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To assess the impact of T‐cell/B‐cell phenotype on clinical outcome, the authors retrospectively compared patients who had peripheral T‐cell lymphoma, unspecified (PTCL‐U), with patients who had diffuse large B‐cell lymphoma (DLBCL).Two hundred ninety‐seven cases of PTCL‐U and 496 cases of DLBCL that had been transferred from the files of the Intergruppo Italiano Linfomi or the Gruppo Italiano Linfomi were integrated into a unique working file and reviewed by the authors.The PTCL‐U group and the DLBCL group had significantly different distribution patterns with respect to patient age, gender, disease stage, performance status (PS), the presence or absence of systemic “B” symptoms, the presence or absence of bulky disease, lactic acid dehydrogenase (LDH) levels, and number of extranodal sites (ENS). A significantly greater number of patients in the DLBCL group experienced complete remission (P < 0.0001). Multinomial logistic regression analysis confirmed that immunophenotype, PS, LDH concentration, and number of ENS were independent predictors of response. At a median follow‐up duration of 43 months, there was no observable difference in disease‐free survival (DFS) between patients with DLBCL and patients with PTCL‐U; however, multivariate analysis did reveal that poorer PS and bone marrow involvement were significantly associated with shorter DFS. Furthermore, although the overall survival (OS) curves associated with the T‐cell and B‐cell immunophenotypes were significantly different from each other at a median follow‐up duration of 37 months (P = 0.0012), Cox multivariate analysis excluded immunophenotype from the final OS model.The findings made in the current study indicate that the natural history of PTCL‐U may differ from that of DLBCL. Patients with PTCL‐U tended to have less favorable clinical outcomes, although the observed difference in outcome was only partially attributable to immunophenotype, which was independently associated with response, but not with survival. Differences in prognostic factor distributions between patients with PTCL‐U and patients with DLBCL may account for some portion of the expected phenotype‐associated risk. Cancer 2004. © 2004 American Cancer Society

The prognosis of follicular lymphomas (FL) is heterogeneous and numerous treatments may be proposed. A validated prognostic index (PI) would help in evaluating and choosing these treatments. Characteristics at diagnosis were collected from 4167 patients with FL diagnosed between 1985 and 1992. Univariate and multivariate analyses were used to propose a PI. This index was then tested on 919 patients. Five adverse prognostic factors were selected: age (> 60 years vs ≤ 60 years), Ann Arbor stage (III-IV vs I-II), hemoglobin level (< 120 g/L vs ≥ 120 g/L), number of nodal areas (> 4 vs ≤ 4), and serum LDH level (above normal vs normal or below). Three risk groups were defined: low risk (0-1 adverse factor, 36% of patients), intermediate risk (2 factors, 37% of patients, hazard ratio [HR] of 2.3), and poor risk (≥ 3 adverse factors, 27% of patients, HR = 4.3). This Follicular Lymphoma International Prognostic Index (FLIPI) appeared more discriminant than the International Prognostic Index proposed for aggressive non-Hodgkin lymphomas. Results were very similar in the confirmation group. The FLIPI may be used for improving treatment choices, comparing clinical trials, and designing studies to evaluate new treatments.

The prognosis of follicular lymphomas (FL) is heterogeneous and numerous treatments may be proposed. A validated prognostic index (PI) would help in evaluating and choosing these treatments. Characteristics at diagnosis were collected from 4167 patients with FL diagnosed between 1985 and 1992. Univariate and multivariate analyses were used to propose a PI. This index was then tested on 919 patients. Five adverse prognostic factors were selected: age (> 60 years vs ≤ 60 years), Ann Arbor stage (III-IV vs I-II), hemoglobin level (< 120 g/L vs ≥ 120 g/L), number of nodal areas (> 4 vs ≤ 4), and serum LDH level (above normal vs normal or below). Three risk groups were defined: low risk (0-1 adverse factor, 36% of patients), intermediate risk (2 factors, 37% of patients, hazard ratio [HR] of 2.3), and poor risk (≥ 3 adverse factors, 27% of patients, HR = 4.3). This Follicular Lymphoma International Prognostic Index (FLIPI) appeared more discriminant than the International Prognostic Index proposed for aggressive non-Hodgkin lymphomas. Results were very similar in the confirmation group. The FLIPI may be used for improving treatment choices, comparing clinical trials, and designing studies to evaluate new treatments.

Graft-versus-host disease in its acute (aGvHD) or chronic form (cGvHD) remains the most important posttransplantation factor influencing outcome after allogeneic hematopoietic stem cell transplantation (HSCT). It increases transplantation-related mortality (TRM) but reduces risk of relapse. The net effect of these 2 discordant effects determines survival. In view of current interests to exploit graft-versus-leukemia (GVL) effects, we analyzed 4174 HLA-identical sibling transplantations for chronic myeloid leukemia in first chronic phase, depending on the presence or absence and severity of GvHD with a landmark analysis. During the first 100 days, only aGvHD grades III and IV had an impact on TRM. During the time period day 100 to 3 years increasing severity of aGvHD is associated with increased TRM and decreased relapse incidence (RI) with hazard ratios (HRs) for TRM as follows: grade 0, HR = 1.0; grade I, HR = 1.52 (1.19-1.96); grade II, HR = 2.48 (1.95-3.14); grade III, HR = 5.76 (4.44-7.48); grade IV, HR = 14.7 (10.9-19.9) and likewise for RI: grade I versus 0, HR = 0.94 (0.76-1.16); grade II, HR = 0.60 (0.46-0.77); grade III, HR = 0.48 (0.29-0.81); grade IV, HR = 0.14 (0.02-0.99). Beyond 3 years, TRM and RI are determined by cGvHD. Limited cGvHD reduces RI to the same extent as extensive cGvHD but has no impact on TRM and, hence, results in best survival with an HR = 0.48 (0.32-0.71). aGvHD grade I has the highest likelihood of subsequent limited cGvHD, which results in cumulative incidence estimates of survival at 10 years being best for patients with initial aGvHD grade I: survival at 10 years grade 0 = 59%, I = 63%, II = 56%, III = 26%, IV = not applicable. These data clarify the role of GvHD in posttransplantation outcome. Considerations for long-term outcome are essential when short-term data of interventions on GvHD are analyzed.

