P
1st generation triazoles (fluconazol) 1990 P, E, PE, T
Quinolone Prophylaxis during neutropenia 1991 P, T
CMV Early Diagnosis / Treatment 1992 P, E, PE, T
Lipid Compound Polyenes 1992 E, T, S
Echinocandens / 2nd generation triazoles 2000 P, E, PE, T, S
Pre-/post-transplant Palifermin 2005 P
P=Prophylactic, E=Empiric, PE=pre-emptive, T=therapeutic, S=Salvage.
Bolded letters designate primary use.
58
come from clinical adaptation of single nucleotide polymorphisms
(SNPs) of toll-like receptor (TLR) or similar inflammatory
response associated genes, potentially permitting an
infectious disease risk allocations of patients based on specific
infection response genotypes.
Also, a better ability to promote earlier and more complete
post-transplant immune reconstitution, and to be able
to control antigen-discrepancies between donor and recipient
without having to use infection facilitating immunosuppressive
agents such as corticosteroids and tumor-necrosisfactor
blockers, would promote infection control in SCT
patients. Lastly, shifting all anti-infectious activities from
empiric and therapeutic to prophylactic and pre-emptive use
also would represent a significant step forward, but the realization
of such a goal will depend on further development of
sensitive and microbe specific early detection tests, of which
only a few are available for clinical use today. Finally, in
today’s strained budgetary environment, an ongoing weighing
of the use of often expensive, but effective, infection
prophylaxis modalities against the cost, both monetary and
human, of devastating and potentially fatal infections, is an
absolute necessity.
Of help to the transplant clinicians are an increasing body
of evidence based guidelines published by specialty groups
and societies, such as what the major national and international
societies involved in SCT did in their most recent update
of »Guidelines for preventing infectious complications
among hematopoietic cell transplant recipients: a global
perspective« in a special issue of Bone Marrow Transplantation
published in 2009 1
Conclusion
While major improvements in detection, prevention and
therapy of SCT related infectious diseases have been significant
over time, and permitted SCT of higher risk patients
and using higher risk transplants, the microbiological, transplant,
and regulatory fields are constantly evolving in unpredictable
ways, presenting clinical stem cell transplant
clinicians with ever new infectious disease challenges.
R E F E R E N C E S
1. M Tomblyn et al: »Guidelines for preventing infectious complications
among hematopoietic cell transplant recipients: a global perspective«.
Bone Marrow Transplantation 2009;44:453–526
OP55 Old drug, new tricks in prevention of graftversus-host
disease (GVHD): Development
and clinical applicability of high-dose
cyclophosphamide
Leo Luznik, Division of Hematologic Malignancies;
Department of Oncology, Sidney Kimmel Comprehensive
Cancer Center at Johns Hopkins, Baltimore, MD. USA
GVHD is a major complication of allogeneic hematopoietic
stem cell transplantation (alloHSCT). The successful
prevention of acute GVHD with CNIs and methotrexate
(MTX) was developed in the 1980s and has revolutionized
the field of alloHSCT; however, at least 50% of patients still

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
develop this complication.(1, 2) There is currently no successful
strategy for the prevention of chronic GVHD, the
most common cause of late morbidity and mortality. It affects
over 50% of patients who would otherwise have been
cured of their primary malignancy.(3) Mechanistically, immunosuppressive
drugs given to control GVHD suppress
alloimmunity by the nonspecific inhibition of alloreactive T
cell activation, proliferation, and differentiation. By blocking
T-cell activation, currently used agents in the GVHD
prophylaxis regimens interfere with the apoptosis of the
alloreactive T cells, causing global immunosuppression
and a delay in the time for induction of transplantation
tolerance. Of all the commonly used immunosuppressants,
only MTX and cyclophosphamide (Cy) can induce the
apoptosis of alloantigen-activated human T cells.(4) MTX,
although active as a single agent for GVHD prevention, due
to its intrinsic toxicity profile, it cannot be administered in
higher doses critical for inducing the en masse alloreactive
T-cell apoptosis. On the other hand, Cy can safely be administered
in high-doses, which are required to eliminate alloreactive
clones after alloHSCT because of its favorable safety
profile, including lack of toxicity to the primitive hematopoietic
stem cells.(5) Our recently published results suggest
that high-dose Cy is sufficient as a single agent in the
prevention of both acute and chronic GVHD after myeloablative
conditioning and allografting using HLA-matched
related and unrelated donors.(6) Patients transplanted using
this strategy have a low incidence of infections and, despite
the advanced disease stage, their survival is favorable, suggesting
that this approach retains the graft-versus-leukemia
(GVL) effect. Our group has been also exploring high dose,
post-transplantation Cy as prophylaxis of GVHD after nonmyeloablative,
HLA-haploidentical bone marrow transplantation,
or mini-haploBMT.(7) Among 210 recipients of
mini-haploBMT, 87% of patients have experienced sustained
donor cell engraftment. The cumulative incidences of
grades II-IV acute GVHD and chronic GVHD are 27% and
13%, respectively. Five-year cumulative incidence of nonrelapse
mortality is 18% and actuarial overall survival and
event-free survivals are 35% and 27%, respectively. Recent
multi-center phase II trial conducted by Blood and Marrow
Transplant Clinical Trials Network confirmed the validity
of posttransplant Cy in GVHD prevention across HLA-barriers.(8)
Survival rates after posttransplant Cy-based minihaploBMT
were comparable to survival rates in patients
with high-risk hematologic malignancies who were transplanted
with blood or marrow from HLA- matched unrelated
donors after reduced conditioning. In conclusion, by
taking advantage of the differential susceptibility of proliferating,
alloreactive T cells over non-proliferating, non-alloreactive
T cells to high dose Cy, this novel strategy provides
a unique opportunity to optimize GvHD prophylaxis
after HLA-matched alloBMT and increase the use of HLAmismatched
donors. (9) (10)
R E F E R E N C E S
1. Appelbaum FR. Hematopoietic-cell transplantation at 50. N Engl J
Med 2007;357:1472–1475.
2. Storb R, Deeg HJ, Whitehead J, Appelbaum F, Beatty P, Bensinger W,
Buckner CD, Clift R, Doney K, Farewell V, et al. Methotrexate and
cyclosporine compared with cyclosporine alone for prophylaxis of
acute graft versus host disease after marrow transplantation for leukemia.
N Engl J Med 1986;314:729–735.
3. Lee SJ. Have we made progress in the management of chronic graft-vshost
disease? Best Pract Res Clin Haematol 23:529–535.
4. Strauss G, Osen W, Debatin KM. Induction of apoptosis and modulation
of activation and effector function in T cells by immunosuppressive
drugs. Clin Exp Immunol 2002;128:255–266.
5. Jones RJ, Barber JP, Vala MS, Collector MI, Kaufmann SH, Ludeman
SM, Colvin OM, Hilton J. Assessment of aldehyde dehydrogenase in
viable cells. Blood 1995;85:2742–2746.
6. Luznik L, Bolanos-Meade J, Zahurak M, Chen AR, Smith BD, Brodsky
R, Huff CA, Borrello I, Matsui W, Powell JD, Kasamon Y, Goodman
SN, Hess A, Levitsky HI, Ambinder RF, Jones RJ, Fuchs EJ. High-dose
cyclophosphamide as single-agent, short-course prophylaxis of graftversus-host
disease. Blood 115:3224–3230.
7. Luznik L, O’Donnell PV, Symons HJ, Chen AR, Leffell MS, Zahurak
M, Gooley TA, Piantadosi S, Kaup M, Ambinder RF, Huff CA, Matsui
W, Bolanos-Meade J, Borrello I, Powell JD, Harrington E, Warnock S,
Flowers M, Brodsky RA, Sandmaier BM, Storb RF, Jones RJ, Fuchs
EJ. HLA-haploidentical bone marrow transplantation for hematologic
malignancies using nonmyeloablative conditioning and high-dose,
posttransplantation cyclophosphamide. Biol Blood Marrow Transplant
2008;14:641–650.
8. Brunstein CG, Fuchs EJ, Carter SL, Karanes C, Costa LJ, Wu J, Devine
SM, Wingard JR, Aljitawi OS, Cutler CS, Jagasia MH, Ballen KK,
Eapen M, O’Donnell PV. Alternative donor transplantation after reduced
intensity conditioning: results of parallel phase 2 trials using
partially HLA-mismatched related bone marrow or unrelated double
umbilical cord blood grafts. Blood 118:282–288.
9. Luznik L, Fuchs EJ. High-dose, post-transplantation cyclophosphamide
to promote graft-host tolerance after allogeneic hematopoietic
stem cell transplantation. Immunol Res 47:65–77.
10. Luznik L, Jones RJ, Fuchs EJ. High-dose cyclophosphamide for graftversus-host
disease prevention. Curr Opin Hematol 17:493–499.
OP56 Chronic Graft-versus-Host Disease
– Anything New in Prevention and
Treatment?
Steven Zivko Pavletic, National Cancer Institute,
Bethesda, Maryland, USA
Chronic graft-versus-host disease (cGVHD) is the leading
cause of non-relapse morbidity and mortality in survivors
after allogeneic hematopoietic stem cell transplantation
(HSCT), but is also associated with lower malignancy
relapse rates. In 2005 an NIH Consensus Conference galvanized
the cGVHD clinical research field by providing standardized
definitions about diagnosis, staging, response criteria,
data collection and conduct of clinical trials. These
consensus documents set the stage for a number of prospective
cohort studies in the United States and internationally
which are currently in progress.
In spite of effective measures available for preventing
acute GVHD, until recently, there were no signs that similar
preventive strategies could be developed for cGVHD. However,
emerging data from cohort studies and clinical trials
indicate areas where progress could be made. The key challenges
for prevention in cGVHD are the lack of specificity
of the current cGVHD therapies and our poor understanding
of the graft-versus-malignancy effect (GVM) targets. There
is a hope that ongoing studies which integrate in depth investigation
of the cGVHD biology in conjunction with well
annotated patient tissue samples will generate necessary information
and lead towards the development of early tar-
59

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
geted therapeutic interventions to prevent severe cGVHD.
Parallel research is needed to identify precisely the GVM
targets on the malignant cells or to integrate some of the
newly emerging anti-cancer drugs in the cGVHD prevention
and treatment algorithms. One of the strategies to develop
better timing of cGVHD prevention is to identify
markers of cGVHD activity that differentiate active disease
manifestations from those that are caused by the irreversible
damage.
In the area of front line therapy there have been several
attempts to bring promising agents as first line in addition to
steroids. None of these combinations have succeeded in improving
symptoms of cGVHD and commonly have been associated
with prohibitive side effects including increased
relapse. Therefore 0.5–1.0 mg/kg/day of prednisone remains
the standard front line systemic treatment for cGVHD.
Unfortunately, about 50% of cGVHD patients fail steroids
and need second line treatments. Currently there is no standard
recommended second line therapy for cGVHD and the
choice of agent is based on the patient and clinician preferences,
prior treatment history and expected side effects profile.
Agents which are most commonly used in steroid refractory
cGVHD include extracorporeal photopheresis, mycophenolate,
sirolimus, rituximab, pentostatin and imatinib.
Currently standard second line therapy is a clinical trial if
available. The treatment of the bronchiolitis obliterans syndrome
(BOS) which is the lung manifestation of cGVHD
poses a specific challenge to clinicians due to the high mortality
and lack of effective treatments for this most devastating
presentation of cGVHD. BOS is increasingly recognized
as an area for clinical research. In summary, although little
progress in improving our ability to prevent or treat cGVHD
can yet be declared, there are a number of promising basic
research studies and clinical trials which suggest significant
breakthroughs in the near future.
OP57 Relapse after Allogeneic Hematopoietic
Stem Cell Transplantation – The Necessity
for New Strategies and Treatments
Michael R. Bishop, Medical College of Wisconsin,
Milwaukee, Wisconsin, USA
Recurrence of disease is the leading cause of mortality
after allogeneic hematopoietic stem cell transplantation (alloHSCT),
whose efficacy is largely attributed to graft-versus-tumor
(GVT) effects. There are several factors that are
responsible for the biologic resistance of malignancies to
beneficial effects of alloHSCT including clonal evolution of
cancer, drug and radiation resistance, cancer epigenetics,
and possibly cancer stem cells. However, several other factors
affect the occurrence and outcome of relapse, including
conditioning regimen, type of allograft, and disease histology,
status, and sensitivity to chemotherapy. Optimally strategies
are needed to precisely balance immune responses to
favor GVT without harmful graft-versus-host disease to protect
against relapse and treat recurrent disease after HSCT.
The outcomes of patients relapsing after an alloHSCT generally
remain poor even with the use of donor lymphocytes
infusions (DLI). Developing strategies to promptly identify
60
patients at risk for relapse after alloHSCT, while malignancy
is in a more treatable stage, could decrease relapse rates
after alloHSCT. Monitoring of minimal residual disease
(MRD) post-transplant, through methods such as molecular
genetics, tumor-specific molecular primers, fluorescein in
situ hybridization, and multi-parameter flow cytometry,
could lead to novel preemptive treatments of relapse. Studies
are also needed to provide data with detail on disease
status, prior treatments, biologic markers, and post-transplant
events to identify patients at high risk for relapse. The
development of strategies to intervene prior to florid relapse
may include non-immunologic therapies, such as targeted
preparative regimens and post-transplant drug therapy, as
well as immunologic interventions, including graft and Tcell
engineering, vaccination, and dendritic cell-based approaches.
There is no standard approach to treating relapse
after alloHSCT. Withdrawal of immune suppression and
DLI are commonly used for all diseases; however, the efficacy
of DLI is quite variable depending on disease histology
and state and has limited efficacy in the majority of hematologic
malignancies. As such, there is a significant need for
novel therapies, strategies, and well-designed, disease-specific
trials for relapse following alloHSCT, particularly in
patients for whom DLI is not an option. The 2009 National
Cancer Institute International Workshop on the Biology,
Prevention, and Treatment of Relapse after Allogeneic Hematopoietic
Stem Cell Transplantation was convened to
identify, prioritize, and coordinate future research activities
related to relapse after alloHSCT. The Workshop suggested
3 major initiatives for a coordinated research effort to address
the problem of relapse after alloHSCT: (1) to establish
multicenter correlative and clinical trial networks for basic/
translational, epidemiologic, and clinical research; (2) to establish
a network of biorepositories for the collection of
samples before and after alloHSCT to aid in laboratory and
clinical studies; and (3) to further refine, implement, and
study the Workshop-proposed definitions for disease-specific
response and relapse and recommendations for monitoring
of MRD. These recommendations, in coordination
with ongoing research initiatives and transplantation organizations,
provide a research framework to rapidly and efficiently
address the significant problem of relapse after alloHSCT.
OP58 Design, conduct and analysis of clinical
trials in acute leukemia: the keys of success
Stefan Suciu, EORTC Headquaters, Brussels, Belgium
Clinical trials are experiments performed in medical settings
in order to determine maximum tolerated dose of a
drug/regimen (phase I), its activity (phase II) or efficacy
(phase III) in a given patient population. In order to shorten
the drug development, phase I/II, or phase II/III, or even
phase I/III trials may be set-up as well. Phase I and II trials
require a limited number of patients, as their endpoints are
toxicity and activity (e.g. CR rate) respectively. In order to
detect moderate treatment differences in term of efficacy,
randomized phase III trials require large numbers of patients
and long follow-up. Such trials are sized according to a pri-

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
mary endpoint, generally overall survival, event-free survival,
progression-free survival or disease-free survival (for
patients who reached CR). Secondary endpoints contain remaining
efficacy endpoints, CR rate, highest toxicity/adverse
events observed during treatment courses, time to recovery
and, if possible, quality-of-life evaluations. Longterm
outcomes and toxicities, incidences of secondary tumors
are evaluated as well, in case of potentially toxic or
long lasting treatments (drugs, drug combinations, irradiations).
A phase III trial may contain several randomized questions.
If no interactions between them are foreseen, such
factorial designs represent an efficient way to use a patient
population. To overcome possible interactions, 10–20% more
patients should be added as compared to a classical one
question trial.
Acute leukemias, lymphoblastic (ALL) or myeloblastic
(AML), are heterogeneous diseases. In AML distinct entities
have been determined (e.g. APL, t(8;21)/inv(16), FLT3,
etc). Age and performance status are important patient-factors
to adjust treatment intensity. In the personalised treatment
era, patient population available to enter into a phase
III trial becomes quite limited, even within a large cooperative
group. Intergroup trials should be set-up in order to
reach adequate patient accrual. The leading group, in cooperation
with a Company, should set-up the protocol, with
the input of other interested groups. Agreements regarding
submissions (e.g. protocol, SAE) to local regulatory authorities,
data collection process, publication rules and authorship,
etc should be set-up and applied.
Phase III trial analyses should be done when mature efficacy
data are available: final analysis, when the required
number of events is reached, and interim looks, if specified
in the protocol. Early stopping rules for efficacy and/or futility
should be based on well defined statistical rules. In
order to avoid any conflict of interest, only an Independent
Data Monitoring committee (IDMC) should evaluate the interim
results and provide adequate recommendations to the
trialists. If there is sufficient evidence that the experimental
treatment is superior to the standard one, or the treatment
difference is already too low or goes in the wrong direction,
one may draw early conclusions, and, if necessary, switch
patients already entered in the trial, from one arm to another.
Statistical analyses should be done in accordance to the trial
design, using efficient statistical tests. If randomization was
stratified by some prognostic factors (e.g. age and WBC),
statistical test (e.g. logrank test or Cox model) should be
stratified/adjusted by these factors, in case a block-size/
minimization method was used for randomization. Such test
will provide unbiased treatment difference estimate, having
an increased efficiency as compared to the unstratified/unadjusted
test. Adjustments by other important factors could
be done. Interactions between some factors and treatment
could be investigated as well, for detection of potential predictive
factors for treatment efficacy.
A successful trial requires a good idea, e.g. the assessment
of a targeted drug to be used alone or in an already
existing treatment scheme, in a »marker«-positive patient
population, in whom the experimental treatment may be applied.
The trial should be properly designed, preferentially
be randomized in order to avoid any systematic bias. Disease
assessments should mirror as much as possible the
usual clinical practice, and be scheduled and made evenly in
the treatment groups. Efficient data collection regarding the
main and secondary endpoints should be done. A good cooperation
of clinical investigators should provide a fast recruitment.
Interim and final analyses using proper statistical
technique should be done on (relatively) mature data in order
to be able drawing valid conclusions. In case of any
safety concerns, in some trials (e.g. phase III, randomized
phase I/III), safety data should be monitored by an Independent
Data Safety Monitoring Board (IDSMB), with no conflict
of interest. This should meet regularly in order to provide
adequate recommendations regarding the study conduct.
OP59 Front line therapy for indolent B-cell
lymphoma
Nathan Fowler, Department of Lymphoma and Myeloma,
MD Anderson Cancer Center, Houston, Texas, USA
A number of treatment options exist for newly diagnosed
patients with indolent non-Hodgkins lymphoma (iNHL).
Several randomized studies have demonstrated an improvement
in both progression free survival (PFS) and overall
survival (OS) with the addition of anti-CD20 directed monoclonal
antibody (MAB) therapy into frontline combinations.
Despite these developments, the majority of advanced
stage patients still relapse with iNHL or undergo aggressive
transformation, and improvements in frontline treatment are
needed. Although maintenance treatment with MABs and
consolidation with anti-CD20 radioconjugates results in
prolongation of PFS, their effect on OS is unknown. Bendamustine
has significant activity in iNHL, and recent randomized
studies suggest a potential role in untreated patients.
Newer agents, such as the immumomodulatory agent
lenalidomide, the proteasome inhibitor bortezomib, and
drugs targeting essential steps in the B-cell receptor pathway
such as Bruton’s tyrosine kinase (BTK) and PI-3 kinase
show promise. Studies are currently underway exploring the
potential to incorporate these and other novel biologic
agents into frontline treatment for iNHL.
OP60 Rituximab maintenance treatment
in indolent lymphoma
Ofer Sphilberg, Inst. of Hematology, Davidoff Center,
Beilinson Hospital & Tel-Aviv University, Israel
Follicular lymphoma, which represents 15%–30% of newly
diagnosed lymphomas, is an indolent lymphoma that is
characterized by slow growth and a high initial response rate
but relapsing and progressive disease. Most patients are diagnosed
with advanced disease, that is, stage III or IV, and cannot
be cured with currently available conventional therapies.
New treatment modalities are therefore urgently needed.
The chimeric monoclonal antibody rituximab targeted
against CD20, a protein that is expressed on the surface of
61

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
all mature B cells, is active in many B-cell lymphomas that
express this molecule. Rituximab administered intravenously
in combination with chemotherapy improves overall survival
in patients with newly diagnosed and relapsed indolent
lymphoma compared with chemotherapy alone.
Rituximab maintenance therapy following successful induction
has recently emerged as a highly effective treatment
for follicular lymphoma. Randomized clinical trials as well
as systematic review and meta-analysis, analyzing the impact
of rituximab maintenance compared to observation
alone have demonstrated a significantly better outcome in
terms of progression-free survival in patients who received
as first-line treatment single-agent rituximab, standard chemotherapy
and recently also immuno-chemotherapy. In the
setting of relapsed disease, rituximab maintenance has shown
a significant benefit even in terms of overall survival.
These data suggest that maintenance therapy with rituximab
as four weekly infusions every 6 months or as a single
infusion every 2–3 months, should be added to standard
therapy for patients with follicular lymphoma after successful
induction therapy.
OP61 Risk adapted treatment for patients
with B-DLBCL
Marek Trneny, (Czech Republic)
62
Abstract not submitted.
OP62 Treatment of peripheral T-Cell lymphomas
Pier Luigi Zinzani, Institute of Hematology »Seràgnoli«,
University of Bologna, Italy
Up till recent years, no major therapeutic advances have
been observed in peripheral T/NK-cell lymphomas (PTCL),
with overall survival (OS) values for most of the systemic
entities in the order of 25–35% at five years. Furthermore,
there has been a rather consistent lack of PTCL-specific
clinical trials, partly due to the rarity of this condition, and
partly to diagnostic difficulties and controversial views on
whether immunophenotype-specific treatment strategies
should be adopted. As a consequence of the REAL and the
subsequent WHO classification of malignant lymphomas,
present day diagnostic approaches identify PTCL entities
based upon immunophenotype in association with clinical,
morphological, and molecular genetic data. These advances
have recently led to PTCL-specific clinical trials.
Analogue to the treatment strategy applied in diffuse
large B-cell lymphoma (DLBCL), combination chemotherapy
with CHOP (cyclophosphamide, adriamycin, vincristine,
prednisone) or CHOP-like variants has up till now been
the most frequently used first line therapy also in PTCL.
Given as standard schedule every three weeks, this approach
does not seem to benefit more than 25–30% of the patients,
while schedule intensification, e.g. shortening of the timeinterval
between courses and/or addition of etoposide, has
by some authors been reported to improve outcome. However,
reported OS values have been varying, often depend-
ing on the included number of prognostically more favourable
cases belonging to the histological subtype anaplastic
large cell lymphoma (ALCL), alk-positive.
Based on small-scale observations on single-agent efficacy,
gemcitabine has also been investigated in some PTCLspecific
trials. Response rates were encouraging, but of relatively
short duration.
High-dose therapy with autologous stem cell transplant
(HDT/ASCT) proved feasible in both relapsed/refractory
and treatment-naïve PTCL. Overall results suggest a more
favorable impact of this approach in first line as compared
to salvage treatment. However, most data are of selected and
retrospective nature. At present, only a few PTCL-restricted
phase II trials investigating HDT/ASCT as part of a firstline
therapeutic approach have been reported. Of these only
very few have a sufficient cohort-size to compensate for the
heterogeneity of this disorder.
Combinations of chemotherapy with T-cell specific monoclonal
antibodies (MoAb) have shown high overall response
rates (ORR) and are currently being investigated in
ongoing clinical trials.
Due to the rarity of T/NK-cell neoplasms, no PTCL-restricted
phase III trials have yet been completed. However,
the first international efforts have recently been launched.
OP63 Therapy of Mantle cell Lymphoma
Christian Geisler, Rigshospitalet, Copenhagen,
Denmark
The treatment of choice in younger, fit MCL patients is
induction immunochemotherapy followed by high-dose
therapy with autologous stem cell support. Phase-II data
have strongly suggested that Ara-C containing immunochemotherapy
is superior to R-CHOP, and this has now been
confirmed by a randomized trial by the European MCL Network.
In elderly/frail patients, however, R-CHOP was superior
to R – fludarabine + cyclophosphamide, possibly as the
combined net effect of efficacy and tolerability. The combination
of R-CHOP with rituximab maintenance has furher
prolonged progression-free survival and may be the regimen
of choice in elderly frail patients, but needs testing
against R-AraC. The treatment goal in both settings is complete
clinical and molecula remission.Targeted therapy with
proteasome inhibitors, m-Tor inhibitors and other new compounds
represents promising areas of development in firstline
and salvage treatment.
OP64 Is there a role of radioimmunotherapy
in NHL
OP65 Therapy for relapsed/refractory aggressive
NHL
Anas Younes, (USA)
Abstract not submitted.

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
OP66 Alternative monoclonal antibodies
for the treatment of NHL
Luis Fayad, (USA)
Abstract not submitted.
OP67 Early favorable and unfavorable Hodgkin
lymphoma in adults, standards and
directions
Patrice Carde, Institut Gustave Roussy, Villejuif, France
Few malignancies, if any, benefited a step-by-step improvement
in tumor control and survival rates as early favorable
and unfavorable Hodgkin lymphoma. Competition
between Cooperative groups through to rigorous prospective
randomized phase III trials result in the current proposal
of an optimal treatment balancing relapse and longterm
risks. Standard treatment consists in 2 to 3 cycles of
ABVD followed by 20–30 Gy involved field radiation therapy
(IFRT) in early favorable and in a minimum of 4 cycles
and of 30 Gy in early unfavorable stages (E. Lugtenburg &
A. Hagenbeek Treatment of Early Favorable HL chapt. 10,
pp. 179 in Hodgkin Lymphoma -A. Engert and S.J. Horning
(eds.) DOI: 10.1007/978-3-642-12780-9_11, © Springer-
Verlag Berlin Heidelberg 2011; Raemaekers JJJ & Engert A
Treatment of Early Unfavorable HL, chapt. 11, pp. 185–187
ibid); These standards provide EFS/PFS/FFTF and OS rates
of 93% and 97%, respectively for early favorable stages
(GHSG HD-10) and of 91 an >97%, respectively for early
unfavorable stages (GHSG HD-14); see Table 1.
Taking into account the already very high level of the current
results, the relatively short follow-up of 3–5 years for
most of these studies and, unhappily, the rarity of late reports,
due to the hard work and low reward from long-term
updates, only dismal differences can be expected between
treatment arms, even adequately powered, as in the HD-13
GHSG study looking at the value of each of the individual
ABVD components. For instance the maximal Progression
free survival (PFS) differential seen among recent trials has
been the 91 to 97% 3-year yield (p

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
Time-dependent covariates (markers, time-to-response,
»quality« or »speed« of response) are particularly subject to
flaws for 2 reasons: (1) they are highly treatment-dependent
(2) as occasional brilliant predictors of response, they are -
wrongly- expected to direct the treatment strategy, and
therefore improve global survival. Actually, even identification
of a poor-faring group in no way means that a more
adequate treatment is available for this precise group. The
EORTC paved the way for such a strategy in advanced HL
(Carde P. Early response to chemotherapy (CT) is a faithful
surrogate independent predictive factor that can influence
treatment strategy in Hodgkin’s Disease (HD). Proc. Fifth
International Symposium on Hodgkin’s Lymphoma 22–25
September 2001, Köln, Germany. Leukemia & Lymphoma
42,suppl.2 :35,2001 (oral presentation, abst. # I-40)).
FDG-PET scans better assess tumor burden than CT scans
and functional imaging has been shown to predict outcome
after combined modality therapy in early stage HL with a
very high negative predictive value (Hutchings M, Loft A,
Hansen M, et al: FDG PET after two cycles of chemotherapy
predicts treatment failure and progression-free survival in
Hodgkin lymphoma. Blood 107:52–59, 2006). FDG-PET,
already known important in staging and treatment evaluation
recently became fashionable to adapt the treatment, for less,
or more...
Calling for less treatment recently proved disappointing,
according to the results of the H10 International/EORTC
study, where deleting involved node irradiation (IN RT) in
PET 2 negative patients (early favorable and unfavorable
stages) resulted in lower PFS (XXXXXX). Other cooperative
groups attempt not to duplicate these results.
Calling for more treatment in early positive PET 2 patients
and being successful is tricky, apart from the false positives,
that in part depend upon the treatment; indeed, most patients
with positive interim PET are cured, so that the positive predictive
value in early stage has been exceeded 15% in a recent
study (Sher DH, Mauch PM, Van Deen AAet al. Prognostic
significance of mid- and post ABVD PET imaging in
Hodgkin’s lymphoma: the importance of involved – field
radiotherapy. Ann Oncol. 2009;20(11):1848–53). In this respect
the result of the International/EORTC H10 trial is eagerly
awaited for.
TARGETED TREATMENT TO HODGKIN LYMPHOMA
TUMOR CELLS
Targeted therapy to receptors and antigens expressed by
the Hodgkin and Reed Sternberg cells (HRS), proves efficient,
whether or not these are the ultimate tumor stem cells
(A. Younes and A. Engert. New agents for patients with
Hodgkin lymphoma. chapt. 20, pp. 283–294 in Hodgkin
Lymphoma -A. Engert and S.J. Horning (eds.) DOI:
10.1007/978-3-642-12780-9_11, © Springer-Verlag Berlin
Heidelberg 2011). Since two decades, among the many candidate-new
drugs for HL, very few reached clinical practice,
and none to first-line advanced HL. However, m-Tor inhibitors,
histone deacetylases (HDAC) inhibitors, immunomodulators
(lenalidomide), and anti-CD30 antibody drug conjugate
brentuximab vedotin (SGN-35) demonstrate a significant
activity in phase II studies.
64
Table 2. References of main large phase 2 and randomized trials reported
in localized HL
4-drug regimens : ABVD (CMT)
Favourable patients
ABVD x2 + IF RT HD-7 Engert JCO 2007. (Engert et al. 3495-502)
Unfavourable patients
ABVD x4 + IF RT Milan Bonadonna JCO 2004.
(Bonadonna et al. 2835-41)
ABVD x6 + M RT H6 Carde JCO 1993. (Carde et al. 2258-72)
ABVD x6 + IF RT H9U Fermé Blood ASH 2005. (Fermé et al. 813)
Noordijk JCO 2005. (Noordijk et al. 6505)
ABVD x4 + IF RT H9U Fermé Blood ASH 2005.(Fermé et al. 813)
Noordijk JCO 2005. (Noordijk et al. 6505)
ABVD x4 + IF RT H9U Fermé Blood ASH 2005.(Fermé et al. 813)
Noordijk JCO 2005. (Noordijk et al. 6505)
ABVD x 4 + IF RT HD-10 Engert NEJM 2010. (Engert et al.)
ABVD x 2 + IF RT HD-10 Engert NEJM 2010. (Engert et al.)
ABVD x4 + IF RT 20 or 30 Gy HD-11 Eich 2010 submitted. (Eich et al.)
ABVD x4 + IF RT 30 Gy HD-14 Borchmann Blood ASH 2008
ABVD x4 + IN RT & FDG-PET adapted) H10 EORTC André Blood
ASH 2009
response adapted strategies – based on FDG-PET imaging
Favourable patients
ABVD x2 & PET2 and adaptation H10F cf André ASH 2009.
(Andre et al. 97)
ABVD x2 & PET2 and adaptation HD-16 GHSG ongoing 2010
Unfavourable patients
ABVD x2 & PET2 and adaptation H10U André ASH 2009 (Andre et al. 97)
escalated BEACOPP x2 + ABVD x 2 +IF/IN RT HD-17 GHSG project 2010
SGN-35 demonstrates an activity/toxicity profile that
may allow rapid upgrading to phase III trials, even in early
stage disease (Younes A, Bartlett NL, Leonard JP et al.
Brentuximab Vedotin (SGN-35) for Relapsed CD30-Positive
Lymphomas. N Engl J Med 2010; 363:1812–1821November
4, 2010). The Italian, French and EORTC groups
may seize a unique opportunity launch a phase III trial
(H12) to assess the benefit of this new drugs in a large number
of early stage unfavorable patients. The purpose is to
compare SGN-35 + AVD (=EXP) with ABVD alone (=STD),
both followed by 30 Gy RT. Population is early stage unfavorable
Hodgkin disease. There would be a phase 2 trial
followed by a phase 3 trial.
TREATMENT STRATEGY FOR HL TENDS TO BE
DIRECTED TO ITHE INDIVIDUAL PATIENT
Unlike »targeted« treatments for certain types of solid
tumors such as colon (KRAS) or lung (EGFR) carcinomas,
or hematological conditions (chronic myeloid leukemia),
where treatment is based on individual patient’s tumor characteristics,
HL strategy remains individually blind. However
biological approaches develop and may comfort the huge
knowledge that a 40 year experience could accumulate in
terms of conventional treatment and late effects, a unique
situation in onco-hematology.
OP68 21st Century Radiation treatments
in Hodgkin lymphoma
Theodore Girinsky on behalf of the EORTC Lymphoma
Group, Institut Gustave Roussy, Villejuif, France
Background. The occurrence of late complications due
to old concepts and techniques forced the radiation oncolo-

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
gy community to evolve. Nowadays modern radiotherapy
allows radiation to be delivered almost »surgically.«
Radiation therapy is now always used in combination
with chemotherapy. This combination allows the implementation
of »mini radiotherapy« in which radiation doses and
fields are reduced to a minimum and precisely implemented
using sophisticated radiation delivery techniques.
Radiation doses can now be reduced to 20–30 Gy, as
demonstrated by the German Hodgkin Study Group. Radiation
fields have become smaller and more precise as a result
of the involved node radiotherapy concept developed a decade
ago by the EORTC group. Tremendous progress in
imaging technology such as CT/PET allow an increasingly
accurate identification of initially involved lymph nodes. In
our experience with 141 patients, FDG-PET depicted undetected
LNs in 70% of the patients. Sophisticated radiation
delivery such as IMRT or the deep inspiration breath hold
technique allow precise implementation of these »surgical
fields« with good results. In our study of 50 patients with
localized Hodgkin lymphoma, 5-year progression-free survival
and overall survival were 92% and 94% respectively.
Conclusions. Sophisticated and precise radiation treatments
combined with chemotherapy should allow excellent
cure and quality of life in patients with Hodgkin lymphoma.
OP69 Improving Outcome in High Risk Hodgkin’s
lymphoma
Andreas Engert, University Hospital of Cologne, Köln,
Germany
Hodgkin lymphoma has become one of the best-curable
malignancies with tumor-free survival rates in excess of
80%. However, the prognosis for high-risk advanced stage
patients or those with relapsed or refractory disease still
needs improving. To this end, the German Hodgkin Study
Group (GHSG) has developed a more dose intense regimen,
BEACOPP, which demonstrated superiority of our old standard
of care in a prospectively randomized trial (HD9). The
ten-years update of this study indicates significant differences
in terms of tumor control (18%) and overall survival
(11%) between the old standard (8xCOPP/ABVD) and 8
cycles of BEAOPP escalated (Engert et al, JCO, 2009). The
follow-up study, HD12 suggested that radiotherapy (RT)
might not be needed in all patients. This was proven by our
HD15 study in which only PET-positive patients having residual
disease of at least 2,5 cm after chemotherapy received
additional RT.
In order to further reduce toxicity of treatment and increase
efficacy, numerous new drugs are currently being
developed for HL. The most promising is SGN-35 (Brentuximab
Vedotin) which has shown 75% responses in the
pivotal phase II study. This and other new approaches will
be discussed.
OP70 What is the role of PET in Hodgkin’s
lymphoma
Martin Hutchings, Departments of Hematology and
Oncology, Rigshospitalet, Copenhagen University
Hospital, Denmark
Combined computed tomography and positron emission
tomography with 18F-fluorodeoxyglucose (FDG-PET/CT)
has become a cornerstone imaging method in the management
of malignant lymphoma, particularly in the management
of Hodgkin lymphoma. FDG-PET/CT provides an
improved staging accuracy, with higher sensitivity than conventional
imaging methods including CT. The FDG uptake
in Hodgkin lymphoma masses decreases rapidly after initiation
of therapy in well responding patients, and this makes
early interim FDG-PET/CT the strongest available predictor
of treatment response and prognosis. A negative posttreatment
FDG-PET/CT is highly predictive of long-term
disease-free survival, and this has led to the incorporation of
FDG-PET/CT into the revised response criteria for malignant
lymphoma. This presentation will critically address the
value of FDG-PET in Hodgkin lymphoma, including shortcomings
of the available scientific evidence and common
problems and pitfalls when FDG-PET/CT is used in the
daily clinic and in clinical trials. The potential value of
FDG-PET/CT in the follow-up setting, and in the management
of relapsed Hodgkin lymphoma will be discussed.
OP71 Treatment of Relapsed/Refractory
Hodgkin’s lymphoma
Igor Aurer, Division of Hematology, Department of
Medicine, Clinical Hospital Center and School of
Medicine, University of Zagreb, Croatia
Hodgkin’s lymphoma (HL) is one of the most curable
forms of cancer. Depending on stage and prognostic factors
between 60% and 95% of patients are cured with standard
front-line therapy. Therefore, about 25% of patients will, at
some point in the course of their disease, need salvage treatment.
Best results in patients below 60–65 (70) years of age in
1 st relapse without significant comorbidities are achieved
with intensive salvage regimens followed by autologous
stem cell transplantation (ASCT) with or without consolidative
radiotherapy. Long-term outcome of this approach is
quite favorable, with disease-free survival rates of about
60%. Although a substantial proportion of patients respond
to alternative front-line chemotherapy regimens, such as
COPP, the advantage of ASCT to chemotherapy alone has
been proven in randomized trials. DHAP is the most frequently
used and studied second-line chemotherapy regimen.
In a recently published randomized trial, 2 cycles of
DHAP followed by BEAM conditioning and ASCT were
less toxic and at least as effective as 2 cycles of DHAP,
high-dose single agent chemotherapy, BEAM and ASCT.
Based on these data, 2 cycles of chemotherapy prior to
ASCT are considered standard. There are no randomized
trials comparing DHAP with other regimens such as ICE,
65

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
HDIM or IGEV, and the results of published phase II trials
are similar. Therefore, no recommendations regarding the
choice of intensive salvage regimens can be made at present.
The outlook of refractory patients (i.e. those that progress
during or relapse within 3 months after the end of frontline
treatment) is substantially worse. Only about 30% of
them are cured with this approach. For both, refractory or
relapsing patients, response to second line treatment is the
most important prognostic factor. ASCT is ineffective in
progressing patients and only about 20% of patients with
stable disease benefit from the procedure.
There are no randomized trials on the role of radiotherapy
(RT) in this setting but most centers use it either before or
after ASCT. The radiation fields vary, some irradiate only
areas that were not in CR (by PET or CT) after ASCT, some
those that were not in remission after salvage chemotherapy
and some all areas involved at relapse.
Patients who are not candidates for ASCT with a localized
relapse in a previously unirradiated area can be effectively
treated with salvage radiotherapy.
About 40–50% of patients fail second-line treatment. For
them the standard approach used to be chemotherapy, either
with different drug combinations or single-agents, such as
vinblastine or gemcitabine, and the judicious use of radiotherapy.
Average survival of such patients is more than 1
year, bearing witness to the chemo- and radiosensitivity of
HL. This approach is probably going to change very soon,
because very promising results have been reported with
brentuximab-vedotin (also known as SGN-35) an anti-CD30
monoclonal antibody linked to a cytotoxic agent with antitubullary
activity. Other new agents that are being tested in
this setting include histone-deacetylase inhibitors, lenalidomide
and m-TOR inhibitors. Finally, the role of allogeneic
stem-cell transplantation remains unclear. While long-term
disease free survival can be achieved with reduced intensity
conditioning in about 40% of patients responding to salvage
chemotherapy, treatment-related mortality and morbidity
remains a significant problem and comparative trials still
have to show which population of patients will benefit from
this approach.
OP72 Allogeneic SCT for Hodkin’s lymphoma
Ana Sureda, Haematology Department, Addenbrooke’s
Hospital, Cambridge, UK
Myeloablative conditioning and allo-SCT
in Hodgkin’s lymphoma
The first reports on allogeneic stem cell transplantation
(allo-SCT) in patients with HL appeared in the mid eighties
[1, 2]. Two larger registry-based studies published in 1996
gave disappointing results. Gajewski et al analyzed 100 HL
patients allografted from HLA-identical siblings and reported
to the International Bone Marrow Transplant Registry
(IBMTR) [3]. The 3-year-rates for OS, DFS, and the probability
of relapse were 21%, 15%, and 65%, respectively.
The major problems after transplantation were persistent or
recurrent disease or respiratory complications, which accounted
for 35% to 51% of deaths. A case-matched analysis
66
including 45 allografts and 45 autografts reported to the
EBMT was performed by Milpied et al [4]. They did not
find significant differences in actuarial probabilities of OS,
PFS, and relapse rates between allo-SCT and ASCT (25%,
15%, 61% vs. 37%, 24%, 61%, respectively). The actuarial
TRM at 4 years was significantly higher for allografts than
for autografts (48% vs 27%, p=0.04). Acute GvHD ≥ grade
II was associated with a significantly lower risk of relapse,
but also with a lower survival rate.
A number of reports confirmed the registry data: allo-
SCT resulted in lower relapse rates but significantly higher
toxicity with no improvement over ASCT when PFS or OS
were considered [5–7]. Although the poor results after myeloablative
conditioning could at least partly be explained
by the very poor-risk features of many individuals included
in these early studies, the high procedure-related morbidity
and mortality prevented the widespread use of allo-SCT.
Reduced intensity conditioning and allo-SCT
in Hodgkin’s lymphoma
The largest cohort of patients treated with RIC/allo-SCT
in HL was recently reported by the LWP of the EBMT [8]
(n=285). Median time from diagnosis to allo-SCT was 41 (4
– 332) months. Patients had received an average of four
lines of prior therapy (1 – 8) and 288 patients (77%) had
failed one or two ASCT. At the time of allo-SCT, 47 patients
(17%) were in CR, 123 patients (43%) had chemosensitive
disease and 115 patients (40%) had chemoresistant disease
or untested relapse. One hundred and seventy two patients
(63%) were allografted from a matched sibling donor
(MRD), 94 (33%) from a matched unrelated donor (MUD),
and 19 from a mismatched donor (7%). Grade II-IV acute
GvHD (aGVHD) was reported in 27% of patients, chronic
GvHD (cGVHD) in 40% of patients at risk. The 100-day
TRM was 12% but increased to 20% at 12 months, and to
22% at three years. The development of chronic GVHD was
associated with a higher TRM and a trend to a lower relapse
rate. In a landmark analysis the development of either acute
or chronic GVHD by 9 months post transplant was associated
with a significantly lower relapse rate.
The MD Anderson Cancer Center updated their experience
[9] in 58 patients with relapsed or refractory HL who
underwent a RIC/allo-SCT from a MRD (n=25) or a MUD
(n=33). Forty-eight (83%) patients had received a prior
ASCT. Disease status at RIC/allo-SCT was sensitive relapse
(n=30) or refractory relapse (n=28). The conditioning regimen
employed was fludarabine (125–130 mg/m2 over 4–5
days), melphalan (140 mg/m2 IV over 2 days) (FM) and antithymocyte
globulin (thymoglobulin 6 mg/kg over 3 days)
was added for the 14 most recent MUD transplants. Cumulative
100-day and 2-year TRM were 7% and 15%, respectively.
The cumulative incidence (CI) of grade II-IV acute
GVHD was 28%. The CI of chronic GVHD at any time was
74%. Fourteen patients (24%) received a total of 25 (range
1–5) donor leukocyte infusions (DLIs) for disease progression/relapse.
Five of them (35%) received CT as well, and
nine (64%) developed acute GVHD after the DLI. Projected
2-year OS and PFS were 64% and 32%, with 2-year projected
disease progression at 55%. There was no statistically

