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Key Points The NGS-MRD assay detected clonotypic DNA in 100% of CSF samples from patients who had lymphoma with parenchymal CNS involvement.Clonotypic DNA in CSF was present in 36% of newly diagnosed aggressive lymphomas and was associated with a 29% risk of CNS recurrence., Visual Abstract, The diagnosis of parenchymal central nervous system (CNS) invasion and prediction of risk for future CNS recurrence are major challenges in the management of aggressive lymphomas, and accurate biomarkers are needed to supplement clinical risk predictors. For this purpose, we studied the results of a next-generation sequencing (NGS)–based assay that detects tumor-derived DNA for clonotypic immunoglobulin gene rearrangements in the cerebrospinal fluid (CSF) of patients with lymphomas. Used as a diagnostic tool, the NGS-minimal residual disease (NGS-MRD) assay detected clonotypic DNA in 100% of CSF samples from 13 patients with known CNS involvement. They included 7 patients with parenchymal brain disease only, whose CSF tested negative by standard cytology and flow cytometry, and 6 historical DNA aliquots collected from patients at a median of 39 months before accession, which had failed to show clonal rearrangements using standard polymerase chain reaction. For risk prognostication, we prospectively collected CSF from 22 patients with newly diagnosed B-cell lymphomas at high clinical risk of CNS recurrence, of whom 8 (36%) had detectable clonotypic DNA in the CSF. Despite intrathecal prophylaxis, a positive assay of CSF was associated with a 29% cumulative risk of CNS recurrence within 12 months of diagnosis, in contrast with a 0% risk among patients with negative CSF (P = .045). These observations suggest that detection of clonotypic DNA can aid in the diagnosis of suspected parenchymal brain recurrence in aggressive lymphoma. Furthermore, the NGS-MRD assay may enhance clinical risk assessment for CNS recurrence among patients with newly diagnosed lymphomas and help select those who may benefit most from novel approaches to CNS-directed prophylaxis.

Background: CNS invasion in aggressive lymphoma (including diffuse large B-cell [DLBCL], double-hit [DHL], Burkitt [BL] and plasmablastic lymphoma [PBL]) remains a major diagnostic and therapeutic challenge. Parenchymal CNS invasion requires a brain biopsy to diagnose, and conventional CSF evaluations lack sensitivity. Furthermore, determining which patients (pts) without CNS disease at diagnosis might be at high risk of future CNS relapse, and thus would most benefit from aggressive CNS prophylaxis, is difficult. Predictors that use clinical variables (e.g. the CNS-IPI) can select a high-risk group with ~10% risk of CNS relapse, but ~50% of events occur in low/intermediate-risk groups. We evaluated a novel CSF assay that detects clonotype-specific cell-free DNA (cfDNA) by next-generation sequencing (NGS) combined with multiplex PCR (Chang T et al, BMC Cancer 2020). This assay can identify minimal residual disease (MRD) in the plasma of pts with DLCBL and can predict systemic relapse (Roschewski et al, Lancet Oncol 2015). Methods: To examine the diagnostic sensitivity of the NGS-MRD assay in the CSF, we prospectively collected CSF from 6 pts with lymphomas who had known parenchymal or leptomeningeal CNS invasion. We also tested stored DNA from historical CSF samples of 8 pts with CNS lymphoma who tested negative by conventional IGH-PCR. We then enrolled 19 pts with newly diagnosed high-risk lymphomas without CNS invasion to examine the prognostic value of the NGS-MRD assay in the CSF collected at diagnosis. In the two-step assay, tumor-specific clonotype sequences were first identified from genomic DNA in primary tumor specimens using NGS of rearranged IGK, IGH (VJ or DJ), and IGL loci. Tumor-specific clonotypes were then selected for tracking in the CSF (split into acellular CSF fluid and cell pellet) and in paired plasma samples. The assay quantitated copy numbers of each tracked sequence per mL of acellular CSF or per 106 cells in the pellet, as well as tumor clonotype frequency (%) per all B-cells. Results: The NGS-MRD detected tumor-specific clonotype in 100% of CSF samples from pts with known CNS lymphoma (n=6; Fig A), including pts with isolated parenchymal-only CNS disease that was not detected by CSF cytology, flow cytometry, or IGH-PCR. For pts with CNS parenchymal disease, median cfDNA copy count in the CSF fluid was 2 /mL (range, 0.4-929) and median clonotype frequency was 9.0% (range, 0.03-68.9%). For pts with leptomeningeal disease, these values were 2233 /mL (1.2-5620) and 37% (1.7-98.4%), respectively (Fig. B). Furthermore, the NGS-MRD assay detected tumor clonotypes in DNA isolates from 6 historical CSF samples (collected in 2014-2018) of pts with known CNS disease, in which lymphoma was not detectable by conventional IGH-PCR (2 additional historical samples failed DNA quality check). Among 19 newly diagnosed pts with no known CNS invasion (median age 57, 42% women, median LDH 352 IU/L), 12 (63%) had DLBCL with high risk of CNS relapse by virtue of high CNS-IPI or epidural tumor, and 7 had other high-risk histologies (2 DHL, 2 BL, HIV+ PBL, and 2 lymphoblastic leukemias). The CSF NGS-MRD assay was positive for tumor-specific clonotype in 8 pts (42%). Median cfDNA copy count in the CSF fluid was 3 /mL (range, 0.9-15.6) and median clonotype frequency was 18.6% (range, 1.4-28.5%). We observed no significant correlation between the amount of cfDNA and number of red cells /mL of CSF (a measure of potential CSF contamination by blood during collection procedure; Fig. C) or between the amount of cfDNA in plasma and in CSF (Fig. D). With median follow-up of 11 months, no pts with negative baseline NGS-MRD assay in CSF relapsed, whereas 2 of 10 with a positive assay had a CNS relapse (12-month incidence, 29%; Fig. E), despite both pts having negative CNS imaging, CSF cytology, flow cytometry, and IGH-PCR at diagnosis. Conclusions: In this proof-of-concept study, the NGS-MRD CSF assay showed 100% sensitivity for diagnosing intraparenchymal CNS invasion in aggressive lymphomas that were not detected in the CSF using conventional methods. In a prospective cohort of newly diagnosed pts without baseline CNS invasion but at high clinical risk for CNS relapse, the assay identified lymphoma-derived cfDNA in 42% of cases. The 100% sensitivity and 100% negative predictive value of the assay for subsequent CNS relapse warrants further prospective evaluation as a potential tool for personalizing CNS-directed prophylaxis. Disclosures Olszewski: Spectrum Pharmaceuticals: Research Funding; TG Therapeutics: Research Funding; Adaptive Biotechnologies: Research Funding; Genentech, Inc.: Research Funding. Mullins:Adaptive Biotechnologies: Current Employment, Other: shareholder.

Clinical trials comparing bendamustine/rituximab (BR) with cyclophosphamide-based regimens (RCHOP/RCVP) have pooled various histologies of indolent B-cell lymphomas. We examined real-life outcomes of older patients with follicular (FL), mantle cell (MCL), or marginal zone/lymphoplasmacytic lymphoma (MZL/LPL), treated with these first-line regimens. We identified Medicare beneficiaries with FL, MCL, or MZL/LPL, who received either first-line BR or RCHOP/RCVP in 2009-2016, and matched groups using a propensity score. Outcomes of claims-based event-free survival (EFS), overall survival (OS), toxicity, secondary cancers, and costs were compared in the aggregate cohort (N = 2736), and in separately matched histology-specific subcohorts. In the aggregate cohort, EFS was better with BR than with RCHOP/RCVP (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.70-0.87). Acute toxicity was lower with BR, including rates of hospitalizations (33% vs 45%), infections (21% vs 30%), cardiovascular events, and transfusions, yet OS did not differ (HR, 1.03; 95% CI, 0.91-1.17) and Medicare spending was higher. There was no difference in the cumulative incidence of secondary cancers (subhazard ratio, 1.11; 95% CI, 0.83-1.48). The EFS advantage of BR was pronounced in MCL (N = 690; HR, 0.64; 95% CI, 0.54-0.76), but less so in FL (N = 1330; HR, 0.83; 95% CI, 0.69-0.98) and absent in MZL/LPL (N = 574; HR, 0.92; 95% CI, 0.73-1.17). Despite improved EFS and lower toxicity, the shift from RCHOP/RCVP to BR in clinical practice did not improve OS for older patients with indolent B-cell lymphomas. Frequent infections and hospitalizations underscore the need for safer treatment approaches in this population. Secondary cancers do not appear to be increased after BR compared with RCHOP/RCVP.

Induction chemotherapy for acute myeloid leukemia (AML) is based on the "7+3" cytarabine/anthracycline regimen. A nonhypocellular day 14 (D14) bone marrow sample with a blast count5% to 10% is suggestive of residual leukemia, for which a second course of induction chemotherapy has been recommended. Although the prognostic value of D14 bone marrow findings has been established, its use as a decision point is controversial because the benefit of repeat induction has been questioned.In the present single-center retrospective study of 113 patients with newly diagnosed AML, we evaluated the role of cellularity on the clinical outcomes of patients with residual morphologic leukemia (blasts ≥ 5%). Among 64 patients with D14 bone marrow samples, 31 had residual morphologic leukemia.The complete remission (CR) rates were greater for the hypocellular (11 of 16) than for the nonhypocellular (4 of 15) patients (P = .03). The median overall survival (OS) for the hypocellular D14 patients was longer than that for the nonhypocellular patients (17 vs. 8 months; P = .02). No significant difference between the receipt of reinduction therapy and CR or OS was found on logistic or survival model analysis. The specificity for residual leukemia on D14 bone marrow samples was better for cellularity ≥ 20% and blasts ≥ 20% than for blasts ≥ 5%.The results of our study have shown that patients with 20% cellularity and 20% blasts on the D14 bone marrow assessment should continue observation until recovery rather than receive additional immediate therapy.

