Abstract 4276
Imatinib mesylate (IM) has shown unprecedented effectiveness in the treatment of Chronic Myeloid Leukemia (CML) patients (pts) in the chronic phase of the disease. As most of the data ...concerning the efficacy of the drug derive either from a single sponsored trial or from single institution reports, we decided to accrue all CML pts diagnosed in the Italian region of Sicily to the observational SCREEN (Siciliy CML Regional Enterprise) study, to evaluate the hematological, cytogenetic and molecular responses of this unselected population to IM.
Although the study is still ongoing, 173 consecutive CML pts have been enrolled between January 2005 and June 2009 (cutoff time for the first interim analysis) by one of the 12 institutions involved. Each center was responsible for the diagnosis, treatment (IM 400 mg qd) and follow-up of the pts accrued, while all molecular analyses were centralized in Catania. Median follow-up time was 31 months. Eleven pts (6.3%) are currently off study.
Pts characteristics were as follows: 95 males (54.9%) and 78 females (45.1%) were enrolled with a median age of 53 years (range 24-90). Eighty-nine pts (51.4%) were low Sokal risk, 62 (35.8%) were intermediate risk and 22 (12.8%) were high risk. Nine pts (5.2%) displayed additional chromosomal abnormalities. Median leukocyte counts (1×109L) were 67.6 (range 3.4-718), median hemoglobin (g/L) was 122 (range 75-170) while median platelet counts (1×109L) were 317 (range 67-2620). Cumulative incidences of complete hematologic response (CHR) and complete cytogenetic response (CCyR) were 98.3% and 85% respectively, while 59.2% of pts obtained a major molecular response (MMR). At 54 months, estimated overall survival was 95.6%. Estimated progression free survival (accounting for all pts that failed IM according to the European Leukemia Net criteria) was 75.1%. Thirty pts (17.3%) presented resistance to IM, either because of failure to obtain a satisfactory response (primary resistance, 21 pts) or because of loss of previously obtained responses (secondary resistance, 9 pts). Thirty-three pts (19%) presented a suboptimal response, 8 because of failure to achieve a CCyR by 12 months of therapy and the remaining 25 because of lack of a MMR after 18 months of IM. Only 3 pts (1.7%) were intolerant to IM. Interestingly, the median amount of BCR-ABL transcript at diagnosis (measured according to the International standardized Scale) displayed by pts that failed IM or achieved a suboptimal response (106.5IS) was significantly higher than that of pts obtaining an optimal response (61.9 IS p=0.0031).
IM is a highly effective and well-tolerated treatment for most chronic phase CML pts, producing high rates of CHR and CCyR. Approximately 60% of cases will also achieve a MMR. 35-40% of pts will either fail IM or obtain only partially satisfying results (suboptimal response). High levels of BCR-ABL transcript at diagnosis might allow a rapid identification of this less responsive pt population.
No relevant conflicts of interest to declare.
Abstract 2471
Eighty-one previously untreated CLL patients, ≤60 years, with advanced/progressive disease were included in the GIMEMA LLC0405 prospective multicenter study. Patients were ...stratified according to the biologic features. High risk (HR) patients were defined by the presence of: 1) 17p- (≥20% of analyzed cells), or 2) 11q- with ≥1 additional unfavorable factor (IGHV germline; Zap-70+ ≥10%; CD38+ ≥7%), or 3) germline IGHV or mutated VH3-21 and ≥2 unfavorable factors (Zap-70; CD38; 6q-; trisomy 12). Low risk (LR) patients were defined by the absence of the above features. HR patients received 4 monthly courses of fludarabine and campath-1H (FluCam; Flu 30 mg/m2 iv; Cam 30 mg iv, days 1–3). Responding patients underwent post-induction therapy: reduced intensity PBSC allogeneic transplant or, in the absence of a sibling donor, an autologous PBSC transplant or, in the absence of a sufficient harvest, Cam sc, 30 mg weekly for a maximum of 12 weeks. For LR patients, treatment included 6 monthly courses of fludarabine and cyclophosphamide (FC; fludarabine 30 mg/m2 iv and cyclophosphamide 250 mg/m2, days 1–3). All patients received bactrim prophylaxis. FluCam-treated patients underwent weekly CMV antigenemia monitoring and valacyclovir prophylaxis (2g/8h). In the presence of severe granulocytopenia, G-CSF