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
significant difference between MRD and MUD transplants
with regard to OS, PFS and disease progression. There was
a trend for the response status prior to allo-SCT to favorably
impact PFS (p=0.07) and disease progression (p=0.049),
but not OS (p=0.4). Partial responders and patients with
stable/ refractory disease fared similarly with regards to OS
and PFS.
Forty patients with relapsed or refractory HL treated with
the combination of fludarabine (150 mg/m 2 ) and melphalan
(140 mg/m 2 ) have recently been presented by the Spanish
group [10]. GvHD prophylaxis consisted of cyclosporine A
(CsA) and methotrexate (MTX). Twenty-one patients (53%)
had received >2 lines of CT, 23 patients (58%) had been irradiated,
and 29 patients (73%) had failed a previous ASCT.
Twenty patients were allografted in resistant relapse and 38
patients received hematopoietic cells from a MRD. Oneyear
TRM was 25%. Acute GvHD developed in 18 patients
(45%) and cGvHD in 17 (45%) of the 31 evaluable patients.
Extensive cGvHD was associated with a trend to a lower
relapse rate (71% vs 44% at 24 months, p=0.07). The response
rate three months after RIC/allo-SCT was 67%.
Eleven patients received donor lymphocyte infusions (DLIs)
for relapse or persistent disease. Six patients (54%) responded.
OS and PFS were 48% and 32% at 2 years, respectively.
Refractoriness to CT was the only adverse prognostic
factor for both OS and PFS.
Investigators from Seattle reported their results in relapsed
/ refractory HL patients [11]. Thirty-eight patients
had a MRD, 24 a MUD and 28 a HLA-haploidentical related
donor. The patients received 2 Gy total body irradiation
(TBI) alone (n=17) or in combination with fludarabine
(90 mg/m 2 ) and immunosuppression consisted of micophenolate
mofetil (MMF) and CsA. All patients were heavily
pre-treated with a median of five prior regimens administered.
92% of the patients had failed a previous ASCT. Prior
to RIC/allo-SCT 22 patients were in CR, 30 in PR, 9 had
relapsed disease, and 29 had refractory disease. The overall
incidence of grade II-IV aGvHD was 50%. The incidence of
extensive cGvHD was 55% at 1 year. TRM was significantly
lower in those patients being allografted from a HLAhaploidentical
donor. Relapse risk was also lower in haploidentical
recipients.
Peggs et al explored the effects of in vivo T-cell depletion
with alemtuzumab followed by fludarabine (150 mg/m 2 )
and melphalan (140 mg/m 2 ) in multiply relapsed patients;
90% of them had failed a previous autograft [12]. At transplant,
8 patients were in CR, 25 patients were in PR, one
patient was in untested relapse, and 15 patients had refractory
disease. Thirty-one patients were allografted from a
MRD and 18 from MUDs. All patients engrafted, grade II-
IV aGvHD occurred in 16% of patients, 14% developed
cGvHD before DLIs. Nineteen patients received DLIs for
progression (n=16) or mixed chimerism (n=3). Nine patients
(56%) showed a response, which was significantly associated
with, acute and/or extensive chronic GvHD. Nonrelapse
mortality was 16% at 730 days. Projected 4-year OS
and PFS were 56% and 39%, respectively.
Finally, the final results of a multicenter phase II prospective
study on the role of RIC/Allo-SCT were presented at
ASH2010 [13]. 92 HL patients with an HLA identical sib-
ling or a MUD were treated with 2 courses of salvage chemotherapy.
Seventy-eight patients (85%) who showed at
least stable disease were eligible to receive a RIC/Allo-SCT;
all 14 patients with chemorefractory disease died from progressive
lymphoma. Most allografted patients had failed a
prior autologous transplantation (86%); 50 patients were allografted
with chemosensitive and 28 with resistant disease;
MUDs were used in 23 patients. Fludarabine (150 mg/m 2
iv) and melphalan (140 mg/m 2 iv) were used as conditioning
regimen and cyclosporine A plus methotrexate as graft-versus-host
disease prophylaxis. Non-relapse mortality was
8% at 100-days and 15% at 1-year. Relapse was the major
cause of failure. PFS was 48% at 1-year and 24% at 4-years.
Chronic GVHD was associated with a lower relapse incidence
and a better PFS (figure 3). Patients allografted in CR
had a significantly better outcome. OS was 71% at 1-year
and 43% at 4-years.
No definitive information is available with respect to the
best conditioning protocol or the impact of T-cell depletion
in this setting. If one accepts that attempting an effective
graft-versus-HL reaction may require several months, preventing
early progression by administering a vigorous conditioning
regimen remains an essential goal still to accomplish.
In this sense, the combination of a more intensive
preparative regimen, the BEAM protocol together with a
profound T-cell depletion with alemtuzumab as aGVHD
prophylaxis has demonstrated to be associated with sustained
donor engraftment, a high response rate, minimal
toxicity (NRM 7.6%) and a low incidence of GVHD [14].
The two analyses presented by the Lymphoma WP of the
EBMT also strengthen this argument.
Comparison of myeloablative and reduced-intensity
conditioning prior to allo-SCT in relapsed and
refractory Hodgkin’s lymphoma
The LWP has performed the only analysis reported so far
which compares outcomes after reduced-intensity or myeloablative
conditioning in patients with HL [15]. Ninetyseven
patients with HL were allografted after RIC and 93
patients were allografted after a conventional regimen. A
previous ASCT was more frequent in the RIC/allo-SCT
group (59% vs 41%, p=0.03) as was the use of peripheral
blood stem cells (82% vs 56% p

Oral presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
HL effect comes from two main sources: the demonstration
that the development of acute or chronic GVHD after allo-
SCT is associated to a lower relapse rate and the clinical
information coming from DLIs. Relapse rate is significantly
lower in those patients developing GVHD after transplantation.
This fact was already indicated by single center analysis
including low number of patients [9,140, 12, 13] but also
by larger retrospective analyses such as those performed by
the Lymphoma WP of the EBMT. The development of either
acute or chronic GVHD by 9 months after transplant
was associated with a lower relapse rate in Robinson’s analysis
[8]. The development of acute GVHD alone did not
reduce the relapse rate but was associated with a significantly
higher TRM and a lower PFS and OS. In contrast,
the development of chronic GVHD alone was associated
with a trend to lower relapse rate, a significantly higher
TRM but had no impact on OS or PFS. In the comparative
analysis between conventional allo-SCT and RIC/allo-SCT
the development of chronic GVHD after transplantation
significantly reduced relapse rate after transplant and improved
PFS in those patients presenting with this complication
[15].
The most direct evidence for a graft versus malignancy
effect comes from observations relating to disease responses
to DLIs. Peggs et al have previously reported clinical responses
in 9 of 16 patients receiving DLIs for measurable
disease post RIC/allo-SCT [12]. Other small series have reported
response rates of 44–54% following DLI administration
[9, 10]. In Robinson’s analysis [8] many DLIs were
administered following adjunctive therapy but disease responses
were reported in 30% of patients receiving DLI
alone. Patients responding to DLIs had a higher incidence
of GVHD post DLI than those not responding. These data
confirm the presence of a clinically effective graft versus
Hodgkin’s effect. However, the efficacy of DLIs is likely to
depend upon the bulk of disease at the time of administration
and the optimal use of DLI requires further refinement.
Preemptive, dose escalating or PET scan guided strategies
may improve the overall efficacy of DLIs [16, 17].
How to improve the results of allo-SCT?
Relapse rate is the major cause of failure for those patients
with relapsed / refractory HL being considered candidates
for such an approach. There are several possible ways
to address this issue: better patient selection and chemosensitivity
of the tumour. Disease status at the time of allo-SCT
is the most important prognostic factor for the long-term
outcome of this procedure. Only those patients in CR or
very good PR should be considered adequate candidates for
an allo-SCT at least with the current protocols. In this sense,
new salvage strategies to try to put patients into a better response
should be sought. Pre-transplant PET does not seem
to have a prognostic impact on either OS or PFS after allo-
SCT but PET was able to diagnose relapse after allo-SCT
earlier than conventional computed tomography [16, 18]. In
this sense, the role of PET should be further explored in this
setting.
Modulation of the intensity of the conditioning regimen
can also result in lower relapse rate after allo-SCT. Low-
68
dose TBI containing regimens seem to be associated to a
high relapse rate in the RIC-allo setting [8, 15]. New drugs
with potential antitumoral activity in front of HL but with a
safe profile are being currently tested by different groups.
The intensity of conditioning regimen can be eventually
augmented without significantly modifying Non-Relapse
Mortality (NRM) taking into consideration the population
of patients that are considered candidates for an allo-SCT
and the fact that GVL effect is not as potent as in low-grade
lymphoproliferative disorders.
Finally, the »so called« maintenance strategy currently
being explored in the ASCT setting can also be analyzed in
the allogeneic one.
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Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Oral presentations
15. Sureda A, Robinson S, Çanals C, et al Reduced-intensity conditioning
compared with conventional allogeneic stem-cell transplantation in relapsed
or refractory Hodgkin’s lymphoma: an analysis from the Lymphoma
Working Party of the European Group for Blood and Marrow
Transplantation. J Clin Oncol 2008;26:455–462.
16. Peggs KS, Thomson KJ, Hart DP et al. Dose-escalated donor lymphocyte
infusions following reduced intensity transplantation: toxicity,
chimerism, and disease responses. Blood 2004;103:1548–1556.
17. Hart DP, Avivi I, Thomson KJ, et al. Use of 18 F-FDG positron emission
tomography following allogeneic transplantation to guide adoptive immunotherapy
with donor lymphocyte infusions. Br J Haematol 2005;
128:824–829.
18. Lambert JR, Bomanju JB, Pegas KS, et al. Prognostic role of PET scanning
before and alter reduced-intensity allogeneic stem cell transplantation
for lymphoma. Blood 2010;115:2763–2768.
OP73 New Drugs in the treatment of Hodkin’s
lymphoma
Anas Younes, (USA)
Abstract not submitted.
69

Meet the Professor
MP01 Chronic myeloid leukemia
Martin Mistrik, Dept. of Hematology and Transfusiology,
University Hospital Bratislava, Slovakia
Introduction
Chronic myeloid leukemia (CML) was first described in
the nineteenth century, but treatment with arsenicals and radiotherapy
was unsatisfactory. In the 1950s busulfan and
hydroxycarbamid were introduced, and the disease control
has improved. Significant progress brought discovery of the
Philadelphia (Ph) chromosome (4), that results from a t(9;22)
translocation and that leukemia originates from a single hematopoietic
»stem cell« with BCR-ABL fusion gene (2; 3).
In the 1980s interferon-alpha replaced chemotherapeuticals
and induced in some patients Ph-chromosome negativity.
Between 1980 and 2000, allogeneic stem cell transplantation
(allo-SCT) was initial treatment for younger patients
with HLA-matched donors. In the last decade, the introduction
of imatinib (imatinib mesylate, IM), the Abl tyrosine
kinase inhibitor (TKI), has dramatically changed CML therapeutic
strategy (1). The annual number of SCT for CML
has fallen markedly and according to the latest ELN recommendations
from 2009 most hematologists today recommend
initial treatment with IM. IM has transformed CML
from an invariably fatal disease in its natural evolution to a
chronic illness, like hypertension, diabetes, or AIDS if patients
comply with daily oral therapy. Although CML is a
relatively rare malignancy, effective treatment has significantly
enlarged population of patients, increased its prevalence
and raised new problems of management.
What is important at diagnosis?
At first spleen size (by palpation cm bellow costal margin
at maximal inspirium) has to be recorded, and complete and
differential blood count, bone marrow aspiration and conventional
cytogenetics performed. In case of Ph-negative
karyotype FISH and PCR for BCR-ABL is mandatory. HLA
typing of siblings should be done in every patient fit for
allo-SCT.
What are the next steps at diagnosis?
1. disease phase assessment according to
blasts (chronic phase: < 10% in peripheral blood
and/ or nucleated bone marrow cells; accelerated
phase: 10 – 19%; blastic phase: ≥ 20%)
basophils (chronic phase: < 20% in peripheral blood;
accelerated phase: ≥ 20%)
platelet count (accelerated phase: persistent thrombocytopenia
< 100 x 109 /l)
spleen size (accelerated phase: increasing spleen
size)
cytogenetics (accelerated phase: evidence of clonal
evolution)
2. Risk score assessment (5)(www.roc.se/sokal.asp) –
Sokal risk: low < 0,8; intermediate 0,8 – 1,2 and high
> 1,2:
Age (years)
Myeloblasts in blood (%)
Platelets (x 10 9 /l)
Spleen size (cm)
What is the first line treatment?
Leukocytosis has to be controlled with hydroxyurea, addition
of allopurinol is important as well. Low risk patients
should start treatment with IM, intermediate and high risk
patients could profit from upfront second generation TKI
therapy. The treatment goal is achievement of major molecular
response (it means 3 log bcr/abl reduction, or bcr/abl

Meet the Professor Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
In summary, there is a lot one can get right or wrong at
diagnosis. The majority or all patients who present with de
novo CML should if possible receive initial treatment with
TKI (imatinib, nilotinib or dasatinib). Monitoring blood
counts, cytogenetics and quantitative PCR are used according
to the level of response. Allo-SCT can be considered
according to the TKI effectivity. For non chronic phase
CML patients TKI ± chemotherapy followed by allo-SCT is
the treatment of first choice.
R E F E R E N C E S
1. Druker BJ, Talpaz M, Resta DJ, et al. Efficacy and safety of a specific
inhibitor of the BCR-ABL tyrosine kinase in chronic myeloid leukemia.
New Engl J Med 2001;344:1031–1037
2. Geary CG. The story of chronic myeloid leukaemia. Br J Haematol
2000;110:2–11
3. Goldman JM, Daley GQ. Chronic myeloid leukemia: a brief history. In:
Melo JV, Goldman JM, editors. Myeloproliferative Disorders. New
York, NY: Springer; 2007. p. 10–13
4. Nowell PC, Hungerford DA. A minute chromosome in human granulocytic
leukemia. Science 1960;132:1497
5. Sokal JE, Baccarani M, Russo D, et al. Staging and prognosis in chronic
myelogenous leukemia. Semin Hematol 1988;25:49–61
MP02 Essential (primary) Thrombocythemia
Petro E. Petrides, Hematology Oncology Center and
Ludwig-Maximilians-University Medical School Munich,
Germany
This seminar will cover all relevant aspects of essential
(primary) thrombocythemia (ET). Starting with the precise
histological diagnosis of ET, which is based on the current
WHO-classification and the discussion of differential diagnosis
from reactive thrombocythemia, it continues with the
novel molecular markers JAK2 V617F and MPL which are
present in 50 or 5% resp.of all ET patients.
Next, platelet production and function under normal and
pathological (ET) circumstances are outlined.
From the limited data on epidemiology (since ET is an
orphan disease), the question of life expectancy is discussed.
Then signs and symptoms of ET patients are outlined.
which are caused by microcirculatory, thrombotic or hemorrhagic
events.
When ET has been diagnosed by histological and molecular
markers, a staging procedure should be performed:
this includes a differential blood smear, serum electrolytes
(with the occurrence of pseudohyperkalemia), uric acid, renal
and hepatic values as well as cholesterol (HDL and
LDL) and triglycerides.
Clinical investigation should include a physical examination,
an ultrasound of the spleen (in three dimensions with
volume determination), Doppler ultrasound of the carotid
arteries (plaque formation, intima media thickness) and an
exercise electrocardiogram.
Goal of therapeutic interventions is primary and secondary
prevention of disease associated complications. At the
moment therapeutical recommendations are based upon
age, thrombosis and platelet counts. A more comprehensive
approach includes life style (physical activities, smoking,
72
diet, biological age), additional thrombophilic risk factors
(through appropriate testing) and how well the patient is informed
about the disease and its potential complications.
Basic therapy includes »wait and see« or platelet antiaggregatory
treatment with aspirin although only retrospective
data confirm the validity of the latter approach. For cytoreduction
three substances are nowadays in use: anagrelide,
hydroxyurea and pegylated interferon-alpha with different
mechanisms of action. Only three randomized clinical trials
testing hydroxyurea and/or anagrelide (Bergamo/Vicenza,
PT1 and Anahydret) have been carried out. Long term efficacy
and adverse effect data are available only for anagrelide
from post marketing registries from different countries. Pros
and cons of the three therapeutical regimens will be discussed.
In addition, novel approaches such as telomerase
inhibitors will be outlined.
Treatment of aged people (up to 96 years), children or
during pregnancy pose additional chalenges.
Case examples for the questions addressed will be given
from daily practise.
MP03 Acute myeloid leukemia
Boris Labar, Division of Hematology, Department of
Medicine, Clinical Hospital Center and School of
Medicine, University of Zagreb, Croatia
Classification of acute myeloid leukemia
The current WHO classification is using morphology, immunophenotyping,
cytogenetic and molecular genetic abnormalities
to delineate entities of AML with a different
prognostic significance (1). The WHO classification of AML
is given in Table 1. A number of recurrent genetic abnormalities
are sufficiently defined to be recognized as entities
of AML.
Moreover some of new genetic abnormalities, mutation
of NPM1 gene and CEBPA gene are also added to classification
(2, 3). These mutations are associated with good prognosis.
FLT3 mutations (4) are not defined as a separate entity
but there are sufficient data that these mutations have
the prognostic impact. The entity of AML with myelodysplasia
related changes is practically based on the morphological
specific changes, i.e. morphological dysplastic changes
in ≥50% of ≥2 cell lineages in bone marrow. In this
group are patients with previous myelodysplastic syndrome
(MDS) or myelodysplastic/myeloproliferative neoplasm
(MDS/MPN) who evolve to AML with marrow or blood
blast counts ≥20%, or if they have myelodysplasia related
cytogenetic abnormality (see Table 1.) (5). Therapy related
myeloid neoplasm (6) is high risk AML and should be treated
with intensive chemotherapy and allogeneic SCT.
A previous FAB classification is recognized in WHO
classification ss the entity acute myeloid leukemia, not otherwise
specified. In this subgroup one can find the morphologic
separation of AML according to the immaturity of
leukemic cells as well as according to the hematopoietic lineage
involved. This subtype of AML is reserved for the patients
without the known cytogenetic or molecular genetic

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Meet the Professor
Table 1. Acute myeloid leukemia and related precursor neoplasm, and
acute leukemia of ambiguous lineage (WHO 2008) (1)
Acute myeloid leukemia with recurrent genetic abnormalities
– AML with t(8;21)(q22;q22); RUNX1-RUNX1T1
– AML with inv(16)(p13.1;q22) or t(16;16)(p13.1;q22); CBFB-MYH11
– APL with t(15;17)(q22;q12); PML-RARA*
– AML with t(9;11)(p22;q23); MLLT3-MLL**
– AML with t(6;9)(p23:q34); DEK-NUP214
– AML with inv(3)(q21;q26.2) or t(3;3)(q21;q25.2); RPN1-EVI1
– AML (megakaryoblastic) with t(1;22)(p13;q13); RBM15-MKL1
– Provisional entity: AML with mutated NPM1
– Provisional entity: AML with mutated CEBPA
Acute myeloid leukemia with myelodysplasia related changes †
Therapy related myeloid neoplasm ‡
Acute myeloid leukemia, not otherwise specified (NOS)
– Acute myeloid leukemia with minimal differentiation
– Acute myeloid leukemia without maturation
– Acute myeloid leukemia with maturation
– Acute myelomonocytic leukemia
– Acute monoblastic/monocytic leukemia
– Acute erythroid leukemia
Pure erythroid leukemia
Erythroleukemia, erythroid/myeloid
– Acute megakaryoblastic leukemia
– Acute basophilic leukemia
– Acute panmyelosis with myelofibrosis (syn.: acute myelofibrosis; acute
myelosclerosis)
Myeloid sarcoma (syn.: extramedullary myeloid tumor; granulocytic
sarcoma, chloroma)
Myeloid proliferation related to Down syndrome
– Transient abnormal myelopoiesis (syn.: transient myeloproliferative
disorder)
– Myeloid leukemia associated with Down syndrome
Blastic plasmacytoid dendritic cell neoplasm
Acute leukemias of ambiguous lineage
– Acute undifferentiated leukemia
– Mixed phenotype acute leukemia with t(9;22)(q34;q11.2); BCR-ABL1 §
– Mixed phenotype acute leukemia with t(v;11q23); MLL rearranged
– Mixed phenotype acute leukemia, B/myeloid, NOS
– Mixed phenotype acute leukemia, T/myeloid, NOS
– Provisional entity: Natural killer (NK) cell lymphoblastic leukemia/
lymphoma
* Other recurring translocations involving RARA should be reported accordingly
e.g. AML with t(1;17)(q23;q12)/ZBTB16-RARA; AML with t(11;17)
(q13;q12); NUMA1-RARA; AML with T(5;17)(q35;q12); NPM1-RARA; or
AML with STAT5B-RARA (the later have normal chromosome 17 on conventional
cytogenetics)
** Other translocations involving MLL should be reported accordingly: e.g.
AML with t(6;11)(q27;q23); MLLT4-MLL; AML with t(11;19)(q23;p13.3);
MLL-MLLT1; AML with t(11;19)(q23;p13.1); MLL-ELL; AML with t(10;11)
(p12;q23); MLLT10-MLL.
† >20% blood or marrow blasts and any of the following previous history of
myelodysplastic syndrome (MDS) or myelodysplastic/myeloproliferative
neoplasm (MDS/MPN): myelodysplasia-related cytogenetic abnormality (see
below); multilineage dysplasia; and absence of both prior cytotoxic therapies
for unrelated disease and aforementioned recurring genetic abnormalities;
cytogenetic abnormalities sufficient to diagnose AML with myelodysplasiarelated
changes are:
– Complex karyotype (defined as 3 or more chromosomal abnormalities)
– Unbalanced changes: -7 or del(7q); -5 or del(5q); i(17q) or t(17p); -13 or
del(13q); del(11q); del(12p) or t(12p); del(9q); idic(X)(q13)
– Balanced changes: t(11;16)(q23;p13.3); t(3;21)(q26;q22.1);
t(1;3)(p36.3;q21.1); t(2;11)(p21;q23); t(5;12)(q33;p12); t(5;7)(q33;p13);
t(5;10)(q33;q21); t(3;5)(q25;q34).
‡ Cytotoxic agents implicated in therapy related hematologic neoplasm: alkylating
agents; ionizing radiation therapy; topoisomerase II inhibitors; others.
§ BCR-ABL1 positive leukemia may present as mixed phenotype leukemia,
but should be treated as BCR-ABL1 positive acute lymphoblastic leukemia.
abnormalities. In some of them, there are markers associated
with prognostic significance.
The rare forms of AML and acute leukemia of ambiguous
lineage recognized in WHO classification are also associated
with poor prognosis. The other WHO AML entities are
rather rare disorders and will not be discussed in detail.
Prognosis of AML
Patient’s related prognostic factors
Age, co-morbidities, performance status and genetic variation
in drug metabolism are the main prognostic factors
related to patients with AML. Increasing age is important
independent adverse prognostic factor (7). Currently all patients
under the age of 60 are candidate to receive standard
intensive chemotherapy and according to prognostic factors
stem cell transplantation or intensive chemotherapy as postremission
therapy. It has to be stressed that age as a factor
is not only dependent on so-called »calendar age«. Recently
many older patients in a good clinical status have been successfully
treated with intensive chemotherapy. Even more,
stem cell transplantation with reduced intensity conditioning
could be offered to older patients with reasonable toxicity
and treatment related mortality (TRM) (8). So to define
the treatment approach it is important to evaluate and to determine
co-morbidities before any therapy. Many different
comorbidity scores have been proposed to outline patients
who are the candidate for intensive therapy (9). It is very
popular especially in older group of patients to differentiate
»fit« from »unfit« or »frail« patients.
Co-morbidity scoring is currently still under the investigation
in many Cooperative groups. In younger patients comorbidity
score is »defined« as inclusion/exclusion criteria.
That means patients with e.g. »unacceptable« renal, cardial
or hepatic abnormalities are not included into the study. By
such approach at least 20–30% of younger patients are excluded
from the treatment in the clinical trials. On the other
hands in older group more than 50% of patients are also
excluded from the clinical trials. So, these patients have not
been reported in any results?! Because of that it would be
important to propose comorbidity score for all AML patients
and to evaluate how many of the patients are able to
receive standard therapy and stem cell transplantation, how
many of them are candidate for low-intensity treatment and
supportive care. It is important to have the prospective data
for the patients treated in the Centers of CELG. This will
give us the real situation concerning the treatment applicability
in the Central and Eastern Europe.
Many trials showed a better outcome for patients less than
45 years of age compared to the group of patients from 45 to
60 years of age. Nonetheless most of the cooperative groups
for adult AML are including patients from 18 to 60 years of
age as younger ones. They received intensive chemotherapy
and stem cell transplantation with standard conditioning. Reduced
intensive conditioning has been predominantly used in
patients older than 50 years of age because of lower toxicity.
Older group of patients are those with age >60. The comorbidity
scoring treatment approaches mentioned before has
been used practically only for older patients.
Disease related prognostic factors
According to AML working party of European Leukemia
Net several important and independent prognostic factors
have been recognized as white blood cell counts, existence
of prior MDS or AML with MDS feature, previous cytotoxic
therapy for another malignancy, and cytogenetic and
molecular abnormalities in leukemic cells (10). The signifi-
73

Meet the Professor Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
cance of prognostic factors is dependent on the therapy
given to a patient. The genetic abnormalities according to
prognostic impact are given in Table 2.
Therapy of AML
In acute leukemia still the first goal of the treatment is
to induce good control of the leukemia (i.e. complete remission)
and after that to maintain the control of leukemia
or to cure it. The first part of therapy is induction therapy
by which we induce remission of leukemia. In the second
one so-called postremission therapy our goal is to maintain
the remission state or by intensive treatment approach
to cure the leukemia.
74
Table 2. Prognostic impact of genetic abnormalities (10)
Genetic group Subsets
Favorable t(8;21)(q22;q22); RUNX1-RUNX1T1
inv(16)(p13.1q22) or t(16;16)(p13.1;q22); CBFB-MYH11
Mutated NPM1 without FLT3-ITD (normal karyotype)
Mutated CEBPA (normal karyotype)
Intermediate I Mutated NPM1 and FLT3-ITD (normal karyotype)
Wild-type NPM1 and FLT3-ITD (normal karyotype)
Wild-type NPM1 without FLT3-ITD (normal karyotype)
Intermediate II t(9;11)(p22;q23); MLLT3-MLL
Cytogenetic abnormalities not classified as favorable
or adverse
Adverse inv(3)(q21q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1
t(6;9)(p23;q34); DEK-NUP214
t(v;11)(v;q23); MLL rearranged
-5 or del(5q); -7; abnl(17p); complex karyotype
Remission-Induction Therapy
Combination chemotherapy is the primary treatment
modality for patients with AML. Options for induction
chemotherapy include standard or high dose cytarabine in
combination with an anthracycline. Approximately half of
patients will require a second induction cycle to obtain a
complete remission. A combination of an anthracycline
such as daunorubicin for three days and »standard« dose
cytarabine for 7 days should be recommended (11). High
dose of cytarabine may increase the complete remission
rate in patients less than 60 years of age. It does so at the
cost of increased toxicity. Treatment-related mortality, the
rate of early relapse, and overall survival are not clearly
improved (12).
At present, there is no conclusive evidence to recommend
one »7+3« regimen over another. Depending on
dose, schedule, and patient selection criteria, they have
similar response rates and share common toxicities such
as severe degrees of myelosuppression with moderate mucositis,
and diarrhea. Idarubicin or mitoxantrone could be
used instead of daunorubicine with a similar outcome.
The best induction chemotherapy for older patients with
AML remains to be identified. Intensive chemotherapy may
be appropriate for selected patients with low or intermediate
risk disease in whom the complete remission (CR) rate
can be as high as 70 to 80 percent. With this approach, median
survival is approximately eight months, but 9 to 12
percent of patients will be alive at five years. Although pilot
studies have used more intensive initial chemotherapy, a
reasonable standard regimen for many older patients who
are medically fit is seven days of continuous infusion cytarabine
plus three days of daunorubicin (13).
In general, the choice of anthracycline (eg, daunorubicin,
mitoxantrone, or idarubicin) does not appear to affect
overall outcome. However, higher doses of anthracyclines
may result in superior rates of complete remission without
an apparent increase in toxicity.
So, for most older adults with favorable or intermediate
risk AML and an ECOG performance status of two or less
and few comorbidities, we recommend remission induction
treatment with a combination of daunorubicin for
three days and »standard« dose cytarabine for seven days
rather than other chemotherapy regimens or supportive
care alone.
While not curative, many Centers consider low-dose
cytarabine to be the standard against which other treatments
for AML in the older patient should be evaluated. A
number of trials have investigated the use of low-dose cytarabine
in older subjects with AML, both for induction
and later for maintenance of remission. Although the number
of complete remissions was greater with intensive
chemotherapy, the early death rate was also higher. As a
result, there were no differences in survival or remission
duration between the patients receiving more intensive
therapy and patients on low-dose cytarabine (14).
Postremission therapy
Post-remission therapy in acute myeloid leukemia remains
problematic and controversial. It has been demonstrated
that younger patients can maintain longer complete
remissions (CR) with aggressive post-remission therapies
after induction treatment: allogeneic autologous stem cell
transplantation, or intensive chemotherapy. Still there is
no evidence that auto-SCT is superior in terms of overall
survival to intensive chemotherapy (15). Data clearly
show that patients with unfavorable risk disease are more
often addressed to allo-SCT and patients with low-risk
disease receive more often intensive consolidation chemotherapy
(16). At the moment most of AML patients generally
receive allo-SCT on the basis of donor availability
(the so called »genetic randomization«). In the recent year
allo-SCT with reduced intensity conditioning have been
successfully performed for the treatment of older AML
patients (8).
R E F E R E N C E S
1. Vardiman JW et al. Blood 2009;114:937–951.
2. Döhner K et al. Blood 2005;106:3740–3746.
3. Schlenk RF et al. N Engl J Med 2008;358(18):1909–1918.
4. Gale RE et al. Blood 2008;111:2776–2784.
5. Mufti GJ et al. Haematologica 2008;93:1712–7.
6. Godley LA, Larson RA. Semin Oncol 2008;35:418–429.
7. Juliusson G et al. Blood 2009;113:4179–4187.
8. Blaise D et al. Exp Hematol 2010;38:1241–50.
9. Sorror ML et al. Blood 2005;106:2912:2919
10. Döhner H et al. Blood 2010;115:453–474
11. Kolitz JE. Br J Haematol 2006;134:555.
12. Weick JK et al. Blood 1996;88:2841.
13. Martin MG, Abboud CN. Blood Rev 2008;22:311–20.
14. Zwierzina H et al. Leukemia 2005;19:1929–33.
15. Cassileth PA et al. Blood 1992;79:1924.
16. Cornelissen JJ et al. Blood 2007;109:3658.

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Meet the Professor
MP04 Allogeneic Stem cell transplantation
for hematological malignancies – current
approach and future trends
Boris Labar, Division of Hematology, Department of
Medicine University Hospital Center Zagreb and School of
Medicine, University of Zagreb, Croatia
At the beginning of the second decade of 21 st century, 40
years after first clinical use of allogeneic stem cell transplantation
(SCT) for hematological malignancies I searched
through the PUBMED to find out what is the current scientific
interest in the field of stem cell transplantation. For this
purpose I analyzed 300 recent publications (mostly 2011).
In these publications 10% of them are committed to SCT in
hematological malignancies. Most of them dealing with the
reports of unusual sources of stem cells predominantly cord
blood mesenchimal stem cells. Some reports are showing
the results of transplants with reduced intensity conditioning.
Late complications and never ending story how to induce
GvL effect without GvHD are also reported. Contrary
to that the majority of publication describe current results of
stem cell treatment in regenerative medicine, chronic disease
and autoimmune diseases, as well as in many non-hematological
tumors. Logical conclusion after this very preliminary
survey could be: The era of allogeneic SCT for
hematological malignancies from the scientific point of
view is finishing?! We solved(?) the most questions as how
and when to perform SCT. We know the efficacy and limitation
of SCT for hematological malignancies(?!). It seems
much more interesting to study the trans-differentiation and
immunomodulatory capacity of stem cells compared to the
investigation how to improve the outcome of allografting in
hematological malignancies. I am not going to say that there
is no interest for these approaches but it may be that scientific
interest is really decreasing. Moreover targeting treatment
approach as in CML with TKI, seems to be more attractive
for the future investigation.
On the other hand in every day clinical medicine transplant
is very efficient therapy for leukemia and lymphoma.
For high risk patients transplant is until now the only curable
therapy. The outcome is improving every decade. Still
this could be a standard therapy for many years from now.
In many transitional countries SCT is not yet a routine treatment
approach. To support this let me share with you some
recent data from the Center(s) in transitional country(ies).
Incidence of stem cell transplant is increasing every year
especially for acute leukemia. The reasons for that could be:
SCT is the most efficient treatment options for acute leukemia
and MDS (1,2);
By using more efficient supportive therapy transplant related
toxicity and mortality is decreasing. This make SCT
more popular (3).
Less intensive conditioning is associated with lower early
mortality. By this approach transplant could be offer an
older patient group, i.e. 50 to 60 years of age. In well developed
countries many centers treated patients older than 60
years of age (4, 5) (Fig. 1.).
The results of transplants with match unrelated donor
(MUD) according to HLA-typing with high resolution (10/10
or 9/10) is similar to the results of transplants with sibling
Figure 1. Incidence of SCT according to standard and RIC conditioning
at Zagreb Center
Figure 2. The incidence of SCT according to sibling and MUD donor in
Zagreb Center
compatible donor; this clearly increase the number of SCT
with MUD donor (6, 7) (Fig. 2.)
In the recent year use of cord blood (two cord blood) are
feasible approach for adult patients (8).
Transplant should be performed in almost all hematological
malignancies. But the approach when to perform transplants
depends on many factors. The high toxicity and mortality
are the major determinants to perform allotransplant
in early phase of the disease when the antitumor efficacy is
the best. Transplant related mortality with standard conditioning
depending on patient’s age range from 20% to 50%
(9, 10).
The main causes of death are given In Fig. 3.
Figure 3. Causes of death in 1 st 100 days following allogeneic transplant
in Zagreb Center.
75

Meet the Professor Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
For the diseases with the high prediction of progression
or relapse (acute leukemia and myelodysplastic syndrome)
after standard therapy allotransplant should be perform immediately.
Indolent hematological malignancies or tumors
with effective and less toxic therapy (lymphoma, CLL, multiple
myeloma and CML) should be treated in more advanced
phase of disease, when other treatment options
failed. In such situation it is crucial to define evidence based
medicine criteria i.e. criteria that allografting have a benefit
compared with the other treatment options.
The transplant outcome is also influenced by the availability
of compatible donor, the source of stem cells, the
intensity of conditioning, the incidence and severioty of
early and late complications after allografting as GvHD and
infections. This will be also presenting during the session.
R E F E R E N C E S
1. Serventi-Seiwerth R et al. Acta Med Croatica 2009;63:205–8.
2. Oosterveld M et al. Leukemia 2003;17:859–68.
3. Vicente D et al. Bone Marrow Transplant 2007;40:349–54.
4. Luger SM et al. Bone Marrow Transplant 2011; in press.
5. Servais S et al. Transfus Apher Sci 2011;44:205–10.
6. Ciurea SO et al. Biol Blood Marrow Transplant 2011;17:923–9
7. Schlenk RF et al. J Clin Oncol 2010;28:4492–9.
8. Brunstein CG et al. Blood 2010;116:4693–9.
9. Remberger M et al. Biol Blood Marrow Transplant 2011; in press.
10. Gupta T et al. Hematol Oncol Stem Cell Ther 2011;4:17–29.
MP05 Acute lymphoblastic leukemia
Deborah Thomas, (USA)
76
Abstract not submitted.
MP06 Myelodysplastic Syndromes (MDS)
Petra Muus, Theo de Witte, Dept Hematology, Radboud
University Nijmegen, Medical Centre, The Netherlands
General characteristics of MDS
Myelodysplastic syndromes (MDS) are a heterogeneous
group of disorders affecting the normal differentiation of
hematopoietic cells. Clinical manifestations of MDS overlap
with aplastic anemia (AA), paroxysmal nocturnal hemoglobinuria
(PNH), acute myeloid leukemia (AML) and myeloproliferative
syndromes (MPS). Differential diagnosis
can be challenging. Most experts do agree that the majority
of MDS clones arise at the level of a pluripotent hematopoietic
stem cell.
All types of MDS share dysplastic features in one or all
of the myeloid, megakaryocytic, and/or erythroid lineages,
frequently resulting in cytopenias of the affected lineages
(thresholds: Hb 10g/dL, absolute neutrophil count

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Meet the Professor
The differential diagnosis of pancytopenia and a hypocellular
bone marrow with or without relative erythroid hyperplasia
is particularly challenging. The patient may have hypoplastic
MDS. But it is important to know that PNH may
have a similar presentation, particularly with a concomitant
viral disease. Alternatively in the presence or absence of a
small PNH clone the diagnosis may be aplastic anemia
(AA). Hypoplastic MDS is relatively rare. Hemolytic PNH
may develop from AA (AA-PNH) or rarely out of what first
appeared to be MDS (MDS-PNH) 9 . In all cases it is important
to follow the patient carefully and repeat diagnostics in
time.
Treatment of MDS
Treatment of MDS is as diverse as its clinical manifestations.
For elderly and low risk patients supportive treatment
is most commonly consisting of transfusions with erythrocytes
and/or platelets. Patients with ineffective hematopoiesis
generally have low intracellular levels of folic acid and
may profit from folic acid suppletion. Early iron chelation
therapy seems important to prevent iron overload and toxicity.
Growth factors (ESA’s with and without G-CSF) influencing
cytopenias have a place in lower risk MDS. International
guidelines suggest that patients who are either erythrocyte
transfusion dependent or have low epo levels are
candidates for ESA’s. G-CSF may be synergistic to ESA’s in
MDS10 . Fase I studies for Romiplostim in patients with
MDS and low platelet counts were promising11 and a randomized
placebo controlled phase II study is presently being
analyzed. Differentiation inducing agents and low-dose
chemotherapy are currently not often used anymore.
An important development in recent years is Lenalidomide
in lower risk MDS with 5q-. A randomized placebo
controlled study demonstrated the effectivity of the agent12 .
Registration of Lenalidomide in Europe is waiting safety
reports, with regards to a potentially increased incidence of
AML. Studies investigating the role of lenalidomide in low
risk MDS without 5q abnormalities are ongoing.
Hypomethylating agents are effective in intermediate and
high risk (IPSS) MDS. Patients on Vidaza had a better survival
than those receiving standard care13 . In an almost comparable
group of patients decitabine demonstrated activity
as well14 . In Europe only Vidaza is approved. Currently the
drug needs to be injected sc for 7 consecutive days every 28
days which is quite a burden for the patient. Of note: in
cases were stable disease is achieved vidaza cannot be stopped.
The only accepted curative treatment for MDS is an allogeneic
stem cell transplantation (alloSCT) alone or after
remission induction with high-dose chemotherapy. Various
studies showed a 4-year survival between 20 and 30% of
treated high-risk patients. This treatment is available to only
a limited number of patients because of the lack of suitable
donors and the intensity of the procedure, which is in many
cases incompatible with the age of the patient. Development
of other transplant modalities (matched unrelated donors,
non-myeloablative conditioning) have rendered alloSCT
accessible to more MDS patients. Hypomethylating agents
may prove sufficient and relative non-toxic cytoreductive
therapy before alloSCT.
As an alternative intensive remission induction, followed
by intensive consolidation chemotherapy alone can be considered.
Some patients responded well to intensive chemotherapy
followed by autologous stem cell transplantation 15 .
MDS patients may have prolonged hypoplasia following intensive
chemotherapy.
MDS classification, prognostic characterization plus well
defined response criteria are helping advance treatment options
for patients with MDS 16 .
R E F E R E N C E S
1. Harris NL, Jaffe ES, Diebold J, Flandrin G, Muller-Hermelink HK,
Vardiman J, Lister TA, Bloomfield CD. The World Health Organization
classification of neoplastic diseases of the hematopoietic and lymphoid
tissues. Report of the Clinical Advisory Committee meeting,
Airlie House, Virginia, November, 1997. Ann Oncol 1999;10:1419–32.
2. Bennett JM, Catovsky D, Daniel MT, Flandrin G, Galton DA, Gralnick
HR, Sultan C. Proposals for the classification of the myelodysplastic
syndromes. Br J Haematol 1982;51:189–99.
3. Greenberg P, Cox C, LeBeau MM, Fenaux P, Morel P, Sanz G, Sanz M,
Vallespi T, Hamblin T, Oscier D, Ohyashiki K, Toyama K, Aul C, Mufti
G, Bennett J. International scoring system for evaluating prognosis in
myelodysplastic syndromes. Blood 1997;89:2079–88.
4. Greenberg PL, Sanz GF, Sanz MA. Prognostic scoring systems for risk
assessment in myelodysplastic syndromes. Forum (Genova) 1999;9:
17–31.
5. Malcovati L, Germing U, Kuendgen A et al. Time-dependent Prognostic
Scoring System for Predicting Survival and Leukemic Evolution in
MDS. J CLin Oncol 2007;25:3503–3510.
6. Aul C, Giagounidis A, Germing U. Epidemiological features of myelodysplastic
syndromes: results from regional cancer surveys and hospital-based
statistics. Int J Hematol 2001;73:405–10.
7. Cogle R, Craig BJ, Rollison DE and List AF. Incidence of MDS using
a novel claims-based algorithm: high number of uncaptured cases by
cancer registries. Blood 2011;117:7121–7125.
8. Madkaikar M, Gupta M, Jijina F, Ghosh K.Paroxysmal nocturnal haemoglobinuria:
diagnostic tests, advantages, & limitations. Eur J Haematol
2009;83(6):503–11.
9. Li Y, Li X, Ge M, Shi J, Qian L, Zheng Y, Wang J. Long-term follow-up
of clonal evolutions in 802 aplastic anemia patients: a single-center experience.
Ann Hematol 2011;90:529–37.
10. Jadersten M, Montgomery SM, Dybedal I et al. Longterm outcome of
treatment of anemia in MDS with Erythropoietin and G-CSF. Blood
2005;106:803–811.
11. Kantarjian H, Fenaux P, Sekeres MA, Becker PS, Boruchov A, Bowen
D, Hellstrom-Lindberg E, Larson RA, Lyons RM, Muus P, Shammo J,
Siegel R, Hu K, Franklin J, Berger DP Safety and efficacy of romiplostim
in patients with lower-risk myelodysplastic syndrome and thrombocytopenia.
J Clin Oncol 2010;20;28(3):437–44.
12. Fenaux P, Giagounidis A, Selleslag D, Beyne-Rauzy O, Mufti G, Mittelman
M, Muus P, Te Boekhorst P, Sanz G, Del Cañizo C, Guerci-Bresler
A, Nilsson L, Platzbecker U, Lübbert M, Quesnel B, Cazzola M,
Ganser A, Bowen D Dr, Schlegelberger B, Aul C, Knight R, Francis J,
Fu T, Hellström-Lindberg E. A randomized phase 3 study of lenalidomide
vs placebo in RBC transfusion-dependent patients with Low-/Intermediate-1-risk
MDS with del5q. Blood. 2011 Jul 13. [Epub ahead of
print].
13. Fenaux P, Mufti GJ, Hellstrom-Lindberg E, Santini V, Finelli C, Giagounidis
A, Schoch R, Gattermann N, Sanz G, List A, Gore SD, Seymour
JF, Bennett JM, Byrd J, Backstrom J, Zimmerman L, McKenzie
D, Beach C, Silverman LR; International Vidaza High-Risk MDS Survival
Study Group. Efficacy of azacitidine compared with that of conventional
care regimens in the treatment of higher-risk myelodysplastic
syndromes: a randomised, open-label, phase III study. Lancet Oncol
2009;10:223–32.
14. Lübbert M, Suciu S, Baila L, Rüter BH, Platzbecker U, Giagounidis A,
Selleslag D, Labar B, Germing U, Salih HR, Beeldens F, Muus P,
Pflüger KH, Coens C, Hagemeijer A, Eckart Schaefer H, Ganser A, Aul
77