Microchimerism has generally been shown to protect against cancer (Gilmore et al. in Exp Hematol 36(9):1073-1077, 2008). The mechanism of how this occurs is an area of intense study, as it may lead to new cancer treatments. The leading theory is that microchimeric cells perform immune surveillance by directly fighting cancerous cells and that they also act as stem cells, repairing damaged tissue (Khosrotehrani et al. in JAMA 292:75-80, 2004). However, there is conflicting evidence to support this theory. Several small studies have found few microchimeric cells in tumor tissue (Gadi in Breast Cancer Res Treat 121(1):241-244, 2010; Cirello et al. in Int J Cancer 126:2874-2878, 2010), while another study contradicted these findings by showing microchimeric cells clustered around tumor tissue (O'Donoghue et al. in Reprod Biomed Online 16:382-390, 2008). To date, we have designed the largest and broadest study to investigate this question of whether microchimeric cells really do cluster at tumor tissue. We analyzed 245 samples from a broad range of cancer types. Using PCR for the male chromosome marker TSPY1, we identified only 12 out of 245 samples with microchimerism for a rate of 4.9% (95% confidence interval 2.2-7.6%). Five of these samples were confirmed using Y fluorescence in situ hybridization. This rate of 4.9% microchimerism is the lowest reported in any study. The low percentage of microchimerism observed in our broad study suggests that microchimeric cells do not invade tumors to fight off neoplasm.

Background: Allogeneic stem cell transplant (allo-SCT) is a cornerstone in the treatment of Acute Myeloid Leukemia (AML) exerting much of its therapeutic efficacy through the graft-versus-leukemia effect. The administration of immunoregulatory cells via engrafted donor lymphocytes is essential to the eradication of residual malignancy and long-term survival. Many patients, however, either do not have an allo-SCT donor or cannot withstand the toxicity of allo-SCT. Previous studies have shown durable responses in AML patients following donor lymphocyte infusions in the absence of engraftment in both the frontline and relapsed setting (Dey et al, BJH 2005, Colvin et al, BBMT 2009, Ai et al, Blood 2010). In this clinical trial we propose a role for donor leukocyte infusions (DLI) in the absence of engraftment. Without the need for engraftment patients will not need to receive high dose chemotherapy or radiation and the toxicities that accompany these therapies. Instead, allogeneic donor cells are infused into patient with relapsed/refractory (R/R) AML to serve as a potent immune stimulator. Prior to DLI, patients will receive fractionated dosing of gemtuzumab ozogamicin (GO). GO is an anti-CD-33 antibody drug conjugate approved in combination with induction therapy for de novo AML and in R/R disease. Patients who demonstrate a CR or CRi to therapy will go on to have up to 2 additional GO + DLI treatments. Bone marrow and blood samples will be obtained from patients before, during, and after treatment to determine immune effector cells (both donor and patient), cytokine release profiles, and extracellular vesicle components. Study Design and Methods: Our study, BrUOG 345 [NCT03374332], evaluates the combination of fractionated GO with non-engraftment DLI in the treatment of patients with R/R AML. Adults patients 18 years of age and older with histologically confirmed R/R AML who have had recurrence or progression after at least 1 prior standard treatment are eligible. Enrollees must have no active systemic infections and have adequate lung, liver, cardiac, and renal function with an ECOG PS 0-1. Fractionated GO 6-9mg/m2 will be administered on days 1, 4, and 7 followed by infusion of 1-2x108 CD3 cells/kg from a 0-3/6 HLA mismatched related donor cell. Patients that are in CR or CRi can receive up to 2 additional treatments with GO+DLI (Figure 1). The primary objective of the phase 1 portion is to determine the maximum tolerated dose (MTD) of DLI in combination with GO while the primary objective of Phase 2 portion is to assess the response rate after one cycle of fractionated GO followed by non-engraftment DLI in patients with relapsed/refractory AML. The study will initially utilize a 3+3 design in Phase 1 to determine if 1-2x108 CD3 cells/kg can be safely administered with GO. This study will target a response rate of 57% considered to be interesting enough to warrant further study in a randomized setting. With this hypothesis in mind, the phase 2 portion of the study will use Simon's two-stage design. The null hypothesis that the true response rate (CR and CRi) is only 29% will be tested against a one-sided alternative. In the first stage, 9 subjects will be accrued. Patients treated at MTD in the Phase 1 portion of the study will be included in this cohort. If there are 3 or fewer responses in these 9 patients, the study will be stopped for futility. Otherwise, 6 additional subjects will be accrued for a total of 15. The null hypothesis will be rejected if 7 or more responses are observed in 15 patients. This design yields a type I error rate of 0.1 and power of 80% if the true response rate is 57%. A continuous assessment of toxicity will be utilized for the Phase 2 portion of this study. Sequential boundaries will be used to monitor dose-limiting toxicity rate for patients after the initial MTD is determined. Accrual will be halted if excessive numbers of dose-limiting toxicities are seen. The primary outcome of the Phase 2 portion is the CR/CRi rate following GO and non-engraftment DLI. Secondary outcomes will include survival, both progression-free (PFS) and overall (OS) until two years post treatment, and dose limiting toxicities until 16 weeks post-infusion. Additional lab correlative studies will be performed including CD33 expression before, during, and after GO infusion and T-cell activation markers, antigen presenting cell/macrophage amounts, cytokine release profiles, and extracellular vesicle measurements (Figure 1). Disclosures Olszewski: TG Therapeutics: Research Funding; Spectrum Pharmaceuticals: Research Funding; Adaptive Biotechnologies: Research Funding; Genentech: Research Funding. Reagan:Pfizer: Research Funding; Incyte: Membership on an entity's Board of Directors or advisory committees.

Background: CNS involvement in aggressive lymphomas (including diffuse large B-cell lymphoma, DLBCL) is associated with poor survival, requiring aggressive CNS-directed therapy to avert dismal outcomes. Early detection of clinically occult CNS invasion is thus critical. Clinical risk factors have low specificity to select patients for CNS prophylaxis, and routine evaluations of the CSF by cytology or flow cytometry have low sensitivity (Doolittle et al., Blood 2008). Moreover, most CNS recurrences of DLBCL occur in the brain parenchyma and remain occult on CSF examination. There is a high unmet need for an accurate method to identify subclinical CNS invasion and help non-invasively diagnose parenchymal disease. Clonotype-specific cell-free DNA (cfDNA) can be detected in the plasma of patients with DLBCL using high-throughput sequencing (HTS) combined with multiplex PCR, and cfDNA reappearance after therapy precedes systemic recurrence (Roschewski et al., Lancet Oncol. 2015). However, clonotypic cfDNA has not been systematically evaluated in the CSF compartment. Because of the blood-brain barrier that isolates CSF from plasma, clonotypic cfDNA might hold promise as a sensitive method of CNS lymphoma detection. Therefore, we sought to evaluate the ability of HTS-based cfDNA assay in the CSF to detect CNS invasion. Methods: We collected CSF samples from consenting patients with aggressive lymphomas who either had clinically overt CNS disease, or who were newly diagnosed and without evident CNS disease, but at high clinical risk. Genomic DNA from primary tumors (formalin-fixed paraffin-embedded [FFPE] tissue; Fig. A) was analyzed for tumor-specific clonotype using a quantitative HTS of rearranged IGK, IGH (VJ or DJ), or IGL loci, as previously described (Carlson CS et al., Nat Commun. 2013). Clonotypes in each primary tumor were selected for subsequent tracking in the CSF based on frequency relative to other B cells and all nucleated cells, as well as distribution. HTS of B-cell receptor (BCR) was performed on 5 mL CSF centrifuged at 1000x for 5 min at 4°C and separated into acellular portion for cfDNA, and a cell pellet suspension. Clonotype copy numbers are expressed per mL for acellular fluid, and per 106 cells for cell pellets. Results: The HTS assay identified median 3 (range, 2-6) dominant immunoglobulin sequences in each primary FFPE lymphoma sample (N=9), with median dominant clonotype frequency 39.0% (range, 22.0-97.9%) and median copy count 753,618 per 106 cells (range 47,455-1,407,748). In the CSF, the HTS/ASO-PCR assay detected the dominant clonotype in 5 out of 9 samples (Table), including all cases (N=3) with overt CNS disease, and 2 without known CNS invasion (sensitivity=100% and specificity=67% for clinically overt disease). Of note, the cfDNA assay detected tumor-specific clonotype in the CSF of a patient with primary CNS lymphoma (PCNSL) who had negative CSF evaluations by flow cytometry and IGH PCR. In the cell-free CSF, median detectable cfDNA clonotype copy count was 1,649/mL (range, 2-5,620), and in the CSF cell suspension it was 389,558 per 106 cells (range, 10,373-1,181,171). Copy counts were significantly higher (P=.004 for cfDNA in CSF fluid, P=.004 for cell suspension) in patients with overt leptomeningeal involvement (positive CSF cytology) than those with parenchymal or clinically occult disease (Fig. B). The 2 cases with positive CSF cfDNA but negative clinical staging and CSF cytology were notable for high risk of CNS dissemination due to ruptured epidural tumor with spinal cord compression, or double-hit histology (MYC-IGH and BCL2-IGH rearrangements) with extensive extranodal invasion of kidneys, pleura, and liver. Both patients were recommended CNS-directed prophylaxis based on clinical risk. Conclusions: HTS of BCR loci in the CSF of patients with aggressive lymphomas can identify intraparenchymal CNS or leptomeningeal disease with high sensitivity. More importantly, it can detect intraparenchymal involvement not identifiable using traditional means of CSF analysis (flow cytometry, standard IGH PCR). Detection of cfDNA in CSF of some high-risk patients without overt CNS disease will be further explored in a larger sample. It suggests that pre-treatment HTS of BCR loci could be prospectively tested to predict the risk of CNS recurrence, with a future potential to enable more sensitive and specific selection of patients for CNS prophylaxis therapy. Disclosures Olszewski: Spectrum Pharmaceuticals: Research Funding; TG Therapeutics: Research Funding; Adaptive Biotechnologies: Research Funding; Genentech: Research Funding. Reagan:Incyte: Membership on an entity's Board of Directors or advisory committees; Pfizer: Research Funding. Mullins:Adaptive Biotechnologies: Employment.