Graft-versus-host disease in its acute (aGvHD) or chronic form (cGvHD) remains the most important posttransplantation factor influencing outcome after allogeneic hematopoietic stem cell transplantation (HSCT). It increases transplantation-related mortality (TRM) but reduces risk of relapse. The net effect of these 2 discordant effects determines survival. In view of current interests to exploit graft-versus-leukemia (GVL) effects, we analyzed 4174 HLA-identical sibling transplantations for chronic myeloid leukemia in first chronic phase, depending on the presence or absence and severity of GvHD with a landmark analysis. During the first 100 days, only aGvHD grades III and IV had an impact on TRM. During the time period day 100 to 3 years increasing severity of aGvHD is associated with increased TRM and decreased relapse incidence (RI) with hazard ratios (HRs) for TRM as follows: grade 0, HR = 1.0; grade I, HR = 1.52 (1.19-1.96); grade II, HR = 2.48 (1.95-3.14); grade III, HR = 5.76 (4.44-7.48); grade IV, HR = 14.7 (10.9-19.9) and likewise for RI: grade I versus 0, HR = 0.94 (0.76-1.16); grade II, HR = 0.60 (0.46-0.77); grade III, HR = 0.48 (0.29-0.81); grade IV, HR = 0.14 (0.02-0.99). Beyond 3 years, TRM and RI are determined by cGvHD. Limited cGvHD reduces RI to the same extent as extensive cGvHD but has no impact on TRM and, hence, results in best survival with an HR = 0.48 (0.32-0.71). aGvHD grade I has the highest likelihood of subsequent limited cGvHD, which results in cumulative incidence estimates of survival at 10 years being best for patients with initial aGvHD grade I: survival at 10 years grade 0 = 59%, I = 63%, II = 56%, III = 26%, IV = not applicable. These data clarify the role of GvHD in posttransplantation outcome. Considerations for long-term outcome are essential when short-term data of interventions on GvHD are analyzed.

Donor lymphocyte infusion (DLI) can produce durable remissions in patients with chronic myelogenous leukemia (CML) who have a relapse after an allogeneic stem cell transplantation. However, the best modality to administer DLI is still unclear. The effect of the initial cell dose (ICD; ie, mononuclear cells × 108/kg received in the first instance) on outcome was retrospectively analyzed in 298 of 344 patients treated with DLI at 51 centers. Patients were classified into 3 groups according to the ICD: 98 in group A (≤ 0.20), 107 in group B (0.21-2.0), and 93 in group C (> 2.0). Additional infusions were given to 62%, 20%, and 5% of patients in groups A, B, and C, respectively. A lower ICD was associated with less graft-versus-host disease (GVHD; A, 26%; B, 53%; C, 62%;P < .001), less myelosuppression (A, 10%; B, 23%; C, 24%; P = .01), and similar response rate (A, 78%; B, 73%; C, 70%; P = .48). Nonadjusted estimates of 3-year survival, failure-free survival, and DLI-related mortality were 84%, 66%, and 5% respectively, in group A; 63%, 57%, and 20% in group B; and 58%, 45%, and 22% in group C. Outcome analysis was adjusted for patient age, donor type, sex of donor, sex mismatch, disease phase at transplantation, T-cell depletion, interval from transplantation to DLI, GVHD prior to relapse, relapse type, and date of DLI. After adjustment, lower ICD was associated with less GVHD, less myelosuppression, same response rate, better survival, better failure-free survival, and less DLI-related mortality. Our results suggest that the first DLI dose should not exceed 0.2 × 108 mononuclear cells/kg.

Donor lymphocyte infusion (DLI) can produce durable remissions in patients with chronic myelogenous leukemia (CML) who have a relapse after an allogeneic stem cell transplantation. However, the best modality to administer DLI is still unclear. The effect of the initial cell dose (ICD; ie, mononuclear cells × 108/kg received in the first instance) on outcome was retrospectively analyzed in 298 of 344 patients treated with DLI at 51 centers. Patients were classified into 3 groups according to the ICD: 98 in group A (≤ 0.20), 107 in group B (0.21-2.0), and 93 in group C (> 2.0). Additional infusions were given to 62%, 20%, and 5% of patients in groups A, B, and C, respectively. A lower ICD was associated with less graft-versus-host disease (GVHD; A, 26%; B, 53%; C, 62%;P< .001), less myelosuppression (A, 10%; B, 23%; C, 24%; P= .01), and similar response rate (A, 78%; B, 73%; C, 70%; P= .48). Nonadjusted estimates of 3-year survival, failure-free survival, and DLI-related mortality were 84%, 66%, and 5% respectively, in group A; 63%, 57%, and 20% in group B; and 58%, 45%, and 22% in group C. Outcome analysis was adjusted for patient age, donor type, sex of donor, sex mismatch, disease phase at transplantation, T-cell depletion, interval from transplantation to DLI, GVHD prior to relapse, relapse type, and date of DLI. After adjustment, lower ICD was associated with less GVHD, less myelosuppression, same response rate, better survival, better failure-free survival, and less DLI-related mortality. Our results suggest that the first DLI dose should not exceed 0.2 × 108mononuclear cells/kg.

Peripheral T‐cell lymphomas (PTCL) are usually characterized by aggressive clinical behaviour and poor clinical outcome, but their biological background has not been extensively investigated to date, due to their low incidence, about 10% of all non‐Hodgkin's lymphoma cases in Western countries, and also to the paucity of specific molecular‐genetic abnormalities. Neverthless, there is increasing biological and clinical evidence that primary nodal PTCL should be considered separately from extra‐nodal cases, but little is known about biological factors of possible clinical and prognostic impact. This immunohistochemical study has analysed the expression of p53, Mdm2, p21WAF1, BCL‐2 and p‐glycoprotein (MDR‐1 gene product) in a series of 45 cases of nodal peripheral T‐cell lymphomas (PTCL) with ‘high‐grade’ histology. The immunohistochemical findings were then correlated with proliferative activity and clinical outcome. p53 was over‐expressed in 13 cases (28.9%). p53 positive cases showed significantly higher proliferative activity (p<0.01), more frequent expression of Bcl‐2 (p<0.01) and less frequent expression of p21WAF1than p53 negative cases. Mdm2 and p‐glycoprotein were expressed in 4/13 (30.8%) and 8/13 (61.5%) p53 positive cases respectively, and in none (0%) of the p53 negative cases (p<0.01). Analysis of the survival curves showed that p53 positive cases were associated with a significantly poorer clinical outcome than p53 negative cases, in terms of both overall survival (p=0.0032) and event‐free survival (p=0.0004). Furthermore, multivariate analysis showed that p53 expression was the most important independent prognostic variable. These findings indicate that p53 over‐expression identifies a subset of nodal PTCL cases with a distinctive biological profile (higher proliferative activity, less frequent expression of p21WAF1and more frequent expression of Bcl‐2, Mdm2 and p‐glycoprotein than p53 negative cases) and poor clinical outcome. The immunohistochemical analysis of p53 expression is a simple, rapid and low‐cost method which may provide information of potential clinical and prognostic value in nodal peripheral T‐cell lymphomas. Copyright © 2001 John Wiley & Sons, Ltd.