was recommended and darbepoietin given in case of anemia (Hb <11g/dl). MRD was monitored in peripheral blood (PB) and marrow by four color-flow cytometry. The median age of patients was 55 years (range: 30–60), Rai stages III-IV were recorded in 23% of cases, 35% of patients showed “bulky” nodes (Ø⊘ ≥5 cm), 35% had 100 × 109/L or more PB lymphocytes and 51% increased β2 M values. A HR profile was found in 43 patients (53%) and a LR profile in 38 (47%). Within HR patients, 93% were IGHV unmutated, 69% CD38+, 80% Zap-70+, 40% 11q- and 21% 17p-. LR patients showed one or more unfavorable biologic factors in less than a third of cases (IgVH unmutated 21%, CD38+ 17%, Zap-70+ 29%); 13q- was recorded in 42% of cases, no detectable abnormalities in 39%, trisomy 12+ in 11% and 6q- in 8%. On an intention-to treat basis, a response was observed in 79% of HR cases (CR 26%, MRD- 19%) and in 87% of LR cases (CR 55%, MRD- 18%). In univariate analysis, age, IgG levels, β2 M, IgVH status, CD38 and Zap-70 played a significant role on CR achievement in HR patients, while CD38 was the only significant parameter for LR patients. As post-remission therapy, 2 HR patients received Cam, while 11 underwent a transplant procedure (allogeneic: 4, autologous: 7). The PFS probability at 36 months was 44% (95% CI: 36.9–51.8) for HR patients and 64% (95%CI: 53.6–76.7) for LR patients. In univariate analysis, β2 M and Zap-70 showed a significant effect on the PFS of HR patients, while a higher PB lymphocyte count (≥60×109/L) was associated with a lower PFS (p=0.07) in LR patients. The CR rate and PFS at 36 months after FluCam were 18% and 18% for 11q- patients, and 11% and 49% for 17p- patients. The OS probability at 36 months was 81% (95% CI: 71–93.3) for HR patients and 89% (95%CI:80.2–98.6) for LR patients. Cytogenetic abnormalities played a significant role (p=.02) on OS probability of HR patients. In particular, 17p- was associated with a lower survival probability (p=.04), while the OS of LR patients was influenced by the lymphocyte count (p=0.05). All transplanted patients are alive with a median follow-up of 31 months (range:16–42). Granulocytopenia was observed in 21% of cases treated with FluCam and in 32% of those treated with FC. Grade III-IV infections were recorded in 7% of FluCam-treated patients and in 13% of FC- treated patients. Asymptomatic CMV reactivation was detected in 3 FluCam-treated cases (7%). No FluCam-related deaths were observed, while 4 FC-related deaths were recorded (febrile granulocytopenia, 2 cases; cerebral hemorrhage, 1; cerebral abscesses of unknown origin, 1). In conclusion, an unfavorable biologic profile was observed in about half young CLL patients requiring first line treatment. Front-line FluCam was well tolerated and effective for most young CLL patients with an unfavorable biologic profile. However, our results suggest that FluCam is not the optimal treatment approach for 11q- patients. Front-line FC was associated with a high CR rate and prolonged PFS and OS probabilities in patients with a favorable biologic profile. Nevertheless, in young CLL patients FC-related severe granulocytopenia was a frequent reason of treatment failure.
Foá: Genzyme: Membership on an entity's Board of Directors or advisory committees.
Introduction Recent experiences suggest a stepwise improvement in survival outcomes for patients with follicular lymphoma with the introduction of new treatment options. Here we report the results of ...2 subsequent phase II trials conducted by Gruppo Italiano Studio Linfomi (GISL) utilizing CHOP-like plus fludarabine regimens with or without rituximab. Our results confirm an improvement in CR rate and show better survival with the addition of rituximab
Materials and Methods: The BACOP/FND study (bleomycin, epidoxorubicin, cyclophosphamide, vincristine, prednisone/ fludarabine, mitoxantrone, dexamethasone), registered 144 patients between 1997 and 2002. After 2 BACOP, patients received 4 cycles of FND. Then, responsive patients were randomized to observation or to receive alpha-IFN + dexamethasone. The BACOP/FR ( BACOP + fludarabine and rituximab) study registered 94 patients between 2002 and 2006. After 3 BACOP, patients in PR or in CR BCL2+ , received 4 cycles of FR. For both trials, eligible patients had histological documented, previously untreated, advanced follicular lymphoma.