Little is known on racial differences in patients with diffuse large B-cell lymphoma (DLBCL). The aim of this retrospective study is to compare characteristics, prognostic factors and outcomes of Asian and Western patients with DLBCL treated with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP).Patient-level data was collected from 8 centers. All patients were diagnosed with DLBCL and treated with R-CHOP. Patients were divided into Asian and Western, according to the country of report. Comparisons and univariate/multivariate survival analyses were performed.712 patients, 455 Asian and 257 Western patients were included. Westerners were more likely to present with elevated LDH (64% vs. 48%, p0.01) and advanced stage (58% vs. 49%, p0.01). After a median follow-up of 36 months, there was no difference in progression-free (PFS; p=0.33) or overall survival (OS; p=0.69). There were no PFS or OS differences between races when evaluating separately each age-adjusted International Prognostic Index category. In the multivariate analyses, performance status and stage were associated with PFS and OS in both races.There are no differences in prognostic factors, PFS and OS between Asian and Western patients with DLBCL treated with R-CHOP.

Our objective was to evaluate the non-germinal center (GC) profile as a marker for response and survival in DLBCL and to compare the characteristics of patients with GC and non-GC DLBCL treated with rituximab-containing regimens. In this patient-level meta-analysis, retrospective data from 712 newly diagnosed DLBCL patients treated with chemoimmunotherapy from 7 centers were analyzed. GC and non-GC profiles were defined according to the Hans algorithm. Although the non-GC profile showed a trend towards worse overall survival (HR 1.24, 95% CI 0.92-1.66; p=0.15) and progression-free survival (HR 1.29, 95% CI 0.96-1.73; p=0.09), it did not retain its value in the multivariate survival analysis. Additionally, the non-GC profile was independently associated with worse complete response rates (OR 0.55, 95% CI 0.37-0.83; p

Abstract 4765 BACKGROUND Gemcitabine induces a 20% response as single agent therapy in patients with relapsed or refractory NHL. We report phase I findings of gemcitabine in combination with standard CHOP chemotherapy with G-CSF support for intermediate grade NHL. The protocol was modified during enrollment to include rituximab in CD 20+ lymphomas. METHODS Patients received CHOP plus gemcitabine at 500 mg/m2 (Cohort 1) or 750 mg/m2 (Cohort 2) on days 1,4 of each 21 day cycle. Accrual was suspended once each cohort was filled. Dose escalation occurred after all patients in the cohort were determined to not have a dose limiting toxicity. RESULTS Between 4/02 and 5/04 10 patients were enrolled and completed the study treatment (6 in cohort 1, 4 in cohort 2). In Cohort 1, grade 3 toxicities included neutropenia, anemia, neuropathy, and constipation. Grade 4 toxicities were febrile neutropenia, and thrombocytopenia. In Cohort 2, grade 3 toxicities included neutropenia, thrombocytopenia, mucositis, anemia and intestinal obstruction. Grade 4 toxicities included febrile neutropenia, neutropenia, and thrombocytopenia. One patient developed MDS 36 months after chemotherapy. Three of four patients in Cohort 2 developed dose limiting toxicities (mucositis and thrombocytopenia) requiring dose reduction of gemcitabine after cycle 1. Overall, the survival rate at 2.5 years was 71%. CONCLUSIONS This Phase I trial concludes that gemcitabine 500mg/m2 on days 1 and 4 of each 21 day cycle is the maximum tolerated dose when combined with standard CHOP chemotherapy with G-CSF support for intermediate grade NHL. Response rates are encouraging for this novel chemotherapeutic regimen. Disclosures: Off Label Use: Gemcitabine was added to standard CHOP chemotherapy in this trial.. Sikov:Eli Lilly: Honoraria.

EBV-positive diffuse large B-cell lymphoma (DLBCL) of the elderly is an entity recently included in the WHO classification of lymphoid tumors. We have reviewed our experience and clinical outcomes of this distinct subtype of DLBCL. Between 2002 and 2009, cases of DLBCL were identified from medical records of the Hospital Nacional Edgardo Rebagliati Martins in Lima, Peru, and underwent pathological evaluation including immunohistochemistry for CD20, CD10, bcl-6, MUM1/IRF4, and EBV-encoded RNA in situ hybridization. Clinical data were gathered, tabulated, and reported descriptively. Survival analyses were performed using Kaplan-Meier estimates. Out of 199 cases of DLBCL, 28 cases of EBV-positive DLBCL of the elderly were identified. The median age was 75 years with male predominance (1.5:1). B-symptoms were present in 43%, advanced stage in 50% and International Prognostic Index (IPI) score > 2 in 57% of patients; 68% of patients had a nongerminal center (NGC) phenotype. The complete response rates to R-CHOP and CHOP were 63% and 33%, respectively. The median overall survival (OS) for the group was 5 months. In the univariate analysis, age ≥70 years, lymphocyte count

Plasmablastic lymphoma (PBL) is an aggressive variant of non-Hodgkin lymphoma initially reported in the oral cavity of HIV-positive individuals. Since its original description, several cases have been reported in patients who do not have HIV infection. However, despite its recognition as a distinct subtype of diffuse large B-cell lymphoma several years ago, comprehensive reviews of this entity are lacking. A MEDLINE search through June 2010 was performed to identify cases with a pathologic diagnosis of HIV-negative PBL based on morphology and minimal immunohistochemical criteria. Our study included a total of 76 cases. The median age was 57 years (range, 1 to 90 years) with a male-to-female ratio of 1.7. Seventy-four percent of cases did not have an apparent association with immunosuppression, 18% had a concurrent lymphoproliferative or autoimmune disorder and 9% developed PBL after solid organ transplantation. Oral involvement was observed in 21%, advanced stage in 60%, Epstein-Barr virus-encoded RNA expression was positive in 45% and Ki-67 expression of greater than or equal to 80% in 61% of the cases. Chemotherapy was documented in 43 patients, from which 43% received the cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP)-like regimens. The median and the 2-year overall survival for the whole group were 9 months and 10%, respectively. Patients who had HIV-negative PBL have distinct clinicopathological characteristics, such as short overall survival and lower rates of oral involvement and Epstein-Barr virus-encoded RNA expression than the previously reported in HIV-positive patients.