Patients with Ph+ chronic myelogenous leukemia who relapse after a first allogeneic stem cell transplant still have a possibility of long-term survival. To assess the value of the individual therapeutic options, the factors predicting outcome should be identified. We investigated data from 500 patients who relapsed before July 1996; follow-up was updated during 1998. The actuarial survival from relapse was 34.2% (95% confidence interval [CI]: 29.9%-38.5%) at 5 years and 23.4% (95% CI: 18.9%-27.9%) at 10 years. Survival after relapse was significantly related to 5 factors: time from diagnosis to transplant (< 2 years vs = 2 years), disease phase at transplant (first chronic phase vs other), disease stage at relapse (cytogenetic or chronic phase vs advanced phase), time from transplant to relapse (< 1 year vs = 1 year), and donor type (HLA-identical sibling vs volunteer unrelated donor). The effects of individual adverse risk factors were cumulative: The probability of survival at 10 years decreased stepwise from 42% (0 factors), 32% (1 factor), 14% (2 factors), 3% (3 factors), to 0% (4 or 5 factors). Novel strategies for high-risk patients are warranted. We conclude that these 5 factors should be taken into account when comparing results of salvage therapies in patients with Ph+ chronic myeloid leukemia relapsing after allogeneic stem cell transplant.

Patients with Ph+ chronic myelogenous leukemia who relapse after a first allogeneic stem cell transplant still have a possibility of long-term survival. To assess the value of the individual therapeutic options, the factors predicting outcome should be identified. We investigated data from 500 patients who relapsed before July 1996; follow-up was updated during 1998. The actuarial survival from relapse was 34.2% (95% confidence interval [CI]: 29.9%-38.5%) at 5 years and 23.4% (95% CI: 18.9%-27.9%) at 10 years. Survival after relapse was significantly related to 5 factors: time from diagnosis to transplant (< 2 years vs ≥ 2 years), disease phase at transplant (first chronic phase vs other), disease stage at relapse (cytogenetic or chronic phase vs advanced phase), time from transplant to relapse (< 1 year vs ≥ 1 year), and donor type (HLA-identical sibling vs volunteer unrelated donor). The effects of individual adverse risk factors were cumulative: The probability of survival at 10 years decreased stepwise from 42% (0 factors), 32% (1 factor), 14% (2 factors), 3% (3 factors), to 0% (4 or 5 factors). Novel strategies for high-risk patients are warranted. We conclude that these 5 factors should be taken into account when comparing results of salvage therapies in patients with Ph+ chronic myeloid leukemia relapsing after allogeneic stem cell transplant.

We have analyzed by immunocytochemistry (ICC) the frequency of p53 protein expression in 181 cases of B-cell chronic lymphocytic leukemia (CLL) followed at a single institution to assess the relationship between p53 and the clinical and morphological features of the disease, as well as the possible involvement of this protein in the pathogenesis of the more aggressive forms of CLL. The overall frequency of p53 protein positivity in CLL was 15% (27 of 181 cases). There were no significant differences in age, sex, absolute lymphocyte count, or lymphocyte doubling time between p53-positive and -negative patients. By contrast, p53-positive patients had a significantly higher percentage of prolymphocytes (P = .002) and a significantly lower percentage of residual CD3-positive T lymphocytes (P = .0001). No correlation was found between the percentage of p53-positive cells and the percentage of cells in cycle assessed by the monoclonal antibody Ki-67. When the percentage of p53 positivity was correlated with the clinical stage of the disease, the proportion of p53-positive cases increased significantly from Binet's stage A (8 of 108; 7.4%), to stage B (12 of 49; 24.4%) and C (7 of 24; 29.2%) (P = .002). p53 positivity correlated also with the phase of the disease, showing a low expression at diagnosis (8 of 112; 7.1%) and a significantly higher expression in patients studied during the course of the disease (7 of 35; 20%) and, to a further extent, with disease progression (12 of 34; 35.3%) (P = .0001). The association of p53 protein expression with mutations in the gene was confirmed by direct sequence of the entire cDNA in 15 of the 17 ICC positive cases tested (88%). A significantly shorter treatment-free interval from diagnosis (P = .003) and a poorer response to therapy (P = .007) was observed in p53-positive compared with p53-negative patients. Overall survival from the time of diagnosis, as well as from the time of p53 protein analysis, was significantly shorter in patients with p53 protein expression (P = .03 and .0001, respectively). Moreover, in multivariate analysis, p53 expression and stage C were independently associated with a short survival. The results of this study indicate that in CLL the expression of the p53 protein, analyzed by a simple and reliable immunocytochemical method, is strongly associated with p53 gene mutations, a morphological variant (CLL with >10% prolymphocytes), advanced clinical stage, progressive disease, poor response to therapy, and short survival.

With the aim of assessing the role of surgery in the management of isolated mediastinal lymphoma, we have reviewed the data of 123 operations performed on 102 patients (64 with Hodgkin's disease and 38 with non-Hodgkin's lymphoma). One death and four major complications occurred in these patients. Macroscopically radical resection was performed in 14 patients who are free of disease after 1 to 14 years. Debulking resection was performed in five patients: Three are alive after 5 to 11 years and two died after 36 and 40 months. Ten patients (seven with non-Hodgkin's lymphoma and three with Hodgkin's disease) had residual mediastinal masses of more than 2 cm after chemotherapy; to assess the nature of the lesion (fibrosis or residual disease), we subjected these patients to surgical restaging of the mediastinum: Results were negative in seven and positive in three. We conclude that open biopsy is indispensable to obtain good tissue specimens suitable for histologic and immunohistochemical assessment. Biopsy must be performed as a major surgical procedure to avoid reoperation: Mediastinoscopy and sternal splitting incisions proved the most reliable approaches. Locally radical or debulking resection might be considered in selected cases to enhance long-term results.

In the present study we investigated the lymph node morphology and distribution of cell surface phenotypes in four cases of adult peripheral T cell lymphoma. Histologically, the tumors were classified as T zone lymphoma, T cell lymphoma with large multilobated nuclei and T cell immunoblastic sarcoma. In the T zone lymphoma the neoplastic lymphocytes were E+(90 %) and exhibited intensive focal staining for acid phosphatase (93 %) and acid esterase (92 %); the phenotype distribution revealed low expression of the T-3 antigen (49 %), selective expression of the T-4 antigen (72 %) and poor expression of T-6 (10 %) and T-10 antigens (22 %). Some of these features are present in normal and in neoplastic immature T cells. In the remaining three cases the majority of lymph node cells were E+(59–75 %), T-3+(67–80 %) and T-8+(43–55 %). A distinctive feature of the T cell immunoblastic sarcoma was the presence of high percentages of DR+cells (62 %; 63 %). Thus our results indicate that the morphological heterogeneity of peripheral T cell lymphoma is also paralleled by a variety of surface phenotypes and that phenotype studies may provide a useful contribution to identification and accurate classification of peripheral T cell neoplasms.