Meet the Professor Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
C, de Witte T, Wijermans PW. Low-dose decitabine versus best supportive
care in elderly patients with intermediate- or high-risk myelodysplastic
syndrome (MDS) ineligible for intensive chemotherapy: final
results of the randomized phase III study of the European Organisation
for Research and Treatment of Cancer Leukemia Group and the
German MDS Study Group. J Clin Oncol 2011;29(15):1987–96.
15. de Witte T, Suciu S, Verhoef G, Labar B, Archimbaud E, Aul C, Selleslag
D, Ferrant A, Wijermans P, Mandelli F, Amadori S, Jehn U, Muus
P, Boogaerts M, Zittoun R, Gratwohl A, Zwierzina H, Hagemeijer A,
Willemze R: Intensive chemotherapy followed by allogeneic or autologous
stem cell transplantation for patients with myelodysplastic syndromes
(MDSs) and acute myeloid leukemia following MDS. Blood
2001;98:2326–31.
16. Greenberg P. Current therapeutic approaches for patients with MDS.
Brit J of Haematology 2010;150:131–143.
MP07 Diagnostic and therapeutic challanges
in B – Chronic lymphocytic leukemia
(B-CLL)
Branimir Jaksic, Department of Medicine, University
Hospital Merkur and School of Medicine, University of
Zagreb, Croatia.
In this session we will address the frequent challenges in
the management of B-CLL. Some of the recent major clinical
research advancements in the diagnostics and clinical
therapeutic trials have put a new perspective on the actual
nature of the disorder and helped to modify conceptual and
practical clinical approaches. Therefore we will address
challenges referring to the diagnostics first, followed by the
therapy, and finally discuss some of the typical scenarios
from the practical clinical point of view.
Diagnostics. Diagnostic criteria have recently been both
simplified and made more specific. Thus, only a peripheral
blood sample is required for the diagnosis, but at the same
time the morphology supplemented by flow cytometry defined
immune phenotype has become mandatory. In clinical
practice this opened the problem in a definition of required
panel of monoclonal antibodies and required level of their
expression to distinguish between »typical« B-CLL and
»atypical or B-CLL variant(s)« as far as immune phenotype
is concerned. Moreover, the concept of variants may encompass
more clinical variability, such as distinct patterns
of the tumor mass distribution and similar.
The simple clinical and hematological parameters are
also commonly used for the evolution monitoring. We have
been using for many years the Total Tumor Mass Scoring
System (TTM) that is exclusively disease related. It proved
to be very useful for both monitoring of the disease evolution
and its response to the treatment independently of toxicities.
Perhaps, the addition of more cellular and humoral
immunological new parameters and/or infection related
triggers may improve prediction of disease evolution.
The comorbidity evaluation is important prerequisite for
sound clinical decisions. As a rule, more effective treatments
are at the same time associated with more toxicities
as shown in the recently published trials. The overall clinical
benefit should be carefully balanced taking into account
expected effect and expected tolerance. Thus, this part of
the diagnostic process aimed to predict tolerance should
never be neglected. The cumulative illness rating scales are
78
helpful (CIRS-G is widely used for CLL) both in clinical
trials and routine practice.
The prognostic factors are individual variables that are
associated with prognosis. The prognosis is usually measured
by the length of survival. The clinical usefulness of a
given prognostic factor is related to the strength of its independent
prognostic power. In addition to help prognostication,
the prognostic analyses represent a powerful research
tool to evaluate both biological and clinical relevance of a
given variable. It is important to note that prognostic factors
may be classified into (1) disease related, (2) patient related
(B-CLL unrelated) and (3) intermediate group that may be
in variable extent both disease and patient related. The distinction
is important since disease related and patient related
factors have different clinical meanings. The careful clinical
evaluation is particularly important in the intermediate
group, to classify a prognostic factor according to underlying
cause. For example the presence of anemia or elevation
of serum beta -2-microglobulin may be present due to disease
itself or to disease unrelated condition, and consequently
may have different impact on clinical decision on
starting therapy
The prognostic indices are composite scales that comprise
several individual variables. The variables are chosen
by their mutually independent prognostic power(s), and are
therefore excellent predictors of prognosis. However, if
combining prognostic factors related to disease with those
unrelated to the disease (which is a very common situation)
they may have limited clinical impact. While a bad prognosis
due to presence of the factors related to the disease warrants
more aggressive treatment, patient related prognostic
factors as for example advanced age may have clinically opposite
indication. Failure to recognize this concept may
have deleterious clinical repercussions.
Therapy. There are two important basic questions for
clinical practice: (1) When to treat? and (2) How to treat?
Both questions are interrelated and depend mostly on the
achievable aims of therapy definition. Based on the clinical
trials results performed in 1980s that showed no advantage
of early institution of therapy, it is today recommended in
most of guidelines to refrain therapy until indication of active
disease present. Although this is the common clinical
practice, it is somehow problematic conceptually. Namely,
this policy has resulted in a watch and wait practice for variable
period of time, but once the indication to start therapy
is adopted, there is a shift in goal, with a tendency to apply
the most effective treatment aiming molecular response, or
in other words, the eradication of the disease. This is in contrast
to general paradigm in oncology that effective treatment
should be applied with no delay. Thus, in current B-
CLL clinical practice we often wait until the full blown
disease to try to eradicate it. If we really believe in eradication
potential of the given antineoplastic therapy (as may be
the case according to the latest reports), this therapy should
definitely be tried earlier in the course of the disease.
As far as to define achievable aims of therapy, there is
little doubt that the best would be to achieve eradication of
the disease resulting in cure. The eradication will also mean
to document molecular remission up to the sensitivity of
available techniques. Also, this approach may be effective

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Meet the Professor
in preventing emergence of therapy resistant, usually more
malignant clones of the disease in contrast to the low intensity
treatment that may favor emergence of resistance. However,
this conceptually sound approach may not be feasible,
because more effective treatment is usually more toxic. For
this reason the aim should be balanced with expected tolerance,
and if appropriate, by defining less ambitious aims
such as major clinical remission or minor remission or stable
disease. To achieve targeted aim the least toxic therapies
should be chosen. This approach is a variant of »toxicity
tailored therapy« taking into account comorbidity and other
patient related factors, which all requires high level of clinical
expertise.
These general principles should be applied with caution
on individual patients, particularly because an individual
response and tolerance may vary considerably and they are
difficult to anticipate with certainty. Therefore therapy should
be interactive and should be modified according to the
achieved results. If necessary the goals should be reset. It is
logical to start with the goal set as high as possible in accordance
with the available data and clinical judgment, and
later proceed pending on the documented response and tolerance.
Note that supportive care is of the utmost importance,
and therefore should be always delivered at the highest possible
level.
Clinical practice typical scenarios. Although the diagnostics
and particularly therapy should be individualized in
order to conform to the above principles and concepts, several
clinical examples of the frequent clinical situations will
be discussed, to illustrate the important challenges that are
present in the B-CLL management.
MP08 Myelofi brosis
Srdjan Verstovsek, MD Anderson Cancer Center, Leukemia
Department, Houston, Texas, USA
Myelofibrosis (MF) is a myeloproliferative neoplasm
(MPN) characterized by abnormal proliferation of megakaryocytes,
fi brosis of the bone marrow (BM), osteosclerosis,
extramedullary hematopoiesis (EMH), and progressive
BM failure with an increased risk of progression to acute
myeloid leukemia (AML). MF was known by other names
in the past, including chronic idiopathic MF, agnogenic
myeloid metaplasia, and MF with myeloid metaplasia. MF
is part of the classic Philadelphia chromosome–negative
MPNs alongside polycythemia vera (PV) and essential
thrombocythemia (ET). MF can occur as a primary disorder
(PMF) or secondary to other MPNs, mainly PV (post-PV
MF) and ET (post-ET MF). MF is a rare disease, with an
incidence rate estimated at 1.46 cases/100,000 persons/year.
Median age at diagnosis is 67 years, and both sexes are
equally affected. The prognosis of patients with MF is quite
variable, as some patients can have a very indolent disorder
with prolonged survival, whereas in other cases, the disease
follows an aggressive course. Median survival of patients
with MF is in the range of 69 months, and survival at 5 and
10 years is decreased 40% and 60%, respectively, compared
with age and sex-matched controls. Major causes of death
include transformation to acute leukemia, progressive BM
failure due to MF, thrombotic and cardiovascular complications,
and portal hypertension. The pathogenesis of MF is
still unknown. Great advances in our understanding of the
pathogenesis of this disorder were made with the discovery
of mutations involved in cytokine receptor signaling pathways
(JAK2V617F and MPLW515K/L). First-degree relatives
of patients with MF and PV/ET have a 5- to 7-fold increased
risk of developing MPNs, suggesting a strong genetic
component in the susceptibility to this disease. Indeed,
a specific single nucleotide polymorphism of the JAK2 gene
(rs10974944) has been associated with an increased risk of
developing JAK2V617F positive MPNs. Treatment of MF
is suboptimal and palliative in nature, mainly directed toward
alleviation of symptoms due to cytopenias or splenomegaly.
In the past decade, several new drugs have been
introduced for the treatment of patients with MF, and it is
expected that the outcomes for these patients will soon improve
as new compounds become available.
MP09 Non-Hodgkin’s lymphoma
Igor Aurer, Department of Medicine, Clinical Hospital
Center and School of Medicine, University of Zagreb,
Croatia
New treatment modalities and new lymphoma classifications
have substantially increased the number of different
scenarios a physician could be facing when seeing patients
with non-Hodgkin lymphomas (NHL). While good evidence
exists for early treatment phases in patients with the
more frequent NHL types, the same is not true for advanced
disease, elderly and patients with significant comorbidities
and rare NHL types.
During this session I will review treatment standards and
recommendations for different types of NHL in different
patient populations. Attendees will be urged to present problems
they are or have been facing and discuss treatment options
with the audience.
Specific problems we will address include:
1) Diffuse large-B cell lymphoma in elderly and patients
with limited cardiac function
2) Burkitt’s lymphoma
3) Relapsing / refractory mantle-cell lymphoma
4) Nodal non-follicular indolent lymphoma
5) Extranodal marginal zone lymphoma
6) Localized nodal indolent lymphomas
7) Peripheral T-cell lymphomas
MP10 Multiple Myeloma
Damir Nemet, Division of Hematology, Department of
Medicine, Clinical Hospital Centre Zagreb and School of
Medicine, University of Zagreb, Zagreb, Croatia
Multiple myeloma (MM) is a malignant hematological
disease characterized by the accumulation of clonal plasma
cells in bone marrow, presence of monoclonal protein in the
blood and/or urine, destructive bone disease, hypercalce-
79

Meet the Professor Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
mia, renal failure, and hematologic dysfunction. MM accounts
for about 13% of all hematological neoplastic disease
and 1% of all cancers. The annual age-adjusted incidence
is 4,0–5,6 cases per 100.000 persons. The median age
of patients at the time of diagnosis is about 65–70 years.
In the marrow, MM cells interact with stromal components
and other cells in the microenvironment to receive
growth and survival factors and to modulate their environment
inducing pathological phenomena, such as neovascularisation
(angiogenesis and vasculogenesis) and bone disruption
(osteoclastogenesis). Almost all patients with MM
evolve from a premalignant condition known as monoclonal
gammapathy of undetermined significance (MGUS). Smoldering
myeloma (SMM) is an intermediate asymptomatic
advanced stage which much more probability of progression
to symptomatic disease. There is no need for treatment
of smoldering MM until progression to active, symptomatic
disease. The most important is to assess risk of progression
in individual patient.
Major clinical manifestations of MM are osteolytic bone
lesions, anemia, hypercalcemia, renal failure, and an increased
risk of infections. Extramedullary plasmacytomas
and extramedullary expansion of lesions originated in the
bone can be observed.
The diagnosis of MM requires ≥10% of clonal BM plasma
cells or a biopsy proven plasmacytoma, presence of serum
and/or urinary monoclonal protein (true non-secretory
myeloma is rare), and evidence of end organ damage known
as CRAB: hypercalcemia, renal impairment, anemia, and
bone lesions. Several staging systems have been built to
separate patients into various risk groups with different outcomes.
The International Staging System (ISS) is now
widely used; it is highly prognostic but presents some limitations.
ISS separates patients into three groups based on
beta-2-microglobulin and serum albumin concentrations
with significant difference in survival. However, chromosomal
abnormalities like del 13 on karyotyping, t(4;14),
t(14;16), del 17p and 1q gains significantly impact outcome
and some prognostic models are based solely on the presence
of chromosomal changes.
Treatment options have traditionally included corticosteroids,
alkylating or other cytotoxic agents, and the use of
high-dose chemotherapy followed by autologous stem cell
transplantation (ASCT). Recent advances include use of
novel immunomodulatory drugs thalidomide and lenalidomide,
and proteasome inhibitor bortzomib. Despite these
advances, most of the patients are not cured and ultimately
develop chemotherapy-refractory disease.
With the use of ASCT and after emergence of novel
agents overall survival in MM has improved significantly in
the last two decades. ASCT is a standard treatment approach
80
for younger (≥65 or even 70 years old) patients, therefore at
initial treatment considerations MM patients are generally
divided in »transplant eligible« and »transplant ineligible«
group. Clinical trials so far have shown that high-dose therapy
and ASCT improves response rates, disease-free survival
(DSF), and overall survival (OS) in symptomatic patients
with MM. More than half of MM patients are not eligible
for high-dose therapy including elderly patients and
those with comorbidities. Recent results indicate significant
improvement by adding novel drugs to standard therapy. AlloSCT
with myeloablative or reduced intensity conditioning
(RIC) is still investigational in myeloma and not widely accepted
primarily due to still high transplant related mortality
and high GvHD rates.
Post-transplant strategies could be defined as »consolidation«
(short term drug therapy, usually 3–6 months of duration)
or »maintenance« (prolonged low dose drug therapy).
At present it is unclear what strategies are effective, do these
strategies prolong OS, do all patients should receive consolidation/maintenance,
and, if not, who should receive
such therapy.
Almost all patients with MM eventually relapse. Options
for further therapy include alkylating agents, corticosteroids,
thalidomide, lenalidomide, bortezomib or liposomal
doxorubicin in various combinations. The choice of treatment
depends on several factors including drugs used as
initial therapy, the degree and duration of response to previous
therapy, type of relapse/progression (aggressive relapse
or more indolent relapse), and previous toxicity. Pomalidomide,
a new immunomodulatory drug and carfilzomib, a
novel proteasome inhibitor, have significant activity in relapsed
and refractory MM. Beside this, promising agents
are histone deacetylase inhibitors vorinostat and panobiostat
and potent anti-CS-1 antibody elotuzumab. Results of
phase II studies with bendamustin are encouraging.
Supportive therapy is an important part of whole strategy
of myeloma treatment. Bisphosphonates, especially nitrogen-containing
compounds (pamidronate, zoledronic acid)
are potent inhibitors of bone resorption. They reduce skeletal
complications in MM patients. RANKL inhibition by
monoclonal antibody denosumab show promising results in
clinical studies. Patients with MM are at high risk of developing
infections. Appropriate prophylaxis is therefore mandatory
during myeloma treatment. Renal failure is an important
complication of myeloma. Symptomatic care (appropriate
hydration, urine alkalization, avoidance of nephrotoxic
therapy and bisphosphonates) are important as well
as immediate anti-myeloma treatment. Bortezomib is probably
the best choice in patients with renal impairment due to
his fast anti-myeloma activity, influence on inflammatory
response, and no need for dose reduction.

State of the Art II.
SA02 Diagnostic and Treatment Approach for
Acute Myeloblastic Leukemia – Report from
Central and Eastern European Leukemia
Group (CELG)
Boris Labar 1 , Agnieszka Wierzbovska 2 , Georgi Mihaylov 3 ,
Andreaa Moicean 4 , Dragica Tomin 5 , Zita Borbenyi 6 ,
Karel Indrak 7 , Lidija Cevreska 8 , Martin Mistrik 9 ,
Wanda Knopinska-Posluszny 10 , Vildan Bijedic 11 .
1 Division of Hematology, Department of Medicine,
University Hospital Center and School of Medicine
University of Zagreb, Croatia; 2 Department of
Hematology, Medical University of Lodz, Copernicus
Memorial Hospital, Lodz, Poland; 3 Queen Joanna
University Hospital, Sofia, Bulgaria; 4 Fundeni Clinical
Institute, Second Department of Hematology, Bucharest,
Romania; 5 Clinic of Hematology, Clinical Center Serbia,
Belgrade, Serbia; 6 Second Department of Medicine,
University Medical School of Szeged,
Hungary; 7 Department of Hemato-Oncology, University
Hospital Olomouc and Faculty of Medicine and Dentistry,
Palacky University Olomouc, Czech Republic;
8 Department of Hematology, Medical Faculty, Skopje,
Republic of Macedonia; 9 Department of Hematology and
Transfusiology, University Hospital, Bratislava, Slovakia;
10 Department of Clinical Biochemistry, University Medical
School, Gdańsk, Poland; 11 Department of Hematology,
KCU, Sarajevo, Bosnia and Herzegovina.
Abstract: Central and Eastern Leukemia Cooperative
Group (CELG) perform retrospective analysis of diagnostic
and treatment possibilities for acute myeloblastic leukemia
(AML). The results of the questionnaire for acute myeloblastic
leukemia (AML) are presented.
In a retrospective manner using the Questionnaire we analyzed
in 26 centers of 10 countries the diagnostic and treatment
possibilities for AML.
In 10 countries more than 880 patients with AML have
been treated per year. Most of the countries have the standard
diagnostic tools. In some countries there are no facilities
for cytogenetic and cryopreservation. Induction and
consolidation chemotherapy is cytarabine based in combination
with anthracycline. The number of transplants is low
due to insufficient number of transplant centers. In four
countries patients are treated in rooms with two or more
beds.
The number of patients is sufficient for the future prospective
clinical trials. Concerning the diagnostic tools,
standard approach has been routinely performing in all centers.
Therapy approach is cytarabine based in combination
with anthracycline. Stem cell transplantation is performing
in majority of Centers but still the number of transplants is
low. The level of supportive care differs from country to
country and one of the priorities of CELG group is to standardize
the diagnostic and treatment approaches. This is a
prerequisite for the future clinical trials.
Introduction
In 2009 the 13 representatives of Central and Eastern European
countries founded the new group named Central and
Eastern European Cooperative Leukemia Group (CELG).
During the several meetings two main goals of the group
activity were defined: 1. to design the prospective clinical
trials for treatment of hematological malignancies and 2. To
propose the guidelines and standards of diagnosis and treatment.
One of the first activities of CELG group was to perform
retrospective analysis dealing with the diagnostic and treatment
possibilities for acute myeloblastic leukemia (AML).
The results of the questionnaire for AML are presented.
Methods
Participating countries and centers:
Twenty-six Centers from 10 countries respond the Questionnaire
(Fig.1).
Figure 1. Number of Centers from participating countries
Questionnaire:
The Questionnaire was create to get the answer about the
AML diagnostic and treatment approach in Central and
Eastern European countries. The questionnaire consists of
three parts:
Part one give the answers about the participating countries,
number of Centers in each country, and number of patients
treated per year.
Part two is dealing with diagnostic possibilities for AML:
morphology/cytochemistry, immunophenotyping, cytogenetic/molecular
genetics, biobanking, HLA typing, microbiology.
Part three is treatment part for AML: Induction therapy,
postremission therapy (intensive chemotherapy, maintenance
chemotherapy, autologous and allogeneic stem cell transplantation),
supportive care (infection prevention, growth
factors, transfusion support).
81

State of the Art Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
Statistical analysis
Descriptive methods 1 have been used to present the obtained
data from Questionnaire.
Results
Number of patients treated in CELG Centers.
In 26 Centers from 10 countries (Fig 2.) 881 patients with
AML have been treated during a period of 1 year.
Figure 2. Number of patients with AML treated per year according to
participating countries
Most Centers were treated more than 20 patients per year;
but in 4 of them less than 10 patients received therapy for
AML. More than 60% of treated patients were younger than
60 years of age (Fig. 3).
Figure 3. Age of treated patients with AML according to participating
countries
Diagnosis of AML
The majority of Centers are able to perform the standard
diagnostic tools for acute leukemia as cytomorphology, cytochemistry
and multiparameter (≥ 3 color) flow cytometry,
as well as qualitative PCR (Fig. 4.).
In one country there is no cytogenetic laboratory. Centers
in 4 countries have no facilities for cryopreservation (Fig.
5.) and they are not able to store the samples of peripheral
blood and marrow. In 6 countries galactommanan test are
routinely performing for diagnosis of fungal infection (Fig
5.). Comorbidity prognostic index2 has been used as a treatment
predictor in 8 countries, especially in older patients.
82
Legends: BMA – bone marrow aspiration, Biopsy – bone marrow biopsy;
Cytochem – cytochmistry; FC/+3 – fl ow cytometry using 3color;
Genome – Genome molecular assays
Figure 4. Standard diagnostic facilities in centers of participating countries.
Legend: Cryopres. – Cryopreservation
Figure 5. Biobanking, cryopreservation, HLA-typing and infection diagnostic
possibilities in centers of participating countries.
Treatment of AML
For patient younger than 60 years of age cytarabine based
chemotherapy was the main regimen (Fig. 6.). For induction
therapy »3+7« regimen 3 is the most frequently used treatment.
For consolidation combination of intermediate dose
of cytarabine in combination with anthracycline 4 is the most
popular treatment option. Some centers treated AML according
to EORTC protocol 5 . They added etopozide to anthracycline
and cytarabine for induction therapy. Polish
Centers have been using their own protocol, combination of
cytarabine, cladribine and anthracycline 6,7 .
Legend: EORTC – European Organization for Research and Treatment of
Cancer; PALG – Polish Acute Leukemia Group; IntAraC – Intermediate
dose of cytarabine
Figure 6. Induction and postremission chemotherapy for patients 18 to
60 years of age

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) State of the Art
For older fit patients most of the CELG centers have been
using 3+7 protocol (Fig 7.) For frail patients low dose cytarabine
or symptomatic therapy has been the most frequent
treatment approach (Fig. 7.).
Legend: 3+7 – (daunoblastin 3 days + cytarabine 7 days); 2+5 (daunoblastin 2
days + cytarabine 5 days); MICE – mitoxantrone, cytarabine, etoposide;
Ara-C based – cytarabine based; LD-Ara-C – Low dose cytarabine;
ASCT – Autologous stem cell transplantation; Hydrea – hydroxyurea
Figure 7. Induction and postremission chemotherapy for patients older
than 60 years of age
Out of 667 patients eligible for transplantation, 194 of
them (28%) received stem cells in post-consolidation period;
15% were treated with allogeneic stem cell transplantation
while 13% of patients received autologous stem cell
(Fig. 8.).
Legend: Allo-SCT – allogeneic Stem cell transplantation;
Auto-SCT – autologous stem cell transplantation
Figure 8. Number of patients treated with allogeneic and autologous
stem cell transplantation
Concerning the source of stem cells in autologous group
most of the patients received stem cells from peripheral
blood (97%). In allogeneic group in ¾ of patients stem cells
were from peripheral blood, while in ¼ of them marrow was
the source of stem cells. Two patients received stem cells
from cord blood (Fig 9.).
Allogeneic stem cell transplantation is not a standard
treatment options in two countries. Therapy with match unrelated
donor as well as conditioning with reduced intensity
is still not available in two countries (Fig 10.).
Legend: Allo-SCT – allogeneic Stem cell transplantation;
Auto-SCT – autologous stem cell transplantation
Figure 9. Source for stem cells
Legend: Allo-SCT – allogeneic stem cell transplantation; MUD – Match
unrelated donor; RIC – reduced intensity conditioning
Figure 10. Availability of allogeneic stem cell transplantation, transplantation
with unrelated donor and transplantation with reduced intensity
conditioning
Concerning the supportive care 6 countries (four of them
with laminar air-flow) are treated AML patients in 1-bed
room, according to the principles of reverse isolation, while
in 4 countries patients are caring in two or more than 2-bed
rooms (Fig. 11.) Laminar air-flow unites are used exclusively
for allogeneic transplantation.
Legend: LAF – laminar air-fl ow
Figure 11. Standard of care of the neutropenic patients
Quinolones and fluconazole are the principal antimicrobial
and antifungal drugs for bacterial and fungal infection
prophylaxis respectively. All centers have the possibilities
for platelet and red blood cell transfusion support although
the criteria for transfusion differ from center to center.
83

State of the Art Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
Discussion
Most of the Centers in the Central and Eastern European
countries are well experienced centers for the diagnosis and
treatment of AML. In most of them the number of patient is
sufficient to get all the necessary skills for AML diagnosis
and treatment. But still some centers are treating small number
of patients. In view of the current diagnostic and treatment
approach especially the need for new molecular genome
technique and transplantation together with the targeted
therapy it is not rational to develop the center with a
small number of patients. The cost of proper care and treatment
is too high for such a small number of patients. The
recommendation is to treat not less than 30 patients per
year.
The total number of patients treated in 10 countries is
quite sufficient to design and conduct prospective clinical
trial. Another very important information coming from the
data is age of the patients treated. Most of the patients (60–
70%) are younger than 60 years of age. The median age of
AML patients is 658 . This means that many patients did not
reach these centers, and they are treated in the local hospitals.
Standard diagnostic facilities are sufficient in most centers
for AML. Cytomorphology, immunophenotyping, cytogenetic
and molecular technique is mandatory according to
ELN criteria9 . The questionnaire delineated that most of the
centers are able to perform these standard diagnostic tools.
In one country cytogenetic is not performing routinely. According
to WHO classification for myeloid neoplasm10 cytogenetic
is important prognostic factor for AML and should
be the part of standard diagnostic test. In the recent years we
are faced with the detection of many new genetic alterations
with prognostic impact11–15 . This represents a new diagnostic
challenge for many centers, especially for four countries
without the cryopreservation facilities. The centers in these
countries have no possibilities to keep the samples for the
more demanding test in AML. The recommendation is to
organize referent laboratory for cryopreservation in a reasonable
period of time.
Induction and consolidation therapy are cytarabine-based
in combination with anthracycline. The well known regime
»3+7« is the most popular one. Still there is no data showing
better treatment protocol for induction therapy3,16–18 . In elderly,
treatment depends on co-morbidities. Fit elderly patients
received less intensive chemotherapy compared to
young patients, who predominantly received »3+7 regimen«.
Frail patients have been treated with low-dose cytarabine
or supportive care19 .
Only the minority of younger patients underwent stem
cell transplantation. About 15% of them have been allografted,
and 13% received their own marrow as postremission
therapy. The reasons that might explain the small number
of transplanted patients are insufficient facilities for
transplants or low number of patients eligible for transplants.
The questionnaire data shows that in some countries
there are no sufficient facilities for allografting. At the moment
the centers in two countries are not able to perform
allogeneic transplants. In four countries allografting from
matched unrelated donor (MUD) (20) was not performing.
84
In addition total body irradiation (TBI) for conditioning and
reduced intensity conditioning 21,22 have not been performing
in 3 and 4 countries respectively. .
Patient care is not on the expected level for immunocompromised
and neutropenic patients. In centers of 4 countries
acute leukemia are treating in the room of two or more beds.
It is mandatory to state that intensive chemotherapy and
stem cell transplantation could be performed only in the
centers with 1-bed room.
Conclusions
The questionnaire revealed important data concerning the
diagnosis and treatment of AML in centers of Central and
Eastern Europe. A large number of patients have been currently
treated in these centers. The number of patients is
quite enough for the future prospective clinical trials. Concerning
the diagnostic tools, standard approach has been
performing routinely in most centers. Therapy approach is
cytarabine based in combination with anthracycline. Stem
cell transplantation is performing in the majority of Centers
but still the number of transplants is low. The level of standard
and supportive care differs from country to country and
one of the priorities of CELG group is to standardize the
diagnostic and treatment approaches. This is a prerequisite
for the future clinical trials.
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leukemia: what is new? Curr Opin Hematol 2011; 18:83–8.
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AK, et al. Diagnosis and management of acute myeloid leukemia in
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12. Gilliland DG, Griffin JD. Role of FLT3 in leukemia. Curr Opin Hematol
2002;9(4):274–81.
13. Schlenk RF, Döhner K, Krauter J, Fröhling S, Corbacioglu A, Bullinger
L, et al. Mutations and treatment outcome in cytogenetically normal
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14. Green CL, Koo KK, Hills RK, Burnett AK, Linch DC, Gale RE. Prognostic
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mutations and the interaction with FLT3 and NPM1 mutations. J Clin
Oncol 2010 ; 28:2739–47.
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85

Poster Presentations
PP01 Rapamycin enhances dimethyl sulfoxidemediated
growth arrest in human
myelogenous leukemia cells
Lalic H, Lukinovic-Skudar V, Banfic H, Visnjic D.
Department pt of Physiology & CIBR, School of Medicine,
University of Zagreb
Aim: The pharmacological inhibitors of phosphoinositide
3-kinase (PI3K)/Akt/mammalian target of rapamycin
(mTOR) pathway have been proposed in the treatment of
leukemia based on their antiproliferative effects, but their
possible role in differentiation therapy is less explored. Rapamycin,
an mTOR-inhibitor, has been recently reported to
potentiate all-trans retinoic acid-mediated differentiation of
HL-60 and NB4 cell lines along granulocytic pathway, and
monocytic differentiation of U937 cells induced by vitamin
D3. Dimethyl sulfoxide (DMSO) is a potent inducer of
granulocytic differentiation of myeloid cell lines and erythroid
differentiation of K562 cells. The aim of the present
study was to test for the possible synergistic effects of rapamycin
and DMSO on growth arrest and differentiaton of
human myelogenous leukemia cells.
Materials and methods: Myeloblastic (AML-M2) HL-
-60, promyelocytic (AML-M3) NB4, monocytic (AML-
-M5) U937, immature (AML-M6) KG-1, and erythro-megakaryocytic
K562 cell lines were maintained in exponential
growth and differentiated in the presence of DMSO (0.6 or
1.25%). The number of viable cells was quantified using a
hemocytometer and trypan blue exclusion. The expression
of differentiation markers and the cell cycle distribution of
propidium iodide-labeled cells were determined by FACS
analyses. Cell morphology was evaluated on May-Grunwald-Giemsa-stained
cytospin preparations. The level of
phosphorylated (Thr389) and total p70 S6 Kinase (p70
S6K) in total cell lysates was determined by Western blot
analysis.
Results: Western blot analysis demonstrated that the incubation
of leukemia cells in the presence of 20 nM rapamycin
for 20 min completely reduced the level of Thr389phosphorylated
p70 S6K, which is one of the principle
downstream targets of activated mTOR. When applied at
the same dose for 96 h, rapamycin alone exerted minimal
antiproliferative effects; significant decrease in the number
of viable cells was observed in rapamycin-treated HL-60
and KG-1 cells. The presence of 1.25% DMSO for 96 h
significantly inhibited the growth of all cell lines tested, and
the combination of rapamycin and DMSO inhibited the
number of viable cells significantly more than either agent
alone. FACS analysis of propidium iodide-labeled cells revealed
a synergistic effect of rapamycin and DMSO on cell
cycle arrest in G0/G1 phase.
Conclusion: Rapamycin potentiates growth-inhibitory
effects of DMSO in the established acute myeloid leukemia
lines. These results suggest that mTOR inhibitors may have
beneficial effects in combination with differentiation agents
in therapy of AML
PP02 Ikaros transcription factors expression
in cell differentiation
Antica M 1 , Paradzik M 1 , Matulic M 2 , Batinic D 3 , Labar B 3 .
1 Division of Molecular Biology, Ru|er Bo{kovi} Institute,
Zagreb, 2 Department of Molecular Biology, Faculty of
Science, Zagreb, 3 University Hospital Center and School of
Medicine, University of Zagreb Croatia.
Ikaros family transcription factors are involved in lymphocyte
differentiation and have a critical role at specific
check points of the haemopoietic pathway. However, how
developmentaly regulated changes are reflected in gene expression
programs of lymphocyte differentiation is not well
understood. We study the mechanisms and predisposition
for leukemia development by analysing genes involved in
hematopoietic differentiation. Gene targeting studies show
that major players in the commitment of hematopoietic progenitors
are Ikaros family transcription factors, and inappropriate
expression of these genes might be involved in
leukemogenesis. Accordingly, we analyzed the differential
expression of Ikaros transcription factors and their splicing
variants in the most frequent leukemia types, CLL, ALL and
AML and in hematological cell lines. We provide evidence
that splicing variants of these transcription factors occur but
they are not restricted to leukemic cells only. Further, the
analysis of Aiolos, showed a clear difference among groups
due to its lower expression in all types of acute leukemia
investigated.
Aims: In this work we analyzed the state of Ikaros family
members in different leukemic cells with the aim to explore
the transcriptional control of human hematopoietic lineages
and shed some new light on our understanding of transcription
factor significance in human leukemia.
Methods: By means of qRT-PCR we investigated the
mRNA expression of Ikaros transcription factors and their
splicing variants in leukemia cell lines and in 30 samples of
leukemia patients, with AML, ALL or CLL and healthy controls.
Results: Ikaros family members are expressed as multiple
splice variants and proteins arising from alternatively
spliced transcripts may act as dominant negatives. In all of
the cell lines examined Ikaros was present as dominant Ik1
to Ik4 isoforms and the small Ik6 isoform was absent. Aiolos
was expressed in the majority of the cell lines, of both, B
and T origin, in the form of the full length Aio1. Helios was
87

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
also present only in two long isoforms Hel1 and Hel2, and
was absent in one third of the samples. Although expression
of these short isoforms has been linked to lymphoid and
myeloid leukemia the quantitative distribution of Ikaros,
Aiolos and Helios mRNA expression level in hemopoietic
cells of patients with lymphocytic leukemia, represented by
the most frequent B-CLL and ALL (T cell ALL and common
ALL), and compared to acute leukemia of myeloid lineage,
AML has not been reported. We found that the relative
quantity of Ikaros and Helios mRNA was similar in all subgroups.
Though, analysis of Aiolos, showed a clear difference
among groups due to its lower expression in all types
of acute leukemia investigated.
Conclusion: Our results, associating a lower Aiolos expression
with acute leukemia point to Aiolos role in human
lymphocyte development as it has been previously shown in
mice.
PP03 Multicenter performance evaluation
of the multidrugquant assay kit
Márki-Zay J 1 , Tauber Jakab K 1 , Sipka S 2 , Nagy G 2 ,
Baráth S 2 , Gyimesi E 2 , Hevessy Zs 3 , Sziráki Kiss V 3 ,
Szabó P 5 , Tõkés-Füzesi M 5 , Nagy É 7 , Trucza É 7 ,
Udvardy M 4 , Borbényi Z 8 , Dávid M 6 , Kappelmayer J 3 .
1 Solvo Biotechnology, Szeged, Hungary; 2 Regional
Immunological Laboratory, 3 Department of Clinical
Biochemistry and Molecular Pathology, 4 2nd Department
of Internal Medicine, University of Debrecen-Medical and
Health Science Center, Debrecen, Hungary; 5 Department
of Laboratory Medicine, University of Pécs-Medical
School, 6 1st Department of Internal Medicine, Pécs,
Hungary; 7 Department of Laboratory Medicine, 8 2nd
Department of Medicine and Cardiology, University of
Szeged – Albert Szent-Györgyi Clinical Center, Szeged,
Hungary
In the last decade it has become widely accepted that
clinical resistance to chemotherapy correlates with the overexpression
of ATP-binding cassette (ABC) transporters, such
as ABCB1 (MDR1 or P-gp), ABCC1 (MRP1), and ABCG2
(MXR or BCRP). There are numerous technical approaches
to study multidrug resistance (MDR), which came into the
centre of interest, but the correlating results derived from
different methods. Although the functional methods separately
gave promising results, standardization and reproducibility
of these tests failed to conform to the values required
from routine diagnostic methods. The MultiDrugQuant kit
(MDQ kit) is a flow cytometric method to measure the functional
activity of the three, clinically most relevant efflux
transporters, such as MDR1, MRP1 and BCRP in viable
cells. The kit applies fluorescent dyes (substrates) and inhibitors
of the all three transporters implicated. After short
incubation of the cell suspension, the MDR activities (MAF
values) of the multidrug transporter were calculated from
the difference between the geo-mean fluorescent intensity
of cells w/o the specific inhibitors, respectively.
Aim: The purpose of the study was the performance evaluation
of the MDQ-kit as routine clinical laboratory flow
cytometric assay.
88
Patients and methods: Performance evaluation of the
MDQ kit was carried out to fulfil the requirements of the
EU IVD directive (98/79/EC) and the harmonised European
norms. Laboratory validation of the kit was performed in
three university centres in Hungary according to the standards
of the Clinical Laboratory Standards Institute. Inaccuracy
and comparative measurements were carried out using
cell lines with low and high activity of transporters.
Mononuclear cells from healthy donors were separated using
Ficoll gradient and results on different flow cytometers
were compared using CD45 or CD19 or CD3 monoclonal
antibodies for gating the population of interest using a harmonized
procedure. The reference interval of MDR activities
in lymphocytes has been determined in a population of
120 healthy volunteers.
Results: The assay proved to be specific and robust at
various concentrations of the fluorescent dyes (10–100% of
the original) or inhibitors (50–150% of the original). Both
intra-assay and inter-assay reproducibilities were < 24.2;
MAF-MRP < 13.2; MAF-BCRP < 23.2.
Conclusion: This functional assay is reliable and provides
transporter specific quantitative results on the function
of the MDR1, MRP1 and BCRP transporters in the
target cells. Recently, clinical trials have been started in haematological
diseases to evaluate the predictive and prognostic
values of these biomarkers.
PP04 NPM1 mutations in AML detected by
fragment analysis and Sanger sequencing
Crncec I, Musani V, Marusic Vrsalovic M, Livun A,
Pejsa V, Jaksic O, Haris V, Ajdukovic R, Stoos Veic T,
Kusec R. Departments of Hematology, Divison of
molecular diagnostics and genetics and Cytology,
Universtiy hospital Dubrava and Zagreb School of
Medicine, Division of molecular medicine, Institute Rudjer
Boskovic, Zagreb, Croatia
NPM1gene mutations can be detected in approximately
1/3 of all de novo AMLs particularly in cases with normal
karyotype and predicts good prognosis. However, associated
with FLT3-ITD is of adverse prognosis
Aim: We have developed a two-step molecular assay for
the detection of NPM1 mutations.
Patients and methods: The first part, prescreening for
mutation, consists of RT-PCR amplification of exon 12 of
the gene with the subsequent gene scan (fragment analysis)
by capillary electrophoresis in AB310 Sequencer analyzer.
What follows is re-amplification of mutation-positive cases
and direct sequencing for the determination of the precise
type of mutation. We tested 60 patients with de novo (46)
and secondary (14) AMLs from our institution. The karyotype
was available for 32% of them and FLT3-ITD analysis
was done in all.
Results: NMP1 mutations were found in 12 patients with
de novo AML (26% of de novo AML; 20% for all AMLs).
None was from the sAML group. Sequencing revealed 8
cases of A-type (TCTG), 2 of D-type (CCTG) and 1 each of
H-type (CTTG) and Nm-type (CCAG) mutation. Expected
frequencies are given in the table.