Results:BACOP/FND. Response rates by intent to treat analysis were: ORR 90%, CR 62%. No differences were observed in FFS and OS between the 2 arms of maintenance. At the time of the last follow up, 35 patients had died, 5 lost at follow up, while 85 patients are still alive, 81 with ongoing response and 4 with progressive disease. After a median follow up of 60 months, FFS and OS were 53% and 77% at 4 years, respectively. BACOP/FR . Response rates by intent to treat analysis were: ORR 93%, CR 79%. At the time of the last follow up, 3 patients had died, 3 patients were lost at follow up, 60 are still alive with ongoing response and 14 with progressive disease. After a median follow up of 36 months , FFS and OS at 4 years were 56% and 97%, respectively. PCR assay for BCL2. Forty two of the 80 patients were found to be positive for BCL2 in the bone marrow obtained prior to treatment. Of these 42 patients, 25 obtained CR molecularly negative. We observed an improved FFS rate in patients who became BCL negative after treatment. Toxicity. The most common toxicities were infections and neutropenia. Overall, the haematological toxicities were transient and reversible. Comparison between the results of the two trials. We observed a CR rate of 62% and 79% and an OS at 4 years of 77% and 97%, respectively in BACOP/FND versus BACOP/FR, and the differences were statistically significant. Side effects were more frequent in BACOP/ FND, however, no significant differences were observed between the 2 trials.
Discussion The results obtained with BACOP/FR in comparison with those with BACOP/FND were better in terms of response and overall survival, while overall toxicity did not increase, remaining transient and tolerable. Patients who obtained BCL2 clearance in BACOP/FR showed a better FFS in comparison with patients treated with BACOP/FND. Further, patients treated with rituximab had a better FFS in comparison with all other patients treated only with chemotherapy. Finally, although conclusion between non randomized groups may depend in differences in observed and unobserved prognostic features, we believe that statistical analysis of our results, suggest that the addition of rituximab to anthracycline-fludarabine containing chemotherapy regimen has a favourable effect on prognosis of advanced follicular lymphoma
Fludarabine in combination with cyclophosphamide (FC) plus rituximab (R) is an effective treatment for newly diagnosed as well as relapsed low-grade non-Hodgin's lymphoma (NHL), including chronic ...lymphocytic leukemia (TAM 2006 and 2008, Keating 2005, Sacchi 2007). Maintenance treatment with R improves overall and progression-free survival in patients both with and without rituximab during induction, with relapsed/resistant follicular NHL (Van Oers 2006). We investigated efficacy and safety of the chemo-immunotherapy FCR followed by rituximab maintenance treatment in patients with advanced untreated indolent B-cell non follicular lymphomas (INFL). Patients and methods: from July 2005 to May 2007, 47 pts whit untreated advanced stage INFL (23 lymphocytic, 20 limphoplasmacytic and 4 nodal marginal zone NHL) were enrolled in an open label, single arm, multicenter phase II study, consisting with 6 courses of FC (Fludarabine, 25 mg/m2 i.v. plus Cyclophosphamide, 250 mg/m2, days 2–4) plus 8 doses of R (375 mg/m2, day 1 every FC cycle and day 14 of cycles 4 and 5) followed by R maintenance (375 mg/m2 every two months for 4 doses). Prophylactic antibiotic treatment with cotrimoxazole (two tablets three times a week) and antifungal profilaxis with itraconazole was planned from the beginning of chemotherapy to three months later or until normalization of CD4 count. The primary endpoint of this study is the percentage of failure free patients after two years from the treatment start. Results: 46/47 pts were evaluable for therapeutic response: median age 59 years (31–68), M/F ratio 28/18; stage III/ IV 44; B symptoms and splenomegaly 11 and 14 pts respectively; FLIPI scores were: 0–1, 16 pts (34.8%), score 2, 19 pts (41.3%) and score ≥ 3, 11 pts (23.9%). Forty-five patients received all the 6 courses of treatment and 1 patient 3 courses only. The ORR was 96% (44/46 pts) with 28 complete (61%) and 16 (35%) partial responses; 2 pts were in MR/SD. A total of 274 courses of FRC were given to 47 patients. The most frequent serious toxicity (NCI-CTC grade 3–4) was neutropenia that was reported in 55% of the courses. Three cases of Herpes zoster infection were reported. All the patients are still alive. Conclusions: in a series of INFL at diagnosis, FCR regimen is safe and effective with a very high CR rate. The whole study will provide insights on the role of R maintenance after R-chemotherapy in a particular subset of low-grade NHLs.