The present study was undertaken to evaluate the frequency, characteristics and actuarial risk of secondary acute non lymphoid leukemia (s-ANLL) in 141 patients treated for non Hodgkin's lymphoma with different modalities. One hundred and twenty-four patients received chemotherapy according to PROVECIP protocol (9). Of these, 15 also received as induction treatment a local nodal irradiation and 33 an extended field radiotherapy. Seventeen out of 141 were treated by total body irradiation. Of these, 15 relapsed and received salvage chemotherapy. Sixteen of the 124 patients treated with PROVECIP also underwent different chemotherapeutic programs as salvage treatment. Of the entire population studied, 2 patients developed an s-ANLL, 45 and 63 months after diagnosis of NHL. The type of treatment significantly affected the occurrence of s-ANLL, since both leukemias occurred in patients treated with total body irradiation, given alone or followed by chemotherapy. The actuarial risk at 8 years was 5.24% in the whole group, whereas it greatly increased in the group of patients treated with total body irradiation (24%). Conversely, no risk was found in the group treated with PROVECIP, alone, with additional chemotherapy, or with associated local or extended field radiotherapy.

The importance of coexpression of myeloid antigens in childhood acute lymphoblastic leukemia (ALL) has long been debated; results are conflicting. We studied children with ALL treated at Italian Association for Pediatric Hematology-Oncology (AIEOP) institutions over 6 years with Berlin-Frankfurt-Muenster (BFM)-based protocols and have analyzed the incidence of coexpression of six MyAg (CD11b, CD13, CD14, CD15, CD33, CD65w) to determine its prognostic impact. Criteria for MyAg coexpression (MyAg+ALL) included positivity to one or more MyAg on at least 20% of blasts and confirmation of coexpression at double-fluorescence analysis. A total of 291 of 908 cases were MyAg+ALL (32%). Incidence was similar in B-ALL and T-ALL; among common, pre-B, and pre-pre–B-ALL. CD13 and CD33 were most common. Patients with MyAg+ALL had presenting features similar to MyAg-ALL. They entered standard or intermediate risk protocols more frequently and had better prednisone response, but similar complete remission rates. Six-year event-free survival (EFS) was 69.0% in 291 MyAg+ALL cases and 65.3% in 617 MyAg-ALL cases, without significant difference. Cases expressing two or more MyAg presented similar clinical features and treatment response. MyAg+ALL had worse EFS only in infants (0% v47%) (P = .01). Therefore, in this series of homogeneously diagnosed and treated ALL, coexpression of MyAg was not associated with prognostic significance, without relevance for clinical purposes or for patient stratification, except for infants. © 1998 by The American Society of Hematology.

Bcl‐6 (LAZ‐3) and Bcl‐2 gene rearrangements have been respectively reported in 20–35 per cent and 10–25 per cent of diffuse large B‐cell lymphomas (DLBCLs). Although these genetic lesions have been associated with different clinical outcomes (i.e., more favourable in Bcl‐6 rearranged cases and poorer in Bcl‐2 rearranged cases), their prognostic significance is still controversial. In the present study, we have investigated by Southern blot analysis the Bcl‐6 and Bcl‐2 gene configuration in a series of 80 lymph nodes involved by well‐characterized DLBCLs, histologically defined according to the REAL and the updated Kiel classifications. The molecular findings have been correlated with the clinical features at presentation and with response to therapy. The majority of cases (57/80=71·2 per cent) had a centroblastic morphology. Bcl‐6 rearrangements were detected in 23/80 cases (28·8 per cent), and were similarly associated with centroblastic (18/57=31·6 per cent) or immunoblastic (3/11=27·3 per cent) histotypes. In contrast, Bcl‐2 was found to be rearranged in only three cases of centroblastic lymphoma (3·8 per cent). No significant differences were found between Bcl‐6 rearranged and germline cases, as far as the clinical features at presentation are concerned. Forty‐one patients, in whom the lymph node biopsy was performed at diagnosis, could be evaluated for response to treatment and clinical outcome. Most of these cases (30/41=73·2 per cent) were nodal DLBCL, without extranodal site involvement. Analysis of the clinical outcome showed no statistically significant differences between Bcl‐6 rearranged and Bcl‐6 germline cases (actuarial overall survival 50 per cent vs. 48 per cent, event‐free survival 45 per cent vs. 46 per cent, at 4 years). These findings confirm that Bcl‐6 rearrangements are the most frequent genetic lesion in DLBCL. The incidence of Bcl‐2 involvement in our series is significantly lower than the figures reported in other studies, mainly from North American countries, probably reflecting heterogeneous patient selection and/or epidemiological variability. Finally, our results suggest that no relevant clinical differences are observed between Bcl‐6 rearranged and Bcl‐6 germline cases, when nodal DLBCLs are considered. © 1997 John Wiley & Sons, Ltd.

A 16-yr-old white female was affected by continuous fever, pancytopenia with relative increase of T-8 lymphocytes, severe bone marrow hypoplasia, generalized lymphadenomegaly and splenomegaly. A first lymph node biopsy, obtained at the onset of the disease, was involved by a paracortical tumor with some S-100+ “lymphocyte-like” cells in the neoplastic areas; in the cell suspension, 70–80% of cells were E4 + /E37 + lymphocytes with prevalent expression of the T-8 phenotype (52%). A second lymph node biopsy, obtained five months later, was involved by a diffuse proliferation of S-100 + cells with high mitotic activity; in the cell suspension, the majority of cells were E-/T-11+/ T-3+/T-8+. At the TEM level, the neoplastic cells were characterized by regular or indented nuclei with finely dispersed chromatin and by regular or indented nuclei with finely dispersed chromatin and by irregular cytoplasmic profiles with thick pseudopodia-like projections. The possibility is discussed that this neoplasm may share some similarities with the T-γ lymphoma being part of a poorly described group of tumors with intermediate features between T cell lymphoma and malignant histiocytosis.

From 1990 to 1994, 3 patients with de novo acute myeloid leukemia (AML) in whom light microscopy and cytochemistry suggested a FAB subtype M3 variant were observed at our Institute. Immunophenotype showed HLA-DR-, CD13+. CD33+, CD2+, CD9+; promyelocytic features were also detected by electron microscopy. However, leukemic cells lacked both translocation t(15;17) and RARα/PML genes rearrangement. These cases were considered to be 'M2 atypical' subtypes and they contribute to point out how cytogenetics and molecular biology are mandatory for a correct diagnosis of acute promyelocytic leukemia (APL) particularly because therapy with all trans retinoic acid (ATRA) is now the best treatment for APL. Nevertheless these 3 cases indicate that the atypical M2 subtype may be confused with the M3v if only cytochemistry, immunophenotype and electron microscopy an: used in the defining the FAB subtypes.