Background: Recent studies (Coombs et al., Cell Stem Cell 2017) have identified presence of clonal hematopoiesis of indeterminate potential (CHIP) in samples of solid tumors. CHIP is more prevalent among cancer survivors who subsequently develop therapy-related myeloid neoplasm (Gillis et al., Lancet Oncol 2017; Takahashi et al., Lancet Oncol 2017; Gibson et al., J Clin Oncol 2017). However, the relationship between CHIP and exposure to myelotoxic chemotherapy delivered as part of treatment for solid tumor is uncertain. We hypothesized that CHIP is more prevalent among recipients of myelotoxic chemotherapy compared with age-matched population. Methods: In this prospective, cross-sectional study, we collected peripheral blood samples from survivors of breast cancer or lymphoma who had received anthracycline- and/or alkylator-containing chemotherapy as part of their curative cancer therapy. All subjects had to be clinically free of cancer, and not have any hematologic disorders or unexplained cytopenias. We recruited patients age 50 to 70, because according to published population datasets (Jaiswal et al. and Genovese et al., NEJM 2014) in a cohort with mean age of 60 the expected CHIP prevalence would be about 5%. To minimize any potential contamination by circulating tumor cells, we isolated genomic DNA from purified CD45+ cells. We determined presence of CHIP by next-generation sequencing using an Illumina TruSeq Custom Amplicon kit (MiSeq V2.2). The assay targeted 757 coding exons of 96 genes commonly mutated in hematologic malignancies, including 20 CHIP-defining genes. To establish presence of CHIP, we required a known pathogenic variant with variant allele fraction (VAF) ≥ 2%. According to a pre-specified statistical plan, assuming one-sided alpha of 0.05, the study had 80% power to reject the null hypothesis of baseline CHIP prevalence of 5% in a cohort with sample size of 80. Results: Among 80 enrolled subjects, median age was 62 years (interquartile range, 56-67). There were 78% women, and 88% of subjects were white non-Hispanic. Patients had received doxorubicin- and/or cyclophosphamide-containing adjuvant or curative chemotherapy for breast cancer (56%) or lymphoma (44%). Median time from completion of chemotherapy to enrollment was 27 months (interquartile range, 11-59). We have completed sequencing of 72 samples (updated analysis will be provided at the meeting). Mean coverage depth was 1418x (±224), and ≥200x coverage was achieved in a mean 91.4% (±1.8%) of target amplicons. We detected CHIP in 12 subjects (17%; binomial 95% confidence interval: 10-27%; P=.0002 for the null hypothesis test of 5% prevalence). Mean VAF for the CHIP mutations was 5.3% (range, 1.4% to 29.9%), and patients had up to 4 CHIP-associated mutations (Fig. A). The CHIP-associated mutations had a typical distribution with most common mutations in DNMT3A, ASXL1, SRSF2, and TET2 (Fig. B). There was only 1 TP53 mutation, previously suggested to associate with exposure to chemotherapy (Coombs et al., 2017). Potentially germline variants of unknown significance (VUS) were found in 78% of patients, at mean VAF 49% (Fig. C), most commonly in ATM (12%), NOTCH2 (7%), BCORL1, and DNMT3B (6% each). Additionally, 2 patients had low-VAF variants suspicious for CHIP: ATM c.6059G>A (3.0%); PRPF8 c.790T>C (VAF 2.3%). Presence of CHIP was not significantly associated with age (within the narrow age range in the study cohort), sex, race, type of cancer (breast or lymphoma), count of white cells, red cells, platelets, or time elapsed from completion of chemotherapy. Conclusions: We have detected a significantly increased, more than 3 times the expected value, prevalence of CHIP among cancer survivors who had received myelotoxic chemotherapy. However, the distribution of mutations was typical for CHIP, without previously suggested over-representation of TP53. Further research is ongoing to determine whether presence of CHIP is related to a direct mutagenic effect of chemotherapy or competitive advantage of pre-existing CHIP clones after the hematopoietic stress of chemotherapy. Our data indicate that an affordable next-generation sequencing screen may be useful for detection of CHIP in cancer patients who are planning adjuvant chemotherapy, or as a surveillance tool after such therapy, to predict the risk of a therapy-related myeloid neoplasm and optimize personalized treatment strategies. Disclosures Olszewski: TG Therapeutics: Research Funding; Genentech: Research Funding; Spectrum Pharmaceuticals: Consultancy, Research Funding. Kim:Aushon Biosciences: Consultancy; LabCorp, Inc.: Consultancy; Papgene, Inc: Consultancy. Fenton:Astellas Pharma US: Other: Spouse employment. Reagan:Alexion: Honoraria; Takeda Oncology: Research Funding; Pfizer: Research Funding.

Background Acute T-cell leukemia/lymphoma (ATLL) is a post thymic (peripheral) T-cell neoplasm caused by human T-cell lymphotropic virus type 1 (HTLV-1). Historically, the chemotherapy regimen CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) has been the standard treatment of this rare malignancy. However, its prognosis is poor and median survival in the aggressive variants of ATLL is only 6-10 months. Recently, a more aggressive regimen piloted in Japan, vincristine/cyclophosphamide/doxorubicin/prednisone (VCAP)- doxorubicin/ranimustine/prednisone (AMP)- vindesine/etoposide/carboplatin/prednisone (VECP), has been reported to yield better survival results over biweekly CHOP in a phase III trial. However, the hyper- cyclophosphamide/vincristine/doxorubicin/dexamethasone (CVAD) regimen is a much more frequently used regimen for the treatment of aggressive hematologic malignancies, and has a higher intensity then CHOP. Yet, there is little reported experience with hyper-CVAD regimen in ATLL. Case Reports We present 2 patients diagnosed with ATLL who were treated with hyper-CVAD chemotherapy and have achieved a durable complete remission. One of the patients has gone on to receive an allogeneic bone marrow transplantation and has been in complete remission for over 18 months. The other has been in a continuous remission for approximately 12 months. We also review the past published experience with the hyper-CVAD regimen in patients with ATLL. Conclusion A commonly used chemotherapy regimen for aggressive hematologic malignancies, hyper-CVAD, can induce durable remissions in patients with ATLL.

Until recently, warfarin has been the primary treatment of venous thromboembolism (VTE). Limited data are available regarding physician attitudes toward anticoagulant choice in the setting of novel oral anticoagulant (NOAC) availability. This study sought to evaluate attending physician attitudes toward NOACs. A survey was sent to attending physicians from internal medicine (primary care and hospitalist medicine), family medicine, cardiology, and hematology-oncology asking about their preference and reasoning for choice of oral anticoagulant for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE). Warfarin was the most common choice of initial treatment of both DVT (85.6%) and PE (89%). Among the specialties surveyed, cardiologists were more likely to use rivaroxaban as initial treatment of VTE as compared to other specialties including internal medicine or hematology (p=0.011 for DVT and 0.004 for PE). Cost-effectiveness and lack of a reversal agent were cited as the major disadvantages for NOAC use.

Spontaneous remission of chronic lymphocytic leukemia (CLL) is an unusual and poorly characterized event. We performed a search for spontaneous remission in patients with CLL. Cases must have had a pathological diagnosis of CLL with disease duration6 months. Spontaneous remission was defined as absence of lymphadenopathy or splenomegaly with lymphocyte counts5 × 10(9)/L for9 months without therapy. We identified 20 cases and included one additional case from our institution. Fourteen cases (67%) showed remission into monoclonal B lymphocytosis (MBL) and seven (33%) into a normal phenotype. There was no difference in age distribution, lymphocyte count or stage between groups. There was a significant difference in the median duration of CLL prior to remission, 13 years in the MBL versus 3 years in the normal phenotype group (p = 0.03). This difference in the duration of CLL prior to remission could be due to a possible distinct pathophysiology for these events.

Primary effusion lymphoma (PEL) is a rare lymphoma associated with Kaposi sarcoma-associated herpesvirus (KSHV), also known as human herpesvirus 8 (HHV8), and characterized by a malignant body cavity effusion without solid organ or nodal involvement. Prognostic factors in patients with PEL have not been systematically studied. We conducted a literature search for patients with HHV8-positive PEL to identify potential prognostic factors for survival. Our search identified 147 patients, among which 104 patients were HHV8-positive. The median overall survival was 9 months. The median age was 57 years with a male predominance (6:1). Pathologically, 33% of the patients expressed CD20 and 69% expressed CD30. Patients with PEL with1 body cavity involved had a median overall survival (OS) of 4 months compared with 18 months in patients with only one cavity involved (p = 0.003). Additionally, in patients with one involved body cavity, pericardial involvement was associated with a longer median OS than pleural followed by peritoneal involvement (40, 27 and 5 months, respectively; p = 0.04). In conclusion, our study suggests that the number and location of body cavities involved are prognostic in patients with PEL.

Much of the therapeutic benefit of allogeneic transplant is by a graft versus tumor effect. Further data shows that transplant engraftment is not dependant on myeloablation, instead relying on quantitative competition between donor and host cells. In the clinical setting, engraftment by competition alone is not feasible due to the need for large numbers of infused cells. Instead, low-level host irradiation has proven to be an effective engraftment strategy that is stem cell toxic but not myeloablative. The above observations served as the foundation for clinical trials utilizing allogeneic matched and haploidentical peripheral blood stem cell infusions with minimal conditioning in patients with refractory malignancies. Although engraftment was transient or not apparent, there were compelling responses in a heavily pretreated patient population that appear to result from the breaking of tumor immune tolerance by the host through the actions of IFNγ, invariant NK T cells, CD8 T cells, NK cells, or antigen presenting cells.

Adult T-cell leukemia/lymphoma is a T-cell malignancy caused by the human T-cell lymphotropic virus type 1. The aggressive forms of the disease carry a poor prognosis with standard therapies. The role of high-dose treatment with blood and marrow transplantation has, therefore, been examined mainly by Japanese groups in the form of retrospective studies. In this study, we review the literature, discuss some of the challenges facing successful transplantation approaches and stress the need for more innovative studies including in the Western hemisphere.

Plasmablastic lymphoma (PBL) is a distinct variant of diffuse large B-cell lymphoma initially described in HIV-positive patients. Several studies have reported the occurrence of PBL in HIV-negative patients, but comparative data are lacking. The goal of this study was to compare the characteristics of HIV-positive and HIV-negative patients with PBL. A MEDLINE search was undertaken through August 2009 for cases of PBL in HIV-positive and HIV-negative patients. Cases were identified and clinicopathological data were gathered. χ(2) was used to compare categorical and t-test to compare continuous variables between groups. Calculated Kaplan-Meier survival estimates were compared using the log-rank test. Cox proportional-hazard regression was used for multivariate analysis. From 228 identified cases of PBL, 157 were HIV-positive and 71 HIV-negative. HIV-positive patients were younger, and more likely to be men, present with oral involvement, respond to chemotherapy, and express CD20, CD56, and EBV-encoded RNA than HIV-negative patients. In univariate analysis, age ≥60, advanced stage, bone marrow involvement, no chemotherapy, Ki-67 expression80%, and HIV-negative status were associated with worse overall survival. In multivariate analysis, advanced stage and no chemotherapy were independent adverse prognostic factors. In conclusion, HIV-positive and HIV-negative patients with PBL have different clinicopathological characteristics, including a better response to chemotherapy and longer survival in HIV-positive patients.