We conducted a retrospective analysis on 168 adult patients with newly diagnosed, limited-stage (I and II) diffuse large B-cell lymphoma (DLBCL) treated from 1988 to 2004 with PROMECE-CYTABOM (P-C) ...plus involved-field radiation therapy (IF-RT). At the end of P-C, the overall response rate was 92%. Radiotherapy (RT) was delivered to 84% of cases. With a median follow-up of 95 months, overall survival (OS), relapse free survival (RFS), and failure free survival at 5 and 10 years was 84% and 77%, 81% and 75%, 71% and 67%, respectively. Age (>60 years, p = 0.002), serum albumin (<3.5 g/dL; p = 0.015), and RT (p < 0.001) were independent predictors of OS. For patients in complete remission the administration of RT didn't improve both RFS and OS. This study confirms that patients with localized aggressive lymphoma have a high chance of cure with anthracycline containing regimens. Though the regimen used to treat these patients does not contain rituximab, results are considered excellent both in terms of efficacy and safety.
Abstract 2341
Poster Board II-318
The clinical heterogeneity of chronic lymphocytic leukemia (CLL) requires parameters to stratify patients into prognostic subgroups to adapt treatment ranging from ...‘watch and wait' to allogeneic stem cell transplantation. To this end, several parameters such as lymphocyte doubling time, β-2 microglobulin, CD38 and ZAP-70 expression, immunoglobulin variable heavy chain (IgVH) mutation status and genetic abnormalities, as assessed by fluorescence in situ hybridization (FISH), have been integrated in clinical practice.
In the present study, we investigated by FISH the incidence of the known major cytogenetic alterations (+12 and 13q14, 17p13, 11q23 deletions) in a series of Binet A B-CLL patients included in the prospective O-CLL1 GISL study started in April 2007.
Molecular markers characterization and FISH analyses were performed as previously reported (Cutrona et al. Haematologica, 2008; Fabris et al. GCC, 2008). A cut-off value of 2% was used to distinguish mutated and unmutated patients. CD38 and ZAP-70 were determined by flow-cytometry and a 30% cut-off was used to distinguish between positive or negative cases.
Up to date, 326 patients have been enrolled in the trial and FISH data concerning trisomy 12 and 13q14, 17p13, 11q23 deletions were available in 305 patients. At least one abnormality was found in 197 (64%) cases. The most frequent was del(13)(q14) (150/305, 49%), followed by +12 (40/303, 13%) (in one and three cases accompanied by 17p13 and 13q14 deletions, respectively), del(17)(p13) (7/305, 2%) and del(11)(q23) (17/305, 5%). 13q14 deletion was found as a sole abnormality in 134 patients; in the remaining cases, it was combined with +12 (3 pts) and 17p13 (3 pts) or 11q23 (10 pts) deletions. Among patients with 13q14 deletions, 99 were monoallelic, 12 biallelic and 39 showed a combination of the two patterns. Biomarkers data were available in all of the patients: 95/305 (31%) cases had unmutated IgVH genes; ZAP-70 and CD38 were positive in 117/305 (38%) and 72/305 (23%) cases, respectively. Concerning the distribution of cytogenetic aberrations, the unmutated IgVH group included 29/150 (19%) 13q14 deleted cases, 23/40 (57%) cases with trisomy 12 and 4/7 (57%) and 16/17 (94%) with 17p13 and 11q23 deletions, respectively. ZAP-70-positive groups included 43/150 (28%) 13q14 deleted cases, 26/40 (65%) cases showing trisomy 12 and 5/7 (71%) and 12/17 (70%) with 17p13 and 11q23 deletions, respectively. Finally, CD38-positive cases included 18/150 (12%) 13q14 deleted cases, 26/40 (65%) cases carrying trisomy 12 and 5/7 (71%) and 7/17 (41%) with 17p13 and 11q23 deletions, respectively. The percentages of IgVH mutations significantly correlated with cytogenetic alterations; namely, 5.8±0.3 for cases with del(13)(q14), 4.6±0.4 for normal karyotype, 2.6±0.5 in +12, 0.3±0.2 in del(11)(q23), and 1.7±0.9 in del(17)(p13) cases (p for trend <0.0001). A significant correlation was also found for ZAP-70 expression: namely 32±1.8 for cases with del(13)(q14), 38.6±2.2 for normal karyotype, 47.6±3.7 for +12, 55.8±7.0 for del(11)(q22) and 42.4±11.7 for del(17)(p13) (p<0.0001). Similarly, CD38 percentages were (mean value ± sem) 9.3±1.7, 16.9±2.1, 52.9±5.7, 26.8±6.2, 37.0±12.7 for del(13)(q14), normal karyotype, +12, del(11)(q23) and del(17)(p13) alterations, respectively (p for trend <0.0001). Finally, cytogenetic abnormalities were clustered in 3 risk groups i.e. low del(13)(q14) and normal; intermediate (+12); and high risk del(11)(q23) and del(17)(p13) and significantly correlated (p<0.0001) with a scoring system in which cases were stratified in 4 different groups according to the absence (group 0) or presence of 1 (group 1), 2 (group 2) or 3 (group 3) biomarkers (Morabito et al., BJH, 2009, voce). Interestingly, 147/154 cases scoring 0, gathered in the low FISH group, whereas 17/22 high FISH risk cases clustered in scoring 2-3.