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
Mutation type N % (95% CI) Expected %
A 8 67 (35-90) 70-80
D 2 17 (2-48) approx. 6, < 10
H 1 8 (0-27) approx. 2
Nm 1 8 (0-27) approx. 0,4, < 1
Σ 12 - -
There was also a significant association of NPM1 and
FLT3-ITD mutation (H 2 =6,322; DF=1; P=0,012).
Conclusion: In conclusion, the two-step molecular assay
for NPM1 mutation detection is rational and acceptable
method for the routine diagnostic application. Frequencies
of NPM1 mutations in our patients are comparable to the
ones reported previously, with type A being the most frequent.
However, although in the small number of patients,
we have observed increased occurrence of relatively rare
molecular types. We can also confirm that there is an increased
association of FLT3-ITD with NPM1 mutation.
PP05 NPM1 mutation A and FLT3/ITD in AML
with myelodysplasia-related changes
Radic Antolic M, Ries S, Zadro R, Davidovic S, Labar B.
Clinical Hospital Center and School of Medicine,
University of Zagreb, Croatia
According to WHO criteria, acute myeloid leukemia
(AML) with myelodysplasia-related changes requires the
presence of at least 20% blasts in the bone marrow and/or
blood and morphologic features of dysplasia in two or more
mature bone marrow cell lines. Chromosomal abnormalities
may be identical to those in myelodysplasia, with either
complex or normal karyotypes. In patients with normal
karyotype, it is important to detect mutations in NPM1 and
FLT3 gene as a predictor of clinical outcome.
The aim of this study was to determine the prevalence of
NPM1 mutation A and FLT3/ITD and to relate them to cytogenetic
abnormalities in patients with AML with myelodysplasia-related
changes.
The study included 52 patients (23 female and 29 male)
with de novo AML with myelodysplasia-related changes.
Bone marrow aspirate at diagnosis was used for cytogenetic
and molecular analysis. GTG-banding was used for karyotype
analysis and FISH was used for detection of del(5q),
del(5), del(7q), del(7) and rearrangement of the MLL gene.
RQ-PCR was used to determine NPM1 mutation A (Ipsogen,
France) and FLT3/ITD was determined by RT-PCR
analysis (Nakao et al, Leukemia 1996).
Among 52 patients included in the study, 29 (56%) had
normal karyotype, 9 (17%) had intermediate, and 12 (23%)
adverse cytogenetic risk, while cytogenetic analysis was not
performed for two patients (4%). FLT3/ITD was positive in
7 (13%) patients: 6 of them were with normal karyotype and
one had adverse cytogenetic risk. NPM1 mutation A was
positive in 9 (17%) patients; 6 of them had normal karyotype,
2 had intermediate and one patient adverse cytogenetic
risk. Three patients (6%) with NPM1 mutation A and
FLT3/ITD had normal karyotype. Although patients with
normal karyotype had higher incidence of NPM1 mutation
A and FLT3/ITD than patients with intermediate and adverse
cytogenetic risk, the difference was not statistically
significant. There was no difference in patient distribution
in cytogenetic risk groups according to gender. In normal
karyotype patients group, higher incidence of NPM1 mutation
A and FLT3/ITD was observed in female patients (4/14)
than in male patients (2/15) but without statistical significance.
AML with myelodysplasia-related changes is a distinctive
myeloid disorder which requires multidisciplinary approach
in diagnostics. Cytogenetic abnormalities have the
most important role in predicting outcome, but in patients
with normal karyotype only small gene mutations (NPM1,
FLT3) can help in risk categorization. In future, those mutations
could be real predicting factors correlating with therapy
response and clinical outcome.
PP06 Prognostic Signifi cance of CD56 Antigen
Expression in Patients with Acute Myeloid
Leukemia
Djunic I, Virijevic M, Djurasinovic V, Novkovic A,
Colovic N, Kraguljac-Kurtovic N, Vidovic A,
Suvajdzic-Vukovic N, Tomin D. Clinic of hematology,
Clinical Center Serbia, Belgrade, Serbia
Aim: CD56 antigen, identified as an isoform of the neural
adhesion molecules, has been found to be associated
with poor prognosis in several hematologic malignancies,
including acute myeloid leukemias (AML). The aims of this
study were to investigate frequency and prognostic relevance
of CD56 expression in patients with AML, as well as
to compare the importance of CD56 expression with standard
prognostic factor such are age, cytogenetic abnormalities
and performance status.
Patients and methods: In this single-center study we
analyzed the data of 184 newly diagnosed patients with
nonpromyelocytic AML with follow-up of 36 months. As
the risk factors for overall survival (OS), rate of achievement
CR and duration of CR, were estimated: age, ECOG
PS, FAB subtype AML, ELN cytogenetic risk group and
CD56 expression on blasts cells. Performance status (PS)
was evaluated by Eastern Cooperative Oncology Group
(ECOG), ranged 0–4 (=2). AML subtypes were classified
by French-American-British (FAB) Cooperative Group.
Cytogenetic risk groups were assessed by recommendation
of European LeukemiaNet (ELN): favorable, intermediate-
I, intermediate-II and adverse group. For CD56 antigen expression,
detected by flow-cytometry, a cut off >=20% was
used as positive (CD56+). Patients were treated with Medical
Research Council (MRC) 12 regimen. Risk factors were
identified using the univariate and multivariate analysis.
Results: The median patients’ age was 58 years, range
18–79. CD56+ antigen was recorded in 40 patients (21.7%).
Significant risk factors for poor OS in univariate analysis
were: age >=55 years (p=2 (p=0.001), adverse cytogenetic
(p=0.019) and CD56+ (p=0.003). The multivariate analysis
indicated that CD56+ was the most significant risk factor
89

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
for OS: p=0.05, relative risk (RR)=1.598 (95% CI 0.984-
2.595). The most significant factor for poor rate of CR was
age >=55 years: p=0.001, RR=0,274 (95% CI 0.125-0.597).
CD56 positivity had not significant influence on CR rate,
but it was the most significant risk factor for shorter duration
of CR: p=0.005, RR=0.443 (95% CI 0.253-0.779). According
to FAB subtypes of AML, CD56 positivity had the
most significant impact on patients’ outcome in M5 subtype.
In those patients CD56+ was the most significant risk
factor for poor OS (p=0.021, RR=2.981, 95% CI 1.174-
7.122) and shorter duration of CR (p=0.03, RR=3.563, 95%
CI 1.132-11.215.
Conclusion: Our data underline the independent negative
prognostic role of CD56 antigen expression in AML,
particularly in M5 subtype. Its presence should be regularly
estimate for a better prognostic assessment of AML patients.
PP07 FLT3 internal tandem duplication is a poor
risk factor in patients with AML with
diverse cytogenetic features
M. Mikulic, R. Zadro, S. Davidovic, R. Serventi Seiwerth,
D. Sertic, D. Nemet, J. Batinic, D. Batinic, K. Gjadrov,
S. Ries, B. Labar. Department of Medicine and
Department of Clinical Laboratory, Clinical Hospital
Center and School of Medicine, University of Zagreb,
Croatia
Aim: Mutations of Fms-like tyrosine kinase 3 (FLT3) are
present in about 30% of acute myelogenous leukemia
(AML) patients that have been shown to have poor prognosis.
The aim of this study was to analyze the prognostic impact
of FLT3 internal tandem duplication (ITD) on the outcome
of patients diagnosed with AML in comparison with
patients with wild-type (WT) FLT3.
Patients and methods: We retrospectively analyzed the
laboratory and clinical data in 78 newly diagnosed patients
with AML who have been treated in our Center from
02/2000-03/2010. Median patients’ age was 45 years (range,
22–72 yrs.). AML diagnosis was based on morphological,
immunophenotypical and cytogenetical features. The presence
of FLT3 ITD was detected by RT-PCR analysis. All
patients received intensive induction chemotherapy followed
by consolidation chemotherapy; 36 patients were
treated with autologous hematopoietic stem cell transplantation
(SCT) in 1 st CR, while 8 and 3 patients were allografted
in 1 st and >1 st CR, respectively.
Results: FLT3-ITD was detected in 20 patients (25%).
Eight FLT3-ITD patients had normal karyotypes, two had
good, and two had intermediate cytogenetic features. Thirteen
FLT3-WT patients had normal karyotypes, five had
good, nine had poor, and nine had intermediate cytogenetic
features. In 30 patients from both groups cytogenetic studies
had failed. CR rate was 85% in FLT3-ITD patients and
71% in FLT3-WT patients (p=0.249). 2-year DFS was 33.8
and 52.5% in the FLT3-ITD and FLT3-WT group, respectively
(p=0.029). 2-year OS was 47.3 and 63% in the FLT3-
ITD and FLT3-WT group, respectively (p=0.665).
90
Conclusion: A higher remission rate after induction, although
not statistically significant, was found in the FLT3-
ITD group. Contrary to that, the DFS was significantly better
in patients with FLT3-WT and a trend for better OS was
observed in patients with FLT3-WT. This data support the
evidence for FLT3-ITD being a poor risk factor, not only in
patients with normal karyotypes, but also in patients with
different cytogenetic risk factors.
PP08 A Philadelphia-negative Chronic Myeloid
Leukemia with a BCR/ABL Fusion Gene
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 , Begovic D 1 .
1 Division of Medical Genetics, Department of Paediatrics
Univesity Hospital Center Zagreb, Zagreb, Croatia.
2 Division of Hematology, Department of Internal Medicine,
Clinical Hospital Merkur, Zagreb, Croatia. 3 Division of
Hematology Departmrnt of Internal Medicine, Clinical
Hospital Dubrava, Zagreb, Croatia. 4 Clinical Laboratory
Diagnostics, University Hospital Center Zagreb, Zagreb,
Croatia. 5 Division of Hematology, Department of Internal
Medicine Univesity Hospital Center Zagreb, Zagreb,
Croatia
Aim: Objective. The causing factor in chronic myeloid
leukemia (CML) is the BCR/ABL chimeric gene. In most
cases, it is cytogeneticlly visualized as a translocation between
chromosomes 9 and 22 as the Philadelphia (Ph) chromosome.
Five to ten percent of patients lack cytogenetics
evidence of the Ph chromosome (CML-Ph) but show BCR/
ABL fusion by fluorescence in situ hybridization (FISH) or
reverse transcriptase-polymerase chain reaction (RT-PCR).
Patients and methods: Methods. Diagnostic bone marrow
samples were diagnosed by morphological, immunophenotypical
criteria, and reverse transcriptase-polymerase
chain reaction. Chromosome studies were performed on
GTG-banded chromosomes obtained from bone marrow after
direct preparation or short-time cultures. FISH studies
were done using BCR/ABL1 dual-color/dual_fusion probes
(Kreatech, Vysys)
Results: Among 231 adult patients with CML, 10%
(n=23) had variant translocations (9;22;v), involving one or
two additional translocation partner chromosome. Two cases
(0.8% in total) had an apparently normal karyotype. In
first case, 56-year-old female diagnosed with CML, conventional
cytogenetic analysis shoved a normal karyotype.
Methaphase FISH showed an insertion of BCR sequences
onto a chromosome 9 within ABL, the karyotype was
46,XX. ish ins(9;22)(q34;q11.2). Second case, 58-year-old
female with clinical findings consistent with CML, by conventionl
cytogenetic analysis showed apparently normal
karyotype. Findings with methapase FISH were interpreted
as an insertion of the ABL gene onto chromosome 22 with
BCR, the karyotype was 46,XX. ish ins(22;9)(q11.2;q34).
The RT-PCR provided molecular evidence that a typical
CML chimeric product resulting from a fusion of BCR exon
with ABL exon is present in both cases.
Conclusion: The clinical significance Ph-CML with apparently
normal karyotype, with 5’BCR/3’ABL fusion gene

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
located on 9q34 and 22q11.2 is unclear. Some studies have
suggested that these cryptic translocationes have no impact
on prognosis, while others have suggested an adverse prognosis,
it is more likely that the prognosis in Ph- is linked to
the presence or absence of associated deletion on the der(9)
rather than positioning of the fusion gene alone.
PP09 Croatian CML Registry based on European
LeukemiaNet CML Registry
Sertic D 1 , Peric Z 1 , Sincic-Petricevic J 2 , Lozic D 3 ,
Mandac-Rogulj I 4 , Duletic Nacinovic A 5 ,
Gveric-Krecak V 6 , Corovic-Arneri E 7 , Pejsa V 8 ,
Suvic-Krizanic V 9 , Skunca Z 10 , Babok-Flegaric R 11 ,
Krmek-Zupanic D 12 , Carzavec D 13 , Lazic-Prodan V 14 ,
Coha B 15 , Ajdukovic R 8 , Romic I 7 , Zadro R 1 , Davidovic S 1 ,
Lasan-Trcic R 1 , Labar B 1 . Croatian Cooperative Group for
Hematologic Diseases-CML Group: 1 University Hospital
Center Zagreb, 2 University Hospital Center Osijek,
3 University Hospital Center Split, 4 Clinical Hospital
Merkur Zagreb, 5 University Hospital Center Rijeka,
6 General Hospital [ibenik, 7 General Hospital Dubrovnik,
8 Clinical Hospital Dubrava-Zagreb, 9 General Hospital
Sisak, 10 General Hospital Zadar, 11 General Hospital
Vara`din, 12 General Hospital Sv.Duh-Zagreb, 13 Clinical
Hospital Center Sestre milosrdnice-Zagreb, 14 General
Hospital Pula, 15 General Hospital Slavonski Brod
Background: Based on European Leukemianet (ELN)
Registry for Philadelphia positive chronic myeloid leukemia
(CML) we collected data on CML epidemiology, the
disease characteristics and treatment, as well as the data
concerning the monitoring and clinical outcome of CML in
Croatia. Here we present the preliminary data of CML Registry
in Croatia.
Methods: Data were prospectively collected from November
15, 2009 until June 30, 2011. Data was sent to the
national coordinator in the University Hospital Center Zagreb
from all the hematologists in Croatia. All patients
signed informed consent prior to the data reporting in the
Registry.
Results: From November 15, 2009 until June 30, 2011,
69 patients with CML were registered. For 66 patients data
were collected in CML Registry. Median age was 54.6 years
(range 17–87). There were more male than female patients
(63.6% versus, 36.4%). At time of diagnosis all were in
chronic phase of CML. The Euro Score risk group distribution
was: 36.4% low, 51.5% intermediate and 12.1% high
risk; the Sokal risk distribution showed: 36.4% low, 30.3%
intermediate and 30.3% high risk The majority of the patients
showed a WHO performance status score of 0 (54.5%)
or 1 (37.9%). FISH for bcr-abl was positive in 100% of
cases and 51 (77.3%) of them were diagnosed by conventional
cytogenetic (G-banding). Molecular Diagnostics (RT-
PCR, quantitative PCR or both) was performed in 48
(72.8%) patients Out of 27 patients who were committed
quantitative-PCR at diagnosis, in 19 of them it is expressed
by the international score. In relation to the population
based approach preliminary data showed a higher frequency
of newly diagnosed CML in two regions (Sisak and Sibenik).
Summary: According to data collected so far the incidence
of CML in Croatia is 0.99 / 100 000 inhabitants.
There is uneven incidence distribution of CML by region,
but due to the small number of patients we need a longer
follow-up. Participation in ELN Registry study clearly improved
the diagnostic possibilities (use of quantitative PCR
for monitoring of CML). We also implemented for most patients
ELN recommendations for treatment response with
TKI.
PP10 Use of Imatinib mesylate in Chronic Phase
CML in Clinical Practice – Our Experience
Miljkovic E, Markovic D, Cojbasic I, Nikolic V,
Marjanovic G, Govedarovic N, Macukanovic-Golubovic L,
Vucic M, Pavlovic M, Vukicevic T, Tijanic I, Simonovic O,
Clinic of Hematology, Clinical Center Nis, Serbia
Chronic myelogenous leukemia (CML) is a pluripotential
stem cell disease characterized by anemia, extreme
blood granulocytosis and granulocytic immaturity, basophilia,
often thrombocytosis, and splenomegaly.
Hallmark of chronic myeloid leukemia is Philadelphia
chromosome that results from a reciprocal translocation between
chromosomes 9 and 22.
T (9;22)(q34;11) creates an aberrant fusion gene derived
from the ABL gene encoded on chromosome 9 and the BCR
gene encoded on chromosome 22.The product of this fusion
BCR-ABL gene is a constitutively active protein-tyrosine
kinase that promotes cellular proliferation and suppresses
apoptosis.
The incidence of CML increases with age, with a peak
incidence of 53 years. Men are affected more often than
women (3:2).
CML has a tri-phasic clinical course: chronic phase, accelerated
phase and blastic phase (myeloid or lymphatic)
defines the transformation of CML in an acute leukemia and
is difficult to treat. Myeloid transformation of CML is more
common (70%) than lymphoid blastic crisis (30%).
Inevitable progression to blast crisis used to occur after a
median of 3.5 years prior to the development of Bcr Abltargeted
therapie.
The Abl tyrosine kinase inhibitor imatinib (IM) induces
durable responses in a high proportion of patients with
chronic phase chronic myeloid leukemia and therefore represents
the current standard first line treatment.
Aim: Aim was to evaluate hematological and cytogenetic
response in patients treating with IM longer then 6 months.
Second aim was to evaluate molecular response in patients
treating with IM longer then 24 months.
Methods: Patients were monitored for hematologic and
cytogenetc reponse at 6 months intervals. Complete hematologic
response is defined by WBC count

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
ter short-term culture (24 or 48 hours or both) with standard
G or Q banding techniques.
Achievement of a complete molecular response (CCyR)
was assessed with the use of a quantitative reverse-transcriptase–polymerase-chain-reaction
(RT-PCR) assay.
Results: 38 patients, 21 men and 17 women were
analised. Median age of patients was 46.6 years (18–73).
After 32.6 months of median follow up (6–80), complete
hematologic and cytogenetic response (mitosis with no
Ph+) was achieved in 79.0 % patients (30),complete hematologic
and no cytogenetic response (>95% mitosis Ph+) in
2.6% (1). 15.8% of patients (6) had resistance to imatinib
mesylate and were switched to other therapeutical options,
two of them with additional chromosomal abnormalities.
(one with 2 Ph+,and one with trisomy 8 and trisomy 22
chromosomes). 1 patient (2.6%) had a severe adverse effect
after 6 months with IM therapy-pancytopenia, mostly
thrombocytopenia and the drug was interrupted.
Achievement of CCyR was assessed with (RT-PCR) assay
in patients treating with IM longer then 24 months. 15
patients were tested for molecular response. A major molecular
response was defined as a BCR-ABL transcript level
of 0.1% or lower on the International Scale (conversion factor
of 0.81), corresponding to a reduction in the BCR-ABL
transcript level by at least 3 log from the standardized baseline
level. Complete molecular response achieved 86.7% of
patients (13) and 13.3% (2) had no molecular response.
Conclusions: Chronic myeloid leukemia has substantially
improved survival with the application of selective
ABL tyrosine kinase inhibitor imatinib mesylate as standrad
treatment of chronic phase CML, with very good quality of
life and few adverse effects.
PP11 Imatinib for CML as a frontline therapy
– Zagreb Experience
Sertic D 1 , Zadro R 2 , Nemet D 1 , Davidovic S 3 ,
Lasan-Trcic R 3 , Radic Antolic M 2 , Horvat I 2 ,
Frani} Simic I 3 , Roncevic P 1 , Radman I 1 , Basic-Kinda S 1 ,
Aurer I 1 , Labar B 1 . 1 Division of Hematolofy Department of
Medicine, 2 Department of Clinical Laboratory,
3 Department of Pediatric, Clinical Hospitral Center and
School od Medicine, University of Zagreb, Croatia
Background: Imatinib is frontline therapy for chronic
phase Philadelphia positive chronic myeloid leukemia (Ph+
CML). In about 70% of patients optimal treatment response
could be achieved and sustained for more than 7 years of
therapy.
We present the experience of the imatinib frontline treatment
for CML in University Hospital Center Zagreb, Department
of Hematology.
Patients and Methods: A total of sixty seven patients
with Ph+CML were treated with first line imatinib, from
February 2003. Here we evaluated fifty eight of them, who
were eligible for twelve months follow up. Median followup
time was fifty two months (range 12–103, months).
There were males and females, with a median age of forty
nine years (range 14–74, years). Patients were treated with
92
400 mg/day. They were regularly checked for treatment response
every 3 months with cytogenetic methods (G-banding
and FISH) and quantitative RT-PCR.
Results: In forty one patients (70%) complete cytogenetic
response (CCR) was documented. Out of those forty
one patients twelve patients (20%) achieved a complete molecular
response (CMR). Twenty three patients (40%)
achieved a major molecular response (MMR), while six patients
(10%) had less than MMR. Two patients (3.4%) were
resistant to first line treatment and were subsequently treated
with nilotinib. Another two patients (3.4%) progressed to
acute lymphoblastic leukemia, both after 2.5 months of therapy
with imatinib. One of them had a T315I mutation, and
was subsequently treated with MUD allogeneic stem cell
transplantation. One patient progressed to acute myeloid
leukemia. Another patient had a progression of the disease
during the chronic phase, with a verified T315I mutation.
He was treated with allogeneic stem cell transplantation.
Eight patients (13%) died during the course of the treatment,
four of which related to CML therapy or progression
of the disease. In four patients imatinib dose was increased
to 600 mg or 800 mg. Subsequent optimal response was
documented in all four patients. Two patients (3%) had serious
side effects to the treatment and were therefore switched
to nilotinib.
Conclusion: Optimal response with imatinib is reported
in 41 patients. Progression of the disease to accelerated/
blastic phase was found in 3 patients. Eight patients died,
four because of CML. Our experience has proved also that
imatinib is an effective frontline therapy for Ph+CML.
PP12 Frequency of 4 bcr-abl1 kinase domain
mutations in chronic myeloid leukemia
patients resistant to imatinib mesylate
therapy
Horvat I 1 , Radic Antolic M 1 , Zadro R 1 , Sertic D 2 , Labar B 2 .
1 Department of Clinical Laboratory, 2 Department of
Medicine, Clinical Hospital Center and School of
Medicine, University of Zagreb, Croatia
Introduction of imatinib mesylate (IM) for treatment of
chronic myeloid leukemia (CML) has brought revolution in
patient survival. Most patients in chronic phase of disease
have high rates of responses to IM with the optimum response
understood as major molecular response and bcrabl1
transcript level ≤ 0.1% according to International Scale
(IS). A proportion of patients become resistant to the drug
after some time. Mutations in bcr-abl1 kinase domain are
found in 50% of resistant patients and IM cannot bind to its
target.
The aim of this study was to determine the frequency of
4 bcr-abl1 kinase domain mutations (T315I, E255K, E255V
and Y253H) in a group of CML patients who became resistant
to IM therapy, and to show the percentage of bcr-abl1
transcript levels in patients with and without mutations. The
study included 28 CML patients, 27/28 were monitored during
the course of IM therapy by real time quantitative PCR
(Ipsogen, France) and their bcr-abl1 transcript values were

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
expressed according to IS. ASO-PCR for detection of T315I,
E255K, E255V and Y253H mutations was performed according
to Kang et al. (Haematologica, 2006).
Among 28 patients tested, T315I was detected in 9 patients
(32.1%), E255K in 3 patients (10.7%), E255V in 2
patients (7.1%) and Y253H in 6 patients (21.4%). Overall,
14/28 patients (50.0%) had one or more mutations. In T315I,
E255K, E255V and Y253H positive patients, bcr-abl1 transcript
levels were 7.7–39.1% IS (median 23.2%), 7.7–12.7%
(median 12.3%), 1.7–12.7% (median 7.2%) and 12.7–39.1%
(median 18.0%), respectively. In 14 patients tested negative
for analyzed mutations, bcr-abl1 transcript levels were
0.55–46.3% IS (median 12.3%). In 4 T315I positive patients
one or more additional mutations were detected; one patient
accumulated all four mutations over time (T315I, E255K,
E255V, Y253H), 2 patients gained Y253H, and E255K mutation
was detected in 1 patient. Among 4 patients who died,
3 were T315I positive and 2 of them had additional mutations.
Mutations in bcr-abl1 kinase domain are to a large extent
responsible for resistance to IM therapy. We have shown
that the monitoring of bcr-abl1 transcript level is important
for detecting resistance to IM and that mutations are found
in a high proportion of resistant patients. Searching for mutations
in patient who lost response to IM therapy is significant
part of CML patient management as the result of mutation
analysis directly affects therapy approach, particularly
in T315I positive patients for whom the treatment of choice
is stem-cell transplantation.
PP13 Imatinib mesylate in Patients with CML
Relapse after Allogeneic Transplantation
Serventi Seiwerth R 1 , Sertic D 1 , Radic Antolic M 2 ,
Mrsic M 1 , Zadro R 2 , Davidovic S 3 , Grubic Z 2 , Mikulic M 1 ,
Labar B 1 . 1 Department of Medicine, 2 Department of
Clinical Laboratory, 3 Department of Pediatric, Clinical
Hospital Center and School of Medicine, University of
Zagreb, Croatia
Intronduction: Allogenic stem cell transplantation is a
curable therapy for substantial number of patients with Ph+
CML. Because of high treatment related toxicity and mortality
in the current era of TKI terapy allografting is not any
more 1st line treatment. CML relapse after allogeneic transplantation
is still a problem in 20% of patients. For these
patient therapy with tyrosine kinase inhibitors (TKI) should
be an treatment option. Here we present the outcome of
three patients in realpse after allografting and treated with
TKI.
Patients and methods: Three patients, one male and two
females with Ph+ CML in chronic phase recived bone marrow
transplant from their HLA identical siblings after myeloablative
conditioning with busulfan and cyclophosphamide.
For GvHD prophylaxis cyclosporin and short methotrexate
was given. In all patients sustained three lineage
engraftmnet occured. Two of them experienced acute GvHD
of gastrointestinal tract gr. II and skin gr. II respectively,
which responded to corticosteroides. The relapse of CML
was documented on 132, 168 and 30 months after allotransplantation
Two of them experienced molecular relapse; one
recieved donor lymphocyte infusion in escalating doses of
CD3+ cells, but without any effect. Third patient had hematologycal
relapse and was treated with hydroxyurea for two
months.All patients received imatinib mesylate 400 mg
daily dose within the 3 months of relapse. Two out of three
patients achieved complete molecular response 10 and 12
months after imatinib was started, while in third patient
maior molecular response was documented 9 months after
initiation of imatinib mesylate. All three patients are 100%
donor chimeras according to the unseparated peripheral
blood cells.
Conclusion: imatinib mesylate is efficient in treating patients
with Ph positive chronic myeloic leukemia in relapse
after allogeneic transplantation. Major or complete molecular
response could be achieved after 9–12 months of therapy
with imatinib mesylate 400 mg/day. Longer follow up time
is mandatory to asses if the treatment efficacy is sustained.
PP14 Long-term survival and late-onset
complications after reduced-intensity
conditioning (RIC) allogeneic stem cell
transplantation (allo-SCT)
Peric Z, Clavert A, Chevallier P, Brissot E, Malard F,
Guillaume T, Delaunay J, Ayari S, Dubruille V,
Le Gouill S, Mahe B, Gastinne T, Blin N, Harousseau JL,
Moreau P, Milpied N, Mohty M, Service d’Hématologie
Clinique, Centre Hospitalier et Universitaire (CHU) de
Nantes, Nantes, France
RIC allo-SCT is increasingly used in elderly or frail patients
not eligible for standard myeloablative conditioning.
While the features and natural history of long-term complications
(LTC) are rather well described in the standard allo-
SCT setting, data are still sparse in the RIC setting.
This report analyzed the outcome and features of LTC in
110 RIC allo-SCT patients who survived for a minimum of
2 years after transplantation. The median age of recipients
was 55 (range, 19–68) years. In all, 74 patients (67%) had a
lymphoid malignancy, whereas 34 (31%) patients were diagnosed
with myeloid malignancies. Two patients (2%) were
treated for severe aplastic anemia. In total, 94 patients (86%)
received G-CSF-mobilized PBSCs whereas 9 patients (8%)
received unmanipulated bone marrow, and 7 patients (6%)
received cord blood. 67 grafts (61%) were obtained from
HLA identical sibling donors, 35 (32%) from HLA matched
unrelated donors and 8 (7%) from 1 Ag HLA mismatched
unrelated donors. The majority of patients received a fludarabine,
busulfan, and ATG-based RIC regimen (n=80; 73%),
11 patients (10%) received fludarabine and low-dose TBI,
while the remaining 17 patients (15%) received different
chemotherapy-based RIC regimens.
Recurrence of the primary malignancy was found in 4
(4%) cases and was the primary cause of late death. A total
of 6 (6%) patients died of non-relapse causes at a median of
3.2 (range, 2.4–6.1) years post allo-SCT. The non-relapse
causes of death were secondary malignancy (n=3), chronic
93

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
GVHD (n=2), and infection (n=1). The Kaplan-Meier estimate
of OS was 81% (95%CI, 71–94) at 10 years. With a
median follow-up of 4.6 years (range, 2–12.1), chronic
GVHD was the most prevalent late complication with a cumulative
incidence of 74% (95%CI, 62–83) at 10 years.
Cardiovascular complications were diagnosed in 47 (43%)
patients, with arterial hypertension ocuring in 32 (29%) patients
and cardial insufficiency in 15 (14%) patients. Renal
impairment occured in 37 (34%) patients. Pulmonary complications
were found in 28 (25 %) patients and were mostly
related to chronic GVHD. Endocrine disorders were diagnosed
in 18 (16%) involving thyroid dysfunction in 6 (5%)
patients. Psychological disorders (mostly depression) were
observed in 9 (8%) survivors. A secondary malignancy
occured in 9 (8%) patients; 3 patients were diagnosed with
two malignancies. The main organs involved were skin
(n=4), colon (n=3), prostate (n=2), lungs (n=1), urinary bladder
(n=1) and neuroendocrine tissue. (n=1)
We conclude that although RIC allo-SCT has the potential
to cure a significant proportion of patients with otherwise
fatal diseases, and though many patients can survive the
acute complications of the procedure, many other patients
may not enjoy full restoration of health with onset of a significant
rate of LTC, waranting lifelong surveillance through
a close partnership between the transplant center, and
organ-specific specialties.
PP15 Factors predicting overall survival in
patients with advanced chronic graft versus
host disease diagnosed by NIH consensus
criteria.
Grkovic L 1,2 , Steinberg SM 1 , Baird K 1 , Williams KM 1 ,
Cowen EW 1 , Mitchell SA 1 , Pulanic D 1,2 , Avila DN 1 ,
Taylor TN 1 , Wroblewski SG 1 , Serventi Seiwerth R 1,2 ,
Gress RE 1 , Pavletic SZ 1 . 1 National Cancer Institute,
National Institutes of Health, Bethesda, USA, 2 Department
of Medicine, Clinical Hospital Center Zagreb, Croatia
Aim: To determine factors predictive for survival in patients
with advanced cGVHD (chronic graft-versus-host
disease) defined by NIH (National Institutes of Health) criteria.
Patients and methods: 189 adults were enrolled onto the
cross-sectional prospective cGVHD natural history study
between 2004 and 2010. Median patient age was 48 years
[18–70], median time from transplant to enrollment was 3
years [0.3–22], and median time from cGVHD diagnosis to
enrollment was 2 years [0–19]. 66% of the patients had severe
and 33% had moderate cGVHD according to the NIH
global scoring with a median of 4 organs involved [1–8].
80% of the patients were receiving systemic immunosuppression
and have failed a median of 4 [0–9] prior systemic
therapies for their cGVHD. Median follow-up of surviving
patients was 2.5 years [0.1–5.8]. 28% of the patients had
Karnofsky performance status less than 80% and 7% had
thrombocytopenia (

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
plant, received HLA-matched related (n=79) or unrelated
(n=60) BM after myeloablative BuCy conditioning. HiCy
(50 mg/kg/day) was given on days +3, and +4 as only
planned GVHD prophylaxis. Patients with acute grade II-IV
GVHD were treated with methylprednisolone 1–2.5 mg/kg/
day IV as a first line therapy, and those with visceral GVHD
also received calcineurin inhibitors (CNI) or other non-CNI
immunosuppressants.
Results: In the competing risk model (death and graft
failure as competing risks), the incidence of acute grade II-
IV and III-IV GVHD by day 200 was 50% and 16%, respectively.
Thirteen percent of patients who developed acute
grade II-IV GVHD were not treated 15% were treated with
steroids alone, 63% with steroids plus a CNI and 9% with
steroids plus non CNI-based agents. Overall cumulative incidence
of SSI use was 45%. Median time to initiation of
SSI was 42 (19–142) days and the median duration of SSI
use was 152 (13–981) days. The cumulative incidence of
glucocorticoid use was 38% in related and 52% in unrelated
group. Steroids were tapered rather quickly, 9 months after
BMT all patients in related group were off glucocorticoid
treatment, while in unrelated group only 14% of patients
were on therapy at that time. Cumulative incidence of nonglucocorticoid
therapy initiation was 29% in related and
44% in unrelated group At 6 months and 1 year, 63% and
83% of patients were off all immunosuppressive therapy,
respectively. With a median follow-up of 26 months, cumulative
incidence of chronic GVHD was 10%. Only 3 patients
have died with refractory GVHD.
Conclusion: These results extend our previous observations
that post-transplantation Cy is effective single agent
strategy for prophylaxis of acute GVHD with both a low
rate of grade III-IV and more than half of the patients never
requiring additional SSI. The limited use of SSI may be responsible
for low infectious rate and excellent immune reconstitution
seen in these patients. This approach also provides
novel platform to facilitate the use of post-transplant
immunotherapy aimed at reducing relapse.
PP17 Allogeneic transplantation from HLA
matched unrelated donor – single Center
experience
Serventi Seiwerth R 1 , Mikulic M 1 , Mrsic M 1 , Grubic Z 2 ,
Bojanic I 3 , Durakovic N 1 , Stingl K 2 , Labar B 1 . 1 Division of
Hematology, Department of Medicine, 2 Department of
Clinical Laboratory, 3 Department of Transfusiology,
Clinical Hospital Center and School of Medicine,
University of Zagreb, Croatia
Introduction: Allogeneic transplantation is a standard
therapeutic approach for malignant and some nonmalignant
congenital and acquired hematopetic diseases. Only one
third of patients who would benefit from allogeneic transplantation
have an HLA identical family donor. Search for
an HLA matched unrelated donor from the International
Bone Marrow Donor Registry gives more patients the opportunity
to get optimal treatment. Acute leukemias and
myelodysplastic syndromes followed by bone marrow failure
syndromes are major indications for allogeneic stem
cell transplantation from matched unrelated donor. With
high resolution HLA typing techniques on the allele level,
results of alogeneic transplantation from matched unrelated
donors have reached results in family transplants.
We present patients transplanted from HLA matched unrelated
donor in University Hospital Center Zagreb in the
period from 1991. – 2010.
Patients and treatment: From 1991 till December 2010.
71 patients, median age 28 years (range 1 month – 61 year)
received HLA matched unrelated donor transplant; 30 female
and 41 male. HLA matches were 10/10 for 23 patients,
9/10 for 14 patients, 8/10 in two patients, 13 patients were
transplanted from 8/8 HLA matched donors; one patient
was transplanted with two umbilical cord blood 6/6 HLA
match. Eight patients transplanted before 2000 received
stem cells from unrelated donor 6 out of 6. Most of our patients
were transplanted for acute leukemia (34 out of 71
patient): 18 for acute myeloid and 16 for acute lymphoblastic
leukemia; 19 out of 71 patients were transplanted because
of chronic myeloid leukemia and myelodisplastic
syndrome while 9 of them received stem cells because of
lymphoproliferative neoplasm. Seven patients were allografted
for other diseases. Only 9 out of 34 acute leukemia
patients (26,5%) were transplanted in first complete remission;
7 out of 16 CML patients received stem cells in first
chronic phase; while patients with non-Hodgkin lymphoma
were allografted in refractory disease; 16 out of 71 patients
who were previously autografted received stem cells from
matched unrelated donor in relapse; one patient received
MUD transplant after rejection of first unrelated transplant
from different donor.
Standard myeloablative conditioning regimen consisting
of busulfan and cyclophosphamide or cyclophosphamide
and total body irradiation with antitymocytic globulin were
given to 46 patients;;. 25 (35, 2%) patients were transplanted
after reduced intensity conditioning regimens, most of
them being fludarabine based (fludarabine + cyclophosphamide;
fludarabine + busulfan) in combination with antithymocytic
globulin. Cyclosporine and short courses of metothrexate
(for standard conditioning) and cyclosporine and
mofetil mycophenolate (for nonmyeloablative conditioning)
were used in GvHD prophylaxis. As a stem cell source
marrow, peripheral blood and umbilical cord blood were
used in 31 patients, 36 patients and 4 patients respectively.
Results: In this high risk group of patients 55% (39/71)
of them were alive on day +100. Infections, acute Graft versus
Host Disease grade III-IV, multiorgan failure and underlying
disease were the principal cause of death in 17, 14, 4
and 8 patients respectively. Data are missing for 9 patients.
Most of the deaths occurred during first 12 months; Overall
survival at 5 years is 24% (17/ 71); Platou was reached after
18 months. Although not significant there is a trend for better
survival in patients with unrelated donor (10/10) compared
to patients with a donor 9/10 or 8/8.
Conclusion: In this high risk group of patients 55% of
them are alive on 100 days after allografting, with 5-year
overall survival of 24%. Main causes of death are serious
infections, GvHD, multiorgan failure and underlying disease.
Better patient selection and transplantation in earlier
phase of the disease would give better antitumor effect with
less toxicity and superior long-term survival.
95

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
PP18 Extracorporeal Photochemotherapy in
Treatment of Chronic Graft-versus-Host
Disease
Bojanic I 1 , Serventi Seiwerth R 2 , Golubic Cepulic B 1 ,
Mazic S 1 , Lukic M 1 , Raos M 1 , Plenkovic F 1 ,
Golemovic M 1 , Dubravcic K 3 , Perkovic S 3 , Batinic D 3 ,
Labar B 2 . 1 Department of Transfusiology, 2 Division of
Hematology, Department of Medicine, 3 Department of
Clinical Laboratory, Clinical Hospital Center and School
of Medicine University of Zagreb, Croatia.
Extracorporeal photochemotherapy (ECP) is an immunomodulatory
therapy which has been used in treatment of
chronic GVHD (cGVHD). ECP involves separation of the
mononuclear cells (MNC) with leukapheresis, followed by
ex vivo administration of photosensitizer 8-methoxypsoralen
(8-MOP) and ultraviolet A (UV-A) radiation, before
reinfusion to the patient.
Aim: Aim of the study was to evaluate clinical and immunomodulatory
effect of ECP procedures performed in
patients with cGVHD. The frequency of adverse reactions
associated with ECP was also evaluated.
Patients and methods: We analyzed 351 ECP procedures
performed in 6 patients; median ECP per patient was 52
(range 13–127). Patients’ median age was 29 years (range,
12–76 yrs). The patients suffered from generalized sclerodermatous
skin changes, impaired join mobility and one
patient had symptoms of oral disease. In all patients concomitant
immunosuppressive treatments for cGVHD were
used as necessary. ECP procedures were performed for two
consecutive days: in initial phase weekly, followed every
two weeks and than monthly according to clinical response.
ECP was performed using the »off line« technique. MNCs
were collected using COBE Spectra cell separator (Caridian
BCT). In all leukapheresis 2 patient’s total blood volumes
were processed. Collected MNC concentrate was transferred
to Extracorporeal UV-A Bag Set (Cell Max GmbH)
and diluted with saline solution. 8-MOP (Gerot) was injected
into the UV-A Bag Set and bag was irradiated by PUVA
Combi-Light UVA Illuminator at wave length of 350 nm
with the irradiation dose of 2 J/cm 2 . Irradiated cells were
reinfused back to the patient. During apheresis and reinfusion
of irradiated cells patients were monitored for adverse
reactions. Number of T-lymphocyte subsets (CD3+, CD3+4+,
CD3+8+, CD4+ CD8+ ratio) and B-lymphocytes (CD 19+),
in patient’s peripheral blood were tested monthly.
Results: The effect of ECP in patients with cGVHD with
skin and joint involvement was mostly beneficial. Five patients
experienced either improvement or stabilization in
sclerodermatous skin changes and joint mobility. The overall
cutaneous response rate was 83% (complete response
rate 50% 3/6 pts), and partial response rate 33% (2/6 pts). In
patient who suffered from oral disease, the total recovery
was observed. Clinical response was typically delayed until
2 to 3 months. In patients who responded to ECP efficiently,
the influence of ECP on T-cell subsets leads to the suggestion
that interactions between T-cell subsets may participate
in the process of ECP.
96
In general ECP was well tolerated. No increased incidence
of infections and no serious adverse reactions have
been observed. After reinfusion of MNCs, one patient experienced
increase in body temperature, likely due to the release
of cytokines from photomodified cells.
Conclusion: ECP proved to be efficient and safe procedure
that may be recommended for patients with cGVHD
who do not respond to conventional therapy.
PP19 Wernicke’s encephalopathy in an
adolescent after allogeneic hematopoietic
stem cell transplantation: a case report
Rajic Lj 1 , Pavlovic M 1 , Femenic R 1 , Bilic E 1 , Krnic N 1 ,
Barisic N 1 , Ozretic D 1 , Tesovic G 4 , Dusek D 4 , Zadro R 2 ,
Serventi Seiwerth R 3 , Mikulic M 3 , Konja J 1 , Labar B 3 .
1 Department of Pediatric, 2 Department of Clinical
Laboratory, 3 Department of Medicine, Clinical Hospital
Center Zagreb, 4 Clinical Hospital for Infectious Diseases,
1,2,3,4 School of Medicine University of Zagreb, Croatia
Introduction: Wernicke’s encephalopathy (WE) is a neurological
emergency caused by a thiamine (vitamin B1) deficiency.
It was first described in 1881 by German neurologist
Carl Wernicke as a triad comprising of global confusion,
ataxia and ophtalmoplegia. The proposed mechanism
of brain lesions is impaired myelination due to decreased
NADPH production. Although most commonly associated
with chronic alcoholism in adults, non-alcoholic WE has
been described in conditions predisposing to poor nutritional
status. Reports of WE in infants and children are rare, and
the majority of paediatric cases are associated with malignancy
and gastrointestinal disease. Patients undergoing hematopoietic
stem cell transplantation (HSCT) are at high
risk of this potentially lethal condition due to chemotherapy-induced
nausea and vomiting, and depletion of thiamine
stores by long-term total parenteral nutrition (TPN) and glucose-containing
i.v.solutions.
Aim: To present the case report of an 18 yr old male adolescent
presenting with Wernicke’s encephalopathy following
unrelated allogeneic HSCT for underlying acute myelogenous
leukemia.
Case report: On day + 42 after HSCT, the patient presented
with vertical nystagmus and hallucinations. He complained
of generalized weakness, gait disturbance, hyperacusia,
difficult swallowing and insomnia. Neurogical examination
revealed mild confusion, lower limb and truncal
ataxia, bilateral abducens nerve palsy, both vertical and rotatory
nystagmus, soft palate palsy and areflexia. Cerebrospinal
fluid analysis and cranial CT scans imaging revealed
no abnormality. Magnetic resonance imaging (MRI) of the
brain showed symmetric high-signal intensities in dorsomedial
nuclei of the thalamus, mamillary bodies, inferior colliculi,
periaqueductal gray and pontine tegmentu, which
were consistent with diagnosis of WE. The patient was
treated with thiamine 500 mg/day i.v. for one month. His
general condition and neurological signs were improved but
not completely.
Discussion: Neurological complications occur in 30–
40% of patients undergoing HSCT. They may be of infec-