Bcl-6 (LAZ-3) and Bcl-2 gene rearrangements have been respectively reported in 20–35 per cent and 10–25 per cent of diffuse large B-cell lymphomas (DLBCLs). Although these genetic lesions have been associated with different clinical outcomes (i.e., more favourable in Bcl-6 rearranged cases and poorer in Bcl-2 rearranged cases), their prognostic significance is still controversial. In the present study, we have investigated by Southern blot analysis the Bcl-6 and Bcl-2 gene configuration in a series of 80 lymph nodes involved by well-characterized DLBCLs, histologically defined according to the REAL and the updated Kiel classifications. The molecular findings have been correlated with the clinical features at presentation and with response to therapy. The majority of cases (57/80=71·2 per cent) had a centroblastic morphology. Bcl-6 rearrangements were detected in 23/80 cases (28·8 per cent), and were similarly associated with centroblastic (18/57=31·6 per cent) or immunoblastic (3/11=27·3 per cent) histotypes. In contrast, Bcl-2 was found to be rearranged in only three cases of centroblastic lymphoma (3·8 per cent). No significant differences were found between Bcl-6 rearranged and germline cases, as far as the clinical features at presentation are concerned. Forty-one patients, in whom the lymph node biopsy was performed at diagnosis, could be evaluated for response to treatment and clinical outcome. Most of these cases (30/41=73·2 per cent) were nodal DLBCL, without extranodal site involvement. Analysis of the clinical outcome showed no statistically significant differences between Bcl-6 rearranged and Bcl-6 germline cases (actuarial overall survival 50 per cent vs. 48 per cent, event-free survival 45 per cent vs. 46 per cent, at 4 years). These findings confirm that Bcl-6 rearrangements are the most frequent genetic lesion in DLBCL. The incidence of Bcl-2 involvement in our series is significantly lower than the figures reported in other studies, mainly from North American countries, probably reflecting heterogeneous patient selection and/or epidemiological variability. Finally, our results suggest that no relevant clinical differences are observed between Bcl-6 rearranged and Bcl-6 germline cases, when nodal DLBCLs are considered. © 1997 John Wiley & Sons, Ltd.

An intensive treatment program was developed to achieve durable remissions in a high proportion of previously untreated patients with advanced stages of diffuse high-grade non-Hodgkin's lymphoma (NHL). Fifty-six patients (15-68 years) received a course of F-MACHOP (5-fluorouracil, methotrexate, cytosine-arabinoside, cyclophosphamide, doxorubicin, vincristine, and prednisone) every 3-4 weeks for 6 courses. Cycle active drugs were sequentially administered to expose rapidly proliferating tumor cells to the synergistic effects of these agents throughout the cell cycle. Forty-three patients achieved complete remission (77%) and 80% of the complete responders are projected to be alive and disease-free at 4'A years (median follow-up 33 months). Up to 70% of all patients are predicted to be alive at 5 years. Bulky tumor, "B"-symptoms and lymphoblastic histology were poor prognostic factors, particularly when associated with clinically detectable disease after three courses. Toxicity included transitory myelodepression in most patients (2 septic deaths). This protocol provides effective and tolerable therapy for the majority of patients with advanced stages of diffuse aggressive NHL.

The expression of complement receptors (C3R) associated or not to sheep erythrocyte receptors (ER) and surface membrane immunoglobulins (SmIg) was determined on lymphoblasts of 45 patients with acute lymphocytic leukemia (ALL) at onset and/or in the first relapse. We found C3R simultaneously expressed with ER or SmIg on lymphoblasts of T cell ALL and B cell ALL. Lymphoblasts were positive for C3R in absence of ER and SmIg only in three patients in the hematological relapse. We stress the importance to find C3R as independent marker on ALL cells at onset and in subsequent relapses.

We have analyzed by immunocytochemistry (ICC) the frequency of p53 protein expression in 181 cases of B-cell chronic lymphocytic leukemia (CLL) followed at a single institution to assess the relationship between p53 and the clinical and morphological features of the disease, as well as the possible involvement of this protein in the pathogenesis of the more aggressive forms of CLL. The overall frequency of p53 protein positivity in CLL was 15% (27 of 181 cases). There were no significant differences in age, sex, absolute lymphocyte count, or lymphocyte doubling time between p53-positive and -negative patients. By contrast, p53-positive patients had a significantly higher percentage of prolymphocytes (P= .002) and a significantly lower percentage of residual CD3-positive T lymphocytes (P= .0001). No correlation was found between the percentage of p53-positive cells and the percentage of cells in cycle assessed by the monoclonal antibody Ki-67. When the percentage of p53 positivity was correlated with the clinical stage of the disease, the proportion of p53-positive cases increased significantly from Binet's stage A (8 of 108; 7.4%), to stage B (12 of 49; 24.4%) and C (7 of 24; 29.2%) (P= .002). p53 positivity correlated also with the phase of the disease, showing a low expression at diagnosis (8 of 112; 7.1%) and a significantly higher expression in patients studied during the course of the disease (7 of 35; 20%) and, to a further extent, with disease progression (12 of 34; 35.3%) (P= .0001). The association of p53 protein expression with mutations in the gene was confirmed by direct sequence of the entire cDNA in 15 of the 17 ICC positive cases tested (88%). A significantly shorter treatment-free interval from diagnosis (P= .003) and a poorer response to therapy (P= .007) was observed in p53-positive compared with p53-negative patients. Overall survival from the time of diagnosis, as well as from the time of p53 protein analysis, was significantly shorter in patients with p53 protein expression (P= .03 and .0001, respectively). Moreover, in multivariate analysis, p53 expression and stage C were independently associated with a short survival. The results of this study indicate that in CLL the expression of the p53 protein, analyzed by a simple and reliable immunocytochemical method, is strongly associated with p53 gene mutations, a morphological variant (CLL with >10% prolymphocytes), advanced clinical stage, progressive disease, poor response to therapy, and short survival.

No relevant conflicts of interest to declare.

Abstract 3309

Allogeneic transplantation continues to have a role in the management of high risk CML. However the place of reduced intensity (RIC) versus myeloablative conditioning (MAC) is uncertain in younger patients. A total of 2331 first HSCT’s performed from 1998–2005 were reported to the European Group for Blood and Marrow Transplantation Registry, RIC was used in 276 and MAC in 2055. Overall survivals were similar for the first 9 months. After 9 months the survival curves separated (HR for RIC 1.8, 95% CI 1.2–2.8 p=0.01). All estimates were based on time dependent Cox models and landmark analyses at 9 months. EBMT score was higher in the RIC group (score 0–2, 27% vs 52% p<0.001) and was associated with 5-year survival estimates: EBMT score 0–2, 68% vs 68%, 3–4, 48% vs 56% and 5–7, 27% vs 33% for RIC and MAC respectively. Comparison of RIC and MAC is complicated by differences in patient characteristics. A propensity score was developed to adjust for these differences from a logistic regression model based on the following factors: age, use of PBSC, T cell depletion, disease phase, year, CMV status, sex mismatch, time to transplant and donor type. The propensity score predicts the likelihood of receiving a RIC (high score, RIC more likely). Adjusting for the propensity score compensates for the differences in the underlying covariates. Forty nine percent of RIC allografts were performed in centres reporting ≥5 RIC transplants. There was a significant interaction between propensity score, a centre’s RIC-activity and conditioning intensity on survival. Excluding centres not performing RIC to avoid bias and adjusting for propensity score, survival >9 months was worse in RIC patients with a low propensity score when treated in centres with <5 RICS (HR 2.4 CI 1.3–4.4) whereas survival >9 months was equal in centres treating ≥5 patients with RIC who had a high propensity score (HR 0.8 CI 0.4–1.6). The figures below illustrate this showing the cumulative risk of non-relapse mortality, relapse and death after relapse for these groups estimated in a competing risk setting. Conclusion: Transplant centre experience and patient selection impact on outcome. Survival with RIC HSCT is inferior to MAC except for the subgroup of patients with a high propensity score transplanted at centres with ≥5 RIC HSCT. Low Propensity Score and <5 RIC HSCT Low Propensity Score and <5 RIC HSCT High propensity Score and ≥5 RIC HSCT High propensity Score and ≥5 RIC HSCT