Medical oncologists often must deliver bad news. The authors were interested in the extent of formal training in delivering bad news in hematology/oncology fellowships in the United States.An e-mail survey was sent to all hematology/oncology fellowship program directors in the United States. Surveys were e-mailed to 124 program directors and responses were received either via e-mail or regular mail. Program directors were asked the adequacy, the perceived necessity, the quality of this training, and the institutional support provided. It was also intended to elicit responses about the degree of formal training fellows receive in delivering bad news. chi(2) Statistics were used to perform comparisons between items; p values of less than 0.05 were considered statistically significant.Sixty-five surveys were completed and returned (52% response rate). The majority of programs, 82%, are in urban areas and 97% of the primary teaching hospitals are considered tertiary care centers and 46% of programs carry a National Cancer Institute (NCI) designation. Median number of fellows in a training program is 6 with the range being 3 to 46. Eighty-nine percent of program directors reported that they themselves received little to no formal training in delivering bad news, but they report 37% of current fellows receive little to no formal training with 40% receiving some training and additional 23% receiving moderate to extensive training (p0.001). Sixty-three percent of program directors felt that extensive, formal training is important for skill development in delivering bad news, while an additional 34% felt that some training is useful. Only 3% of respondents did not believe any training is needed. Seventy-six percent of program directors want improvements in how their fellows are trained, but 43% reported little to no institutional support for training (p0.001).Of the program directors who responded to our survey, a large majority did not have formal training in delivering bad news. Despite this lack of training, most program directors felt that training was useful for skill development in delivering bad news. The majority of today's fellows do receive training in delivering bad news. However, there was still a significant percentage of program directors who reported little or no formal training for fellows. Most program directors would like to see improvements in how fellows are trained. Specific institutional support for training fellows in delivering bad news remains lacking.

BACKGROUND: A case of donor cell leukemia (DCL) is reported. A 42-year-old female developed acute myeloid leukemia (AML) of donor cell origin 18 months after a bone marrow transplant (BMT) from her brother. At the time DCL presented, the donor-brother was also diagnosed with AML showing identical cytogenetic abnormalities. The classification of DCL and recommendations for laboratory testing of potential hematopoietic stem cell (HSC) donors are discussed. STUDY DESIGN AND METHODS: Marrow specimens were obtained from the posterior iliac crest and analyzed using standard techniques. Leukemic cells were analyzed by flow cytometry. Karyotyping and fluorescence in situ hybridization were performed using standard methods. RESULTS: The recipient-sister's original diagnosis was erythroleukemia. Chromosome analysis showed a 46,XX,t(3;5)(q25;q34) karyotype. Both the recipient's new AML and the donor's AML showed an identical karyotype: 46,XY,inv(3)(q21q26),-7. Both patients were resistant to therapy and died. CONCLUSION: The clinical and biological aspects of DCL are discussed including the distinction between transformation of healthy donor cells to leukemic cells and transmission of preformed leukemic cells. The former represents almost all the reported cases of DCL compared with transmission of leukemic cells from donor to recipient. With an aging donor population, it is estimated that the latter will increase. Increased testing of older donors to include routine morphologic study of blood and marrow, cytogenetic studies, and evaluation for clonal lymphoproliferative disorders is recommended.

Acute myeloid leukemia (AML) is a heterogeneous disease with outcomes dependent upon several factors, including patient age, karyotype, mutational status, and comorbid conditions. For younger patients, approximately 60% to 80% achieve complete remission with standard therapy involving cytarabine and an anthracycline. However, only 20% to 30% have long-term disease-free survival. For adults older than 60 years of age, only 40% to 55% achieve a complete remission, with dismal long-term survival rates. Unfortunately, the median age at diagnosis for AML is 70 years. Significant advances in our understanding of the molecular biology of AML have led to newer therapies that specifically target molecular abnormalities. Examples of such therapies include the immunoconjugate gemtuzumab ozogamicin, FMS-like tyrosine kinase 3 inhibitors, farnesyl transferase inhibitors, histone deacetylase inhibitors, DNA hypomethylating agents, multidrug-resistance inhibitors, BCL-2 inhibitors, antiangiogenesis agents, and various nucleoside analogs. This review summarizes the standard treatments for AML and discusses the role of novel therapies.

Allogeneic stem cell transplantation (allo-SCT) is an effective treatment modality for acute myeloid leukemia (AML) that exerts its therapeutic benefit via a graft versus leukemia effect.1 Its applicability is limited by toxicity from preconditioning chemoradiation in addition to the threat of graft versus host disease, which precludes many patients with AML from receiving this definitive consolidative therapy.2 Previously, we have shown an ability to generate responses, some of which were complete, in patients with relapsed/refractory AML using haploidentical donor lymphocyte infusions in the absence of engraftment.3 We present data from our FDA-approved Phase II clinical trial (BrUOG H-273, IND 015008, NCT01685606) in which haploidentical allogeneic cells are infused. Unlike our previous trial these cellular infusions occur without granulocyte colony stimulating factor (G-CSF) mobilization or preconditioning low-dose total body irradiation (TBI). The goal is to generate a robust allogeneic response that breaks host tumor tolerance without the toxicity profile seen with allo-SCT. This trial was approved by the Rhode Island Hospital Institutional Review Board. Eligible patients had relapsed or refractory AML without curative options. Family members who were human leukocyte antigen (HLA) haploidentical donors at the A/B/DR loci were identified. Both patients and donors were consented. Donors then underwent leukapheresis without stem cell mobilization. In all, 1–2 × 108 CD3+ cells/kg were infused unprocessed immediately following collection. Peripheral blood samples were collected on days 2, 7 and 14 post-cellular infusion for short tandem repeat chimerism analysis. Additional peripheral blood samples were collected pre-infusion as well as at 0–4, 8–24, 34–48, 72–96 and 168–192 h post infusion to evaluate recipient effector cells and cytokine release profiles. Following centrifugation to obtain plasma, peripheral blood mononuclear cell (PBMNC) were obtained using Ficoll–Hypaque discontinuous centrifugation. Recipient versus donor cells in the PBMNC were identified by the use of donor-specific anti-HLA antibodies that had previously been used to detect microchimerism during pregnancy.4, 5 Recipient PBMNC T-cell subpopulations were characterized for activation markers, cytolytic markers and checkpoint inhibitors. In addition, CD273 (PD-L2) and CD274 (PD-L1) expression on leukemic blasts was determined. Cytokine (IL-2, IL-6, IL-10, IFNγ) levels present in the plasma were determined using the CD8 Milliplex assay (EMD Millipore, Darmstadt, Germany). Wilcoxon rank-sum test was used to determine statistical significance using STATA /SE 12.1 (StataCorp LP, College Station, TX, USA). Five patients (age 52–77 years, 1–4 previous therapies) were infused with haploidentical donor cells. Four developed hyperpyrexia post infusion that lasted 24–48 h (median temperature maximum (Tmax) 0–4 h post infusion 98.6 °F, median Tmax 8–192 h post infusion 101.9 °F, P=0.009). Recipient CD8 T cells demonstrated decreased perforin expression post infusion compared with pre-infusion with no changes in granzyme A/B, LAMP-1 or FasL expression. Recipient CD4 T cells showed increased LAMP-1 expression post infusion compared with pre-infusion with no changes in perforin, granzyme A/B or FasL expression. Rapid upregulation of PD-1 on host CD8 T cells was present (Table 1). The greatest difference in PD-1 expression was pre-infusion compared with 60–96 h post infusion. Non-statistically significant upregulation of surface PD-1 ligands occurred on CD33+ leukemic blasts from 0–4 (median 6.9%) to 8–24 h post infusion (median 26.9%) for PD-L1, and 0–4 (median 11%) and 72–96 h post infusion (median 28.6%) for PD-L2. No change was seen in PD-1 expression of recipient CD4 T cells. Likewise, no changes in CTLA-4, OX40, 4–1BB and CD40L expression on recipient CD8 and CD4 T cells pre- or post infusion were observed. Table 1 Median recipient T-cell activation, cytolytic and immune checkpoint markers pre- and post-haploidentical donor lymphocyte infusion A statistically significant increase in IFNγ immediately post infusion and IL-2 at the onset of fever development (8–24 h post infusion) was seen (Table 2). Two patients developed grade 4 neutropenia whereas one patient developed grade 4 lymphocytosis. There were no signs of graft versus host disease. No dose-limiting toxicities or durable chimerism was seen as all patients had