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
tious, cerebrovascular, toxic, immune-mediated, or metabolic
origin. The diagnosis of WE is clinical but only 16%
of affected patients develop pathognomonic clinical triad.
Measurements of blood or erythrocyte thiamine concentrations
are limited by a lack of specificity and are not routinely
available in hospital laboratories. Due to selective
vulnerability of the midline gray matter areas, MRI plays an
important role in the diagnosis of this condition. It is crucial
to consider WE in the differential diagnosis for all patients
after HSCT presenting with confussion, ataxia and ophtalmoplegia.
To prevent this devastating and often fatal neurologic
complication, all patients underwent HSTC should be
empirically treated with thiamine.
PP20 Need + Information + Satisfaction
Vieira S, Monroe D, Librojo M. London, United Kingdom
Over the last decade, information for cancer patients has
become increasingly more importance.
The very nature of the cancer requires patients to learn
about their disease in order to cope with the consequences
of treatment and in inform the decision making process.
It is therefore vital to provide enough information for patients
and relevant others.
People/patients vary in the amount of information they
require. Evidence suggests that some patients do not want
very much information about their diseases or any treatments.
Stage Information provided on the following topics
On admission
N %
1. Side effects of therapy or chemotherapy 20 (40%)
2. Procedures
(Bone Marrow Aspiration, Hickman Line insertion etc)
19 (38%)
3. Sexuality 5 (10%)
4. Fertility 9 (18%)
5. Results of diagnostic test 27 (54%)
6. Follow up, appointments 25 (50%)
7. Diet 14 (28%)
other 0 (0%)
During their stay 1. Side effects of therapy or chemotherapy 18 (36%)
2. Procedures
(Bone Marrow Aspiration, Hickman Line insertion etc)
20 (40%)
3. Infection Control 21 (42%)
4. Sexuality 4 (8%)
5. Fertility 6 (12%)
6. Results of diagnostic test 29 (58%)
7. others
blood exams
3 (6%)
On discharge 1. Outcome of your treatment 30 (60%)
2. Follow up, appointment 47 (94%)
3. Medication 49 (98%)
4. What happens next 38 (76%)
5. When to call the medical team (Hospital) 41 (82%)
6. Work life 26 (52%)
7. others:
alternative treatment models
1 (2%)
Total 50 (100%)
Aim: This study aims to explore how much information
our patient group wants to know and how much information
our team provides to the patients
Patients and methods: A questionnaire was prepared to
collect data on how much information was given to patients
on three different stages of their treatment plans. These
stages were: on admission, during their inpatient stay and
on discharge. A fourth section was added, to investigate
other information need patient felt required.
The questionnaire was used between May 2010 till October
2010, total of 50 questionnaire. Outcome of these data
collection is shown in table I.
Results: 50 malignant haematology patients were admitted
to our unit for various reasons (See Table I).
Our audit was evaluated in three different stages. In admission
stage most of the information provided were about
side effects of treatment, test results. (See Table I).
During in patient period was the llowest stages where information
provided. It should be bare in mind that haematology
patient group has long hospitalisation, the data collection
tool was given on discharge. Therefore, data might
be lost due to poor recalling the information required.
Results also showed our patient were happy about the information
they were given especially on discharge as most
aspect of information covered (See Table I)
PP21 CD43 expression is associated with inferior
survival within activated B-cell group of
diffuse large B-cell lymphoma
Mitrovic Z 1,4 *, Iqbal J 1 , Fu K 1 , Smith LM 2 ,
Weisenburger DD 1 , Greiner T 1 , Auon P 1 , Bast M 3 ,
Armitage JO 3 , Vose JM 3 , Chan WC 1 . Departments of
1 Pathology/Microbiology and 3 Hematology/Oncology,
2 College of Public Health, University of Nebraska Medical
Center, Omaha, NE, USA, 4 School of Medicine University
of Zagreb, Croatia
CD43 expression is associated with inferior survival within
activated B-cell group of diffuse large B-cell lymphoma.
Aim: The expression of CD43, an abundant membrane
glycoprotein, was associated with an inferior survival of patients
with diffuse large B-cell lymphoma (DLBCL) in a
single-center study. The aim of the present study is to evaluate
the prognostic significance of CD43 in our cohort of
patients and correlate protein expression data with gene expression
profiling (GEP).
Patients and methods: A total of 129 patients treated
with R-CHOP from Nebraska Lymphoma Study Group
were included. Tumor samples on tissue microarray (TMA)
were stained for CD43, CD10, BCL6, and MUM1 to correlate
CD43 expression and cell of origin according to the
Hans algorithm. GEP data were available for 31 patients.
Results: CD43 was expressed in 25 of 129 DLBCLs
(19.4%). There was no difference in the pre-treatment clinical
characteristics between CD43+ and CD43-group of patients.
CD43 expression was associated with inferior failure-free
survival (FFS) and overall survival (OS), p=0.032
and p=0.018, respectively. Furthermore, CD43 was signifi-
97

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
cantly related to activated B-cell (ABC) group defined by
GEP and by immunohistochemistry, p=0.006 and p=0.0485,
respectively. Interestingly, patients with CD43+ DLBCL
had very poor OS (p < 0.001) within the ABC group and 4.3
times the risk of death by multivariate analysis compared to
CD43-. When patients with GEP data were compared within
the ABC group, a significant enrichment in stromal-1 signature
and immune-response-1 signature was observed in
CD43- group.
Conclusion: CD43 is an adverse prognostic marker in
DLBCL and is preferentially expressed in the ABC group. It
can identify patients with extremely poor outcome within
the ABC group. A possible explanation is the association
with more favorable microenvironment signatures for CD43-
cases within the ABC group.
* This work was financed in part by a grant from the National
Foundation for Science, Higher Education and Technological
Development of the Republic of Croatia
PP22 Association of Interleukin-10,TNF-Alpha
and TGF-Beta Gene Polymorphisms on The
Outcome of Diffuse Large B-cell Lymphoma
Tarabar O, Tukic Lj, Cikota B, Milanovic N, Aleksic A,
Magic Z. Military Medical Academy, Belgrade, Serbia
Abstract: Diffuse large B-cell lymphomas (DLBCL)
represent a heterogeneous group of lymphoproliferative disorders
with highly variable clinical course and outcome.
Published date indicated that common genetic variants in
immune/ inflammatory response genes can affect outcome
of diffuse large B-cell lymphomas (DLBCL).
Aim: To analyze the association of IL-10 –3575, –1082,
TNF-alpha –308 and TGF-beta Leu10Pro polymorphic
variants with clinical characteristics and outcome of DLB-
CL patients (pts) treated with rituximab (R)-CHOP therapy.
Patients and methods:Between January 2004 and December
2007, a total of 64 pts (M/F 33/31; aged 22–76, median
48 yrs) with newly diagnosed DLBCL were entered
into this study. Factors examined for prognostic significance
included sex, age (60 yrs or younger vs. older), Ann Arbor
(CS) stage (I-II vs. III-IV), serum lactate dehydrogenase
level (normal vs. elevated), number of extranodal sites of
disease (0 or 1 vs. 2 or more), performance status (0 or 1 vs.
2 or more), and IPI score (0–2 vs. 3–5). The therapy for all
pts was R-CHOP (6–8 cycles). Genotypes were determined
with PCR-based methodology.
Results:TGF-beta Pro10 was associated with an unfavorable
features of DLBCL. A significantly more frequent
stage III-IV (OR 4.65, 95% CI 1.33-16.12; p=0.016) and IPI
score 3–5 (OR 5.37, 95% CI 1.45-20.0; p=0.012) were
found in pts with the Pro allele variant (LeuPro/ProPro)
than in carriers of LeuLeu genotype. IL-10 and TNF-alpha
gene polymorphisms were not associated with established
prognostic factors. Considering survival, only TNF-alpha –
308 influenced overall survival (OS) in R-CHOP treated
pts. With a median follow-up of 23 months, there was significantly
difference between GG and GA/AA carriers (log
98
rank test, p=0.048). Overall survival at 3 years was 61.5%
(95% CI 28.8-46.9) for GA/AA genotypes and 83.2% (95%
CI 50.8-98.9) for GG genotype of TNF-alpha –308.
Conclusion:Our results indicate that TNF-alpha –308
and TGF-beta Leu10Pro gene variations could be associated
to the clinical course and outcome of R-CHOP treated DL-
BCL patients.
PP23 Dose Adjusted EPOCH – Rituximab as First
Line Treatment for High Risk Diffuse Large
B-Cell Lymphoma: A Single Center
Experience
Pejsa V, Prka Z, Lucijanic M, Jaksic O, Pirsic M,
Ajdukovic R, Kusec R. Division of Hematolofy,
Department of Medicine, Universiti Hospital Dubrava
and School of Medicine, University of Zagreb, Croatia
Abstract: Dose-adjusted EPOCH- rituximab (DA-EP-
OCH-R) is an infusional protocol which is based on pharmacodinamical
adjustment of drug dosage depending on
laboratory values of absolute neutrophil count and platelets
(Wilson WH et al. Blood 2002;99:2685–2693). Rationale
for this regimen is well known fact that tumor cells are less
resistant on prolonged exposition to low dose of chemotherapy
than to short exposition to high dose of drugs.
Aim: To assess clinical outcome in patients with diffuse
large B-cell lymphoma (DLBCL) with poor prognostic factors
(IPI ≥2 and/or high proliferation index; PI>80%, measured
as percentage of Ki67+ cells) treated with DA-EP-
OCH-R as first line treatment.
Patients and methods: From May 2005. to July 2011.,
22 patients, median age 48.5 years (range 17–75) with diffuse
large B-cell lymphoma were included. Elevated LDH
had 16 out of 22 patients (73%) and 17 out of 22 patients
(77%) were in Ann Arbor stages 3 and 4. IPI ≥2 had 18 out
of 22 patients (82%). DA-EPOCH-R was administred according
to original schedule. Six of these patients proceed
to autoHSCT as consolidation therapy due to very aggressive
histology and biology of disease.
Results: Overall response rate (ORR) was 86% (19/22),
including 13 (59%) complete responses (CR) and 6 (27%)
partial responses (PR). Overall survival (OS) was 64% at 5
years (median not reached) with median follow up of 14
months (range 3–68). Progression free survival (PFS) was
70% at 5 years. Of patients who achieved CR, 12 are still in
complete remission.
Conclusion: In this report we presented 22 patients with
high risk diffuse large B-cell lymphoma. Our results showed
that DA-EPOCH-R is highly effective regimen in this group
of patients. These results are conclusive with results of Garcia-Suarez
and colleagues (Garcia-Suarez J et al. British
journal of Haematology 2007;136:276–285) who also find
this regimen effective as first line treatment in DLBCL patients.
Some of our patients were consolidated with autoHSCT
due to high proliferation index or IPI≥3. Only 1
patient relapsed during follow up period. Of 6 patients who
were transplated, all but one are still in CR. We conclude
that DA-EPOCH-R is highly effective regimen as first line
treatment in high risk diffuse large B-cell lymphoma.

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
PP24 Immunoblastic Morphology as a Possible
Prognostic Indicator for the Outcome of the
Patients with Diffuse Large B cell
Lymphoma in Era of the Rituximab Based
Treatment: Single Centre Experience
Trajkova S, Panovska-Stavridis I, Stojanovik A,
Petrusevska G, Dukovski D, Cevreska L. Department of
Hematology, Medical Faculty, Skopje, Republic of
Macedonia
Immunoblastic morphology as a possible prognostic indicator
for the outcome of the patients with diffuse large B
cell lymphoma in era of the Rituximab based treatment:
single centre experience
Aim: In order to investigate the prediction value of the
immunoblastic morphology(IB) as a possible prognostic indicator
for the outcome of our DLBL patient treated with
the Rituximab (R)-CHOP regimen we conducted a retrospective
study.
Patients and methods: Our study enrolled 192 DLBL
patients diagnosed and treated at the University Clinic of
Hematology in the period between February 2002 and December
2007. They were all treated with R-CHOP regimen
and the median follow-up of the patient was 36 months. We
analyzed the biopsy samples immunohistochemically for
markers of germinal center (Bcl6), post-germinal center
(MUM1) and apoptosis (Bcl-2).
Results: The patients were categorized as DLBL(132;
68,7%), IB(60;31,2). The median overall survival time (OS)
were 59,3 months in DLBL group and,and 42,2months in
IB group, and time to treatment (TT) were 56,8, and
30,6months respectively for the IB group. The DLBL and
IB groups were comparable regarding the age, gender distributions
and all others already established prognostic parameters
as performance status, advanced IPI, albumin level
except for the low IPI 0–2 which was statistically associated
with the DLBL group (p=.024).
Conclusion: Our results did not show any statistical survival
advantage and better outcome for the patient classified
as DLBL when treated with R-CHOP and indicate that immunohistohemical
markers do not really reflect the molecular
diversity of the tumor. Our work shows that IB morphology
is a major risk factor in DLBL patients treated with R-
CHOP. Therefore this morphology appears to capture some
adverse molecular events that a currently hard to detect with
routine diagnostic procedures.
PP25 Primary Mediastinal Large B-Cell
Lymphoma – Results of our Center
Miljkovic E, Marjanovic G, Cojbasic I, Tijanic I,
Markovic D, Nikolic V, Macukanovic-Golubovic L,
Govedarovic N, Vucic M. Clinic of Hematology, Clinical
Center Nis, Serbia
Abstract: Primary mediastinal large B-cell lymphoma
(PMBCL) is a distinct clinico-pathological subtype of diffuse
large B-cell lymphoma (DLBCL) and represents less
than 3% of all non-Hodgkin lymphoma cases.The tumor ap-
pears to be derived from medullary B cells within the thymus
gland.Phenotypically tumor cells are positive for CD45,
B cell markers(Pax-5, CD19, CD20, CD22, CD79a) and
bcl-2, often positive for CD30, MUM1 and bcl-6. and negative
for CD10 and CD21. The optimal treatment is unknown,
with some studies suggesting a superior outcome with doseintensive
chemotherapy regimens. The role of mediastinal
radiotherapy upon completion of chemotherapy remains unclear
Aim: Aim was to evaluate response in patients treating
with R-MACOP-B regimen.
Patients and methods:We performed a retrospective review
of 5 patients with PMBCL, who were treated at our
clinic during the period between Januar 2009 and December
2010.
Results: Among 5 patients there were 4 women and 1
man.Median age was 31 years (24–33). Most patients were
in stage II–80% (4) and one in stage III–20%, all of them
with B simptoms. Bulky mediastinal mass (>5cm in diameter)
was present in all of our patients. Superior vena cava
syndrom with facial edema, neck vein distention and upper
extemity swelling was seen in 60% of the patients (3). After
treating with R-MACOP-B regimen (rituximab, methotrexate,
doxorubicin, cyclophoshamide, vincristine, prednisone,
beomycin) complete response was accomplished in 40%
(2),partial response in 20% (1).Two patients (40%) died,
one due to progression of disease and one due to the toxicity
of the treatment. Two patients who complited R-MA-
COP-B had involved-field radiation therapy (IFRT) following
chemotherapy and complete remission was confirmed
by performing PET scan.
Conclusion: PMBCL, an uncommon disease affects
young people with a female prevalence and frequent bulky
mediastinal mass.Studies have demonstrated advantage of
R-MACOP B compared to CHOP,so we were treated our
patients with this regimen. Two patients who complited R-
MACOP B and had IFRT are still in complete remission
after two years of follow up.
PP26 Dose-intense BACOP for Treatment
of High-risk Peripheral T-cell NHL
Aurer I 1 , Dujmovic D 1 , Basic-Kinda S 1 , Nemet D 1 ,
Radman I 1 , Ilic I 2 , Stern-Padovan R 3 , Santek F 4 , Sertic D 1 ,
Cigrovski N 3 , Labar B 1 . 1 Department of Medicine,
2 Pathology, 3 Radiology and 4 Oncology, University Hospital
Center and School of Medicine, University of Zagreb,
Croatia
PTCLs, except ALK+ ALCL, have a bad prognosis with
overall 5-year survival rates below 30%. Because of their
relative rarity, no large randomized trials have been performed
and the importance of individual cytotoxic agents,
their dose density and intensity as well as that of autografting
remains unproven. At our center we have been using
dose-intense BACOP, a regimen modeled after the French
ACVBP, for treatment of patients with high risk PTCL. The
regimen consisted of cyclophosphamide 1500 mg/m 2 day 1,
doxorubicin 75 mg/m 2 day 1, bleomycin 15 mg days 1 and
99

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
5, vincristine 2 mg days 1 and 5 and prednisone 50 mg/m 2
days 1–5 every 3 weeks for 4–6 cycles. Responding patients
underwent stem-cell collection and autografting after
BEAM conditioning. Areas of initially bulky disease and
those not in CR prior to transplantation were irradiated posttransplant
with 30–40 Gy. Patients with high risk for development
of CNS disease received intrathecal methotrexate
prophylaxis. Response evaluations were performed after
2–3 cycles and at the end of chemotherapy. Patients were
considered high risk if they had any PTCL type with IPI 3
or more, bulky disease or failed to respond to 2–3 cycles of
standard CHOP-21. We treated 28 patients, 20 men and 8
women, 17–67 years old (median 46). Thirteen had PTCL-
NOS, 8 ALCL, 3 AILD, 2 nasal type, 1 panniculitis-like and
1 hepatosplenic PTCL. Two had stage IE bulky, 1 stage II
bulky, 2 stage III and 23 stage IV disease. The toxicity of
treatment was substantial, all patients experienced serious
hematological toxicity and infections or neutropenic fever,
3 died of infection during chemotherapy and 1 during stemcell
transplantation, 2 had DVT/PE, 1 died of complications
related to the necrosis of an extremely bulky tumor and one
underwent emergency splenectomy after tumor necrosis
caused splenic rupture. Three patients were unavailable for
efficacy analysis due to early death, 4 progressed and 21
initially responded (75%); 14 achieved CR and 7 PR. None
of the 3 patients with nasal type or hepatosplenic PTCL responded.
Of the responders, 11 underwent autografting as
100
intended, 3 relapsed prior to transplantation, treatment was
modified in 3 due to toxicity, 2 were not transplanted due to
patient refusal or physician decision, 1 underwent allogeneic
transplantation and 1 failed to mobilize.
After a median follow-up of survivors of 20 months, 9
patients are still alive, including 8 who were autografted as
intended. Median response duration was 12 months, FFS 6
months and OS 10 months (Fig 1 and 2.). In conclusion, a
significant proportion of high-risk PTCL-NOS, ALCL and
AILD patients respond to dose-intense BACOP followed by
autologous stem-cell transplantation but the toxicity of
treatment is substantial.
PP27 Oral lomustine, chlorambucil, etoposide
and prednisolone (CCEP) for treatment of
patients with advanced lymphoma
Radman I, Vodanovic M, Mitrovic Z, Aurer I, Basic-Kinda
S, Labar B. Division of Hematology, Department of
Medicine, Clinical Hospital Center and School of
Medicine, University of Zagreb, Croatia
Abstract: Oral palliative chemotherapy is reserved for
the refractory and relapsed lymphoma patients who are not
candidates for further aggressive treatment. Herein we report
single institution experience.
Aim: CCEP, all – oral chemotherapy containing CCNU,
chlorambucil, etoposide and prednisone was tested in refractory
and relapsed lymphoma patients in advanced stages.
Patients and methods: Twenty patients with refractory/
relapsed lymphoma observed between 2000 and 2010 were
treated with CCEP. Eight patients were diagnosed with
Hodgkin lymphoma, 9 with aggressive non-Hodgkin lymphoma
and 3 with indolent lymphoma. All patients were in
advanced stage disease (Ann Arbor III/IV) and previously
treated > 2 lines of therapy.
Results: The median age was 51 (range 20–76 years).
Thirteen patients (65%) had been extensively pretreated (≥3
treatment), including autologous or allogeneic stem cell
transplantation. All patients were in advanced stage disease
(Ann Arbor III/IV), with extramedullary spread; lung 10 patients
(50%), liver 7 patients (35%), spleen 5 patients (25%)
and bone marrow 4 patients (20%). Overall response rate
was 50%; 6 patients (30%) obtained stable state and 4 (20%)
progressive disease. Median follow-up was 11 months with
30% of 2-year survival rate. Patients receiving ≥ 3 cycles of
CCEP achieved better response rate and longer survival.
The progressive disease and toxicity were the main reasons
for discontinuation of treatment.
Conclusion: CCEP is low cost and effective chemotherapy
with acceptable toxicity and good tolerability. In half of
the patients with very adverse prognosis one can expect
temporary treatment success.

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
PP28 Effi cacy and Safety of Ruxolitinib, a JAK1
and JAK2 Inhibitor, in Patients With
Myelofi brosis: Results From a Randomized,
Double-Blind, Placebo-Controlled, Phase III
Trial (COMFORT-I)
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 ,
Silver R 10 , Talpaz M 11 , Winton E 12 , Harvey J 13 ,
Arcasoy M 14 , Hexner E 15 , Lyons R 16 , Paquette R 17 ,
Raza A 18 , Vaddi K 4 , Erickson-Viitanen S 4 , Koumenis I 4 ,
Sun W 4 , Sandor V 4 , Kantarjian H 1 . 1 The University of Texas
MD Anderson Cancer Center, Houston, TX, USA; 2 Mayo
Clinic, Scottsdale, AZ, USA; 3 Stanford Cancer Center,
Stanford, CA, USA; 4 Incyte Corporation, Wilmington, DE,
USA; 5 Princess Margaret Hospital, Toronto, Canada;
6 Washington University School of Medicine, St. Louis, MO,
USA; 7 Frankston Hospital, Frankston, Australia;
8 University of Utah Huntsman Cancer Institute, Salt Lake
City, UT, USA; 9 Saint Agnes Cancer Institute, Baltimore,
MD, USA; 10 Weill Cornell Medical College, New York, NY,
USA; 11 University of Michigan, Ann Arbor, MI, USA;
12 Emory University School of Medicine, Atlanta, GA, USA;
13 Birmingham Hematology & Oncology, Birmingham, AL,
USA; 14 Duke University Health System, Durham, NC,
USA; 15 University of Pennsylvania Health System,
Philadelphia, PA, USA; 16 Cancer Care Center of South
Texas, San Antonio, TX, USA; 17 UCLA Medical Hematology
& Oncology, Los Angeles, CA, USA; 18 Columbia
Presbyterian Medical Center, New York, NY, USA
Background: Myelofibrosis (MF) is characterized by
splenomegaly, debilitating symptoms, cytopenias, and shortened
survival. No effective drug therapies are available;
however, dysregulated JAK-STAT signaling, a key feature
of MF, is a promising therapeutic target. Ruxolitinib (Rux),
a selective JAK1 and JAK2 inhibitor, showed clinical activity
in MF.
Aim: COMFORT-I was designed to compare the efficacy
and safety of Rux with that of placebo (PB) in MF patients
(pts).
Patients and methods: Pts with intermediate-2 or highrisk
MF (per IWG-MRT) were randomized to Rux or PB.
Rux starting dose was 15 mg or 20 mg PO BID for pts with
baseline platelet count of 100–200 x 10 9 /L or >200 x 10 9 /L,
respectively; the dose could be adjusted during the study to
optimize efficacy and safety. The primary endpoint was the
proportion of pts with >=35% reduction in spleen volume at
week (wk) 24, as assessed by magnetic resonance imaging
or computed tomography (blinded review). Secondary endpoints
included duration of spleen response, changes in
daily symptom burden (Total Symptom Score [TSS] using
the modified Myelofibrosis Symptom Assessment Form
[MFSAF] v2.0), and survival. Changes in quality of life
(QOL) and fatigue were exploratory measures, as were molecular
and serum biomarkers and transfusion dependence.
Results: 155 pts were randomized to Rux and 154 to PB
(median follow-up: 32.2 wks). At 24 wks, the proportion of
pts achieving a >=35% reduction in spleen volume was
41.9% for Rux vs 0.7% for PB (p=50% improvement in
TSS was 45.9% for Rux vs 5.3% for PB (p< 0.0001). Ruxtreated
pts had a mean 46.1% improvement in TSS; PBtreated
pts experienced a 41.8% worsening (p20% of pts)
non-hematologic adverse events in pts on Rux vs PB were
abdominal pain (10.3% vs 41.1%), fatigue (25.2% vs
33.8%), diarrhea (23.2% vs 21.2%), and peripheral edema
(18.7% vs 22.5%). The most common grade 3 or 4 hematologic
laboratory abnormalities at any time during the study
(Rux vs PB) were low hemoglobin (45.2% vs 19.2%) and
low platelets (12.9% vs 1.3%). Anemia and thrombocytopenia
were manageable through dose modification/ temporary
hold and rarely led to study discontinuation (1 pt in each
arm for each event).
Conclusion: Rux demonstrated rapid and sustained clinical
benefits in spleen size and debilitating symptoms, and
improved QOL in pts with MF; conversely, pts on PB had
progressive worsening of disease. Rux was generally well
tolerated. These results suggest that Rux may become an
important new treatment option for the management of this
chronic, advancing neoplasm.
Support: Incyte Corp
PP29 Prevalence of the JAK2 V617F Mutation in
Croatian Patients with Classic Ph-Negative
Myeloproliferative neoplasm
Duletic Nacinovic A, Dekanic A, Hadzisejdic I, Seili I,
Grahovac B, Grohovac D, Valkovic T, Host I, Petranovic
D, Jonjic N. Department of Medicine and Deppartment of
Pathology, Clinical Hospital Center and School of
Medicine, University of Rijeka, Croatia.
The classic Ph-negative myeloproliferative neoplasms
(MPNs) are clonal disorders of multipotent haematopoietic
progenitors. The Janus-associated Kinase-2 mutation JAK2
V617F in such neoplasms has been described as a frequent
genetic event in majority of these patients.
Aim: To investigate the status of the JAK2-V617F mutation
in patients with classic Ph-negative MPNs treated in
Clinical Hospital Center Rijeka and to compare it with hemoglobin
and hema-tocrit level, white blood cells and platelet
count, splenomegaly, leukocyte alkaline phosphatase
score and clinical features.
Patients and methods: DNA was isolated from peripheral
blood granulocytes in 115 patients: 41 with polycythemia
vera (PV), 43 with essential thrombocythemia (ET), 9
with primary myelofibrosis (PMF), 10 with myeloproliferative
neoplasm-unclassifiable (MPN-u), 4 with secondary
erithrocytosis and 5 patients with secondary thrombocytosis.
The JAK2-V617 mutation was determined using allele
specific PCR.
Results: The JAK2-V617F mutation was found in 71/106
(66.98%) patients with MPNs or in 36/41 with PV (87.80%),
25/43 with ET (58.14%), 5/9 with PMF (55.56%) and 5/13
MPNs-unclassified (38.46%) disorders. The JAK2-V617
mutation was absent in patients with secondary erythrocytosis
and seconrary thrombocytosis. There were significant
differences in hemoglobin and hematocrit level, leukocyte
alkaline phosphatase score and white blood cells at diagno-
101

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
sis in JAK2-V617F non mutated versus mutated patients
with MPNs. Vascular events were present in 23/106 (21.7%)
patients with MPNs or more specifically in 13/41 (31.7%)
with PV, 8/43 (18.6%) with ET, 1/9 (11.1%) with PMF and
1/13 (7.7%) with MPN-u. The majority of those patients
with one or more vascular events were JAK2-V617F positive.
When analyzed within each entity than it could be emphasized
that one or more vascular events, or recurrent
thrombosis was detected in 13/41 (31.7%), 7/41 (17.1%)
cases, respectively with PV, or in 10/13 with JAK2-V617F
positive status. In patients with ET, compare to PV, vascular
events (8/43) were less present (18.6%). Though, as noticed
for PV, most of those patients (6/8) were associated with
JAK2-V617F mutation. In patients with PMF only 1vascular
event was confirmed (patient was JAK2V617F negative),
as well as in patients with MPN-u (patient was JAK2 positive).
Conclusion: The JAK2-V617F mutation was frequently
detected in our patients with MPNs in accordance with literature
data, and therefore should be incorporated in the
diagnostic evaluation of patients with suspected MPNs.
Further analysis should focus on contribution of the JAK2-
V617F mutation in the clinical phenotype of patients with
distinct subgroups of MPNs. These correlations imply that
detection of this mutation will not only have a diagnostic
value, but also a role in treatment given the development of
STAT/JAK patway inhibiting drugs.
PP30 Frequency and Clinical Correlates of JAK2
46/1 Haplotype in Essential
Thrombocythemia: Single Center
Experience
Panovska-Stavridis I, Matevska N, Ivanovski M,
Trajkova S, Dukovski D, Pivkova Veljanovska A,
Cevreska L, Dimovski A. Department of Hematology,
Medical Faculty, Skopje, Republic of Macedonia
Background: It is predicted that the inherited genetic
background in the individual patients with myeloproliferative
neoplasm (MPN) influences the disease susceptibility
and the phenotype expression of the MPN. Several groups
discovered that the germline JAK2 haplotype, tagged by the
»C« allele of single nucleotide polymorphism (SNP)
rs12343867 (C/T) is associated with the JAK2V617F positive
MPN. Also, some recent studies showed equal distribution
of this SNP among JAK2V617F negative MPN and
questioned the role of this hyplotype in MPN patients.
Aim: In order to extend further those observations we
conduct a retrospective study. First, we assess the frequency
of JAK2 46/1 haplotype in Essential thrombocyhemia (ET)
patients in comparison with population controls. As second
we evaluate the association of 46/1 with the JAK2V617F
mutational status and the clinical characteristics in the series
of patients with ET that were diagnosed and treated at
the University Clinic of hematology-Skopje, Republic of
Macedonia.
Patients and methods: Ninthly five consecutive patients
diagnosed with ET according to proposed criteria for diag-
102
nosis in 2008 by the World Health Organization were included
in our study. The 46/1 tag SNP rs12343867 (C/T)
was genotyped on a MxPro 3005P real-time PCR system
(Stratagene, La Jolla, CA,USA) using the TaqMan SNP genotyping
assay (Applied Biosystems, Foster City, CA,
USA) according to the manufacturer’s instructions.
Results: The incidence of 46/1-linked C allele was significantly
higher in ET (genotype: CC 13%, CT 60%, TT
27%; C-allele frequency: 43,7) than in population control
(C-allele frequency 29%), P

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
resection.Three patients treated with CT underwent haematopoietic
stem cell transplantation (HSCT), autologous in
one, and allogeneic from related donor in other two patients,
Tottaly, five patients died. Median group overall survival
was 28 months. Mean survival time in the group of patients
treated with chemotherapy was 22.1 months. Within the
group of patients initially treated with surgical resection
who were followed later on, mean survival time was 25.2
months. No significant difference in survival was observed
between these two groups of patients (p>0.05). Mean survival
time to systemic leukemia development was 21.9
months.
Conclusion: According to the results in our series of patients,
it is clear that in cases of suspected MS, employment
of wide spectrum of antibodies during immunohistochemical
work-up of tumor tissue is mandatory. Also, optimal
treatment is not defined, in part because of different clinical
presentation. Chemotherapy, HSCT, surgical resection, or
combination of these approaches, is used depending on actual
case.
PP32 The Risk of Hematopoetic Malignancy
in Children Born after in vitro Fertilization
Bilic E, Stemberger L, Slipac J, Stojsavljevic S, Bilic E,
Konjevoda P, Konja J, Femenic R, Rajic Lj. Department
of Pediatrics and Departmen of Neurology, Clinical
Hospital Center and School of Medicine, University
of Zagreb, Croatia
Infertility is one of the major health and social problems
where assisted reproductive technology such as in vitro fertilization
(IVF) can offer an efficient solution. Evaluation of
children conceived by IVF is neccessary to determine the
safety of the method. Hematopoetic tumors (leukemia and
lymphoma) are the most common childhood cancers. Some
study found an association with IVF and increased risk for
acute lymphoblastic leukemia (ALL) and non-Hodgkin
lymphoma (NHL) in children.
Aim: The aim of present study was to determine whether
there is an increased risk for hematopoetic tumors in children
conceived by IVF in comparison to children born after
natural conception.
Patients and methods: The study included 550 children
treated for leukemia or lymphoma (345 ALL, 67 acute myeloblastic
leukemia (AML), 63 Hodgkin lymphoma and 75
NHL) in the Department of Pediatric, University of Zagreb,
School of Medicine Zagreb, Croatia, between 1994. and
2009.y.
Results: Three children of 550 included in the study were
born after IVF. Two suffered from ALL and one from AML
Conclusion: Results of our study showed no increased
risk for childhood leukemia and lymphoma in children conceived
by IVF in comparison to children conceived naturally.
The main limitation of our, and most of other similar
studies was the sample size not large enough to decline the
discrepancy of literature data and to provide an unambiguous
answer to the question of increased risk of hematopoetic
tumors in children concieved by IVF
PP33 H1N1 Infl uenza pneumonia in patient with
chronic lymphocytic leukemia – case report
Vince A 1 , Barsic B 1 , Dusek D 1 , Vrhovac R 2 , Kutlesa M 1 ,
Santini M 1 . 1 University Hospital for Infectious Diseases
»Dr. Fran Mihaljevic«, Zagreb, Croatia, 2 Department of
Medicine, Division of Hematology, University Hospital
»Merkur« Zagreb, Croatia
Initial experience with the 2009 H1N1-Influenza A
(H1N1) suggests that this virus can cause severe disease in
immunosuppressed patients such as influenza pneumonia
and respiratory failure.
We present a case of 41-year old man with chronic lymphocytic
leukemia (CLL) who was treated at the University
Hospital for Infectious Diseases in February 2011 because
of influenza pneumonia. The patient was first diagnosed in
2008, with small tumor mass (TTM 5.7) CLL, Rai stage I.
His phenotype was typical for B-CLL, and due to low CD38
expression and trisomy 12 he was not regarded as a patient
with adverse prognosis. Although his tumor mass gradually
increased over time, he never required specific treatment.
Patient was not vaccinated against influenza although recommended
by his hematologist. Present illness started on
2/11/2011 with dry cough and low-grade temperature. He
was initially prescribed clarithromycin. On 2/16/2011 patient
became febrile up to 40 C with shaking chills and productive
cough. He was admitted to small local hospital on
2/17/2011 because of bilateral pneumonia. Upon admission,
the patient was febrile (40 C), with decreased breath sounds
on the left side with fine crackles bilaterally. The remainder
of physical examination was unremarkable. Therapy with
oseltamivir, ceftriaxone and doxycycline was commenced.
On the fifth day of hospital stay patient’s condition started
to deteriorate with development of respiratory insufficiency
and he was transferred to Intensive Care Unit (ICU) where
mechanical ventilation was started. Ceftriaxone was changed
to meropenem and vancomycin; doxycycline and oseltamivir
were continued. Unfortunately, respiratory insufficiency
worsened and extracorporeal membrane oxygenation was
considered as only life-saving procedure. He was transferred
to ICU of University Hospital for Infectious Diseases
on the twelfth day of illness. Upon admission patient was
mechanically ventilated (fiO2 100%) and hypoxemic (satO2
80%). Pulmonary X-ray showed bilateral confluent, mixed
alveolar and interstitial infiltrates, consistent with acute respiratory
distress syndrome (ARDS). ECMO was started
upon admission. On the seventh day of hospitalization there
was further deterioration of patient’s condition, probably
because of nosocomial sepsis with development of septic
shock and multiple organ dysfunction syndrome. Patient
died on the tenth day of hospitalization, i.e. twenty-first day
of influenza illness. Diagnosis of influenza A-H1N1 was
confirmed by RT-PCR from tracheal aspirate.
CLL patients are particularly at risk for influenza complications
because of hypogammaglobulinemia and deficient
T-cell compartment. Therefore physicians should strongly
encourage their patients to get influenza vaccine. Otherwise,
during influenza season empirical therapy with oseltamivir
should be started at the first symptoms of influenza.
103

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
PP34 Treatment of paroxismal nocturnal
hemoglobinuria – a case report
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 of
Hematology, Department of Medicine, 2 Department of
Clinical Laboratory, Clinical Hospital Center and School
of Medicine, University of Zagreb, Croatia
Introduction: Paroxismal nocturnal hemoglobinuria
(PNH) is clonal acquired disorder characterized by hemolytic
anemia, thrombosis, fatigue and bone marrow failure.
It is caused by acquired mutation of PIG-A gene in mutipotent
hematopoietic stem cell. As a consequence, cells are
lacking glycosil phosphatidylinosiol (GPI) – anchored proteins,
namely CD55 and CG 59, which are complement
regulatory proteins. The lack of complement regulatory proteins
makes erythrocytes susceptible to both intravascular
and extravascular hemolysis. Intravascular hemolysis is responsible
for majority of morbidity form the disease. Eculizumab
is a monoclonal antibody that inhibits terminal complement
activation, which reduces intravascular hemolysis
in PNH patients.
Aim: Here we present the first PNH patient in our Center
treated with eculizumab.
Case presentation: The patient was diagnosed having
aplastic anemia in 2009, at the age of 21. The treatment
started with corticosteroids, and later altered into cyclosporine.
In 2005 the patient presented with severe headache and
transitory ischemic attack. At that point PNH was suspected,
and diagnostic procedure was carried out. Diagnose of
PNH was made based on PNH clone on flow cytometry. In
2007, the progression of intravascular hemolysis was noted,
with significant increase in bilirubin and lactate dehidrogenase
levels, followed by the signs of bone marrow failure.
The need for blood transfusions and fatigue increased, while
quality of life decreased. Allogenic stem cell transplantation
was indicated, but no related donor was found. The patient
was eligible for eculizumab treatment.
The treatment with eculizumab started in January 2010.
Patient was vaccinated for Naisseria meningitides, and developed
severe cellulitis with skin necrosis on the place of
the puncture, hence the reconstructive surgery of the left upper
arm was needed. At the time when eculizumab was
started, patient had severe hemolysis, thrombocytopenia,
and anemia with need of blood transfusions every 2–3 weeks
and secondary hemochromatosis. Subjectively, she complained
mostly on severe fatigue. The patient received induction
treatment without side effects and continued with
maintenance treatment for 19 months. A significant decrease
of hemolysis was noted, and consequently reduced
need for transfusions and disappearance of symptoms,
mainly fatigue with dramatic improvement in her quality of
life.
Conclusion: Eculizumab treatment significantly improved
quality of life of the PNH patient form our center. Patients
main symptom, fatigue, disappeared almost completely,
and rate of blood transfusion was reduced to once in
5–6 weeks. We found eculizumab effective in treatment of
PNH patients.
104
PP35 Anti-proliferative and pro-apoptotic action
of the combined cytostatic/
immunosuppressive treatment of myeloma
cell lines in vitro
Zelic A 1 , Ivcevic S 1 , Kovacic N 1 , Kusec R 2 , Grcevi} D 1 .
1 Zagreb University School of Medicine; 2 Dubrava
University Hospital, Zagreb, Croatia
Multiple myeloma (MM) is B-lymphocyte neoplasia,
characterized by the slow proliferation of malignant plasma
cells in the bone-marrow (BM). Multiple anti-apoptotic signaling
mechanisms contribute to the accumulation of myeloma
cells within the BM and account for their resistance
to chemotherapy. Therefore, investigation of the effects of
different agents on the balance between pro- and anti-apoptotic
factors in the malignant clone would contribute to the
development of novel therapeutic strategies in MM.
Aim: We determined the effects of several currently used
anti-myeloma agents and their possible additive action on
the inhibition of proliferation and enhancement of apoptosis
of different human myeloma cell lines.
Material and methods: Human myeloma cell lines NCI-
H929, RPMI 8226 and JJN3 (ADCC-LGC and DSMZ cell
line collection) and Theil (a gift from Dr. K. Pulford, University
of Oxford, UK) were treated with bortezomib (Millenium
Pharmaceuticals), dexamethasone, cyclosporine and
thalidomide (Sigma-Aldrich) for 48 hrs. Cell line proliferation
was assessed by the colorimetric MTT assay, whereas
viability and apoptosis were evaluated by annexin V/propidium
iodide staining. Gene expression of pro-apoptotic
(Bax and p21) and pro-survival molecules (Bcl-2 and c-
Myc) was assessed by real-time AB7500 instrument (Applied
Biosystems). Additionally, we assessed the expression
of SPARC (secreted protein acidic and rich in cysteine), involved
in the cell de-adhesion from BM matrix and tumor
pathogenesis.
Results: Anti-myeloma agents (dexamethasone, bortezomib
and thalidomide) achieve their effects by different cellular
mechanisms. In addition, cyclosporine was included
for its ability to increase cell sensitivity to other cytostatics.
Each cell line, representing different biological variant of
MM, has shown unique pattern of the expression of pro- and
anti-apoptotic genes and, in addition, responded differently
to anti-myeloma treatment. The most potent additive effect
of drug combinations, including thalidomide/bortezomib,
thalidomide/cyclosporine and bortezomib/cyclosporine,
was noticed on the cellular and molecular level, as suppressed
proliferation and shift in the balance of pro- and
anti-apoptotic genes.
Conclusion: Resistance to apoptosis, common in myeloma
cells, depends on the constitutive expression of molecules
acting at cell-cycle checkpoints and activated intracellular
pathways in the particular circumstances. We observed
that the susceptibility of myeloma cells to specific
treatment is determined by their intrinsic balance between
pro-survival and pro-apoptotic factors. Certain drug combinations,
specifically thalidomide or bortezomib with cyclosporine,
decreased Bcl-2/Bax ratio, a key indicator of enhanced
apoptosis. Our findings suggest that the insight into