Allogeneic transplantation continues to have a role in the management of high risk CML. However the place of reduced intensity (RIC) versus myeloablative conditioning (MAC) is uncertain in younger patients. A total of 2331 first HSCT's performed from 1998–2005 were reported to the European Group for Blood and Marrow Transplantation Registry, RIC was used in 276 and MAC in 2055. Overall survivals were similar for the first 9 months. After 9 months the survival curves separated (HR for RIC 1.8, 95% CI 1.2–2.8 p=0.01). All estimates were based on time dependent Cox models and landmark analyses at 9 months. EBMT score was higher in the RIC group (score 0–2, 27% vs 52% p<0.001) and was associated with 5-year survival estimates: EBMT score 0–2, 68% vs 68%, 3–4, 48% vs 56% and 5–7, 27% vs 33% for RIC and MAC respectively. Comparison of RIC and MAC is complicated by differences in patient characteristics. A propensity score was developed to adjust for these differences from a logistic regression model based on the following factors: age, use of PBSC, T cell depletion, disease phase, year, CMV status, sex mismatch, time to transplant and donor type. The propensity score predicts the likelihood of receiving a RIC (high score, RIC more likely). Adjusting for the propensity score compensates for the differences in the underlying covariates. Forty nine percent of RIC allografts were performed in centres reporting ≥5 RIC transplants. There was a significant interaction between propensity score, a centre's RIC-activity and conditioning intensity on survival. Excluding centres not performing RIC to avoid bias and adjusting for propensity score, survival >9 months was worse in RIC patients with a low propensity score when treated in centres with <5 RICS (HR 2.4 CI 1.3–4.4) whereas survival >9 months was equal in centres treating ≥5 patients with RIC who had a high propensity score (HR 0.8 CI 0.4–1.6). The figures below illustrate this showing the cumulative risk of non-relapse mortality, relapse and death after relapse for these groups estimated in a competing risk setting.

Donor lymphocyte infusions (DLI) have radically changed the prognosis of patients relapsing after allogeneic hematopoietic stem cell transplant (SCT) for chronic myeloid leukemia (CML). Major obstacles to success with DLI are represented by leukemia resistance and by secondary GvHD (GvHD2). The best result of is when a patient treated with DLI achieve a durable molecular remission without experiencing GvHD2. It is unclear which factors may predict for such a favourable outcome when CML patients are treated with DLI. We retrospectively identified 500 patients (59% males, median age 39 years, range 4–64), treated with DLI for CML relapse (81 molecular [16%], 150 cytogenetic [30%], 211 hematological chronic [42%], and 58 hematological accelerated [12%]) at 68 EBMT centers before 2004 with adequate information collected on disease response, GvHD2 and survival after DLI. Donor was an HLA-identical sibling in 73%, unrelated in 27%. DLI started with a cell dose <2×107 CD3+ cells/Kg in 62% of the cases; 208 patients (42%) received 2 or more additional infusions of donor cells. Cumulative cell dose ranged from 1×105 CD3+ cells/Kg to 1.4×109 (median 7×107). Molecular remission and/or cytogenetic complete remission was achieved in 340 patients (68%) in a median of 7.5 months (95% within 41 months). GvHD2 occurred in 60% of patients at a median of 3 months from 1st transfusion of donor lymphocytes (95% within 24 months). Sixteen recurred at a median of 19 months (range 3–48). Actuarial probability of being alive and responsive to DLI without experiencing any GvHD2 was 29% (95% confidence interval [95CI]: 27–31%) and 27% (95CI: 24–30%) at 5 and 10 years after DLI, respectively. We studied the prognostic effect of following factors: patient age at DLI, donor type, donor sex, sex mismatch with the donor, phase at SCT, stem cell source, T-depletion, total body irradiation in the conditioning regimen, GvHD prior to DLI, interval from SCT to DLI, type of relapse. Multivariate analysis with a Cox model adjusted for the period of DLI (=1997 vs >1997), showed that chronic GvHD after transplant and prior to relapse (hazard ratio [HR]: 1.5, 95CI: 1.2–1.9, p<0.001), an interval from SCT to DLI <1 year (HR: 1.7, 95CI: 1.3–2.2, p<0.001), and hematological relapse (HR: 1.6, 95CI: 1.2–2.0, p<0.001), were adverse features. 94 patients (20%), 222 (48%), 133 (28%), and 17 (4%) had 0, 1, 2, and 3 adverse features, respectively. Survival in remission without experiencing GvHD2 at 5 years improved from 14%, 30%, to 56% in patients with 2–3, 1, and 0 adverse features, respectively. We conclude that:“pure” GvL effect (ie. durable remission without GvHD2) was observed in more than 25% of patients treated with DLI for CML relapsing after allogeneic SCT;occurrence of chronic GvHD prior to relapse, the interval from SCT to DLI, and the type of relapse are the main factors associated with the chance of a “pure” GvL effect;patients treated with DLI beyond 1 year from SCT for a molecular/cytogenetic relapse that was not preceded by chronic GvHD have more than 50% chance of exploiting the “pure” GvL effect.