Introduction In the treatment of acute myeloid leukemia, initial induction guidelines frequently include performing a day 14 bone marrow biopsy to assess response. A second induction is then recommended for patients with morphologic residual leukemia (≥5% blasts). Recent retrospective reviews have shown no difference in complete response (CR) rates amongst patients with residual leukemia based on day 14 marrow assessment who were and were not given a second induction. In our single center retrospective study, we compared patients with residual blast counts ≥5% to identify differences in leukemia free survival (LFS) and overall survival (OS) in those who did and did not receive a second induction. In addition we examined the cytogenetic profile of Day 14 and remission bone marrows. Methods: Consecutively treated patients with newly diagnosed primary and secondary AML over the age of 18 who received daunorubicin based induction with a curative intent from 2006 to 2014 were obtained via cancer center medical records. Outcome data was followed until May 1st 2015. We reviewed demographic (age, sex, ECOG PS, co-morbidities) as well as AML specific data (daunorubicin dose, use of etoposide, initial bone marrow blast count, initial white blood cell count, bone marrow blast count at day 14, cytogenetic stratification, CR rate, allogeneic stem cell transplant, LFS and OS). Patients included in survival analysis were required to have an initial and day 14 bone marrow biopsy with morphologic identification of residual leukemia on the day 14 marrow. Cytogenetic risk stratification was based on NCCN guidelines. Morphological CR was defined based on International Working Group criteria (Cheson, JCO, 2003). Positive (PPV) and negative predictive value (NPV) for CR were calculated by considering a BM of less than 5% at Day 14 a positive screening test for obtaining CR. Data was analyzed using Mann Whitney U test and chi square analysis as appropriate. LFS and OS were estimated using the Kaplan Meier method and compared using the log rank test. All calculations and graphs were obtained using STATA/SE 12.1. Results: Of the 91 patients initially identified, 67 had Day 14 marrows performed and 31 had residual blast counts ≥5%. For our overall cohort, we found a PPV of 76% and NPV of 65% for Day 14 marrows in determination of CR, which is in line with previous studies. No statistical differences were seen between the groups (Table 1), although patients who were reinduced trended toward higher initial white blood cell counts while those who were not reinduced trended towards improved CR rates. Comparing patients with residual disease at Day 14 who were or were not reinduced, we found no statistical difference for LFS and OS between the two groups (p 0.87 and 0.96 respectively). Interestingly, in comparing cytogenetics, two patients with unfavorable cytogenetics on initial BM converted to normal/intermediate cytogenetics after induction despite a residual blast count greater than 5%. Both obtained CR, one with and one without reinduction. Another patient with unfavorable cytogenetics at day 14 obtained CR with normal cytogenetics without reinduction. Conclusions: Although of limited size, our study suggests that reinduction based on Day 14 marrow is of limited use in predicting LFS and OS in AML. Better methods to determine residual leukemia following initial induction therapy are required in order to help guide treatment decisions. | | No Reinduction (n=17) | Reinduction (n=14) | p value | | ------------------------------------------------------- | ---------------------------- | ------------------------- | ------- | | Age (Median) | 63 | 57.5 | 0.46 | | Male:Female | 8:9 | 8:6 | 0.58 | | ECOG PS 0 1 | 11 6 | 10 4 | 0.69 | | Initial WBC (Median) | 5.2 | 11.7 | 0.06 | | Initial % Bone Marrow Blast (Median) | 0.53 | 0.48 | 0.56 | | DNR Dose 60mg/m2 90mg/m2 | 11 6 | 8 6 | 0.67 | | Etoposide Given | 5 | 4 | 0.96 | | Cytogenetic Risk Intermediate Unfavorable | 9 8 | 7 7 | 0.87 | | Complete Response | 10 | 4 | 0.09 | | Allo-SCT | 7 | 8 | 0.38 | Table 1. Demographics of patients with and without reinduction chemotherapy with residual disease on repeat bone marrow biopsy ![Figure 1.][1] Figure 1. Kaplan-Meier Curve for Overall Survival ![Figure 2.][1] Figure 2. Kaplan-Meier Curve for Leukemia Free Survival Disclosures No relevant conflicts of interest to declare. [1]: pending:yes

Factor VII deficiency, although rare, is now recognized as the most common autosomal recessive inherited factor deficiency. It is usually considered to be associated with bleeding only in the severely affected subject and heterozygotes (>10%) are not considered at risk. The general recommendation for surgery is to achieve a FVII level in excess of 15% (0.15 1U/mL). We present three cases of severe factor VII deficiency, each of whom appeared hemostatically competent based on clinical history. Subject 1 is a 33 year-old African-American female with a baseline FVII of

Introduction: Many patients with Acute Myelogenous Leukemia (AML) will transiently develop blasts in the peripheral blood upon recovery of induction chemotherapy, despite going on to obtain a complete remission. These are presumably non-leukemic marrow blasts. Recovery blasts can sometimes reach over 20% in the peripheral blood in remission patients. The significance of recovery blasts cells after induction chemotherapy in patients with AML is not clear. We sought to define the incidence of recovery blastocytosis (RB) and determine if the presence of RB has prognostic relevance. Methods: We performed a retrospective analysis of 72 patients with newly diagnosed AML who underwent induction chemotherapy with 7+3 (cytarabine and daunorubicin) with or without etoposide between the years of 2006 and 2013 at our institution. Patients were included in the analysis as having RB only if their blasts resolved by day 14 of induction chemotherapy, blasts reappeared upon recovery after day 14, recovery blasts were > 5% in the peripheral blood of a duration of >5 days, and subsequently resolved by day 45 and remission was obtained. We recorded patient's absolute and percentage peripheral blast counts on presentation, upon nadir and throughout recovery of induction chemotherapy. The incidence and level of RB in patients who achieved a remission was tabulated. This group (group 1) was compared to the patients who achieved a remission whom did not develop RB (group 2). Results: 45/77 AML patients obtained a CR after induction chemotherapy. Recovery blasts were seen in 9/45 (20%) remission patients (group 1), with a median RB of 9% for a median duration of 8 days. Of these 9 patients, 4 developed RB > 10%, and 2 developed RB >20 % Group 1 did not differ in respect to age, gender, cytogenetic profile, etoposide use, or whether the patient received 1 or 2 induction therapies from the 36/45 remission AML patients who did not develop RB (group 2). Median survival for group 1 was = 1,376 days, and 1,036 days for group 2 (p= .035). Conclusion: Recovery Blasts in the peripheral blood after induction chemotherapy is seen commonly in AML patients who obtain a complete remission. RB can be seen even as high as > 20% in remission patients. AML patients who develop RB on their way to remission after induction chemotherapy have a better overall survival then patients who do not develop RB. Figure 1 Figure 1. Graph 1. Kaplan-Meier survival curves for AML patients with RB (group 1) and without RB (group 2). Disclosures No relevant conflicts of interest to declare.

Background Grey Zone Lymphoma (GZL), with features intermediate between diffuse large B-cell lymphoma (DLBCL) and classical Hodgkin lymphoma (CHL), is a relatively new entity per the latest WHO classification. Limited clinical data exists on this rare lymphoma and the ideal management remains uncertain. We performed a comprehensive literature review of reported cases to better define its clinical characteristics and the natural history of this rare entity. Methods A comprehensive MEDLINE search was performed using key words “gray zone or grey zone or unclassifiable or indeterminate and lymphoma” through July of 2013. Cases were included in the analysis if they met the pathological definition of GZL as defined by the WHO criteria, based on the typical morphological and immunophenotypic pattern. Cases without primary patient data were excluded. Of the 554 abstracts reviewed from the primary MEDLINE search, 45 articles met study criteria for review. Of those, 8 articles involving 39 cases met criteria for inclusion in our analysis. Two additional cases were identified at our local institution. Comparison of complete response (CR) rates between ABVD-like and CHOP-like regimens was calculated using Fisher’s exact test. P-values Results Of the 41 cases included in this analysis, the median age of presentation was 33.5 (range 13-85) with a slight male predominance (59%). B symptoms were present in 77% of cases and 75% presented with early stage (I or II). Mediastinal lymphadenopathy was the most common site of disease (89%). Pathological data were available for analysis in all 41 patients. Sixty-eight percent of cases had a morphological appearance of CHL with Reed-Sternberg cells. Immunophenotype revealed positivity for CD20 (90%), CD30 (95%), CD15 (63%), CD45 (73%), CD79a (100%), BOB1 (72%), OCT2 (89%) and PAX5 (100%). Forty-one percent were positive for EBV based on EBER and/or LMP1 expression. Clinical outcome data were available for review for 20 of the 41 patients Treatment was variable and included either initial CHL regimens (ABVD, BEACOPP) or DLBCL regimens (CHOP, EPOCH, with or without rituximab). Seven patients received initial treatment with ABVD-like regimens, of which 4 did not show a response, 3 achieved a partial response (PR) and there were no reported complete responses. Of the seven patients treated with CHOP-like regimens, 5 had clinical outcome data available. Four patients achieved a CR, 1 patient achieved a PR (Fisher’s for CR rate P=0.01). All patients that achieved CR after CHOP-like regimens received consolidation radiation therapy. Seven patients underwent an autologous stem cell transplantation, of which there were two reported relapses within the first 6 months. The median follow up for the entire cohort was 15 months and the 2-yr overall survival (OS) was 87% with a median OS that was not reached. Conclusions GZL, with features intermediate between CHL and DLBCL, is a rare entity with variable prognosis. This lymphoma subtype commonly presents at an early stage with B symptoms and mediastinal involvement. A high proportion were EBV positive. None of the patients that received initial ABVD-like regimens achieved a CR. The response rates were higher in patients that received initial CHOP-like regimens, although the sample size was small. Additional studies are warranted to better understand the optimal treatment regimens in these patients. Disclosures: No relevant conflicts of interest to declare.