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
the molecular events in the affected clone could enable administration
of a specific individualized therapy which
would be more effective in eradicating the malignant clone.
PP36 Tandem Transplantation in Multiple
Myeloma – Single Center Experience
Batinic J 1 , Durakovic N 1 , Sertic D 1 , Bojanic I 2 , Batinic D 3 ,
Golubic-Cepulic B 2 , Mazic S 2 , Radman Livaja I 1 ,
Basic-Kinda S 1 , Aurer I 1 , Labar B 1 , Nemet D 1 . 1 Division of
Hematology, Department of Medicine, 2 Department of
Transfusiology, 3 Deaprtment of Clinical Laboratory,
Clinical Hospital Center and School of Medicine,
University of Zagreb, Croatia
High-dose chemotherapy followed by autologous hematopoetic
stem cell transplantation is well established first
line therapy for multiple myeloma. It has been previously
shown that tandem transplantation carries survival benefit
when compared to a single transplantation. We have conducted
a trial of two successive high-dose chemotherapy
followed by peripheral blood stem cell rescue for patients
with advanced stage multiple myeloma.
Aim: Aim was to evaluate feasibility, efficacy and toxicity
of tandem transplantation.
Patients and Methods: We included 107 patients, median
age 54 years (32–66), 49 were female, and 58 male
patients. Most of the patients had IgG monoclonal protein
(54.2%), 17.7% patients had IgA monoclonal protein,
17.7% had light chain myeloma, while 9.3% had non-secretory
myeloma, and one patient had IgD monoclonal protein.
Patients were evaluated on a intention to treat basis, and
from 107 included patients, 83 (77.5%) received tandem
transplantation; 4 patients did not collect adequate number
of cells for two transplantations, 10 patients had low performance
score, 7 were not transplanted due to physician decision,
1 patient refused second transplantation, 1 patient relapsed
and for 1 patient the reason is unknown.
Results: Progression free survival (PFS) and overall survival
(OS) were evaluated. Median time of progression free
survival for the entire group was 77 months, while median
time of overall survival was 138 months. Prior to first transplantation
8.6% of patients were in complete remission or
very good partial remission (CR/VGPR), 78% were in partial
remission (PR) and 11.4% had minimal response, while
1.9% had progressive disease. After the first transplantation
42.3% achieved CR/VGPR and 50% of patients were in PR,
while after the second transplantation 71.8% of patients
were in CR/VGPR and 26.2% were in PR. We conducted
analysis of PFS and OS according to disease status prior to
second transplantion and found no significant difference between
patients that achieved CR or VGPR and the patients
that did not do so. However, when the same analysis was
done according to disease status 6 months after the second
transplantation, a significant difference in both PFS and OS
was found between patients that achieved CR/VGPR and
the patients that did not achieve CR/VGPR (p=0.0179 and
p=0.0056 respectively).
Conclusion: Tandem transplantation as first line treatment
for multiple myeloma is an effective therapy offering
patients long term progression free survival and overall survival.
We found no significant difference in long term PFS
and OS between patients that achieved CR/VGPR prior to
second transplantation and those that did not, indicating important
therapy efficacy of second transplantation. Also, patients
achieving CR/VGPR after second transplantation
have statistically better PFS and OS than patients failing to
do so, which emphasizes importance of achieving CR as a
final outcome.
PP37 The Role of Thalidomide as Maintenance
Therapy in Multiple Myeloma
Bila J 1,2 , Bodrozic J 2 , Todorovic M 1,2 ,
Sefer D 2 , Kraguljac N 2 , Antic D 2 , Andjelic B 2 , Elezovic I 1,2 ,
Tomin D 1,2 , Gotic M 1,2 , Mihaljevic B 1,2 . 1 Medical Faculty,
University of Belgrade, 2 Clinic of Hematology, CCS,
Belgrade, Serbia
The aim of study was to analyse results of thalidomide
maintenance in patients with multiple myeloma.
Patients and methods: The study included 130 newly
diagnosed patients: 1) 50pts treated with high-dose treatment
(HDT) and autologous stem cell transplant (ASCT, 29
male/21 female, mean age 53 yrs, range 41–65); and 2) 80
elderly pts (45 male/35 female, mean age 68 yrs, range 66–
83yrs); with IgG myeloma in 75pts; IgA 27pts; light chains
25pt; non-secretory 3pts. Distribution according to the clinical
stage and ISS score was as follows: 1) II 56pts; III
74pts; ISS3 in and 59pts with ISS3 score. Induction treatment
in the first group was: a) VAD (average 4 cycles, range
3–6 cycles in 35/50pts); b) CTD (average 4 cycles, range
3–6 cycles in 15/50pts), followed by Melphalan 200mg/m²
and ASCT. The maintenance therapy was: Alfa-Interferon
(aIFN) in 10/35pts after VAD; Thalidomide (100mg/day) in
35/50pts after VAD/CTD. Median duration of maintenance
was 19m (range 6–36 m). Initial treatment for the elderly
pts: a) MP (30/80pts); b) MPT (35/80pts); c) Thal-Dex
(15/80pts). The maintenance therapy was: Alfa-Interferon
(aIFN) after MP (30/30pts); Thalidomide (100mg/day) after
MPT/Thal-Dex (50/80pts). Median duration of maintenance
was 16m (range 4–28 m).
Results: In the first pts group, after VAD, VGPR was
achieved in 4/35pts; PR in 25/35pts. Following HDT,
7/35pts achieved CR; VGPR 9/35pts; PR 14/35pts. After
CTD induction, CR existed in 3/15pts; VGPR/PR in 8/15pts.
Median follow-up was 26m (range 18–60 m). Thalidomide
maintenance after CTD significantly improved 3-yrs probability
of relapse-free survival (VAD+HDT+aIFN: RFS
25% vs. VAD+HDT+Thal: RFS 37% vs. CTD+HDT+Thal:
RFS 51%, P
Conclusion: Thalidomide as maintenance therapy significantly
improves treatment results in myeloma patients
with limitations due to toxic effects.
105

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
PP38 Modifi cated dosing of the VMP /Velcade +
melphalan + prednisone/ regime in multiple
myeloma /MM/ patients
Masarova K, Stefanikova Z, Mistrik M. Department of
Hematology and Transfusiology, University Hospital,
Bratislava, Slovakia
Aim: To establish efficacy and sefety modificated dosing
of VMP regime once weekly in MM patients not eligible for
autologous stem cell transplantation /ASCT/.
Abstract: In september 2008, J. San Miguel et al. published
the results of the study Phase III VISTA comparing
treatment regime VMP /Velcade+melphalan + prednisone/
vs MP in newly diagnosed patients with MM not eligible for
ASCT. In the VISTA study bortezomib administration was
1,3 mg/m 2 in 9 six weeks cycles, in the first 4 cycles the
administration was more intense /day 1,4,8,11,22,25,29,32/
and the following 5 cycles the administration of bortezomib
in days 1,8,22,29. This study confirmed significantly longer
medium OS /medium overal survival/ of patients in the
VMP arm. ORR in this arm was 71% /CR: 31%, PR: 40%/,
existence of negative adverse events of grade 3 /4 was: neutrophenia
40%, trombocytophenia 37%, anaemia 19%,
polyneuropathy /PN/ 13%. In 2008 A.Palumbo at al. published
a study which compared effectiveness and safety of
the VMP regime vs. VMPT in newly diagnosed patients not
eligible for ASCT. In this study, at the beginning the bortezomib
administration was as in the VISTA study, but in
march 2007 the protocol was changed and the administration
of bortezomib was changed to 9 five weeks cycles /1,3
mg/m 2 in days 1,8,15,22/. The effectiveness of bortezomib
remained unchanged /ORR: 81%, CR: 21%/ but the adverse
events, especially PN of grade 3/4 /2%/ decreased and also
decreased the amount of the treatment discontinuations
/10%/.
Published results led us to administration VMP regime in
treatment of MM in patients not eligible for ASCT in five
weeks cycles with administration of bortezomib 1x weekly
/1,3 mg/m 2 in days 1,8,15,22/, melphalan 9mg/m 2 and prednisone
60 mg/m 2 in days 1–4. Since April 2009 we have
collected group of 33 patients with median line of previous
MM treatment 3. Currently is possible to evauluate 33 patients
who absolved min. 4 cycles of previous treatments. In
this patients we achieved CR in 33%, PR in 42%, ORR in
75% with no PN of grade 3 /4. No patient had to discontinuate
or terminate treatment due to adverse events. Median of
administered cycles was 6,9 cycles. Median TTP /time to
progression/ was 25,7 months /VISTA 24 months/. Median
OS was not yet reached /VISTA not yet reached/.
Conclusion: On the base of our experience we can confirm
that the effectiveness of modificated VMP regime in
MM patients not eligible for ASCT remained stable and we
did not observed any adverse events of grade 3/4 or discontinuations
of the treatment due to adverse events. Decreased
frequency of bortezomib administration was well tolerated
also by the patients who were comming for the administration
once weekly.
106
PP39 Tevagrastim and Plerixafor as fi rst line
mobilizing regimen in patients with
lymphoma and Multiple Myeloma
Andreola G., Babic A., Negri M., Drera M., Martinelli G.,
Laszlo D. Department of Haematology, European Institute
of Oncology, Milan, Italy
Patients affected by hematologic malignancies might benefit
from high dose chemotherapy followed by peripheral
stem cells (PBSC) transplant. Chemotherapy in combination
with G-CSF is effective in mobilizing stem cells but
often toxic, might require prolonged hospitalization and extensive
supportive care. Moreover a high proportion of patients,
ranging from 11 to 53%, fail to collect an adequate
number of stem cells with this approach. Plerixafor, a
CXCR4 chemokine antagonist, has shown to increase the
number of circulating CD34+ cells in cancer patients when
used alone or with G-CSF and to be able to rescue patients
unable to mobilize with traditional regimens. Recently several
forms of biosimilar nonglycosylated recombinant human
G-CSF have been clinically developed and approved
by the European Medicines Agency for the same indications
as the reference filgrastim product on the basis of comparable
quality, efficacy and safety. Biosimilars also represent
a more cost-effective strategy and their use in clinical setting
may provide cost savings in their indicated uses. In order
to test the efficacy of the combination of biosimilar version
of G-CSF (Tevagrastim) and plerixafor in mobilizing
PBSC, from 12/10 to 5/11, 11 patients, affected by Non-
Hodgkin Lymphoma (3), Hodgkin Disease (2) and Multiple
Myeloma (MM) (6), were treated as follows: Tevagrastim
(10µg/kg/die) was self administered for 3 days; on day 4
patients were admitted to the hospital, circulating CD34+
cells counted and if 500 of 12 (9–13) and of PLT>20.000 of
13 (9–19) days.
The combination of tevagrastim and plerixafor is safe and
effective in mobilizing PBSC and allows a collection of a
more than adequate number of cells in most of the patients
in a maximum of 2 apheresis procedures, even in patients
with MM who need to collect a double amount of cells.
PP40 Does Prelixafor do the trick in mobilising
Stem Cells?
Vieira S, Monroe D, Librojo M. London, United Kingdom
Abstract: Plerixafor (MOZOBIL) is an antagonist of alpha-chemokine
receptor CXCR and one of the new additions
to Haematology discipline and it is used as a stem cell
mobiliser. CXCR4 alpha-chemokine receptors are important
in a hematopoietic stem cell homing to the bone marrow
and in hematopoietic stem cell quiescence. It is indicated
in combination with Granulocyte Colony Stimulating
Factor (GCSF) for Peripheral Blood Stem Cell (PBSC) collections
in the Multiple Myeloma (MM) and Lymphoma
patient group with a poor mobilisation history
Patients and methods: In our organisation, data was collected
prospectively. 14 patients received Plerixafor for
PBSC collection between May 2009 and September 2010.

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
All patients except one met the criteria prior to treatment
(White Blood Count> 2.5 x 109/L, Absolute Neutrophil
Count > 1.5 x 109/L, Platelet> 85 x 109/L, Serum Creatinine
< 1.5 mg/dL, Aspartate transaminase (AST), Alanine
Transaminase (ALT), Bilirubin < 2 x ULN with no evidence
of Hepatitis B and C. One patient had low platelet count.
Patient demographic data is shown in Table 1. Three patients
had an underlying documented medical problem (cortochondritis
and glaucoma).
Results: Nine of the patients were diagnosed with MM
and three with Non-Hodgkin’s Lymphoma (NHL), two patients
with Hodgkin’s Disease and one with Neuroblastoma.
All patients received four consecutive days of GCSF 10 ľg/
kg prior to Plerixafor. Plerixafor was given 10 hours before
the PBSC collection and GCSF was repeated one hour prior
to PBSC collection time in the morning. All patients received
0.24mg/kg/day of Plerixafor. There were no side effects
observed. Only one patient required a second dose of
Plerixafor.
For all cases, the target CD34+ count was 4 x 106 cells/
kg of recipient body weight. Two patients responded extremely
well with a CD34+ count of 21.79 x 106 cells/kg
and 15.16 x 106 cells/kg achieved and six patient had
achieved the target of 4 X 106 cells/kg or above with positive
outcome. However seven patients failed to achieve to
reach target CD+ 34 4 X109cells/kg of CD34 count was
collected. Six of these patients had adequate amount of
CD34 count for an autologus transplant. Only one patient
failed to mobilise any CD34 at all.
Conclusion: Plerixafor was used at The London Clinic
recently with mostly favourable outcomes. According to
this study Plerixafor has improved PBSC outcomes with
one exception case. Prelixafor definitely made a positive
difference 54% of our patient and 40% of our patient had
enough cells for an aoutologus transplant. However, results
are inconclusive due to small patient numbers. Ongoing
studies with new patient experiences are needed. More than
one dose of Plerixafor maybe required for heavily pre-treated
patients who are historically poor mobiliser of PBSC
collections.
PP41 Multidrug Resistance: From Research
to Clinics
Tauber Jakab K 1 , Márki-Zay J 1 , Kis E 1 , Udvardy M 2 ,
Borbényi Z 3 , Dávid M 4 , Krajcsi P 1 . 1 Solvo Biotechnology,
Szeged, Hungary; 2 2nd Department of Internal Medicine,
University of Debrecen-Medical and Health Science
Center, Debrecen, Hungary; 3 2nd Department of Medicine
and Cardiology, University of Szeged – Albert Szent-
Györgyi Clinical Center, Szeged, Hungary; 4 1st
Department of Internal Medicine, Pécs, Hungary
Since the beginning of the 90’s several studies have confirmed
the role of multidrug transporter proteins as major
mechanism of chemoresistance in a variety of haematological
malignancies. This phenomenon usually results from the
overexpression of ATP-binding cassette (ABC) transporters,
such as ABCB1 (MDR1 or P-gp), ABCC1 (MRP1), and
ABCG2 (MXR or BCRP), which are known to function as
drug efflux pumps causing drug resistance by actively extruding
multiple anticancer drugs with expenses of ATP. According
to a number of multicentric trials, P-glycoprotein or
ABCG2 expression are bad prognostic markers in acute myeloid
leukemia (AML) regarding remission rate and overall
survival.
Aim: The primary goal of our study was to evaluate the
frequency of the three clinically relevant ABC transporters
in AML and chronic lymphoid leukemia (CLL) using a
functional routine clinical laboratory flow cytometric assay.
In addition, we have characterized several anticancer drugs
for their interactions with efflux transporters using cellular
and membrane-based assays.
Patients and methods: In the frame of a multicentric
trial, flow cytometric assays were performed using the MultiDrugQuant
kit (MDQ kit) on CD45dim blast cells of 26
AML patients and CD19+ 28 CLL patients prior to the initiation
of chemotherapy. The MDQ kit applies the calcein-
and mitoxantrone-assays for the measurement of the function
of MDR1, MRP1 and BCRP transporters. Activities of
the multidrug transporters are calculated from the difference
between the geomean cellular fluorescent intensities
determined w/o transporter specific inhibitors and are expressed
as multidrug resistance activity factor (MAF) values.
Substrate or inhibitory profiles of 20 anticancer drugs
have been characterized using membrane-based ATPase and
vesicular transport assays and cellular dye efflux assays
such as the Calcein- and Hoechst-assays. The results of
these experiments have been correlated to the cytotoxicity
of the compounds on control (HL60, PLB) and transporter
overexpressing (HL60-MDR1, HL60 MRP1 and PLB-
BCRP) cell lines.
Results: The median age of AML and CLL pts was 55
and 67 years, respectively. MAF values were above the cutoff
value in 9 of the 26 AML and in 12 of the 28 CLL patients
at enrollment. Results of the membrane-based and
cellular assays to test the drug-transporter interactions
agreed well.
Conclusion: Based on these preliminary data the MDQ
kit is reliable and provides transporter specific quantitative
results on the function of the MDR1, MRP1 and BCRP
transporters in the target cells. Besides other prognostic factors
measurement of transporter activity allows risk stratification
of the AML or CLL patients. The high-throughput in
vitro assays presented here enable to characterize the interactions
of antineoplastic drugs with multidrug transporters.
PP42 P-glycoprotein activity and Flt3 internal
tandem duplication in 39 patients with
acute myeloid leukemia
Batinic D 1 , Perkovic S 1 , Zadro R 1 , Labar B 2 , 1 Department
of Clinical Laboratory, 2 Division of Hematology, Clinical
Hospital Center and School of Medicine, University of
Zagreb, Croatia
Aim: Flt3 internal tandem duplication (Flt3/ITD) and
high P-glycoprotein (Pgp) activity are adverse prognostic
factors in patients with acute myeloid leukemia (AML). The
107

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
aim of this study was to determine the association of Flt3/
ITD, Pgp activity and CD34 antigen expression in AML.
Patients and methods: Data on Flt3/ITD status and Pgp
activity were retrospectively analyzed in a group of 39 patients
with AML diagnosed and treated at the University
Hospital Centre Zagreb between January 2010 and May
2011. Patients with acute promyelocytic leukemia were excluded
from the study. CD34 antigen expression was determined
by routine flow cytometric immunophenotyping of
AML blasts. Pgp functional activity was assessed using
Rhodamine 123 (Rho123) as a fluorescent probe and Pgp
substrate, and verapamil (Vpm) as an inhibitor of Pgp activity.
Pgp was considered to be active if ratio of fluorescence
intensity (RFI) (Vpm+/Vpm-) was ≥ 2,0. FLT3/ITD was detected
by RT-PCR analysis (Nakao et al, Leukemia 1996).
Results: Flt3/ITD was found in 7/39 (18%), Pgp activity
in 22/39 (56%) and CD34 expression in 26/39 (67%) of all
our patients. Flt3/ITD- Pgp- group accounted for 13/39
(33%); Flt3/ITD+ Pgp- 4/39 (10%); Flt3/ITD- Pgp+ 19/39
(49%); Flt3/ITD+ Pgp+ 3/39 (8%). Four out of seven (57%)
Flt3/ITD+ patients did not express active Pgp, and only 3
out of 22 (14%) Pgp+ patients were Flt3/ITD+, demonstrating
no significant association between these two parameters
(Fisher’s exact test; p=0.6765). In addition, Flt3/ITD status
was not associated with CD34 expression (p=0.1938), in
contrast to Pgp+ cases that were CD34+ positive in 19/22
(86%) AMLs (p=0.0054).
Conclusion: Our results confirm the published data on
the association between Pgp activity and CD34 marker expression,
and the lack of association between the Pgp activity
and Flt3/ITD in patients with AML. One possible explanation
for this mutual exclusion might be the origin of leukemic
cells, i.e. more frequent finding of Flt3/ITD in CD34negative
blasts of monocytic origin. Further analysis of
Flt3/ITD and Pgp in well-defined subgroups of AML in a
larger cohort of our patients should clarify the role of combined
Pgp and Flt3/ITD determination in risk assessment
and prognostic classification of patients with AML.
PP43 The pretreatment risk factors and
importance of comorbidity index for overall
survival, complete remission and early
death in patients with acute myeloid
leukemia
Djunic I, Virijevic M, Novkovic A, Djurasinovic V,
Colovic N, Vidovic A, Suvajdzic-Vukovic N, Tomin D,
Clinic of hematology, Clinical Center Serbia, Belgrade,
Serbia
Aim: The aims of this study were to determine as the
pretreatment risk factors for overall survival (OS), rate of
complete remission (CR) and early death in patients with
acute myeloid leukemia (AML), as to estimate the influence
of comorbidity on patients’ outcome.
Patients and methods: This single-center study involved
184 patients with nonpromyelocytic AML with follow-up
of 58 months. The following parameters were estimated as
the risk factors for OS, CR and early death: age, WBC
(=30x10 6 /L), level of serum lactate dehydrogenase (LDH)
108
more than 1.5 x upper limit of normal and expression of
CD34 antigen on leukemic blasts (=10%). Performance status
(PS) was evaluated by Eastern Cooperative Oncology
Group (ECOG), ranged 0–4 (=2). Cytogenetic risk group
was assessed by recommendation of European LeukemiaNet
(ELN). Comorbidities evaluated by using the hematopoietic
cell transplantation-specific comorbidity index
(HCT-CI). Patients treated by Medical Research Council
(MRC) 12 regimen. Risk factors were identified using the
univariate and multivariate analysis.
Results: The mean patients age was 56 years, range 18–
79. The most significant risk factor for poor OS was the
adverse cytogenetics: p=0.014, relative risk (RR)=1.314
(95% CI 1.057-1.633). The age >=55 years indicated as the
most significant risk factor for poor rate of CR: p=0.001,
RR=0.274 (95% CI 0.125-0.597). The most significant factor
for early death was the HCT-CI>=3: p=0.027, RR=4.310
(95% CI 1.186-15.665). The cut-off of the age >=55 years
was significant for poor OS and CR. The incidence of HCT-
CI>=3 was significantly increased in patient with age >=55
years than in patients younger than 55 years (p=3 had half
of patient aged >=55 years, while 75% of patients younger
than 55 years have HCT-CI=0. Mostly patients (87.9%)
with age=1) had impact of infection on HCT-CI score (according
HCT-CI definition). So, we estimated risk factors
for both of these groups. The most significant risk factor for
OS in group aged=55 years it was HCT-CI>=3: p=0.005,
RR=1.874 (95% CI 1.208-2.907). In the group aged=55
years, elevated serum LDH level was the most significant
factor for poor rate of CR: p=0.015, RR=0.291, (95% CI
0.107-0.790) and ECOG PS>=2: p=0.005, RR=0.730 (95%
CI 0.586-0.910) for early death.
Conclusion: This study identified the pretreatment risk
factors for OS, CR and early death in patients with AML.
We point out the importance of comorbidity for OS and
early death, as well as the impact of infection on outcome in
patients with AML.
PP44 Treatment of Adolescents with Acute
Lymphoblastic Leukemia
Konja J, Rajic Lj, Bilic E, Femenic R, Anicic M.
Department of Pediatric, Clinical Hospital Center and
School of Medicine, University of Zagreb, Croatia
Adolescents with acute lymphoblastic leukemia (ALL)
have languished in the shadow of successful therapeutic
outcome in childhood ALL. While 80% of children aged
1–15 years are long-term survivors, less than 40% of adults
are cured with current therapies. Adolescents and young
adults who may be eligible for both adult and pediatric protocols
have continued to have an intermediate outcome,
which has remained inferior to that in children.
Aim: This article has summarized the recent and updated
retrospective comparative analysis of adolescents treated
with pediatric and adult trials.
Patients and methods: Data on ALL adolescents aged
16–18 treated with pediatric trial ALL IC-BFM 2002 were
compared with literature reports on the treatment of ALL
adolescents according to adult protocols.

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
Results: During the 2002–2006 period, 143 ALL patients
aged 16–18 were treated with pediatric trial ALL IC-BFM
2002. The 3-year event free survival (EFS) was 71%. During
the 1997–2002 period, 67 ALL patients aged 15–17
were treated with adult trial UKALLXII/E2993, and 61
ALL age-matched patients were treated with pediatric trial
MRC ALL97, with 5-year EFS of 49% and 65%, respectively.
A similar 6-year EFS has been reported for the American
pediatric regimen (CCG) that was by 26% higher in
comparison with their adult regimen (Cancer and Leukemia
Group B,CALCB).
Conclusion: Therapeutic outcome in adolescents with
ALL treated according to pediatric protocols is better (16 –
26%) in comparison with adult regimen.
PP45 FLAG-IDA as the Salvage Regime for
Relapsed and Refractory Acute Leukemias
Virijevic M, Suvajdzic N, Djunic I, Novkovic A,
Djurasinovic V, Colovic N, Vidovic A, Tomin D. Clinic
for hematology, Clinical Center Serbia, Belgrade, Serbia
Aim: Relapsed and refractory acute leukemias (AL) have
poor prognosis. There is no standard chemotherapy regimen
that provides a durable second complete remission (CR).
One of the most effective salvage regimen is FLAG-Ida.
This study evaluated the efficiency and the toxicity of
FLAG-Ida regimen in a relapsed and primary refractory AL.
Patients and methods: This single-center study involved
42 patients (pts) with AL with follow-up of 5 years. Twentyfour
(52.4%) pts with acute myeloid leukemia (AML) and
18 (42.9%) with acute lymphoblastic leukemia (ALL) were
included. All patients were treated with FLAG-Ida regimen
(Fludarabin 30mg/m 2 days 1–5; Cytarabin 2000mg/m 2 days
1–5; Idarubicin 8mg/m 2 days 1–3; G-CSF 300mg/m 2 was
given subcutaneously from day 1 until neutrophil recovery).
The following parameters were estimated as the risk factors
for CR achievement and overall survival (OS): age, WBC
(=30x10 9 /l), cytogenetics at diagnosis, refractory vs relapsed
AL, early (in first 6–12 months after CR) vs late relapse
(after 1 year) of disease. Cytogenetic risk in AML
patients was according to European LeukemiaNet (ELN).
Patients with ALL with unfavorable cytogenetics (Philadelphia
chromosome or bcr-abl positivity) were considered as
a high risk group. Event-free survival (EFS) and OS were
calculated by Kaplan-Meier and differences log rank method.
Toxicity was evaluated according to the World Health
Organization (WHO) classification.
Results: The mean pts’ age was 35 years, range 18–55;
twenty-two (52.4%) had relapsed and 20 (47.6%) primary
refractory AL. Sixteen of 42 (38.1%) patients achieved CR,
10 (41.7%) pts with AML and 6 (33%) pts with ALL
(p=0.03). Hematological toxicity (grade III-IV) occurred in
all AL cases. The median time to neuthrophil recovery
(ANC >500/µl) and platelet recovery (>20x10 9 /l) were 17
and 20 days from the start of therapy. Nonhematological
toxicity was mild (grade I-II). Febrile neutropenia was registered
in 39 (90.5%) pts. Infection of unknown cause was
registered in 21 (54.7%) and of known cause in 18 (46.3%)
pts, respectively. The significant risk factor for poor CR rate
in relapsed AL was WBC>=30x10 9 /l (p=0.043). The most
significant risk factor for OS was early relapse vs late relapse
(10 vs 24 months, p
Conclusion: FLAG-Ida proved to be highly effective and
low toxic regimen, very useful in our group of relapsed and
primary refractory AL pts, enabling them to achieve CR and
to undergo allogeneic stem cell transplantation.
PP46 Clinical outcome and prognosis related
factor in acute promyelocytic leukemia
patients treating with PETHEMA LPA 099
protocol.
Mitrovic M, Suvajdzic N, Bogdanovic A, Novkovic A,
Kraguljac N, Sretenovic A, Antic D, Djunic I, Vidovic A,
Colovic N, Virijevic M, Djurasinovic V, Elezovic I,
Tomin D. Clinic of hematology, Clinical Center Serbia,
Belgrade, Serbia
In acute promyelocytic leukemia (APL) a cure rate of
75–80% can be anticipated with a combination of all-trans
retinoic acid (ATRA) and anthracyclines. But, understanding
of the prognostic factors associated with the induction
mortality has remained controversial and limited.
Aim: To analyze the clinical outcome and the prognostic
factor in APL patients (pts) treating with PETHEMA LPA
099 protocol.
Patients and methods: From 2004 to 2010, 42 consecutive
APL pts confirmed either by t(15; 17) or PML/RARA
were treated with PETHEMA LPA 99. The median followup
was 32 months (range: 1–78).
Results: Median time from the first symptoms to diagnosis
was 23 days (range: 5–90). Pretreatment pts characteristic
were as follows: median age 42 years (range: 21–69),
22/42 male; mean WBC 25.6 x10 9 /L (range: 0.6–183); mean
platelet count 34x10 9 /L (range: 4–101); hypergranular form
in 39/42 (93%) pts; PETHEMA risk stratification: high
17/42 (40%), intermediate 17/42 (40%), low 8/42 (20%);
mean D-dimer 3606 ľg/L (range: 996–11340). DIC was
confirmed in 32/42 (86%) pts, mean DIC score 6 (range:
3–7). Additional cytogenetics abnormalities were detected
in 8/42 (19%) pts.
Therapy results: 33/42 (76%) pts achieved complete remission
(CR). Induction death occurred in 9/42 (21%) pts,
due to: differentiation syndrome (DS)- 4/42 (9.5%), central
nervous system hemorrhage- 4/42 (9.5%) and infection-
1/42 (2.3%). Early died pts had higher WBC (55.9x10 9 /L
vs. 14.1x10 9 /L, p=0.014), higher percentage of peripheral
blood (PB) promyelocytes (15.0% vs. 9.59%, p=0.03) and
higher DIC score (6.32 vs. 5.85, p=0.014). All died patients
were CD15- with DIC score >5. Predictors of induction
death in univariate analysis were: WBC >30x10 9 /l (p=0.03),
DIC score >5 (p=0.01), CD15- (p=0.04). In multivariate
analysis only WBC >30x10 9 /l was an independent predictor
factor. DS occurred in 11 pts (26%). Pts with DS had significantly
higher percentage of PB promyelocytes (48% vs.
28.68%, p=0.04). Microgranular subtype (p=0.048) and
CD15- (p=0.04) were predictive for DS. There are no predictive
parameters for bleeding. Three relapses occurred
after the third consolidation, during maintenance and 6
109

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
months after the maintenance termination, respectively.
Mean time to relapse was14 months (range: 2–31). The
26/42 (62%) pts are alive in first continuous CR. Three-year
overall survival (OS) is 76% and disease free survival (DFS)
82%.
Conclusion: PETHEMA LPA-99 proved effective in our
APL patients concerning OS, DFS and relapse rate. High
rate of early death could be attributed to the numerous highrisk
pts and increased rate of DIC. WBC>10x10 9 /L, DIC
score>5 and CD15 negativity were poor prognostic factors
for early death. Reduction of the incidence of early deaths is
mandatory and requires a timely diagnosis and better management
of both DS and bleeding.
PP47 Acute myeloid leukemia with
t(8;21)(q22;q22); RUNX1-RUNX1T1
– case report
Radic Antolic M, Rajic Lj, Femenic R, Bilic E,
Pavlovic M, Perkovic S, Lasan R, Markovic-Glamocak M,
Zadro R. Department of Clinical Laboratory and
Department of Pediatrics, Clinical Hospital Center and
School of Medicine, University of Zagreb, Croatia
A 17-year-old male patient was diagnosed with AML in
December 2009; hepatosplenomegaly was present along
with increased white blood cell count (12.1x10 9 /L), anemia
and thrombocytopenia. Cytomorphological diagnosis was
AML M2 with eosinophils according to FAB classification.
Immature aberrant myleoid cell immunophenotype (MPO+
CD13+/–CD33+CD34+CD117+CD133+HLADR+) with
coexpression of TdT but without other lymphoid, erythroid,
monocytic or megakaryocytic markers was confirmed. Presence
of t(8;21)(q22;q22) and RUNX1-RUNX1T1 fusion
gene was detected in the bone marrow with negative FLT3/
ITD. The patient was treated according to AML-BFM 2004
(combination of intensive chemotherapy and hematopoietic
stem cell transplantation, HSCT). Although the patient
achieved cytogenetic response in March 2010, one month
later 3% of bone marrow cells showed t(8;21)(22q;22q).
Because of his age, gender and poor response after 15th day
of intensive chemotherapy, the patient was scheduled for allogeneic
HSCT. After allogeneic HSCT, the patient developed
Wernicke encephalopathy with bacterial infections
that were successfully treated. However, he never achieved
molecular response during chemotherapy as well as in posttransplantation
period. This prompted us to quantify
RUNX1-RUNX1T1 fusion gene and WT1 gene expression.
Expression of WT1 gene showed decreased tendency prior
to allogeneic HSCT and was lower than that of RUNX1-
RUNX1T1 fusion gene. In posttransplatation period WT1
gene expression increased 3.5 times and was higher than
RUNX1-RUNX1T1 fusion gene expression. Three months
later allogeneic HSCT bone marrow was negative for t(8;21)
but del(20q) was present in 10% of nuclei with the lowest
value of RUNX1-RUNX1T1 fusion gene expression during
the entire follow-up period. NPM1 mutation A and FLT3/
ITD were negative at that time as well. Two months later
del(20q) was present in 2% of nuclei. Nine months after
110
SCT the patient is still in clinical, cytologic and cytogenetic
remission, but with positive molecular finding of RUNX1-
RUNX1T1 fusion gene expression. This case report shows
that patients, despite favorable clinical, cytogenetic and
molecular prognostic markers, do not always have a good
outcome. It also confirms that molecular monitoring of a
patient with leukemia represents the most sensitive method
for estimating response to therapy and assessing disease
course.
PP48 Successful treatment of B-cell
prolymphocytic leukemia (B-PLL)
with FCR-Lite protocol
Batar P, Telek B, Udvardy M. Department of Hematology,
University of Debrecen Health Sciences Center, Debrecen,
Hungary
B-cell prolymphocytic leukemia is a rare disorder accounting
approximately for 2% of all lymphoid malignancies.
It is chracterized by marked lymphocytosis in the peripheral
blood, matured lymphocytic infiltration in the bone
marrow and prominent splenomegaly. It has a distinct immunophenotype
pattern (CD19, CD20, CD22, FMC7, intensive
surface immunoglobulin positivity) which helps to
differentiate from other lymphoproliferative malignancies.
The disease has poor prognosis and its treatment is unsettled.
Here we present a case of a 71 year old male patient
who was admitted to the outpatient facility of the University
of Debrecen Health Sciences Center Department of Hematology
on December 2008. He was presented with 71.0 G/L
WBC of witch 65% were prolymphocyte. Prominent splenomegaly
was also present. The lower border of the spleen
exceeded the left costal margin by 14 cm. No anaemia,
thrombocytopenia or lymphadenopathy were present. Bone
marrow aspiration revealed hypercellularity and 80% matured
lymphocytic infiltration. Flow cytometry identified CD5-
, CD19+, CD20+, CD22+ and FMC+ phenotype. Surface
kappa light chain positivity was also present. Cytogenetics
and FISH were also performed. Chromosomal abnormalities
were not detected. The patient had an excellent clinical
performance status (ECOG: 0). FCR-Lite protocol (fludarabine,
cyclophosphamide, rituximab)l was initiated. Lymphocytosis
and splenomegaly have disappeared after 4 cycles.
Six weeks after 6 cycles of chemotherapy flow cytometry
showed complete remission. No major hematological
complications were observed during treatment. However G-
CSF support was needed due to grade III-IV neutropenia
but no fever or infection has developed. After completion of
6 cycles of FCR-Lite treatment maintenance rituximab
monotherapy was started administering 500 mg/m 2 rituximab
every three monts. After a follow up of 2.5 years the
patient is still in complete remission. According to our experience
the FCR-Lite protocol can not only be used in patients
with B-CLL but it also can be effective in patients
with B-PLL. No clinical experience has been reported yet in
the literature with this protocol.

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
PP49 Combination of rituximab and high-dose
chlorambucil in therapy of small
lymphocyte lymphoma / chronic
lymphocytic leukemia
Aurer I 1 , Hude I 1 , Basic-Kinda S 1 , Dujmovic D 1 ,
Nemet D 1 , Radman I 1 , Ilic I 2 , Stern-Padovan R 3 , Santek F 4 ,
Sertic D 1 , Labar B 1 . 1 Department of Medicine, 2 Parthology,
3 Radiology, 4 Oncology, University Hospital Center and
School of Medicine, University of Zagreb, Croatia.
Introduction: Chronic lymphocytic leukemia / small lymphocyte
lymphoma (CLL) is the most common leukemia
among adult Caucasians. It is typically a disease of the elderly,
with a median age of onset of 69 years. Clinical course
of the disease is variable and the prognosis depends on the
clinical stage at the time of diagnosis and other established
prognostic factors. Despite the intensive promotion of fludarabin-based
protocols as the fundamental treatment of CLL,
high dose chlorambucil remains the most efficient monochemotherapy
for these patients. Low toxicity, short treatment
duration and favorable cost make this therapy a convenient
platform for addition of non-toxic targeted drugs, like rituximab.
Rituximab is a monoclonal antibody aimed at the
CD20-antigen on the surface of B-lymphocytes.
Aim: Combination of rituximab and chlorambucil has
been in routine clinical use for some time. The aim of this
research is to assess its effectiveness.
Patients and methods: Twenty-five patients treated at
KBC-Zagreb were included in this study. Median age was
67 years. Patients had received high-dose chlorambucil (10–
20 mg, median 18 mg) continuously and 700–800 mg of
rituximab. Eight cycels were planned. Treatment was conducted
with or without addition of glucocorticoids. In analysis,
patients were divided into groups depending on Binet
and Rai stages and total tumor mass score as well as other
prognostic factors. Adverse events (AE) were evaluated. Assessed
outcomes were response rates and survival.
Results: Complete remission (CR) was achieved in 12
patients (48%), partial remission (PR) in 7 (28%), 2 patients
were refractory to therapy (8%) and in 4 treatment is still
ongoing. After median follow-up of 15 months of survivors,
progression-free survival (PFS) is 72% and overall survival
(OS) 92%. Patients with Binet stage C and Rai stages 3 and
4 have a statistically significant lower PFS than patients
with favorable stages (26% vs, 86%, p=0, 047). The effect
of total tumor mass (TTM) score as well as other prognostic
factors on PFS was not statistically significant (p > 0,05).
Likewise, correlation between assessed prognostic factors
hasn’t been proven. Serious toxicity occurred in 7 patients,
6 of whom were ≥ 65 years. However, correlation between
age and toxicity wasn’t statistically significant. The most
common serious AE was leukopenia.
Conclusion: Combination of rituximab and continuous
high-dose chlorambucil is a very effective front-line treatment
of CLL, leading to high overall response. Therapy
does not cause unexpected toxicity and is well tolerated. To
obtain more relevant results for comparison with larger
studies, further follow-up and inclusion of new patients is
needed.
PP50 Atypical Blastoid Variant of Hairy Cell
Leukemia: a Case Report
Hadji-Pecova L, Petrusevska G, Panovska I, Stojanovski Z,
Stojanovic A. Department of Hematology, Medical Faculty,
Skopje, Republic of Macedonia
Hairy Cell Leukemia (HCL) is a rare B-cell indolent lymphoproliferative
disorder, also known as one of the B-cell
chronic lymphatic leukemia (B-CLL). HCL-blastoid variant
describes an entity of HCL that is important from the point
of view of requiring differential diagnosis from classic
HCL, HCL-variant and others Non-Hodgkin’s Lymphoma.
Differential diagnosis includes HCL, HCL-v, B-CLL,
Mantle cell lymphoma, Folicular lymphoma (FL). and
Splenic lymphoma vith vilous lymphocyte.
HCL-blastoid variant differs from the classic form of
HCL with respect to the lack of monocytopenia, leucocyosis
and unique morphology and immunophenotype.
We report a 30 years male patient who presented at our
department in May 2005 with leucocytosis, mild anemia,
skin bleeds and splenimegaly. The blood smear showed
more than 50% of heterogenous lymphoid population with
balstoid hairy cells prdominance. In the bone marrow biopsy
diffuse infiltration of lymphoid cells were seen positive
for CD20, CD79a and HLA-DR, and negative for CD103,
CD11, DBA44, CD5, and CD23. The splenic biopsy showed
diffuse lymphoid infiltration of the white and red pulp immunohoistochemically
positive for CD20, CD79a, BCL-2,
HLA-DR, and CD10 slightly positive in a subset of cells,
and negative for CD103, CD11 and DBA44.
Based on bone marrow and spleen morphology and immunohistochemistry
the patient was unfortunately misdiagnosed
as having diffuse FL.
He was initially treated with splenectomy followed by
seven cycles of CHOP chemotherapy but with minimal response.
In the meantime the second opinion of the bone marrow
and spleen histopathology and immunohistochemistry were
received, and the patient was rediagnosed as a case with rare
atypical blastoid variant of HCL exhibiting aberrant phenotype.
The therapy with cladribine was immediately started
which resulted with complete remission (CR). The patient
was in CR for two years (April 2006 – April 2008).
By the end of April 2008 relapse was confirmed. Peripheral
blood and bone marrow showed massive, almost 100%
infiltration with bizarre blastoid cells.
The patient was treated as acute leukemia. He received 3
cycles of Hyper C-VAD chemotherapy (he was in CR after
the first cycle) followed by consolidation with cladribine.
Recently, positive mutation of BRAF was confirmed.
Since November 2008 the patient is in CR.
This case suggests that we should be extremely careful
during the period of diagnosis having in account the existence
of aberrant phenotypes, and that the morphology still
remains important tool. Literature research reveals that aberrant
phenotype CD20+, CD10+ in particular the conjunction
with CD103 negative has been known for several years,
comprising roughly 2–5% of HCL cases.
111