Donor lymphocyte infusions and imatinib have been the mainstay of treatment for chronic myeloid leukemia (CML) patients relapsing after allogeneic hematopoietic stem cell transplantation (alloSCT) in recent years. Improvements in transplant related mortality and a reduction of lethal infections have been documented. No comprehensive data are yet available about the impact of relapse (REL) itself on survival and a possible improvement over calendar time. We analyzed 13418 patients with CML transplanted between 1980 and 2003 (60% male, median age 36 years [range 0–71]) from an allogeneic donor (65% HLA identical sibling, 1% twin, 7% other related, and 27% unrelated). Of those, 2558 (19%) were reported with REL. We investigated the impact of REL on death rate in 4 periods: A [1980–92], B [1993–96], C [1997–99] and D [2000–03], adjusting for other factors. We applied a series of Cox models where REL was used as a time-depending covariate and where we used an integrated approach in the framework of multi-state models, with REL representing an intermediate event in a patient’s post-transplantation history. We used the EBMT risk score as a propensity score to adjust for intrinsic differences in survival over calendar time and Calendar time as categorical factor to assess trends. REL increased death rate over the whole observation period. However, there was a significant improvement over the years: death hazard ratio (HR) decreased from 4.5 to 3.2, 2.7 and 2.4 for the periods A, B, C and D, respectively. The impact of REL on death rate was also influenced by the EBMT risk score [HR 1, 1.9, and 3.5 for low, intermediate, and high risk score, respectively]. We investigated, with the same methodology used above, the impact of REL on death rate in a subset of 1977 patients transplanted after 1992 and with known information on the type of relapse at its first evidence (molecular/cytogenetic [M-REL] or hematological [H-REL]). The M-REL/H-REL ratio increases over the years (1.1, 1.2, and 2.5 in periods B, C, and D, respectively). Results confirmed that the impact of REL on death rate decreases over the years, but hardly and not significantly for H-REL (HRs around 6 in periods B, C, D) and more pronounced and significantly for the M-REL (HRs 0.68, 0.52, and 0.12 in periods B, C, and D, respectively). It is notable that H-REL was associated with higher death rate, M-REL with lower. We have shown that:REL after alloSCT for CML is associated with a higher risk for subsequent death;the effect of REL on death rate is decreasing in more recent years;the effect of REL on death rate depends on the type of REL (H-REL or M-REL) and the EBMT risk score;an integrated approach like multi-state modeling is flexible and allows clinically relevant interpretations. Our findings suggest that the effect of REL on death rate is decreasing in more recent years, mainly because of the increasing proportion of patients in whom REL is first detected at pre-clinical level (ie. molecular/cytogenetic relapse). Our results will form the basis for future description and characterization of patient groups in comparative retrospective analyses and prospective trials.

Donor lymphocyte infusions (DLI) have radically changed the prognosis of patients relapsing after allogeneic hematopoietic stem cell transplant (SCT) for chronic myeloid leukemia (CML). Major obstacles to success with DLI are represented by leukemia resistance and by secondary GvHD (GvHD2). The best result of is when a patient treated with DLI achieve a durable molecular remission without experiencing GvHD2. It is unclear which factors may predict for such a favourable outcome when CML patients are treated with DLI.

Donor lymphocyte infusions and imatinib have been the mainstay of treatment for chronic myeloid leukemia (CML) patients relapsing after allogeneic hematopoietic stem cell transplantation (alloSCT) in recent years. Improvements in transplant related mortality and a reduction of lethal infections have been documented. No comprehensive data are yet available about the impact of relapse (REL) itself on survival and a possible improvement over calendar time.

Donor lymphocyte infusions (DLI) are an well established treatment for relapsed chronic myeloid leukemia (CML) after allogeneic stem cell transplantation. In a previous analysis including mainly patients receiving DLI from HLA-identical siblings (Guglielmi et al., Blood 2002), it could be shown, that it was of major prognostic significance to start with a low cell dose (≤ 0.2 x 108 mononuclear cells/kg body weight). In the present analysis we retrospectively analyzed patients receiving DLI from unrelated donors. In the data base of the Chronic Leukemia Working Party of the European Group for Blood and Marrow Transplantation 130 patients from 28 centers were identified, who received DLI from unrelated donors between 1987 and 2003 for treatment of relapse of Philadelphia chromosome positive CML and in whom data on the cell doses of DLI were available. According to the cell dose of the initial DLI patients were divided in 3 groups: 59 patients received DLI in a starting cell dose of ≤1x106 CD3 cells/kg body weight (group A), 39 patients received between 1 and 10x106 CD3 cells/kg (group B) and 32 patients received an initial cell dose of ≥10x106 CD3 cells/kg (group C). The three groups did not differ regarding age (median age 34 ys. in all groups), sex, sex mismatch and were comparable regarding the time interval from transplant to relapse (190d, 231d and 241d) and that from transplant to first DLI (453 d, 581d and 417d). In group C more patients were transplanted for CML beyond first chronic phase (41%), compared to 20% (group A) and 21% (group B), respectively. At first DLI relapse was molecular/cytogenetic in 60%, 64% and 38% of the patients, respectively. Relapse in accelerated phase/blast crisis at DLI was present in 3%, 13% and 22% of the patients. Multiple infusions were given in 80% of the patients in group A, 46% in group B and 6% in group C. In group A 61% of the patients received 2–3 DLI and 19% 4 or more DLI. The numbers were 33% and 13% in group B and in group C no patient received more than 2 DLI. The median total number of CD3 cells/kg given was 11 x 106 (0.5–311), 10 x 106 (3–860) and 75 x 106 (11–712) in the three groups. A cytogenetic or molecular response was achieved in 68% of the patients in group A, in 65% in group B and in 63% in group C. Acute GvHD occurred in 27% of the patients in group A (I/IIo 17%, IIIo 9%), in 28% in group B (I/IIo 20%, IIIo 8%) and in 66% in group C (I/IIo 31%, IIIo 25%, IVo 10%). Myelosuppression occurred in 20%, 23% and 22% of the patients, respectively. Survival at 6 ys. was 68± 6% in group A, 67±12% in group B and 30±9% in group C. If patients treated for acc. phase or blast crisis were excluded, survival was 71±6% in group A, 72±13% in group B and 39±11% in group C.We conclude that treatment with DLI from unrelated donors with a starting dose of <10 x 106 CD3 cells/kg is efficient and results in a GvHD incidence of 27–28% with 8–9% GvHD>IIo. Starting with a lower cell dose (group A) did not compromise overall efficacy but did not reduce the incidence of GvHD or myelosuppression, probably due to the fact that total number of cells given was comparable to group B. An initial cell dose of > 10 x 106 CD3 cells/kg resulted in more GvHD and a poorer survival.