Introduction Based on the activity of ofatumumab in patients with indolent B-cell non-Hodgkin lymphoma (NHL) and the potential synergistic effect of bortezomib in combination with anti-CD20 antibody therapy, a phase II study to investigate the effect of the combination of ofatumumab and bortezomib in patients with relapsed indolent B-cell NHL who relapsed >6 months after receiving a rituximab-containing regimen was initiated. Methods Patients 18 years or older with a pathologically confirmed low-grade B-cell NHL who relapsed >6 months after a rituximab-containing regimen were included in our study. Other inclusion criteria were ECOG performance status 0.75, and platelets >50,000/uL). Exclusion criteria included HBV+, HIV+, transformed lymphoma, primary cutaneous lymphoma, central nervous system involvement, Results We present data on 10 patients enrolled between October 2010 and April 2013. Median age was 66 years (range 55-93 years); eight patients (80%) were 60 years or older. There were 7 (70%) men and 3 (30%) women. LDH was elevated in 8 patients (80%). ECOG performance status was 0 in 9 (90%) and 1 in 1 patient (10%). Six patients (60%) had a histological diagnosis of follicular lymphoma, 1 (10%) mantle cell lymphoma, 1 (10%) small lymphocytic lymphoma, 1 (10%) marginal zone lymphoma, and 1 (10%) low-grade B-cell lymphoma, not otherwise specified. Stage III/IV was seen in 5 patients (50%). Eight patients (80%) had a high-risk FLIPI score. Median time from initial diagnosis to current therapy was 65 months (range 20-204 months). Median time from last rituximab-containing regimen was 24 months (range 11-48 months). Median number of previous therapies was 2 (range 1-4). Three patients (30%) had previously received radiotherapy. One patient (10%) had previously undergone autologous stem cell transplantation. Response rates after induction therapy were: 1 (10%) complete response (CR), 3 (30%) partial response (PR), 3 (30%) stable disease, 1 (10%) progressive disease, and 2 (20%) not evaluable for response. With exception of 1 patient who continues on therapy, the patients who achieved a response or had stable disease after induction therapy showed progression of disease during maintenance. Median duration of response in patients who responded was 4 months (range 1-9 months). At the time of this report, 7 patients (70%) are alive with disease, 2 (20%) are alive without evidence of disease, and 1 (10%) has expired. Five grade 3 or 4 adverse events (AEs) occurred; grade 4: diarrhea (n=1) and hyperglycemia (n=1); grade 3: infusion reaction (n=1), nausea (n=1) and rash (n=1). No grade 3 or 4 peripheral neuropathy or hematological AEs were observed. The most common grade 1 or 2 AEs were: infusion reactions (n=6), anemia (n=5), thrombocytopenia (n=5), fatigue (n=4), diarrhea (n=4), hyperglycemia (n=4) and lymphopenia (n=4). No deaths have occurred while on therapy. Conclusions The combination of ofatumumab and bortezomib given weekly for 4 weeks induced a response in 40% and stable disease in 30% of the patients. However, most of the patients experienced progression of disease during the maintenance phase of the study. Furthermore, there were five grade 3 or 4 AEs associated with therapy. Based on this interim analysis, it was decided to stop enrollment. The combination of ofatumumab and bortezomib, however, appears potentially active and deserves further study. Different schemas of therapy with longer induction or different maintenance schedule could prove to be safer and more effective. Disclosures: No relevant conflicts of interest to declare.

Abstract 4589 Introduction: Spontaneous remission of chronic lymphocytic leukemia (SRCLL) has occassionaly been reported since the 1950s. About 40–50 cases have been reported in the English literature. The often quoted incidence of such a phenomena is estimated to be 1% of all CLL cases (Table 1). However, a review of these reports which have determined this incidence suggests that many patients did not have a true SRCLL. The authors have conducted a systemic search within their own institution database to determine the true incidence of SRCLL. Methods: After obtaining appropriate IRB approval, a systemic search was performed within the our institution's hematopathology databases for the diagnosis of chronic lymphocytic leukemia from year 2000 to 2012. Records and laboratory findings were reviewed for all cases. Records for patients with laboratory data suggestive of remission were reviewed to determine if they had received any form of therapy. All cases were included in the review if the diagnosis of CLL was firmly established by flow cytometry. SRCLL was defined as: 1) the patient's elevated lymphocyte number at diagnosis was >5 × 109/L and persisted for >6 months confirming the initial diagnosis of CLL, 2) the lymphocyte number subsequently normalized to Results: After reviewing 167 cases, only one case met our inclusion criteria, with an estimated incidence of 0.6%. Conclusion: Spontaneous remission of CLL is a rare phenomenon. This review suggests that the incidence of SRCLL is less then the previously often quoted incidence of 1% and may more appropriately approximate 0.6%. Disclosures: No relevant conflicts of interest to declare.

Abstract 3336 Introduction: Heparin Induced thrombocytopenia (HIT) is a clinicopathological entity in which thrombocytopenia occurs in temporal relation to the initiation of heparin therapy. The diagnosis is made using clinical criteria and a scoring system (4T) can be applied to assess the probability of the diagnosis. A variety of sensitive tests are available but the most widely applied is an enzyme immunoassay (EIA), which detects and semi-quantifies antibodies of any class to the heparin-PF4 complex. The role of testing is largely supplementary, but recently focus has been placed on the epidemic of HIT overdiagnosis due to overreliance on laboratory tests irrespective of the clinical scenario. A newer EIA can measure the pathogenic IgG antibody only. This study examines the number of patients started on direct thrombin inhibitor (DTI) therapy for a presumptive diagnosis of HIT prior to the implementation of the IgG antibody and after its introduction at one large academic tertiary care center. Methods: All patients placed on the DTIs argatroban and lepirudin between October 2006-May 2009 in the pre IgG subtype antibody period and May 2009-February 2012 in the post IgG subtype period for a presumptive diagnosis of HIT were identified. Demographic data including age, sex, and primary service were recorded. All HIT antibody (Ab) immunoglobulin class EIA and IgG specific EIA optical density were recorded, as available. 4T criteria and rates of thrombosis were assessed retrospectively. Incidence of WHO Grade III (requiring transfusion) or IV (life threatening) bleeding was documented. Chi Square, Mann Whitney U, and Fisher's exact tests were used as appropriate for statistical analysis. Results: 89 patients pre availability of the IgG EIA assay and 100 patients post availability of the IgG EIA assay met inclusion criteria and were evaluated. Groups were matched in terms of sex and 4T pretest probability distribution as well as rates of thrombosis. Patients post IgG EIA availability were older and had lower mean total HIT Ab optical densities. Post IgG EIA patients were treated with DTI therapy 5 days less, which was statistically significant. The incidence of Grade III and IV bleeding episodes, however, was statistically similar between groups. In the pre IgG EIA group, 7 bleeds (4 Grade III, 3 Grade IV) occurred in patients with low pretest probability for HIT based on 4T criteria. In the post IgG EIA group, 8 bleeds (5 Grade III, 3 Grade IV) occurred in patients with low pretest probability for HIT based on 4T criteria. Conclusion: Implementation of the IgG HIT EIA resulted in a decrease in the number of days on a DTI without an observed change in serious bleeding events, indicating that such bleeding occurs early after initiation of DTI therapy. Further, patients pre and post availability of the IgG EIA were started on DTI therapy despite a low pretest clinical risk for HIT. The use of a test with a shorter turn-around time to exclude HIT or more rigorous enforcement of clinical guidelines will be required to minimize misdiagnosis and avoid therapy related morbidity. Disclosures: No relevant conflicts of interest to declare.

Abstract 4383 Introduction: Black cohosh (known as both Actaea racemosa and Cimicifuga racemosa), a member of the buttercup family is a perrenial plant that is native of North America. It has been widely used to relieve premenstrual problems, menstrual cramps and to control hot flushes and other menopausal symptoms. The mechanism of action of the black cohosh is not fully understood. Here, we report the case of a patient with pancytopenia related to the use of the black cohosh. Case Report: A 58 year old female patient with past medical history of dyslipidemia, presented with bruising after several months of taking black cohosh. Her complete blood count revealed a white blood cell count of 3.1×109/L (normal 3.5–11 ×109/l), hemoglobin of 10.6 g/dl (normal 11–15 g/dl), hematocrit of 31 % (normal 32–45%), mean corpuscular volume of 109 fL (normal 80–98 fl), platelets count of 37 000/μL (normal 150000–400000/μL). Her medications included lipitor, black cohosh and vitamin D. Her physical exam was remarkable only for bruising. Serum protein electrophoresis did not show any evidence of a monoclonal spike and a coomb’s test was negative. She had normal immunoglobulins level, haptogloin, LDH, liver function tests, iron studies, vitamin B12 and folate. Her prothrombin and activated partial thromboplastin times were within reference range. Her peripheral smear showed macrocytic red blood cells and decreased platelets. Her bone marrow biopsy and aspirate showed a hypocellular bone marrow (cellularity of 25–30%), with a predominance of erythroid precursors that exhibit shift toward immaturity and mild to moderate megaloblastoid changes, moderately decreased myeloid precursors, slightly decreased megakaryocytes, and normal iron stores, there was no increase in the bone marrow blasts (0.6%). She also had a flow sent for paroxysmal nocturnal hemoglobinuria, which showed normal levels of expression of CD55 and CD59 of the neutrophils and the red cells. Upon presentation, the black cohosh was stopped. Following this, her white count, hemoglobin and platelets improved slowly (figures 1,2,3,) without any further interventions, but it took over 2 years for her counts to normalize. Conclusion: Black cohosh is an over the counter herbal medicine that has been widely used by women to control premenstrual symptoms, menstrual cramping and menopausal symptoms. Many side effects have been described in the past but its effect on the bone marrow has never been studied. In our patient, Black cohosh caused pancytopenia that was reversible; however the recovery was very slow. Disclosures: No relevant conflicts of interest to declare.