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
PP51 Intravascular T-cell lymphoma presented as
a subcutaneous panniculitis-like lymphoma:
A case report
Ilic I 1 , Basic-Kinda S 2 , Bosnic D 2 , Aurer I 2 , Dotlic S 2 ,
Gasparovic V 1 . 1 Department of Pathology, 2 Department of
Medicine, Clinical Hospital Center and School of
Medicine, University of Zagreb, Croatia
Introduction: Intravascular lymphoma (IVL) is a rare
type of non-Hodgkin lymphoma characterized by proliferation
of lymphoma cells only within the vessel lumina involving
in most cases the skin and/or the brain. Majority of
IVL are of B-cell origin but rare cases of T-cell and NK cell
IVL have been reported.
Case presentation: A 45-year old female was admitted
to the hospital because of the fever of four month duration,
elevated erythrocyte sedimentation rate, elevated level of
lactate dehydrogenase, thrombocytopenia and multiple erythematous
patches and nodules on her legs and lower back,
suggesting a subcutaneous panniculitis-like T-cell non Hodgkin
lymphoma. During the observation she developed severe
dyspnea and impairment of consciousness. Biopsy of
skin lesion was performed and it showed dermal vessels
filled with large atypical lymphatic cells. Immunophenotypic
analysis showed that the tumor cells were CD2-,
CD3+, CD4+, CD5−, CD7+, CD8−, CD30-, EMA-, CD56−,
ALK−, TIA1-, Granzyme B-, Perforin-, CD20-, Cytokeratin
-. There was no tumor cell infiltrate outside the vessels or
in the subcutaneous fat tissue. Treatment with Methotrexate
combined with Asparginase and Dexamethasone was initiated,
but the patient died of multiple organ failure about a
month after admission to the hospital.
Discussion: We found about 20 cases of intravascular Tcell
lymphoma reported so far in the literature, and therefore
T-cell IVL is still considered a very rare entity. The
patients may show a variety of symptoms, usually nonspecific,
such as abdominal pain, altered mental status or fever,
making this diagnosis difficult to recognize and delaying
the treatment. Some of the patients with IVL present with
skin lesions reminiscent of panniculitis or subcutaneous
panniculitis-like T-cell lymphoma. The only way to obtain a
correct diagnosis is to perform a biopsy of such lesions.
Histopathological differential diagnosis includes intravascular
lymphomatosis seen in hepatosplenic T-cell lymphoma
or in angioimmunoblastic peripheral T-cell lymphoma,
making an IVL a diagnosis of exclusion. Thus, without
proper clinical information the diagnosis cannot be established.
Conclusion: Intravascular lymphoma is a rare disease,
however in patients with fever of unknown origin, pancytopenia
or nonspecific neurological symptoms, IVL should be
considered. The biopsy, as well as thorough examination of
the patient is crucial for reaching the exact diagnosis.
112
PP52 Primarily Localized non Hodgkin
Lymphoma of Testes with Relapse
Localized in Buccal Area – Case Report
Hotic-Lazarevic S, Kezic Lj, Mandic D, Stojcic B,
Malinovic J, Mrdja J. Division of Hematology, Department
of Internal Medicine, Clinical Center Banja Luka, Banja
Luka, Bosnia and Herzegovina
Introduction: Primarily localized lymphoma of testes is
rare and aggressive extranodal non Hodgkin lymphoma. It
is the most frequent tumor of testes in men aged 60–80
years.
The Aim of the study: to present the case of a patient
with primarily localized lymphoma of testes, in whom there
has been performed orchiectomy within two different periods,
performed chemotherapy and radio therapy, and the
relapse of the disease in both cheeks and submandibular
gland on the left.
Case presentation: a patient of 56 years of age, with
painless swelling of the left scrotal area and non-homogenhypoechogne
mass (48x32 mm) of the left testis with microcalcifications
verified by ultrasound. After the left orchiectomy
(pathohystological diagnosis was Lymphoma non
Hodgkin of the left testis- diffused large cell B-phenotype,
CD-20+, of high proliferation activity) there was implemented
the chemotherapy R-CVP on the 21st day in the
planned therapy doses, as well, which the patient underwent
well. During the therapy of maintaining by rituximab, after
the second treatment, swelling of the right scrotal area.
There was indicated the right orchiectomy, and the obtained
pathohystological finding was almost identical to the first
one. The implemented irradiation of both testes boxes, abdomen
and pelvis with 36 Gy/20 fractions by the method of
reversed Y. Seven moths upon the completed irradiation,
and after the first dose of substance of Testosterone depot
(due to exceptionally low values of testosterone and difficulties
related to it), occurrence of tm forming of both buccal
areas and submandibular gland on the left. After biopsy,
by pathohystological finding, there was verified the Hodgkin
lymphoma understood as the relapse of the disease and
there started the therapy according to MINE protocol, which
is still being realized.
Conclusion: Primarily localized lymphoma of testes and
buccal area are rare extranodal localizations of non Hodgkin
lymphoma.
PP53 A 48 Year Old Woman with a Rare Case
of a Midline Destructive Disease Presenting
as Having both Midline and Nonmidline
Lesions – a Case Report
Fernandez S, Lapus F, Barez MY. Davao Medical Center,
Davao City, Philippines
Objectives: To describe a rare case of lethal midline granuloma
presenting in a rare location. This type of lymphoma
which needs a tissue biopsy for diagnosis and immunohistochemical
staining for confirmation is a challenge in a developing
nation to diagnose, treat and follow up. This paper is

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
presented to be able to show how a rare case of lymphoma
was appropriately diagnosed in sans the modern methods of
immunohistochemical staining with promising results of
chemotherapy.
Midline destructive lesions are a heterogeneous group of
rare lesions where the classification angiocentric lymphoma,
or peripheral Natural Killer/T cell lymphoma, nasal
type belongs. It usually presents with destructive mass lesions
and extensive destruction in the midfacial areas. We
describe a case of an angiocentric lymphoma, or Natural
Killer/T cell lymphoma who presented with both a nasal
mass and a skin lesion in the medial aspect of her left leg. A
tissue biopsy was done to make the diagnosis. She underwent
six cycles of chemotherapy and radiotherapy with very
promising results
Conclusions: We report this case to document a rare type
of lymphoma. Our patient was unique in that she presented
with a rare type of lymphoma that is not usually documented
in the Philippines and is rare even in international reports.
Moreover, she presented also unusually having both a
nasal mass and a skin lesion in the medial aspect of her left
leg.
PP54 Successful mobilisation with Plerixafor-
clinical report
Babic A, Istituto Europeo di Oncologia, Divisione di
Ematologia, Milan, Italy
Background: Our Clinical Transplantation Program sometimes
sees a young people treated in abroad interrupting
or changing their clinical pathway.
Clinical Case: Here is the case of a young russian girl,
16 year old girl, affected by Hodgkin Lymphoma, nodular
sclerosis, stage IIIB. Diagnosis was performed in Russia in
October 2009 on a biopsy of a supraclavicolar lymphnode.
She then underwent 6 cycles of chemotherapy including antracycline,
cyclophosphamide, vincristine, procarbazine and
prednisone which was followed by mantle and inverted Yfield
radiotherapy until June 2010. All these treatments has
been performed by using peripheral veins. During the treatment
she developed Herpes Zoster and Parvovirus infection
treated respectively with antiviral drugs and Ig ev. In August
2010, a CT scan showed relapse of disease. She was inserted
the Gronshong central catheter and on October 25th, she
underwent the first cycle of chemotherapy with ifosfamide,
etoposide and prednisone and on November 2nd she was
admitted in our inpatient department
Methods: We wanted to use this chemotherapy cycle as
»mobilization« adding GCSF if necessary to see if we are
able to collect her stem cells for autologous transplant. We
followed her blood cell counts recovery, monitoring circulating
CD34+ as soon as white blood cells reached 500 /ul,
but counts showed very low numbers, only 2 cells/ul at 11th
November. We therefore decided to ad plerixafor and the
very next day she had 10 cells/ul of CD34+ and we positioned
a central venous cathether in the femoral vein deciding
to perform the firsth apheresis procedure and permitting
her to achieve 0.7 x 106 cells/kg at the very day (12 November).
We therefore administered a second dose of plerixafor
and repeated the procedure the day after with 19 cells/ul and
a collection of 1.5 x 106 cells/kg, for a total of 2.2 x10E6
CD34+/kg.
Results: Therefore she underwent additional two cycles
with ifosfamide, carboplatin and etoposide therapy and
achieved a complete response PET and CT scan documented
in Jaunary 2011.
Conclusions: She then was able to undergo the autologous
stem cell transplantation after a conditioning regimen
according to BEAM schedule and in February 2011 PET
and CT scans confirmed the complete response.
PP55 Isolation and in vitro cell culture of
mesenchymal stem cells from human
umbilical cord blood
Mazic S 1 , Golemovic M 1 , Skific M 1 , Bojanic I 1 , Humar I 2 ,
Golubic Cepulic B 1 . 1 Department of Transfusiology,
2 Deaprtment of Clinical Laboratory, Cliniacal Hospital
Center, Zagreb, Croatia
Mesenchymal stem cells (MSCs) are multipotent bone
marrow (BM) cells that give stromal support for hematopoiesis
and express immunomodulatory properties and regenerative
potential. Although cord blood (CB) is easily accessible
source of MSCs and could serve as alternative to BM,
isolation success of MSCs is very low. Therefore attempts
are made to enhace isolation and expansion rates and in this
regard different culture conditions in vitro are being examined.
Lately, human platelet lysate (PL) has been proposed
as fetal bovine serum substitute.
Aim: The aim of this study was to evaluate success rate
of MSCs isolation from CB by imunomagnetic depletion of
CD34+ hematopoietic fraction and to investigate biological
properties of MSCs expanded in presence of 10%PL.
Samples and methods: 15 CB units were selected according
to predefined criteria; volume >40ml, total nucleated
cells (TNC) >6x10 8 , mononucleated cells (MNC) >1x10 8
and processing within 15 hr from collection. Each CB was
divided in two cell fractions; CD34- and unmanipulated
fraction. MNCs of each fraction were plated at 1x10 6 /cm 2 .
Adherent cells were cultured in presence of 10% PL until
reaching confluence and then harvested by trypsinization
and replated at 5000 MSCs/cm 2 . At each passage (P) cells
were counted and population doublings (PD) were calculated.
In order to evaluate clonogenic potential of cultured
cells, colony-forming unit-fibroblast (CFU-F) assays were
performed starting at P2. Flow cytometry analysis of surface
phenotype was done in P3. Cells harvested in P5 were
added to mixed lymphocyte cultures (MLR) in order to test
their immunomodulatory properties.
Results: Expansion of MSCs in presence of PL resulted
in 27% (4/15) overall success rate. Within successfully cultured
MSCs 3/4 (75%) originated from CD34- fraction.
Cells cultivated from two fractions were morfologicaly different.
Cultured MSCs showed slow growth kinetics; time
needed for one MSCs PD in 4 samples was 8.5, 18, 16 and
7.4 days respectively. Initialy high clonogenic potential rapidly
decreased by P5. Analysis of surface phenotype showed
113

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
expected lack of hematopoietic markers and variable expression
of typical MSCs markers. All cultivated MSCs expressed
CD73 while CD90 was expressed in variable intensity.
Expression of CD105 was not detected. Addition of
cultivated MSCs in different concentrations to MLR resulted
in modest immunomodulatory effect.
Conclusion: None of the predefined selection criteria
correlated with MSCs isolation success. Depletion of
CD34+ cells favoured growth of MSCs. Whether unexpected
immunophenotype of cultured MSCs correlates with
specific culture conditions or with some additonal parameter
needs to be evaluated in larger group of samples. Despite
availability of CB as potential source of MSCs, their low
frequency and unpredictable expansion success along with
time consuming and laborious procedure, make CB unreliable
source of MSCs for clinical use.
PP56 Biological properties of human
mesenchymal stem cells expanded in vitro
in media supplemented with human
platelet lysate
Skific M 1 , Golemovic M 1 , Mazic S 1 , Bojanic I 1 , Humar I 2 ,
Davidovic S 3 , Crkvenac Gornik K 3 , Ilic I 4 , Durakovic N 5 ,
Mikulic M 5 , Serventi Seiwerth R 5 , Labar B 5 ,
Golubic Cepulic B 1 . 1 Department of Transfusiology,
2 Department of Clinical Laboratory, 3 Department of
Pediatric, 4 Department of Pathology, 5 Department of
Medicine, Clinical Hospital Center and School of
Medicine, Universiuty of Zagreb, Croatia
Human mesenchymal stem cells (MSCs) are nonhematopoietic
multipotent cells that express regenerative and immunomodulatory
properties in vitro and appear immunoprivileged
what gives them considerable therapeutic potential.
Because of very low incidence in the bone marrow
(BM) aspirates MSCs need to be expanded in vitro. Recently
human platelet lysate (PL) has been evaluated as fetal
bovine serum (FBS) substitute in MSCs in vitro expansion.
Aim: The aim of this study was to evaluate biological properties
of MSCs expanded in vitro in the presence of PL and
create basis for the development of clinical expansion protocol.
Patients and methods: Mononuclear cells (MNC)
were isolated from the BM of 8 healthy individuals by Ficoll
density gradient centrifugation and plated at 160000
MNC/cm 2 in media suplemented with 10%FBS, 10%PL or
5%PL. When the cells reached 80% confluence, they were
harvested by trypsinization and replated at 1000 MSCs/cm 2
until reaching passage 5 (P5). To evaluate growth kinetics in
different culture conditions, number of cells was determined
by light microscopy techniques and to evaluate MSCs clonogenic
potential, colony forming unit-fibroblast (CFU-F)
assays were performed at each P. Characteristic immunophenotype
was assesed by flow cytometry whenever sufficient
number of cells was obtained. To assess their multipotency,
MSCs were induced into adipogenesis and osteogenesis
in vitro (n=6). Immunomodulatory properties were
evaluated by adding 10-40000 MSCs to mixed lymphocyte
reaction (MLR) (n=1). Karyotype analysis was performed
to validate chromosomal stability of expanded cells (n=5).
114
Results: Dominant growth of MSCs was observed in the
presence of 10%PL and confirmed by CFU-F tests. Cell
growth analysis showed that, by the P5, median time needed
for one MSC population doubling (PD) in the presence of
10%FBS was 154hr compared to 50hr and 40hr in 5%PL
and 10%PL, respectively. More than 96% of cells cultured
in the presence of 10%PL expressed CD90 and CD73 already
in P1 and P2, while CD105 expression was either
very low or not detected. Cultured cells were devoid of hematopoietic
markers already in P1. Cells cultured in presence
of 10%PL differentiated into adipocytes and osteoblasts.
In MLR experiment, MSCs cultured with 10%PL
displayed stronger immunomodulatory effect compared to
those cultured in 5%PL. Karyotype was analyzed in 5 samples
of different donors mostly obtained in P3 or P4. Analysed
metaphases displayed normal karyotype with the exception
of one sample where trisomy 8 was detected in P4,
but not in subsequent P5.
Conclusion: MSCs cultured in the presence of 10%PL
display almost all expected biological and immunomodulatory
properties. Whether absence of CD105 expression correlates
with specific culture conditions, needs to be confirmed
in the bigger cohort of samples. This study provides
a basis for further efforts in evaluating PL as a valuable FBS
substitute in clinical grade MSCs expansion.
PP57 Croatian Cord Blood Bank: the fi rst 4 years
Mazic S 1 , Bojanic I 1 , Zlopasa G 2 , Mrsic M 3 , Plenkovic F 1 ,
Lukic M 1 , Raos M 1 , Gojceta K 1 , Golemovic M 1 , Skific M 1 ,
Tomac G 1 , Burnac IL 1 , Novoselac J 1 , Vidovic I 1 ,
Biskup M 1 , Labar B 3 , Golubic Cepulic B 1 . 1 Department of
Transfusiology, 2 Department of Gynecology and
Obstetrics, 3 Department of Medicine, Clinical Hospital
Center and School of Medicine, Universiuty of Zagreb,
Croatia
Croatian cord blood bank (CBB) was established in
March 2007 with the aim to provide patients with transplants
according to international standards and increase
their chance in finding a match. Furthermore, our goal was
to promote cord blood (CB) donation and by educating all
croatian maternities give every mother an opportunity for
donation.
In that regard a team of doctors from CBB, maternity
hospital and national bone marrow donor registry, starting
with Zagreb and gradually spreading out throughout the
country, visited every maternity ward and educated complete
staff about donor information and selection, CB collection,
processing, storage and therapeutic use. Our CBB
collaborates with 22 maternities for which we give full logistic
support. We give them feedback through quaterly reports
of collected and discarded donations, point out problems
and if necessary reeducate the staff.
Samples and methods: CB is collected in utero, in term
deliveries with mother´s informed consent. Transport is organized
within 24 h through courier service. The unit is
checked for volume and total nucleated cell number (TNC)
and accepted if TNC is > 10x10 8 . CB is processed using

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
Sepax cell separator, ISBT code labelled and stored in Bioarchive.
Results: In a period from 2007–2011 our CBB received
2879 donations out of which 1411 (49%) were stored. The
reasons for rejection of donated units at initial control were
low TNC (97,7%), period from collection to storage exceeding
48 h (0,3%), administrative error (0,1%), twin pregnancy
(0,1%), validation study (1,6%). Additional 240 doses
were rejected at final control due to quality of CB unit
(76,7%), problems during transport or processing (14,7%),
medical information about newborn (0,8%), mother (3,3%)
or father (2,9%), or incomplete documentation (0,4%).
Among reasons for inadequate quality of CB unit, low TNC
after processing accounted for most rejections (44%), microbiological
contamination for 31,1% while no detectable
growth in clonogenic assay accounted 1,6% of cases.
For this period we had 1171 doses enter the registry of
World Marrow Donor Association (WMDA) which makes
40,6% of recieved donations. Despite numerous preliminary
search requests for our units up till now we issued only one
CB to treat a patient in Croatia.
In the past year we had a noticable drop in the percentage
of stored CB units; 39% versus average of 56,6% in first 3
years. Reason for this is increased number of donations
which allowed us to set higher initial TNC criteria. Units
that entered the WMDA registry in 2010. had mean TNC
count of 9,64±2,7 and mean CD34+ count of 5,58±3,85.
Conclusion: To increase our chances for issuing units for
transplantation we plan to continue promoting CB donation,
setting higher initial TNC criteria and working on receiving
FACT accreditation and entering Netcord.
PP58 Italian nurses group in mobilisation and
apheresis (GIIMA): ideation and activity
Babic A, Laszlo D, Galgano L, De Marchi E, Orlando L,
Martinelli G. Istituto Europeo di Oncologia, Divisione di
Ematologia, Milan, Italy
Background: The Clinical Transplantation Program consists
in a process performed by a multidisciplinary team
working with common staff training, programs, protocols,
and quality management systems. Peripheral blood stem cells
represent the most used source of hematopoietic cells and
apheresis is a routine technique applied to collect them.
The collection is generally performed by National Transfusion
Services while the mobilization and reinfusion of
stem cells is carried out by Clinical Units. For these reason,
there is difficult to assure a continuity of patient assistance,
especially from a nurse’s point of view.
Methods: We therefore created in April 2010 a dedicated
group (Gruppo Italiano Infermieristico in Mobilizzazione
ed Aferesi – GIIMA), with a committee linked to the GIT-
MO and EBMT nurses groups. The group includes medical
doctors and nurses working in National Transfusion Services
and Transplant Centers with the aim to:
1) create the stabile link between the apheresis nurses
who works in transfusion centers and those who operate
in transplant centers, following both the patients in
mobilization and apheresis.
2) create the material for nurse education in apheresis
and for patient information
3) develop the program for nurses education in apheresis
for new students based by Jacie’s regulation and coherent
with Italian low.
Results: The group translated the EBMT handbook »The
Practical Guide for Nurses and Other Health Care Professionals«
in Italian language and have distributed it to each
Italian transplant and transfusion center. Currently the GI-
IMA is distributing the DVD already available on demand
on: Giima.italy@gmail.com after been distributed, again to
all transplant and transfusion centers in Italy and Switzerland
(Italian Canton). This DVD will be an additional tool
for nurse education. It contains interactive presentation of
autoPBSC process, from mobilization, apheresis, autoPBSC
to follow-up.
The next step is to collaborate in developing the specialized
university program for apheresis nurse education to be
inserted in regional university program REL – SIDEM
Conclusions: GIIMA is a group who created a link between
two realities who performs similar protocols in parallel
ways. The aim of the group is to promote the unique
pathway in stem cell mobilization and apheresis. The next
step is to collaborate in developing the specialized university
program for apheresis nurse education hopefully to be
inserted in regional university program REL-SIDEM.
PP59 Unrelated Donor Search Experience
in the Croatian Hematopoietic Stem Cell
Transplantation Program
Grubic Z 1 , Stingl K 1 , Serventi Seiwerth R 2 , Labar B 2 ,
Zunec R 1 . 1 Tissue Typing Centre, 2 Department of
hematology, Clinical Hospital Centre Zagreb, Croatia
The donor search protocols in the unrelated hematopoietic
stem cell transplantation (HSCT) program vary between
transplantation centers due to many different factors, such
as preferences in the source of stem cells (unrelated donor
or umbilical cord unit – CBU), characteristics of the donor,
resolution of the required HLA typing etc. However, the differences
among populations arising from the HLA polymorphism
also play a role and should be considered in establishing
the donor search protocol. The aim of this study
was to address this question with respect to the Croatian
population.
In the period 2009–2010, a successful search for an unrelated
donor/CBU in the Bone Marrrow Donors Worldwide
(BMDW) was performed at our centre for 51 patients for
whom a matched donor could not be previously found
among family members. The donor was an unrelated individual
in 48 cases while for the remaining two patients CBU
was chosen as a source of HSCT, double CBU transplantation
in one case. The gender mismatched donor was chosen
for 43% of male patients, while this percentage was slightly
higher for female patients (54%). The median donor age
was 36.2 (range 21 to 57). The HLA resolution typing criteria
in our transplantation centre is high resolution typing for
HLA-A, -B, -C, -DRB1 and -DQB1 loci. However, the
115

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
10/10 matching level was not achieved for 24 patients.
Twenty-one patient received a 9/10 matched transplant,
while three had an 8/10 matched donor. The highest number
of mismatches was found at the HLA-C locus (9 patients).
However, the most interesting finding regarding the matching
at the HLA loci was observed among our patients positive
for the HLA-DRB1*11 specificity. Namely, patients
with HLA-DRB1*11:04 allele were more difficult to match
than those with HLA-DRB1*11:01 allele. This was the case
for four patients in the group of patients mismatched for one
DRB1 allele (N=6), and one patient who received an 8/10
matched transplant and in addition to a rare DRB1 allele
also had the HLA-DRB1*11:04 allele. All those patients ultimately
received a DRB1*11:01 positive transplant. The
explanation for this finding lies in the almost equal frequency
of DRB1*11:01 and DRB1*11:04 alleles in the Croatian
population as opposed to the predominance of DRB1*11:01
elsewhere. The mismatches in other cases were mainly due
to the either a rare allele or an unusual haplotype of the patient.
In conclusion, results of the study revealed some specific
characteristics of the Croatian population which should be
taken into account while performing the donor search. The
finding regarding the HLA-DRB1*11 alleles is an important
example of how the differences in allele distribution
between Croatian population and populations with potential
donors can influence the search outcome.
PP60 Following the Chimerism Status of Patients
after Hematopoietic Stem Cell
Transplantation – Ten Years Experience
Stingl K 1 , Grubic Z 1 , Serventi Seiwerth R 2 , Labar B 2 ,
Rajic Lj 3 , Vrhovac R 4 , Zunec R 1 . 1 Tissue Typing Centre,
2 Department of Medicine, 3 Clinic of pediatrics, Clinical
Hospital Centre, 4 Department of Medicine, Clinical
Hospital Merkur, Zagreb, Croatia
The analysis of the patient’s chimerism status following
the hematopoietic stem cell transplantation (HSCT) has
been accepted in the last decade as a valuable tool in the
post-HSCT treatment and prediction of the transplantation
outcome. The aim of this retrospective study was to evaluate
the current protocol used for this purpose in our centre.
In the period from 2001–2011, the peripheral blood or
bone marrow samples of 273 patients have been received
for the chimerism analysis. The protocol consisted out of
DNA isolation using the commercial kit, PCR amplification
of the chosen microsatellite loci and electrophoresis on a
6% polyacrilamide gel. Microsatellite loci tested were
HUMTH01, HUMVWFA31, HUMFES/FPS, HUMF13A01,
SE33, D1S80 and D22S683. In cases when two or less tested
loci were informative (both recipient and donor specific
alleles could be identified), additional microsatellites were
analysed (D1S549, D1S1656, D12S391, D18S535).
The number of informative loci ranged from 2 (7.3%) to
7 (2.6%) with the highest percentage of patients having 4
informative loci (32.2%). The most informative locus was
SE33 (61.1%). Additional loci had to be tested for 68 pa-
116
tients. In this period, the analysis could not be performed
only once, in a case when patient and donor were identical
twins. The number of times the patient underwent the chimerism
analysis varied, depending on the conditioning regimen,
diagnosis and the clinical status of the patient. This
number ranged from one to 25. The majority of the patients
had a full donor chimerism (FDC) status for the entire time
of the follow-up (69.2%). However, various other situations
have been encountered: patients who reached FDC after a
period of decreasing mixed chimerism (MC, 10.3%), patients
with a transient MC (5.9%), patients who had a stable
or decreasing MC (2.6%), patients with an increasing proportion
of recipient cells either after a period of FDC status
or without ever reaching FDC (5.1%), patients who, after a
FDC status, showed MC in the last performed analysis
(3.7%), and patients who never achieved engraftment with
only recipient cells detectable (4.0%). A good correlation
between the clinical status and the results of the chimerism
analysis has been observed, especially in the cases of increasing
MC.
In conclusion, the protocol for chimerism analysis established
in our centre has proven to be a reliable and useful
tool in the patient treatment after transplantation. Regular,
consecutive analyses enable the determination of the chimerism
dynamics and thus provide necessary data for timely
interventions and improvement of the transplantation outcome.
PP61 Venous access for Apheresis and
Photopheresis procedures
Babic A. Istituto Europeo di Oncologia, Divisione di
Ematologia, Milan, Italy
Background: Our Clinical Transplantation Program consists
in a process performed by a multidisciplinary team
working with common staff training, programs, protocols,
and quality management systems, according to JACIE and
ISO guidelines. Peripheral blood stem cells represent the
most used source of hematopoietic cells and apheresis is a
routinary technique applied to collect them. In our Collection
Unit we use Cobe Spectra System for apheresis procedures
and also perform photopheresis procedures with
UVA-PIT off line system for GvHD treatment.
Aims: To perform the apheresis pocedures, single or
multiple, we need the presence of good vascular access,
able to provide constant blood flow pressure of 40–90 ml/h
during the whole procedure time (3 hours approximately)
with minor complication risks, due to the procedure itself or
to a long time presence of central venous catheter.
Methods: For apheresis procedures to collect CD34+
cells or lymphocytes, where possible, usually with healthy
donors, we prefer to use the peripheral veins (cephalic or
basilical) for the procedure. On the contrary, in patients the
peripheral veins are often insufficient or severely compromised
by multiple chemotherapy cycles, therefore we need
to use central veins to perform the procedure. Frequently
our patients are provided with a Porth-a-Cath Catheter
which can be used as a return way during the procedure so
it becomes easier to find only one peripheral access rather

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Poster presentations
than two. In case of complete absence of peripheral access
we put another central venous catheter preferably in femoral
vein. On the other hand, when we perform the extracorporeal
photopheresis procedure with off line system we first
need to execute the lympho+monocytes collection by Cobe
Spectra; therefore we need two good venous access available
during the whole program of cure. There are a variety
of schedules depending on disease but usually the treatment
takes 5–6 months to be completed. The choice of the central
venous catheter to be used also depends on the psychophysical
conditions of each patients and it needs to be evaluated
carefully and on a one-to-one basis.
Results: Depending on the situation, the choice of the
catheters to be used for procedures is personalised. Venous
access, risks of infections and thrombosis are evaluated by
the apheresis team while the nurse is dedicated to perform
the procedure and to schedule catheter’s medications. Complications
due to catheters used for apheresis procedure are
usually rare , mostly those linked to thrombotic or infection
complications. (Bern MM e coll.,1990)
Conclusions: Choosing the right venous access we can
guarantee the optimum blood flow able to collect in less
time the selected cell types with low contamination of unwanted
cells, minor risks due to the platelet loose, minor
stress to the patient and major security to patient and to operator.
PP62 Pure red cell aplasia preceding a DLBCL
with 6 years
Barca G, Marin S, Nada S, Dragan C, Barbu D,
Angelescu S, Tevet M, Saguna C, Bizu I, Lupu AR,
Coltea Clinical Hospital, Hematology Clinic, Bucharest,
Romania
Background: Pure red cell aplasia (PRCA) is one of the
autoimmune diseases seen during the course of lymphomas.
However, the relation of PRCA with the underlying lymphomas
remains unclear, and cases were reported in which
PRCA occurred concomitantly, preceded, or followed the
diagnosis of lymphoma.
Aims and case description: we report the case of a 49
years-old women with pure red cell aplasia diagnosed in
2003 and confirmed by bone marrow biopsy with immunohistochemical
analysis. After 6 years of treatment with red
blood cell mass transfusion, erythropoietin and iron chelation
therapy she developed a left supraclavicular tumor. The
biopsy followed by imunohistochemical analysis showed a
diffuse large B cell lymphoma and the initial workup established
stage IIIB disease. She received 8 R-CHOP cycles of
chemotherapy, with PET/CT confirming complete remission
at the end. During chemotherapy the hemoglobin concentration
started rising, despite the grim expectations. At
the time this report was written, she does not need transfusions
any more.
Discussion and conclusions: Immunotherapy with
Rituximab and immunosuppressive medication, including
ciclofosfamide are mentioned in the literature as viable
treatments for PRCA. Both Rituximab and the immunosuppressive
effects of the CHOP regimen could be responsible
for the favorable response seen in this case. The peculiarity
of the case consists in the the occurence of lymphoma at a
considerable interval from the diagnosis of PRCA and the
prompt response of PRCA to the R-CHOP therapy for lymphoma.
PP63 Can Platelet be Unnecessary
Vieira S, Monroe D, Librojo M. London, United Kingdom
Blood transfusion continues to be an essential part of
modern practise but not without risks. During the last decade
there has been an increase interest in national level
across the United Kingdom (UK) and Europe for collecting
data on the hazards of transfusion of blood components.
Therefore avoiding unnecessary transfusion is accepted as
one way of reducing the risk which is associated with blood
transfusion. In our stem cell transplant unit we have audited
platelet transfusion (PT) frequency and reason for it.
Patients and methods: The audit was carried out prospectively.
A log in book was kept in unit for recording the
red cell transfusion orders. The data was validated with
cross check retrospectively all inpatient episodes record on
monthly basis. The audit was carried over 6 months of period
form May 2010 till end of October 2010.
Results: Unit policy is to keep platelet count above 10
with the exception of 20 if the patient is febrile. It is also
aimed to keep plt above 50 if pat is receiving anticoagulant
or bleeding for various reasons.
In six months period, total of 105 episodes platelet transfusion
occurred. Only 10% of these were routine transfusion
and they were below 10 X109/L. and 26% of plt was
given due to bleeding. However 10% of routine transfusion
was given when platelet count was higher than 31 X 109/L.
In overall 36% of the total platelet transfusion was given
when platelet count was higher than 31 x109/L. 26% of the
PT was given due to bleeding and 19% was given as unit
policy i.e. anticoagulant treatment.
Conclusion: Our organisation recognises the importance
of risk associated in unnecessary blood product transfusion.
Our 6 moths audit has shown interesting figures.
In six months period total of 105 platelet transfusion carried
out, only 36.5% of these transfusion was fitting the unit
policy. 9.5% of these were given when platelet count was
higher than 31 x109/L. There were various reason to transfuse
platelet even though count was reasonable for haematology
patient group such as bleeding and anticoagulant
use.
PP64 Transfuse or Not to Transfuse?
Vieira S, Monroe D, Librojo M. London, United Kingdom
Blood transfusion continues to be an essential part of
modern practise but not without risks. During the last decade
there has been an increase INTEREST in national
level across the United Kingdom (UK) and Europe for collecting
data on the hazards of transfusion of blood components.
Therefore avoiding unnecessary transfusion is ac-
117

Poster presentations Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
cepted as one way of reducing the risk which is associated
with blood transfusion. In our stem cell transplant unit we
have audited red cell transfusion frequency and reason for
it. Unit policy is to keep Haemoglobin level above 8gr/dl,
this may change time to time to 8.5 mg/dl depends on patient
symptoms or if post chemo.
Patients and methods: The audit was carried out prospectively.
A log in book was kept in unit for recording the
red cell transfusion orders. The data was validated with
cross check retrospectively all inpatient record on monthly
basis. The audit was carried over 6 months of period form
May 2010 till end of October 2010.
Results: During this 6 months period total of 90 episodes
RCT performed in our unit. Haemoglobin level was 8.5 gr/L
or below in 75.5% episodes, where as only 11% of the trans-
118
fusion performed when haemoglobin level was 9.1 gr/L or
above.
The reason for transfusion was categorised as routine as
unit protocol, bleeding, pre procedure and on doctor’s instruction
due to patient symptoms or keeping high trash
hold haemoglobin level. Routine RCT was 87% of total
episodes and 76% of this was 8.5 gr/L or below. However
10% of the RCT transfusion was done when haemoglobin
level is 9.1 gr/L or higher.
Conclusion: Our organisation recognises the importance
of risk associated in unnecessary blood product transfusion.
Our 6 moths audit has shown interesting figures. 10% of
total episodes RCT was given as routine were above 9.1 gr/
L where as 70% of routine RCT was performed due to low
haemoglobin level according to our unit policy.

Satellite Symposia
Satellite Symposium:
Therapy of fungal infections
in immunocompromised patients
SP01 Hematologic patients dying of IFI? Trends
in IFI epidemiology
Lubos Drgona, Slovakia
Invasive fungal infections/diseases (IFD) are life threatening
infectious complications in the population of immunocompromised
patients. Patients with acute acute leukemia
and patients undergoing hematopoietic stem cell transplantation
(HSCT) are considered as the high risk group for
development of IFD. During the last years of previous millenium
an increase of incidence of invasive aspergillosis
(IA) and decrease of invasive candida infection were observed
at hematological departments. Today, invasive candidaemia
(IC) in high-risk haematological patient is quite rare
fungal infection when compared with IA but IC is still associated
with high mortality (40–50%). Incidence of IC
started to decline after the introduction of fluconazole to
profylaxis of high risk patients during the 90-ties. But, results
from our consecutive, prospective studies documented
that the incidence of candideamia in Slovakia during the recent
5 years is increasing. The population at risk is situated
at ICUs and hematology-oncology departments and the
most common pathogen is C.albicans in 38–50% of all episodes
followed by C. parapsilosis in 26–29%. Infections
caused by non-albicans species dominated at our hematooncology
wards. The resistance of some non-albicans strains
to fluconazole and voriconazole is slightly increasing. The
local epidemiological data are important and they should
help to guide the therapy for the patients with candidaemia.
The incidence of IA is 5–15% among the patients after
allogeneic HSCT; the incidence in AML patients after induction
therapy can reach 5–10%. Autopsy surveys identifyied
the high prevalence of IA (30%) in patients with AML
or after allogeneic HSCT but only about 1/3 of them were
diagnosed before the death. Unfortunately, autopsy rate is
very low in some countries. Several factors are associated
with the increased risk for invasive fungal disease and higher
mortality. Many studies have confirmed that good performance
status, controlled malignancy, rapid neutropenia recovery,
other than allogeneic transplantation and localized
infection are factors associated with the higher probability
of successfull outcome. The ascent of novel therapies for
lymphoid malignancies (e.g. fludarabine, alemtuzumab) is
associated with the higher incidence of opportunistic infections,
including the IA. Despite the better knowledge of risk
factors, useful diagnostic tools (e.g.GM, HRCT) and appropriate
use of antifungal drugs – which are able to decrease
mortality – the overall and infection-related mortality is still
a problem. Mortality of high-risk haematological patients
with IA is still high (40–80%) but there is a trend to decrease
of mortality of IA confirmed by recently published
studies. Our data from Czech and Slovak Fungal Infection
Database (FIND) showed the overall mortality of 59% at 1
year after the diagnosis of IA. The long-term overall survival
of patients patients with IA who failed on the 1.line
therapy was only 30% according to our observation in another
survey. Genetic and prognostic risk factors are more
widely studied now to better define the high-risk population
and to improve the selection of appropriate antifungal strategy.
A better knowledge about the epidemiology and risk factors
is one of the key issues in the complex management of
haematologic patients with IFD and may help to decrease
mortality.
SP02 Invasive aspergillosis in hematological
patients – from empirical to early
pre-emptive therapy
Michael Girschikofsky, Austria
The management of invasive fungal infection (IFI) is still
a major challenge in patients with hematological malignancies
or undergoing allogeneic stem cell transplantation. The
incidence depends on the severity and duration of neutropenia,
co-morbidity and co-medication, as well as local hospital
factors like reconstruction works. Despite development
of novel agents the mortality of proven invasive aspergillosis
remains about 50%, which is mainly attributed to a delayed
onset of antifungal therapy.
Several guidelines support the decision finding for a prophylactic
use of antimycotics in this high risk population.
Nevertheless about 30% of patients develop neutropenic fever
and 72–96 hours after failure of broad spectrum antibiotics
the use of empirical antifungal therapy is considered as
standard of care. Overtreatment und drug related toxicity is
a well known problem of this approach. Targeting the time
frame between the first evidence of pathogens and manifest
clinically signs of IFI, the pre-emptive strategy which is
based on regularly screening with non-culture microbiological
techniques (aspergillus galactomannan and PCR)
and early CT-scanning may lead to a more effective use of
antimycotic therapy.
The detection of fungal associated signs in computed tomography
scan (CT) is helpful but never pathognomonic.
Thus, if clinically justifiable invasive diagnostic procedures,
like CT guided biopsy are recommended to exclude other
diseases or to determine the fungal species.
119

Satellite Symposia Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
SP03 Management of Invasive aspergillosis:
guidelines at the bedside
Ben De Pauw (The Netherlands)
The relative incidence of the various fungal infections depends
on geography as well as on local medical practices in
a given hospital. In general, the number of patients at risk of
invasive fungal infections has increased over the last decennium
with the introduction of modern immunosuppressive
and monoclonal antibodies for the treatment of both malignant
and immune-mediated diseases. The problems in the
management of invasive fungal disease hinge around three
pivotal factors: 1) Difficulty to establish the diagnosis in an
early stage of development; 2) Availability of safe, efficacious
and affordable antifungal agents; 3) Impact of the
evolvement of the underlying immune deficiency on the
outcome of the infection.
Diagnostic tools, notably serological tests and imaging
techniques have improved over the last decade but their still
doubts about their potency to detect an invasive fungal infection
in an early stage of disease, partly because the required
knowledge and facilities are only available at specialized
centers where only a minority of the patients is being
treated. As to avoid the confrontation with a stage of
infection beyond a chance of cure, strategies based on early
intervention became very popular. However, after having
randomized more than 7000 patients in clinical trials there
is still no convincing scientific evidence to support a theoretically
attractive prophylactic strategy. Using fluconazole
as prophylaxis against candidiasis in reasonably well defined
risk groups appeared effective but the story is different
for mould infections. Even the most recent trials on posaconazole
in the prevention of aspergillosis failed to provide a
definite answer. Moreover, the risk of inducing resistance of
selection of resistant stains is the price to be paid for intensive
use of antifungals as has been witnessed after the introduction
of fluconazole. Empirical treatment, i.e. institution
of systemically active antifungals for fever not responding
to adequate antibacterial therapy, was originally designed to
eliminate life-threatening candidosis but gained general recognition
as an anti-aspergillosis strategy as well. As there
are myriad causes of fever, it is inevitable that, following an
empirical strategy, many patients will receive antifungals
without actually requiring them. Improved diagnostics
might help to reduce the number of candidates for antifungals
substantially; it is expected that such an pre-emptive
strategy will become more popular.
Systemically active antifungal compounds from four different
classes of drugs are regularly used to treat invasive
fungal infections. Amphotericin B was the drug of choice
for all invasive fungal infections for more than 30 years.
Presently, fluconazole is prescribed mainly to treat new infections
by Candida species and Cryptococcus neoformans.
Recommendations on the management of aspergillosis for
high-risk patients is now confusing since posaconazole
would appear the drug of choice for prophylaxis, while voriconazole
remains the drug of choice for the treatment of
proven and probable aspergillosis leaving caspofungin and
liposomal amphotericin B the preferred drugs for empirical
120
therapy. This is the unfortunate consequence of mixing efficacy
studies that ought to be designed to explore the options
and limitations of a given drug with strategy trials.
It has become customary to issue guidelines for the management
of life-threatening diseases such as invasive fungal
infections. These guidelines are supposed to offer the clinician
easy access to the overwhelming amount of sometimes
confusing data assuming that the assorted information will
help to select the most suitable treatment for the seriously ill
patient. Moreover, patients and authorities alike demand
clear regulations to provide insight in the medical procedures
and an objective benchmark for quality control, repectively.
It is obvious that administrative people and clinician
appreciate treatment guidelines in a different way. The individual
patient occupies the central position in the vision of
the clinician, while administrators see a group of patients
with a similar disease who require a particular therapy.
Guidelines for its treatment have been published in English
by working parties from various countries and as all
committees had the same data set at their disposal, great
congruency amongst the various documents could be expected.
The differences, however, are considerable. Most
discrepancies are related to a different interpretation of the
clinical trials. Empirical trials and salvage studies, which
are rather strategic than drug-efficacy studies are of no value
at all. The value of clinical trials for this purpose is largely
overestimated, especially by unexperienced practitioners
and regulatory authories. Therefore the published guidelines
for the treatment of invasive fungal disease have to be
taken into consideration but applied in clinical practice with
prudence. They are provided for groups but there are frequently
good reasons to deviate from the recommendations
in individual cases.
Satellite Symposium:
Iron chelation therapy for MDS
SP04 The Role of Iron Chelation Therapy in MDS
Heather A. Leitch (Canada)
Most patients with MDS develop RBC transfusion dependence
and resulting iron overload (IOL) impacts negatively
on survival. 1 Mechanisms of toxicity may include
non-transferrin-bound iron (NTBI) resulting in oxidative
stress, damaging lipids, proteins, and nucleic acids, and potentially
leading to apoptosis or mutagenesis and malignant
progression, both features of MDS. Guidelines recommend
iron chelation therapy in lower-risk MDS with reasonable
life expectancy, where retrospective studies show a survival
benefit; these data will be reviewed. 2–4
Chelation is also considered for patients eligible for stem
cell transplantation (SCT), where decreased survival and
increased treatment-related mortality with IOL is seen, a
sharp increase in NTBI occurs, and lower infection risk, delayed
leukaemic transformation and improved outcome
with chelation are suggested. 5,6
While awaiting results of phase 3 trials of chelation in
MDS, treatment should be individualized and monitored ac-