DLT has become the gold standard for the treatment of reccurrent CML after allogeneic stem cell transplantation. However, so far, published data are based on DLT following bone marrow transplantation (BMT). During recent years, mobilized peripheral blood stem cell transplantation (PBSCT) have been increasingly performed. To evaluate the efficacy of DLT following PBSCT, we retrospectively analysed the results of 86 patients treated with DLT for CML relapse after PBSCT from HLA-identical family donors. Results were compared to 260 patients receiving DLT for relapse after related BMT. Reduced intensity transplants were excluded. BMT and PBSCT groups were balanced in terms of patient age (median: 40 vs 42 y), conditioning, stage at transplant (84% vs 76% in first chronic phase (CP) p=.2), and stage at relapse (molecular/cytogenetic: 59% both, CP: 28% vs 20%, advanced: 13% vs 21%, p=.2). However, BMT patients had been transplanted in earlier years (median: 1994 vs.1998, p<.001), had a longer remission after transplantation (median: 677 vs. 275 d, p<.001), and had experienced more aGvHD after transplantation (58% vs. 34%, p<.001). Complete molecular or cytogentic remission was achieved in 71% of the patients, with a trend towards better response in BMT recipients (p=.06). Overall (OS) and event free survival (EFS) at five years from DLT are shown in table 1. Outcome was significantly superior in BMT recipients, in particular if DLT was given for hematological, rather than cytogenetic or molecular relapse. In a cox regression model, four factors were associated with better OS/EFS: Transplantation in CP1 (p<.001/.002), early stage at relapse (molecular/cytogenetic vs. hematological, p<.00/<.001), a longer remission after transplantation (p=.005/.028), and BM vs. PBSC for transplantation (p= .003/.004). In contrast, age of patient and donor, acute or chronic GvHD after transplantation, the use of chemotherapy or imatinib before DLT, and the initial number of transfused CD3+ cells were not significant. The results of this retrospective study suggest a reduced efficacy of DLT in CML relapse following related allogeneic PBSCT as compared to BMT. This effect seems to be independent from established risk factors as disease stage and remission duration. However, since several adverse factors are not equally distributed among the two groups, a bias might be induced, although no statistically significant imbalance could be detected. Therefore, the observation needs to be confirmed in a larger cohort or a prospective study. Table 1. Outcome after DLT No BMT PBSCT p Total 346 260 86 OS at five years from DLT 71% 75% 66% < .001 EFS at five years from DLT 61% 64% 41% < . 001

Using data submitted to the EBMT registry, we analyzed outcome on 344 patients (pts) who had received donor lymphocyte infusions (DLI) for relapse after allogeneic hematopoietic stem cell transplantation (HSCT) for chronic myeloid leukemia (CML) in 31 centers. 113/344 pts (33%) developed acute graft-versus-host disease (aGVHD) a median of 50 days post DLI (max grade: I=42, II=30, III=31, IV=6)(60% grade II–IV). Organs involved (%): skin (88), liver (42), gut (30). Median age was 38 (4–59), 58% pts were male, 62 transplants were HLA-identical sibling and 51 unrelated. 74 were T-cell depleted, 92 transplanted in CP1, 21 beyond CP1. Relapse was molecular in 19 pts, cytogenetic in 31, hematological in 49, accelerated or blastic in 12. Median initial cell dose was 107CD3+ cells/kg (0.01–32), median number of DLI was 1 (1–10). aGvHD was treated with prednisone in 92% of pts, CSA in 52 %, ATG and monoclonal antibodies in 2% and other in 19%. aGVHD resolved in 53% of the pts within a median of 63 d (7–546). 82/344 pts (24%) had chronic GVHD (cGVHD)(30 limited, 50 extensive, 2 not specified), of those 46 (56%) following aGVHD post DLI. Organs involved (%): skin (75), liver (35), lungs (13), mouth (43), eyes (22) and gut (5). Median age was 35 (6–58), 51% were male, stem cell source was PB in 15% and marrow in 85%, 43 underwent HLA-identical sibling HSCT and 39 unrelated donor HSCT. Forty-three were T-cell depleted, 66 transplanted in CP1, 16 beyond CP1. Relapse was molecular in 21 pts, cytogenetic in 29, hematological in 22, accelerated or blastic in 7. Median initial cell dose was 107 CD3+ cells/kg (0.05–40), median number of DLI was 1 (1–7). 61 pts are alive with a median follow-up of 50 mth. Treatment was with steroids in 83% of pts, CSA in 58 %, MMF in 20%, thalidomide in 15%, photopheresis in 15%, PUVA in 10% and other in 17%. cGVHD resolved in 39% of the pts within a median of 354 d (44–1588). The estimated 5-y OS post-DLI was significantly lower in pts who developed aGVHD post-DLI, 61 ± 10% vs 74 ± 7% in the one that did not, p=0.007 and also a tendency to have a lower 5-y EFS, 58 ± 10% vs 65 ± 7%, p=0.19. Median duration of response to DLI in aGVHD pts was 4 y. aGVHD post-DLI did not influence the relapse rate (5 ± 5% vs 6 ± 5% in the absence of aGVHD). 5-y DLI related mortality was significantly higher in aGVHD pts, 31 ± 8% vs 4 ± 4%, p<0.00001. On the other hand, pts that developed cGVHD post-DLI had a tendency to have a better 5-y OS and EFS, 74 ± 11% and 71 ± 11% respectively vs 69 ± 6% and 62 ± 7% in those that did not, p=0.32 and 0.09. This was related to a tendency to lower incidence of relapse, 2 ± 3% in pts with cGVHD vs 9 ± 6% without, p=0.2. DLI related mortality was not different, 11 ± 8% vs 10 ± 5%, p=0.77. aGVHD post-DLI for CML relapse is mainly of advanced stage and negatively influence OS and EFS with a higher DLI related mortality. cGVHD post-DLI is mainly extensive, but pts with cGHVD tend to have better outcome with better 5-y OS, EFS and less relapse than those without, although this was not statistically significant.

DLT has become the gold standard for the treatment of reccurrent CML after allogeneic stem cell transplantation. However, so far, published data are based on DLT following bone marrow transplantation (BMT). During recent years, mobilized peripheral blood stem cell transplantation (PBSCT) have been increasingly performed. To evaluate the efficacy of DLT following PBSCT, we retrospectively analysed the results of 86 patients treated with DLT for CML relapse after PBSCT from HLA-identical family donors. Results were compared to 260 patients receiving DLT for relapse after related BMT. Reduced intensity transplants were excluded.

Donor lymphocyte infusions (DLI) are an well established treatment for relapsed chronic myeloid leukemia (CML) after allogeneic stem cell transplantation. In a previous analysis including mainly patients receiving DLI from HLA-identical siblings (Guglielmi et al., Blood 2002), it could be shown, that it was of major prognostic significance to start with a low cell dose (≤ 0.2 x 108mononuclear cells/kg body weight).

Using data submitted to the EBMT registry, we analyzed outcome on 344 patients (pts) who had received donor lymphocyte infusions (DLI) for relapse after allogeneic hematopoietic stem cell transplantation (HSCT) for chronic myeloid leukemia (CML) in 31 centers. 113/344 pts (33%) developed acute graft-versus-host disease (aGVHD) a median of 50 days post DLI (max grade: I=42, II=30, III=31, IV=6)(60% grade II–IV). Organs involved (%): skin (88), liver (42), gut (30). Median age was 38 (4–59), 58% pts were male, 62 transplants were HLA-identical sibling and 51 unrelated. 74 were T-cell depleted, 92 transplanted in CP1, 21 beyond CP1. Relapse was molecular in 19 pts, cytogenetic in 31, hematological in 49, accelerated or blastic in 12. Median initial cell dose was 107CD3+cells/kg (0.01–32), median number of DLI was 1 (1–10). aGvHD was treated with prednisone in 92% of pts, CSA in 52 %, ATG and monoclonal antibodies in 2% and other in 19%. aGVHD resolved in 53% of the pts within a median of 63 d (7–546).