Abstract 4126 Introduction: The immunohistochemical (IHC) profile as described by Hans and colleagues has emerged as a potential prognostic and predictive factor in patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) treated with chemotherapy. However, its role has not been completely elucidated. The main objective of this patient-level meta-analysis was to evaluate the IHC profile as a prognostic and predictive indicator in newly diagnosed DLBCL patients treated with R-CHOP. Secondary objectives were to identify potential novel prognostic factors in these patients. Methods: Patient-level clinical data was requested from 13 research groups that published studies on the role of the IHC profile in prognosis for DLBCL patients treated exclusively with R-CHOP. Six groups (46%) submitted their data, accounting for a total of 701 patients. The requested clinical data included age, sex, performance status, LDH levels, number of extranodal sites, clinical stage, expression of CD10, BCL-6 and MUM1, IHC profile, type of response, outcome and overall survival (OS). Logistical regression analyses were used to identify independent variables associated with overall and complete response rates. Univariate survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test. Multivariate analysis was performed using the Cox proportional-hazard regression test. P-values of Results: The median age was 63 years (range 16–90 years), 54% were men, 59% were 60 years or older, 24% had an ECOG ≥2, 55% had elevated LDH levels, 15% had ≥2 extranodal sites involved, 52% had stage III/IV and 48% had a non-germinal center (NGC) IHC profile. The overall response rate was 92% with complete responses seen in 78% and partial responses in 14%. The median follow-up was 34 months. In the logistical regression analysis, age ≥70, high LDH, ECOG ≥2, stage III/IV and a NGC profile were associated with improved overall response, and MUM1 expression, ECOG ≥2 and stage III/IV were associated with improved complete response. In the survival analysis, the estimated 5-year OS was 66% and the median OS was not reached. Age ≥60 years, elevated LDH levels and NGC IHC profile (Figure) were not associated with worse OS. In the multivariate analysis, age ≥70 years, male sex, ECOG ≥2 and clinical stage III/IV were independent prognostic factors for OS. A prognostic score was formulated using these 4 prognostic factors and then compared against the IPI and R-IPI scores. This novel score and the IPI score were the only independent factors for OS with HR 1.4 (95% CI 1.19–1.64) and 1.38 (95% CI 1.15–1.67) with p Conclusion: The IHC profile is not a prognostic indicator for OS, and it is predictive of overall response but not complete response in newly diagnosed patients with DLBCL treated with R-CHOP. Age ≥70, male sex, ECOG ≥2 and stage III/IV were independent prognostic factors for OS. A score consisting of these 4 factors showed a significant prognostic value in DLBCL patients treated with R-CHOP. Disclosures: No relevant conflicts of interest to declare.

Abstract 4223 Acquired amegakaryocytic thrombocytopenia is a rare disorder in which there is a marked decrease in bone marrow megakaryocytes leading to severe thrombocytopenia with preserved hematopoeisis in the remaining lineages. The clinical course is variable and no standardized treatment exists. Multiple cases in the literature report treatment using immunosuppressive agents including cyclosporine and antithymocyte globulin. In this case report, we describe the first successful use of rituximab in a patient with amegakaryocytic thrombocytopenia in the absence of any underlying autoimmune disorders. Our patient, an 86- year-old woman, presented with epistaxis, ecchymoses, and blood-tinged sputum. She had thrombocytopenia (platelets 6 × 109/L, MPV 8.3) with a normal hemoglobin and white blood cell count. Peripheral blood smear showed no obvious cause for thrombocytopenia. Bone marrow biopsy revealed focal lymphocytic infiltrates and severe megakaryocytic hypoplasia with nearly absent megakaryocytes. Cytogenetic and molecular analyses were normal, revealing no evidence of a clonal myelo- or lymphoproliferative disorder. The diagnosis of amegakaryocytic thrombocytopenia was made. She was started on prednisone 50mg per day. There was no significant improvement in her platelet count and she was then given IVIG without response. Repeat bone marrow biopsy showed persistent severe bone marrow hypoplasia with near absence of megakaryocytes. After 6 weeks of platelet transfusion dependence and steroids, she was tapered off her steroids and was given rituximab 375mg/m2 weekly for 4 doses. Three weeks after starting rituximab, her platelet counts began to recover and by day 37, her platelet counts normalized and remained within normal limits 12 months after treatment. This case demonstrates the possible utility of rituximab in treating patients with isolated acquired amegakaryocytic thrombocytopenia. Disclosures: No relevant conflicts of interest to declare.

Abstract 4468 Introduction The diagnosis of HIT can be challenging. Short of the serotonin release assay, which can be difficult to get in a timely manner, the 4T method developed by Lo et al., in conjunction with the HIT elisa assay (EIA), is the best established criteria for the rapid diagnosis of Heparin Induced Thrombocytopenia (HIT). We sought to determine how often the 4Ts were being applied at a large academic institution. In addition, we sought to understand the outcome of patients started on direct thrombin inhibitors (DTIs) who did not meet the 4T/EIA criteria for HIT. Methods A retrospective case series identified patients placed on DTI for HIT treatment from 10/2006 to 5/2008. The 4T pretest probability was then applied retrospectively. HIT EIA Ab testing, optical densities, duration of DTI treatment, and bleeding incidence were recorded. Liberal and modified conservative criteria from Lo et al.'s study were used to define patients with HIT. Overdiagnosis of HIT was then recorded based on the above criteria. Results 76 patients were included for analysis. The average age was 61.4 years. Based on the 4T pretest probability, 30 patients were classified as low risk, 37 intermediate risk, and 9 high risk for HIT. The average HIT OD for low, intermediate, and high pretest probability was 0.49, 1.17, and 2.05. 76% and 36% of patients treated with DTIs for HIT met the liberal and modified conservative HIT definitions, respectively. 18 patients (24%) did not meet liberal HIT criteria but remained on DTI treatment for 1 to 60 days. Cost of DTI overuse in this subset was $84,960. Cost of DTI use in patients who did not meet modified conservative criteria was $462,246. All 16 patients who developed bleeding complications fulfilled a liberal diagnosis of HIT while only 6 of these patients fulfilled the modified conservative definition of HIT. Conclusions 1) The 4T method for diagnosing HIT is not being applied to a large percentage of patients in a tertiary academic center. 2) There is an overdiagnosis of HIT regardless of definition criteria with 24% of patients treated for HIT not meeting the liberal definition while 64% of patients did not meet the modified conservative definition. This overdiagnosis has both a significant monetary and morbidity cost. Disclosures: No relevant conflicts of interest to declare.

Abstract 2665 Introduction: Little is known on the racial differences in characteristics and outcomes of patients with a diagnosis with diffuse large B-cell lymphoma (DLBCL) treated with rituximab-containing regimens. The aim of this retrospective study is to compare the clinicopathological characteristics, prognostic factors and outcomes of Asian and Western patients with a diagnosis of de novo DLBCL treated with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP). Patients and Methods: Patient-level data was collected from 8 centers (USA, Italy, Sweden, Finland, Croatia, Japan, Korea and China). This study was approved by the Institutional Review Board at each of the participant centers. All patients were diagnosed with de novo DLBCL and treated with R-CHOP administered every 3 weeks. HIV-positive and primary brain DLBCL were excluded. The requested clinical data included age, sex, performance status, lactate dehydrogenase (LDH) levels, number of extranodal sites, clinical stage, expression of CD10, BCL6 and MUM1/IRF4, response to chemotherapy, outcome and overall survival (OS). Patients were divided in Asian and Western, according to the country of report. Comparison between groups was performed with Mann-Whitney and Chi square tests for continuous and categorical variables, respectively. Univariate survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test. Multivariate analysis was performed using the Cox proportional-hazard regression test. P-values of Results: A total of 712 patients, 455 Asian and 257 Western patients were included in this study. Western patients were more likely to present with elevated LDH levels (70% vs. 48%; p1, elevated LDH levels and advanced clinical stage were significantly associated with a worse median OS in Westerners (p1, >1 extranodal sites and advanced clinical stage were significant adverse factors for Asians (p1 and advanced clinical stage were independent prognostic factors associated with a worse median OS in Westerners and Asians (p Conclusions: Asian and Western patients with de novo DLBCL present with distinct clinical and pathological characteristics, and although the CR rate to standard R-CHOP was higher in Westerners than in Asians, the final outcome, prognostic factors and median and 5-year OS rates are similar in both populations. Disclosures: Castillo: GlaxoSmithKline: Research Funding; Millennium Pharmaceuticals: Research Funding.

The etiology of venous thromboembolism in young patients is frequently associated with hereditary coagulation abnormalities, immunologic diseases, and neoplasia. The advent of radiological advances, namely Computed Tomography (CT) scans and venography has identified vena cava malformations as a new etiologic factor worthy of consideration. In this case report, we describe the unusual occurrence of venous thromboembolism in association with a duplicated inferior vena cava. Duplications of the inferior vena cava (IVC) are seen with an incidence of 0.2% to 3.0% in the general population. Embryogenesis of the IVC is a complex process involving the intricate formation and regression of numerous anastomoses, potentially leading to various anomalies. We present a 23-year-old Caucasian woman with IVC duplication who developed a deep venous thrombosis and multiple pulmonary emboli. Anomaly of the IVC is a rare example of a congenital condition that predisposes to thromboembolism, presumably by favoring venous stasis. This diagnosis should be considered in patients under the age of 30 with spontaneous occurrence of blood clots.