Our preliminary results indicate that in Binet stage A B-CLL patients at diagnosis cytogenetic abnormalities with an expected negative clinical impact are relatively few (7.2%) but significantly associated with prognostic biomarkers which negatively predict the clinical outcome in B-CLL.
No relevant conflicts of interest to declare.
Abstract 2375
Poster Board II-352
A prognostic index based on widely available clinical and laboratory features was recently proposed to predict survival in patients with previously untreated ...patients with chronic lymphocytic leukemia (CLL) by MD Anderson investigators. However, whether proposed clinical risk categories may surrogate new biological variables of prognostic relevance (i.e., mutational status of the IgVH gene regions, ZAP-70 or CD-38 expression, cytogenetic abnormalities) is unclear thus far.
In a series of 160 asymptomatic Binet stage A patients enrolled in a Gruppo Italiano Studio Linfomi (GISL) multicentre trial designed to validate prospectively biological parameters in early CLL as well as to assess the impact on clinical outcome of an early versus delayed policy of treatment with subcutaneous alemtuzumab in the high biological risk, we evaluated whether clinical categories derived from newly proposed prognostic index reflected biological risk.
Since the original prognostic index was derived from a database including cases with more advanced disease we used an optimal cutoff search to determine how to best split Binet stage A patients in different prognostic groups. To this purpose an independent patient cohort consisting of 310 Binet stage A patients included in a GIMEMA (Gruppo Italiano Malattie EMatologiche Maligne dell'Adulto) database was used. According to recursive partitioning (RPART) model, a classification tree was built that identified two subsets of patients who scored respectively: 0-3 (low risk) and 4-7 (high risk). Therefore, by prognostic index, 48.7% and 51.2% of 160 asymptomatic stage A patients, respectively, met criteria of low risk and high risk disease.
In our prospective series high- risk score was more frequently associated with both unmutated IgVH status (P=0.009) and higher CD38-expression (P=0.002); in contrast only a trend towards an increased ZAP-70 expression could be found (P=0.06). As far as cytogenetic abnormalities are concerned, we observed that 11q deletion occurred more frequently among patients belonging to high-risk score (P=0.005), while cases with 13q deletion or trisomy 12 were homogeneously distributed among low- and high-risk patient category(P=0.151 and P=0.452, respectively). We did not consider suitable for correlation analysis 17p deletion since observed only in 2 out of 160 Binet stage A patients.
In conclusion, our results demonstrate in a prospective cohort of patients with early CLL that clinical categories of a revised score index may surrogate biological parameters of prognostic relevance. The observation reinforces the revised IWCLL guidelines recommendations to assess the risk of CLL patients on clinical basis and to deserve biological studies to patients eligible for clinical trials.
No relevant conflicts of interest to declare.
CD38 expression was investigated in 161 untreated patients with B-cell chronic lymphocytic leukemia (B-CLL). A score system, devised ad hoc by integrating the percentage and the mean fluorescence ...intensity (MFI) values of CD38
+ cells, indicated that B-CLL patients with a CD38 score ≤3 are characterized by a significantly longer survival compared to those with a CD38 score >3 (
P=0.0026). Thirty-seven percent of patients with a CD38 score ≤3 and 58% of those with a score >3 were dead at 10 years. Multivariate analysis indicates that only the CD38 score successfully predicts survival (
P=0.0028), with an estimated 3.8-fold greater risk of death for those cases with CD38 score >3.