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Satellite Symposia
cording to guidelines. If observations that chelation could
improve outcome in higher-risk MDS are confirmed, future
expansion in the role for iron-lowering therapy may be
seen.
R E F E R E N C E S
1. Sanz G, Nomdedeu B, Such E, Bernal T, Belkaid M, Ardanaz MT, et al.
Independent impact of iron overload and transfusion dependency on survival
and leukemic evolution in patients with myelodysplastic syndrome.
Blood 2008;112:[abstract 640].
2. Leitch HA, Leger CS, Goodman TA, Wong KK, Wong DHC, Ramadan
KM, et al. Improved survival in patients with myelodysplastic syndrome
receiving iron chelation therapy. Clin Leuk 2008;2:205–11.
3. Fox F, Kündgen A, Nachtkamp K, Strupp C, Haas R, Germing U, Gattermann
N. Matched-pair analysis of 186 MDS patients receiving iron
chelation therapy or transfusion therapy only. Blood 2009;114:[abstract
1747].
4. Rose C, Brechignac S, Vassilief D, Pascal L, Stamatoullas A, Guerci A,
et al. Does iron chelation therapy improve survival in regularly transfused
lower risk MDS patients? A multicenter study by the GFM. Leuk
Res. [Epub ahead of print 2010 Feb 1].
5. Pullarkat V, Blanchard S, Tegtmeier B, Dagis A, Patane K, Ito J, Forman
SJ. Iron overload adversely affects outcome of allogeneic hematopoietic
cell transplantation. Bone Marrow Transplant 2008;42:799–805.
6. Sorror ML, Storer BE, Schoch G, Sandmaier BM, Martin PJ, Scott BL,
et al. Low albumin, high ferritin, and thrombocytopenia before transplant
predict non-relapse mortality (NRM) independent of the hematopoietic
cell transplantation comorbidity index (HCT-CI). Blood 2009;
114:[abstract 651].
SP05 Which MDS patients are eligible for iron
chelation therapy?
Aristoteles Giagounidis (Germany)
SP06 Deferasirox in iron-overloaded patients
with transfusion-dependent MDS
de Witte T, de Swart L, Swinkels D, MacKenzie M
(The Netherlands)
Myelodysplastic syndromes (MDS) are a heterogeneous
group of clonal hematopoietic stem cell disorders. They are
characterized by abnormal differentiation and maturation of
myeloid cells, bone marrow failure and genetic instability
with an enhanced risk of progression to secondary leukaemia.
The International Prognostic Scoring System (IPSS)
for MDS is based on the percentage of marrow blasts, the
number of cytopenias and cytogenetic characteristics and
has shown to be effective in predicting outcome mainly for
MDS patients treated with supportive care 1 . A new scoring
system, the WHO Prognostic Scoring System (WPSS), is
based on the WHO classification, transfusion dependency
and cytogenetic abnormalities.
Diagnosis and treatment of iron overload and iron toxicity
is of great importance in the clinical management of
MDS patients, because iron overload is likely an important
predictor of morbidity and mortality. In a retrospective
study 2 , heart failure was the most important non-leukemic
cause of death (50%), followed by infection (31%) and liver
cirrhosis (8%). These causes can be the result of iron overload.
Iron overload in MDS is mainly caused by red blood cell
transfusions 3 . Transfused iron probably accumulates initially
in the liver before it is loaded into the heart as is described
in β-thalassemia patients 4 . In a study with transfusion-dependent
MDS patients, iron accumulation of the heart occurred
after 75–100 blood transfusions when patients did
not receive iron chelation therapy 6 .
Ineffective erythropoiesis may also play an important
role in iron accumulation in MDS patients in addition to red
blood cell transfusions associated iron overload. Similar to
β-thalassemia patients, ineffective erythropoiesis may lead
to an increased growth differentiation factor (GDF)15 level,
which subsequently lowers the hepcidin levels and results in
an increased iron absorption from the intestinal tract 7 . Until
now, only small studies have been performed in MDS patients
to evaluate the hepcidin level 8–10 , but GDF15 has
shown to be increased in RARS patients 11 . It is not clear if
ineffective erythropoiesis itself leads to significant symptomatic
iron overload. However, serum ferritin levels can be
elevated before blood transfusions are given, especially in
patients with RARS 12 , suggesting that iron overload is already
present.
Besides iron accumulation, iron toxicity probably plays
an important role in MDS. Free iron in the plasma becomes
available when the capacity of transferrin to carry iron is
exceeded. This non-transferrin-bound iron (NTBI) is even
elevated in MDS patients who did not yet receive any blood
cell transfusions and is associated with a higher level of
apoptosis 13 . In a recent study with thalassemia patients,
NTBI was correlated with transferrin saturation but not with
serum ferritin level. Patients with heart diseases had significantly
higher NTBI levels than those without heart disease,
suggesting that NTBI will be responsible for functional organ
damage 14 . The presence of NTBI will be reflected in a
rise of labile plasma iron (LPI) and reactive oxygen species
(ROS) that causes cell and tissue damage 15,16 . LPI is the
fraction of NTBI that is redox active and eliminated by iron
chelators 17 . The determination of NTBI remains difficult
and new methods are under investigation to improve the reliability
of this important iron toxicity parameter. In the near
future a more reliable assessment of NTBI in combination
with LPI will be most valuable to determine iron toxicity in
MDS patients.
Recently new oral iron chelation therapy has become
available (deferasirox), which makes iron chelation therapy
more feasible and effective despite possible side effects.
Several prospective studies have demonstrated that oral
iron chelation therapy is effective in the reduction of the
iron accumulation, but it is not yet clear which patients benefit
most of this treatment 18–21 . Iron chelation therapy will
probably reduce iron accumulation in end target organs as
well as decrease iron toxicity by reducing potentially toxic
iron 19,22 . Some studies have shown benefit of iron chelation
therapy for survival in MDS patients 23,24 .
Several guidelines for iron chelation therapy in MDS patients
have been published the last years, without clear evidence
for the optimum treatment of iron overload 25 . By
gaining more insight into the pathophysiology and toxicity
of iron overload in MDS patients, the guidelines for iron
121

Satellite Symposia Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
chelation therapy can be optimized to reduce iron related
morbidity and mortality.
An ongoing registry study organized by the MDS Working
Package of the European LeukemiaNet has collected
prospectively demographic and treatment data on more than
1,000 patients with lower risk MDS from 15 European
countries. An interim analysis presented at the most recent
EHA meeting showed that transfusions dependent patients
had a 4.1 times higher chance of dying during a short observation
period of 18 months only. This registry consortium
will continue to collect data, including data on the impact of
iron chelation on outcome.
R E F E R E N C E S
1. Greenberg P, Cox C, LeBeau MM et al. International scoring system
for evaluating prognosis in myelodysplastic syndromes. Blood 1997;89
(6):2079–2088.
2. Malcovati L, Porta MG, Pascutto C et al. Prognostic factors and life
expectancy in myelodysplastic syndromes classified according to WHO
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(30):7594–7603.
3. Porter JB. Practical management of iron overload. Br J Haematol
2001;115(2):239–252.
4. Chacko J, Pennell DJ, Tanner MA et al. Myocardial iron loading by
magnetic resonance imaging T2* in good prognostic myelodysplastic
syndrome patients on long-term blood transfusions. Br J Haematol
2007;138(5):587–593.
5. Jensen PD, Jensen FT, Christensen T, Eiskjaer H, Baandrup U, Nielsen
JL. Evaluation of myocardial iron by magnetic resonance imaging during
iron chelation therapy with deferrioxamine: indication of close relation
between myocardial iron content and chelatable iron pool. Blood
2003;101(11):4632–4639.
7. Tanno T, Bhanu NV, Oneal PA et al. High levels of GDF15 in thalassemia
suppress expression of the iron regulatory protein hepcidin. Nat
Med 2007;13(9):1096–1101.
8. Murphy PT, Mitra S, Gleeson M, Desmond R, Swinkels DW. Urinary
hepcidin excretion in patients with low grade myelodysplastic syndrome.
Br J Haematol 2009;144(3):451–452.
9. Tanno T, Bhanu NV, Oneal PA et al. High levels of GDF15 in thalassemia
suppress expression of the iron regulatory protein hepcidin. Nat
Med 2007;13(9):1096–1101.
10. Winder A, Lefkowitz R, Ghoti H et al. Urinary hepcidin excretion in
patients with myelodysplastic syndrome and myelofibrosis. Br J Haematol
2008;142(4):669–671.
11. Ramirez JM, Schaad O, Durual S et al. Growth differentiation factor 15
production is necessary for normal erythroid differentiation and is increased
in refractory anaemia with ring-sideroblasts. Br J Haematol
2009;144(2):251–262.
12. Gattermann N. Clinical consequences of iron overload in myelodysplastic
syndromes and treatment with chelators. Hematology/Oncology
Clinics 2005;19:13–17.
13. Cortelezzi A, Cattaneo C, Cristiani S et al. Non-transferrin-bound iron
in myelodysplastic syndromes: a marker of ineffective erythropoiesis?
Hematol J 2000;1(3):153–158.
14. Piga A, Longo F, Duca L et al. High nontransferrin bound iron levels and
heart disease in thalassemia major. Am J Hematol 2009;84(1):29–33.
15. Esposito BP, Breuer W, Sirankapracha P, Pootrakul P, Hershko C, Cabantchik
ZI. Labile plasma iron in iron overload: redox activity and
susceptibility to chelation. Blood 2003;102(7):2670–2677.
16. Ghoti H, Amer J, Winder A, Rachmilewitz E, Fibach E. Oxidative
stress in red blood cells, platelets and polymorphonuclear leukocytes
from patients with myelodysplastic syndrome. Eur J Haematol 2007;
79(6):463–467.
17. Pootrakul P, Breuer W, Sametband M, Sirankapracha P, Hershko C,
Cabantchik ZI. Labile plasma iron (LPI) as an indicator of chelatable
plasma redox activity in iron-overloaded beta-thalassemia/HbE patients
treated with an oral chelator. Blood 2004;104(5):1504–1510.
18. Gattermann N, Schmid M, Della PM, et al. Efficacy and safety of deferasirox
during 1 year of treatment in transfusion-dependent patients
122
with myelodysplastic syndromes: results from EPIC trial. ASH Annual
Meeting Abstracts 633. 2008. Ref Type: Abstract
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improves iron burden in patients with myelodysplastic syndromes
(MDS). ASH Annual Meeting Abstracts 634. 2008. Ref Type: Abstract
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myelodysplastic syndromes and other transfusion-dependent anaemias
to deferasirox (ICL670): a 1-yr prospective study. Eur J Haematol
2008;80(2):168–176.
21. Wood JC, Kang BP, Thompson A et al. The effect of deferasirox on
cardiac iron in thalassemia major: impact of total body iron stores.
Blood 2010;116(4):537–543.
22. Ghoti H, Amer J, Winder A, Rachmilewitz E, Fibach E. Oxidative
stress in red blood cells, platelets and polymorphonuclear leukocytes
from patients with myelodysplastic syndrome. Eur J Haematol 2007;
79(6):463–467.
23. Rose C, Brechignac S, Vassilief D et al. Does iron chelation therapy
improve survival in regularly transfused lower risk MDS patients? A
multicenter study by the GFM (Groupe Francophone des Myelodysplasies).
Leuk Res 2010;34(7):864–870.
24. Leitch HA, Leger CS, Goodman TA et al. Improved survival in patients
with myelodysplastic syndrome receiving iron chelation therapy. Clinical
Leukemia 2008;2(3):205–211.
25. Messa E, Cilloni D, Saglio G. Iron chelation therapy in myelodysplastic
syndromes. Adv Hematol 2010;2010:756289.
Satellite Symposium
The Optimal Management of CML
SP07 Nilotinib versus Imatinib for Newly
Diagnosed CML patients: ENESTnd study
results
Giuseppe Saglio (Italy)
Patients with newly diagnosed chronic phase (CP) chronic
myeloid leukemia (CML) have a high probability of longterm
survival, which is mainly due to the efficacy of imatinib,
the first targeted inhibitor of the oncogenic BCR-
ABL1 kinase to be registered. In a recent report from IRIS
study, patients in the imatinib arm had a 8-year rate of overall
survival (OS) of 85% and freedom from progression to
accelerated- (AP) or blast-phase (BP) disease of 93%. Cumulative
rates of complete cytogenetic response (CCyR)
were 69% at 1 year, 87% at 5 years, and 89% at 8 years.
These data highlight that for at least one-third of patients,
the potential exists to improve on what can be achieved with
standard imatinib 400 mg/d treatment. After imatinib failure,
current treatment recommendations include dose escalation
to 600–800 mg/d, or switch to an approved next-generation
tyrosine kinase inhibitor (TKI. Although stem cell
transplant (SCT) remains an important and potentially curative
option, favorable response rates and tolerability achieved
with TKIs have resulted in SCT being increasingly reserved
for patients who have failed on TKIs and for those who have
progressed to advanced phases. The results from ENESTnd
trial testing nilotinib at two different dosages, 300mg BID
and 400 BID, clearly indicate a superior efficacy of the more
potent second-generation TKI nilotinib with respect to imatinib,
particularly in terms of higher rates of major molecular
responses (MMR), of complete cytogenetic responses
(CCyR) that, more importantly, lead to a decreased number
of progressions to more advances phases of the disease.

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Satellite Symposia
These results will probably modify imatinib-based strategies
in the first-line therapy of CML and are becoming a key
area of clinical research during the next few years.
REFERENCES
1. Saglio G, Kim DW, Issaragrisil S, et al. Nilotinib versus Imatinib for
Newly Diagnosed Chronic Myeloid Leukemia. N Engl J Med 2010;362:
2251–2259.
2. Kantarjian H, Shah NP, Hochhaus A, et al. Dasatinib versus Imatinib in
Newly Diagnosed Chronic-Phase Chronic Myeloid Leukemia. N Engl J
Med 2010;362:2260–2270.
SP08 Optimal treatment for newly diagnosed
CML patients
Francis Giles (Ireland)
Nilotinib (Tasigna ® ) is a much more potent and selective
BCR-ABL inhibitor than imatinib and was designed to
overcome imatinib’s deficiencies. Nilotinib has very significant
efficacy in patients with CML in chronic (CP) and
accelerated (AP) following imatinib failure. Based on the
results of the Evaluating Nilotinib Efficacy and Safety in
Clinical Trials-Newly Diagnosed Patients (ENESTnd) study,
the Food and Drug Administration (FDA) on June 17 th 2010
granted approval of nilotinib for the treatment of adult patients
with newly diagnosed Philadelphia-chromosome positive
CML in CP. Imatinib changed our perceptions of the
therapeutic power of targeted inhibition of a pathologically
active kinase. Nilotinib, a designer agent built on the imatinib
scaffold, has proven superior to its template agent by
every significant surrogate marker used in monitoring CML.
The largest CML-related threat to life on imatinib therapy is
development of AP/BP within the first 3 years of imatinib
therapy. In terms of both the clinically relevant surrogate
markers, CCyR and MMR, and of the clinically vital endpoints
of early transformation events and overall survival,
nilotinib has proved superior to imatinib as first line therapy
in CML. Nilotinib has a low incidence of grade 3/4 extramedullary
adverse events, predominantly transient biochemical
abnormalities, which tend to occur early in therapy.
Nilotinib in the frontline setting is associated with less
myelosuppression than imatinib. The ENEST1st study, a
pan-European study, will further examine the efficacy of nilotinib
300mg BID in newly diagnosed patients with CML
using CMR as the primary study endpoint. The ENEST1st
study has a range of integral international collaborative biology
studies which include a focus on CML stem cells,
indices of genomic instability, very sensitive mutated bcrabl
phenotype clone detection and quantitation, and genomic
analyses. Nilotinib PK and patient adherence to therapy
will also be focused on in this study.
R E F E R E N C E S
1. Hochhaus A, Saglio G, le Coutre PD, et al. Superior efficacy of nilotinib
compared with imatinib in newly-diagnosed patients with chronic myeloid
leukemia in chronic phase (CML-CP): ENESTnd minimum 24month
follow-up. Paper presented at: 16th Annual Congress of the European
Hematology Association; June 9–12, 2011; London, UK.
2. Saglio G, Hochhaus A, Guilhot F, et al. Nilotinib is associated with
fewer treatment failures and suboptimal responses vs imatinib in pa-
tients with newly diagnosed chronic myeloid leukemia in chronic phase
(CML-CP): results from ENESTnd. Paper presented at: 16th Annual
Congress of the European Hematology Association; June 9–12, 2011;
London, UK.
3. Weisberg E, Manley PW, Cowan-Jacob SW, Hochhaus A, Griffin JD.
Second generation inhibitors of BCR-ABL for the treatment of imatinib-resistant
chronic myeloid leukaemia. Nat Rev Cancer. 2007;7(5):
345–356.
4. Hughes TP, Hochhaus A, Saglio G, et al; for the ENESTnd investigators.
ENESTnd 24-month update: continued superiority of nilotinib versus
imatinib in patients with newly diagnosed chronic myeloid leukemia
in chronic phase (CML-CP). Slides presented at: 52nd Annual Meeting
of the American Society of Hematology; December 4–7, 2010; Orlando,
FL. Abstract 207.
5. Saglio G, Kim D-W, Issaragrisil S, et al; for the ENESTnd investigators.
Nilotinib versus imatinib for newly diagnosed chronic myeloid leukemia.
N Engl J Med. 2010;362(24):2251–2259
6. Pinilla-Ibarz J, Cortes J, Mauro MJ. Intolerance to tyrosine kinase inhibitors
in chronic myeloid leukemia: definitions and clinical implications.
Cancer. 2011;117(4):688–697.
7. Kantarjian HM, Giles FJ, Bhalla KN, et al. Nilotinib is effective in patients
with chronic myeloid leukemia in chronic phase following imatinib
resistance or intolerance: 24-month follow-up results. Blood. 2010;
117(4):1141–1145.
SP09 The importance of molecular monitoring
in CML patients
Martin M. Mueller (Germany)
Topic: The importance of molecular monitoring in CML
patients
Abstract: Molecular characterization of diseases has
been implemented in routine work-up of hematologic patients
in many countries. Molecular monitoring of CML patients
represents one of the most advanced fields applying
qualitative and quantitative RT-PCR using peripheral blood
samples. Besides mentioning the advantages and disadvantages
of the techniques, the differences compared to cytogenetic
assessment as the current gold-standard will be highlighted.
Quantification of BCR-ABL mRNA transcripts
represents the most sensitive tool of monitoring CML patients
allowing to predict for future response at early timepoints
and to find suboptimal treatment outcomes triggering
mutation analysis. Further, current European efforts of harmonizing
laboratories for BCR-ABL quantification will be
discussed.
Satellite Symposium:
Optimal Management of PNH
SP10 PNH – Morbidities & Mortality
Boris Labar (Croatia)
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare,
chronic, life-threatening disorder caused by the somatic
mutation of the PIG A gene in hematopoetic stem cells (1).
Because of this mutation PNH cells are missing glycosilphosphatidylinositol
(GPI) So GPI anchored proteins are
not bind and present on the cell surface. For PNH it is important
that CD59 (1)(forms a defensive shield for erythrocytes
from complement-mediated lysis) and CD55 (2) (pre-
123

Satellite Symposia Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
vents formation and augments the instability of the C3 convertases,
attenuating the complement cascades) are not
present at the surface of red cells. Such cells underwent hemolysis
because of uncontrolled complement activation (3).
As a consequence of chronic hemolysis, progressive morbidities
could develop such as thrombotic events (TEs),
chronic kidney disease (CKD), and pulmonary hypertension.
These and other PNH-associated symptoms (ie, abdominal
pain, dyspnea, dysphagia, fatigue, hemoglobinuria,
and erectile dysfunction) have a significant effect on patient
quality of life (QoL). The 5-year mortality rate for patients
with PNH is ∼35%,(4) and the leading cause of death is
TE.(5) As many as 29% to 44% of patients with PNH suffer
from at least one TE during their disease,(6) and TE may
occur regardless of transfusion history. Many patients with
PNH have impaired renal function, with up to 64% having
CKD; renal failure is a common (8% to 18%) cause of death
among patients with PNH.(7, 8) Nearly 50% of patients
have some evidence of pulmonary hypertension.(9) Although
not life-threatening, fatigue and pain are common in
patients with PNH and can substantially impair QoL.
Historically, PNH has been managed with transfusions,
red blood cell supplements, anticoagulants, and steroids,(5,
10) none of which have reduced the risks of disease progression
or severe morbidity. Hematopoeitic stem cell transplant
is associated with a high risk of morbidity and mortality;
thus, for most patients, the associated risks preclude this option.
As such, recent studies in PNH have focused on inhibiting
the complement system to reduce the chronic hemolysis
underlying the progressive morbidities and mortality.
Treatment with eculizumab, a fully humanized monoclonal
antibody that inhibits terminal complement activity, can
normalize the survival of patients with PNH(11).
R E F E R E N C E S
1. Johnson JR et al. J Clin Pathol Mol Pathol. 2002;55:145–52
2. Brodsky RA. In Hematology, Basic Principles and Practices, 4th ed. R
Hoffman, EJ et al. Eds Philadelphia, Elsevier Churchil Livingstone,
2005, pp 419–27.
3. Rother RP et al. Nat Biotechnol. 2007;25:1256–1264.
4. Hillmen P et al. N Engl J Med. 1995;25:1253–1258
5. Parker C et al. Blood. 2005;106:3699–3709
6. Hillmen P et al. Blood. 2007;110:4123–4128.
7. Hillmen P et al. Am J Hematol. 2010;85:553–559.
8. Nishimura J et al. Medicine (Baltimore). 2004;83:193–207.
9. Hill A. et al. Br J Haematol. 2007;137:181–192
10. Rachidi S et al. Eur J Intern Med. 2010;21:260–267.
11. Kelly RJ et al. Blood. 2011;117:6786–6792
SP11 Shifting the Paradigm in PNH Management
Peter Hillmen (United Kingdom)
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare,
acquired, chronic and life-threatening hematopoietic stem
cell disorder characterized by chronic uncontrolled activation
of the complement system. 1–3
The primary clinical manifestation of PNH is chronic hemolysis,
which is associated with severe morbidities, including
thromboembolism (TE), chronic kidney disease
(CKD), anemia, and fatigue. 4 For patients with PNH, treatment
with eculizumab, a fully humanized monoclonal anti-
124
body that inhibits terminal complement activity, has represented
a major paradigm shift.
The clinical program of eculizumab in patients with PNH
consists of 195 patients in total, and 4 trials [Pilot study
(N=11), TRIUMPH (phase III, placebo-controlled trial)
(N=87), SHEPHERD (broader patient population) (N=97)]
and a subsequent long-term extension trial evaluating longterm
efficacy and safety. 5 In the long-term trial, following
eculizumab treatment, the reduction in lactate dehydrogenase
(LDH) was sustained after 36 months follow-up (P <
.0001), TE events were significantly reduced from 52 pretreatment
to 10 trial events by matched time analysis (P <
.0005), and CKD stage (stages 1–5) was reduced from 69%
of patients at baseline to 31% at 36 months. 5 Hemoglobin
increased significantly and was sustained over 36 months
(mean increase over baseline 9.5 g/L; range, –31 to 68; P <
.0001). Among patients receiving ≥ 36 months of eculizumab
(n=87), 29% became transfusion independent and remained
so throughout treatment. Eculizumab was well tolerated;
most adverse events (AEs) were mild-to-moderate.
Of the 10% of patients who discontinued (n=20), 9 were the
result of an AE. In 16-weeks of follow-up, 3 of the 20 discontinuing
patients had TE, including 1 death. Two cases of
meningococcal sepsis were successfully treated without sequelae.
Four patients died during study; 3 were considered
unrelated and 1 possibly related to eculizumab. Per Kaplan
Meier estimation, overall survival was 97.6% at 3 years and
maintained through 5.5 years of treatment; this compares
favorably to a survival rate previously reported in historical
controls (65% at 5 years).
In another analysis of survival (N=79), the efficacy of
eculizumab was sustained over 8 years of therapy and was
not different to that in an age-, sex-matched normal control
population 6 .
In conclusion, eculizumab significantly reduces chronic
hemolysis and TE, improves CKD and PNH-associated
symptoms, and improves probability of survival. These effects
are sustained during long-term treatment. Thus, eculizumab
inhibition of terminal complement activity is an effective
treatment approach for patients with PNH.
Alexion Pharmaceuticals, Inc: Consultancy, Honoraria,
Membership on an entity’s Board of Directors or advisory
committees, Research Funding.
R E F E R E N C E S
1. Brodsky R, Schrezenmeier H, Muus P et al. Blood [ASH]. 2009;114:
Abstract 3007.
2. Brodsky RA. Blood. 2009;113(26):6522–6527.
3. Hillmen P, Elebute M, Kelly R et al. Am J Hematol. 2010;85(8):553–
559.
4. Parker C, Omine M, Richards S et al. Blood. 2005;106(12):3699–3709.
5. Hillmen P, Risitano A, Schrezenmeier H et al. Haematologica [EHA]
2011;96(s2):105. Abstract 0254.
6. Kelly RJ, Hill A, Arnold LM et al. Blood. 2011;117(25):6786–6792.
SP12 Acute renal failure and PNH – Case report
Jaroslav Cermak (Czech Republic)
Diagnosis and management of patients with PNH can be
challenging. This case-based presentation provides a real-

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Satellite Symposia
world context for PNH treatment and clinical trial data and
provides a forum for discussion of their application to evidence-based
medicine in day-to-day practice.
Patients with PNH often experience increased rates of infection,
fatigue, insomnia, pain in the joints and abdomen,
dyspnea, and dysuria, each of which can undermine quality
of life and can also lead to an increased risk of thrombotic
events and mortality. 1,2 In patients who present with these
symptoms, a differential diagnosis based on histologic and
flow cytometry analyses is essential. 3 With only supportive
care, PNH is invariably progressive. 4 In later stages, renal
failure, infections, and cardiopulmonary and hematologic
complications can become life-limiting. 1,3
Historical therapies for PNH have included supportive
care with red blood cell transfusions and iron chelation as
needed, steroids, antithrombotic prophylaxis, and dialysis. 1,4
However, the introduction of eculizumab, a terminal complement
inhibitor, has provided an option to treat the underlying
disease rather than palliating disease symptoms and
end-organ damage. 4,5 Nonetheless, several questions remain:
What is the role for stem cell transplant? Will antithrombosis
prophylaxis be needed during eculizumab treatment?
What is the role of eculizumab in patients with aplastic
anemia/PNH syndrome and other PNH-related conditions?
Generation of an international PHN registry may
provide insight into these questions.
R E F E R E N C E S
1. Parker et al. Blood. 2005;106:3699–3709.
2. Lee et al. Haematologica. 2010;95: Abstracts 505 and 506.
2. Borowitz et al. Cytometry B Clin Cytom. 2010;78:211–230.
3. Rachidi et al. Eur J Intern Med. 2010;21:260–267.
4. Hill A et al. Haematologica. 2010;95:567–573.
SP13 Treatment of Paroxismal nocturnal
hemoglobinuria – a case report
Ana Boban (Croatia)
Paroxismal nocturnal hemoglobinuria (PNH) is clonal
acquired disorder characterized by hemolytic anemia, thrombosis,
fatigue and bone marrow failure. It is caused by acquired
mutation of PIG-A gene in mutipotent hematopoietic
stem cell. As a consequence, cells are lacking glycosil phos-
phatidylinosiol (GPI) – anchored proteins, namely CD55
and CG 59, which are complement regulatory proteins. The
lack of complement regulatory proteins makes erythrocytes
susceptible to both intravascular and extravascular hemolysis.
Intravascular hemolysis is responsible for majority of
morbidity form the disease. Eculizumab is a monoclonal
antibody that inhibits terminal complement activation,
which reduces intravascular hemolysis in PNH patients.
Here we present the first PNH patient in our Center treated
with eculizumab.
The patient was diagnosed having aplastic anemia in
2009, at the age of 21. The treatment started with corticosteroids,
and later altered into cyclosporine. In 2005 the patient
presented with severe headache and transitory ischemic attack.
At that point PNH was suspected, and diagnostic procedure
was carried out. Diagnose of PNH was made based
on PNH clone on flow cytometry. In 2007, the progression
of intravascular hemolysis was noted, with significant increase
in bilirubin and lactate dehidrogenase levels, followed
by the signs of bone marrow failure. The need for
blood transfusions and fatigue increased, while quality of
life decreased. Allogenic stem cell transplantation was indicated,
but no related donor was found. The patient was eligible
for eculizumab treatment.
The treatment with eculizumab started in January 2010.
Patient was vaccinated for Naisseria meningitides, and developed
severe cellulitis with skin necrosis on the place of
the puncture, hence the reconstructive surgery of the left upper
arm was needed. At the time when eculizumab was
started, patient had severe hemolysis, thrombocytopenia,
and anemia with need of blood transfusions every 2–3 weeks
and secondary hemochromatosis. Subjectively, she complained
mostly on severe fatigue. The patient received induction
treatment without side effects and continued with
maintenance treatment for 19 months. A significant decrease
of hemolysis was noted, and consequently reduced
need for transfusions and disappearance of symptoms,
mainly fatigue with dramatic improvement in her quality of
life.
Eculizumab treatment significantly improved quality of
life of the PNH patient. Patient’s main symptom, fatigue,
disappeared almost completely, and rate of blood transfusion
was reduced to once in 5–6 weeks. We found eculizumab
effective in treatment of PNH patients.
125

Author Index
Abdel-Wahab, O., 23
Ajdukovic, R., 88, 91, 98
Aleksic, A., 98
Amadori, S., 17, 22
Andjelic, B., 105
Andreola, G., 106
Angelescu, S., 117
Anicic, M., 108
Antic, D., 102, 105, 109
Antica, M., 87
Arcasoy, M., 101
Armitage, JO., 97
Auon, P., 97
Aurer, I., 65, 79, 92, 99, 100, 105,
111, 112
Avila, DN., 94
Ayari, S., 93
Babic, A., 106, 113, 115, 116
Babok-Flegaric, R., 91
Baird, K., 94
Banfic, H., 87
Baráth, S., 88
Barbu, D., 117
Barca, G., 117
Barez, MY, 112
Barisic, N., 96
Barlogie, B., 48
Barrett, J., 56
Barsic, B., 103
Basic-Kinda, S., 92, 99, 100, 104,
105, 111, 112
Bast, M., 97
Batar, P., 110
Batinic, D., 87, 90, 96, 104, 105, 107
Batinic, J., 90, 105
Begovic, D., 90
Bijedic, V., 81
Bila, J., 105
Bilic, E., 96, 103, 108, 110
Bishop, M. R., 60
Biskup, M., 114
Bizu, I., 117
Bladé, J., 47
Blaise, D., 23
Blin, N., 93
Boban, A., 104, 125
Bodrozic, J., 105
Bogdanovic, A., 109
Bojanic, I., 95, 96, 105, 113, 114
Bolaños Meade, J., 94
Borbenyi, Z., 81, 88, 107
Borckhardt, A., 19
Bosnic, D., 112
Brissot, E., 93
Burnac, IL., 114
Burnett, A., 21
Carde, P., 63
Carzavec, D., 91
Catalano, J., 101
Cermak, J., 124
Cevreska, L., 81, 99, 102
Chan, WC., 97
Chevallier, P., 93
Cigrovski, N., 99
Cikota, B., 98
Clavert, A., 93
Coha, B., 91
Cojbasic, I., 91, 99
Colovic, N., 89, 108, 109
Corovic-Arneri, E., 91
Cortes, J., 3, 36
Cowen, EW., 94
Crkvenac Gornik, K., 114
Crncec, I., 88
Crowley, J., 48
Dávid, M., 88, 107
Davidovic, S., 89, 90, 91, 92,
93, 114
Deininger, M., 101
Dekanic, A., 101
Delaunay, J., 93
De Marchi, E., 115
De Pauw, B., 120
de Swart, L., 121
de Witte, T., 17, 26, 76, 121
Dimovski, A., 102
DiPersio, J., 101
Djunic, I., 89, 102, 108, 109
Djurasinovic, V., 89, 108, 109
Dotlic, S., 112
Dragan, C., 117
Drera, M., 106
Drgona, L., 119
Dubravcic, K., 96, 104
Dubruille, V., 93
Dujmovic, D., 99, 111
Dukovski, D., 99, 102
Duletic Nacinovic, A., 91, 101
Durakovic, N., 94, 95, 105,
114
Dusek, D., 96, 103
Elezovic, I., 102, 105, 109
Engert, A., 65
Erickson-Viitanen, S., 101
Faderl, S., 3, 49
Fayad, L., 63
Femenic, R., 96, 103, 108, 110
Fernandez, S., 112
Ferrajoli, A., 53
Fowler, N., 61
Frani} Simic, I., 92
Freireich, E., 17
Fruchtman, S., 35
Fu, K., 97
Fuchs, EJ., 94
Gale, R. P., 47
Galgano, L., 115
Garcia-Manero, G., 28
Gasparovic, V., 112
Gastinne, T., 93
Geisler, C., 62
Giagounidis, A., 121
Giebel, S., 52
Giles, F., 123
Girinsky, T., 64
Girschikofsky, M., 119
Gjadrov, K., 90
Gojceta, K., 114
Golemovic, M., 96, 113, 114
Golubic Cepulic, B., 96, 105, 113,
114
Gotic, M., 105
Gotlib, J., 101
Govedarovic, N., 91, 99
Grahovac, B., 101
Gratwohl, A., 54
Grcevi}, D., 104
Greiner, T., 97
Gress, RE., 94
Grkovic, L., 94
Grohovac, D., 101
Grubic, Z., 93, 95, 115, 116
Guillaume, T., 93
Gupta, V., 101
Gveric-Krecak, V., 91
Gyimesi, E., 88
Hadji-Pecova, L., 111
Hadzisejdic, I., 101
Haferlach, T., 20
Haïat, S., 50
127

Author Index Lije~ Vjesn 2011; godi{te 133; (Supl. 4)
Halkes, S., 17
Haris, V., 88
Harousseau, JL., 93
Harvey, J., 101
Hehlmann, R., 35
Heuck, C. J., 46
Hevessy, Zs., 88
Hexner, E., 101
Hillmen, P., 54, 124
Hoelzer, D., 48
Hoffman, R., 35
Horowitz, M. M., 55
Horvat, I., 92
Host, I., 101
Hotic-Lazarevic, S., 112
Hude, I., 111
Humar, I., 113, 114
Hutchings, M., 65
Ilic, I., 99, 111, 112, 114
Indrak, K., 81
Iqbal, J., 97
Ivanovski, M., 102
Ivcevic, S., 104
Jabbour, E., 3, 28, 36, 46
Jaksic, B., 78, 90
Jaksic, O., 88, 90, 98
Jansen, J., 21
Jones, RJ., 94
Jonjic, N., 101
Kantarjian, H., 3, 23, 28, 36,
101
Kappelmayer, J., 88
Kardum, I., 90
Keating, M., 18
Kezic, Lj., 112
Khouri, I., 54
Kis, E., 107
Knopinska-Posluszny, W.,
81
Kolb, H.-J., 19
Konja, J., 96, 103, 108
Konjevoda, P., 103
Koumenis, I., 101
Kovacic, N., 104
Kowalski, J., 94
Kraguljac, N., 105, 109
Kraguljac-Kurtovic, N., 89
Krajcsi, P., 107
Krmek-Zupanic, D., 91
Krnic, N., 96
Kröger, N., 34
Kusec, R., 88, 90, 98, 104
Kutlesa, M., 103
Labar, B., 17, 72, 75, 81, 87, 89, 90,
91, 92, 93, 95, 96, 99, 100, 104,
105, 107, 111, 114, 115, 116, 123
128
Lalic, H., 87
Lapus, F., 112
Lasan-Trcic, R., 90, 91, 92, 110
Laszlo, D., 106, 115
Lazic-Prodan, V., 91
Le Gouill, S., 93
Legrand, O., 50
Leitch, H. A., 120
Levine, R. L., 23
Levy, R., 101
Librojo, M., 97, 106, 117
Livun, A., 88
Lozic, D., 91
Lucijanic, M., 98
Lukic, M., 96, 114
Lukinovic-Skudar, V., 87
Lupu, AR., 117
Luznik, L., 58, 94
Lyons, R., 101
MacKenzie, M., 121
Macukanovic-Golubovic, L., 91, 99
Magic, Z., 98
Mahe, B., 93
Malard, F., 93
Malcovati, L., 24
Malinovic, J., 112
Mandac-Rogulj, I., 91
Mandic, D., 112
Marie, J.-P., 17, 50
Marin, D., 36
Marin, S., 117
Marjanovic, G., 91, 99
Márki-Zay, J., 88, 107
Markovic, D., 91, 99
Markovic-Glamocak, M., 110
Martinelli, G., 106, 115
Marusic Vrsalovic, M., 88
Masarova, K., 106
Matevska, N., 102
Matulic, M., 87
Mazic, S., 96, 105, 113, 114
Meloni, G., 17
Mesa, R., 101
Mihaljevic, B., 105
Mihaylov, G., 81
Mikulic, M., 90, 93, 95, 96, 114
Milanovic, N., 98
Miljkovic, E., 91, 99
Miller, C., 101
Milpied, N., 93
Mistrik, M., 71, 81, 106
Mitchell, A., 48
Mitchell, SA., 94
Mitrovic, M., 102, 109
Mitrovic, Z., 97, 100
Mohty, M., 52, 55, 93
Moicean, A., 81
Monroe, D., 97, 106, 117
Moreau, P., 93
Mrdja, J., 112
Mrsic, M., 93, 95, 114
Mueller, M. M., 123
Musani, V., 88
Muus, P., 17, 76
Nada, S., 117
Nagy, É., 88
Nagy, G., 88
Najfeld, V., 35
Negri, M., 106
Nemet, D., 79, 90, 92, 99, 105,
111
Niederwieser, D., 55
Nikolic, V., 91, 99
Novkovic, A., 89, 108, 109
Novoselac, J., 114
O’Brien, S., 3, 53
Orlando, L., 115
Ottman, O., 51
Ozretic, D., 96
Panovska, I., 111
Panovska-Stavridis, I., 99, 102
Paquette, R., 101
Paradzik, M., 87
Pavletic, SZ., 59, 94
Pavlovic, M., 91
Pavlovic, Maja 96, 110
Pejsa, V., 88, 90, 91, 98
Peric, Z., 91, 93, 104
Perkovic, S., 96, 107, 110
Perunicic Jovanovic, M., 102
Petersen, F. B., 57
Petranovic, D., 101
Petrides, P. E., 32, 72
Petrusevska, G., 99, 111
Pirsic, M., 98
Pivkova Veljanovska, A., 102
Plenkovic, F., 96, 114
Prka, Z., 98
Pulanic, D., 94
Radic Antolic, M., 89, 92, 93, 110
Radman, I., 92, 99, 100, 105, 111
Rajic, Lj., 96, 103, 108, 110, 116
Raos, M., 96, 114
Ravandi, F., 3, 22
Raza, A., 101
Ries, S., 89, 90
Romic, I., 91
Roncevic, P., 92
Rosti, G., 46
Saglio, G., 122
Saguna, C., 117
Sandor, V., 101
Santek, F., 99, 111
Santini, M., 103

Lije~ Vjesn 2011; godi{te 133; (Supl. 4) Author Index
Sanz, M. A., 22
Scalise, A., 35
Schmetzer, H., 19
Sefer, D., 105
Seili, I., 101
Selleslag D, D., 17
Sertic, D., 90, 91, 92, 93, 99,
105, 111
Serventi Seiwerth, R., 90, 93, 94, 95,
96, 104, 114, 115, 116
Shaughnessy, J. D., Jr, 48
Shih, A., 23
Silver, R. T., 33, 35, 101
Silverman, L., 35
Simonovic, O., 91
Sincic-Petricevic, J., 91
Sipka, S., 88
Skific, M., 113, 114
Skunca, Z., 91
Slipac, J., 103
Smith, LM., 97
Sphilberg, O., 61
Sretenovic, A., 109
Steensma, D., 24
Stefanikova, Z., 106
Steinberg, SM., 94
Stemberger, L., 103
Stern-Padovan, R., 99, 111
Stingl, K., 95, 115, 116
Stojanovic, A., 99, 111
Stojanovski, Z., 111
Stojcic, B., 112
Stojsavljevic, S., 103
Stoos Veic, T., 88
Suciu, S., 17, 60
Sun, W., 101
Sureda, A., 66
Suvajdzic, N., 102, 109
Suvajdzic-Vukovic, N., 89, 108
Suvic-Krizanic, V., 91
Swinkels, D., 121
Szabó, P., 88
Sziráki Kiss, V., 88
Talpaz, M., 101
Tarabar, O., 98
Tauber Jakab, K., 88, 107
Taylor, TN., 94
Telek, B., 110
Tesovic, G., 96
Tevet, M., 117
Thomas, D., 52, 76
Tijanic, I., 91, 99
Todorovic, M., 105
Tõkés-Füzesi, M., 88
Tomac, G., 114
Tomin, D., 81, 89, 102, 105, 108,
109
Trajkova, S., 99, 102
Tripodi, J., 35
Trneny, M., 62
Trucza, É., 88
Tukic, Lj., 98
Udvardy, M., 88, 107, 110
Vaddi, K., 101
Valkovic, T., 101
Van Etten, R. A., 31
Vekhoff, A., 50
Verstovsek, S., 31, 79, 101
Vidovic, A., 89, 108, 109
Vidovic, I., 114
Vieira, S., 97, 106, 117
Vignetti, M., 17
Vince, A., 103
Virijevic, M., 89, 108, 109
Visnjic, D., 87
Vodanovic, M., 100
Vose, JM., 97
Vrhovac, R., 103, 116
Vucic, M., 91, 99
Vukicevic, T., 91
Weisenburger, DD., 97
Wierda, W., 53
Wierzbovska, A., 81
Wijermans, P., 25
Willemze, R., 17
Williams, KM., 94
Winton, E., 101
Wroblewski, SG., 94
Younes, A., 62, 69
Zadro, R., 89, 90, 91, 92, 93, 96,
107, 110
Zahurak, M., 94
Zelic, A., 104
Zinzani, P. L., 62
Zlopasa, G., 114
Zunec, R., 115, 116
129