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Weibull: Janssen Cilag: Research Funding. Wahlin:Gilead Sciences: Research Funding; Roche: Consultancy, Research Funding. Smedby:Takeda: Research Funding; Janssen: Research Funding; Celgene: Consultancy.

Waldenström macroglobulinemia (WM) is a B-cell disorder characterized by the infiltration of lymphoplasmacytic cells into bone marrow and the presence of an IgM monoclonal gammopathy. As part of the Third International Workshop on WM, held October 7 to 10, 2004 in Paris, France, a consensus panel charged with providing treatment recommendations for WM updated its recommendations on both frontline and salvage therapies. The panel considered encouraging results from recent studies that addressed the use of extended-dose rituximab as well as other treatment options: therapy with either nucleoside analogs and alkylator agents, rituximab in combination with nucleoside analogs, nucleoside analogs plus alkylator agents, or combination chemotherapies, such as CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) or cyclophosphamide and dexamethasone. The panel determined that these were reasonable treatment options for WM patients and such therapeutic approaches were likely to yield results that are at least as good as if not better than the currently recommended use of single-agent alkylator, nucleoside analog, or standard-dose rituximab therapy. Such approaches were deemed to be reasonable treatment for WM patients in both the upfront and salvage settings, though randomized studies addressing the efficacy and toxicity of such novel approaches over previously established standard of care options are needed.

Introduction:Regulatory T cells (Tregs), a highly immunosuppressive subset of CD4 +T cells, represent a key challenge in the tumor microenvironment by limiting potent antitumor immune responses. While high densities of tumor-infiltrating Tregs are associated with poor prognosis in patients with various types of solid cancers, their prognostic impact in B-cell non-Hodgkin lymphoma (NHL) remains unclear. Emerging studies suggest substantial heterogeneity in the phenotype and suppressive capacities of Tregs, emphasizing the importance of understanding Treg diversity and the need for additional markers to identify highly suppressive Tregs. Our in-depth characterization of Tregs in NHL tumors could open new paths for rational drug design, facilitating selective therapeutic manipulation of Tregs to reduce immunosuppression and improve anti-tumor immunity.

Buske: Roche, Janssen, Bayer, MSD: Research Funding; Morphosys: Membership on an entity's Board of Directors or advisory committees; Roche, Janssen, AbbVie, Pfizer, Celltrion: Honoraria, Speakers Bureau. Dimopoulos:Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Personal fees, Research Funding, Speakers Bureau; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Personal fees, Research Funding, Speakers Bureau; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Personal fees, Research Funding, Speakers Bureau; BMS: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Personal fees; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Personal fees, Speakers Bureau. Kastritis:Genesis Pharma: Consultancy, Honoraria; Janssen: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; Amgen: Consultancy, Honoraria, Research Funding. Tomowiak:Roche: Research Funding; Gilead: Research Funding; Janssen: Honoraria; AbbVie: Honoraria; Beigene: Honoraria; Takeda: Honoraria. Hajek:Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Consultancy, Honoraria; PharmaMar: Consultancy, Honoraria; Janssen: Consultancy, Honoraria, Research Funding; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Research Funding; Oncopeptides: Consultancy. Viardot:Roche: Honoraria, Other: advisory board; Kite/Gilead: Honoraria, Other: advisory board; Novartis: Honoraria, Other: advisory board; Amgen: Honoraria, Other: advisory board. Aurran:Janssen: Honoraria. Lepretre:Gilead: Honoraria; Astra Zeneca: Honoraria; AbbVie: Honoraria; Janssen: Honoraria. Leblond:AbbVie: Honoraria; Gilead: Membership on an entity's Board of Directors or advisory committees; AbbVie: Membership on an entity's Board of Directors or advisory committees; Janssen: Membership on an entity's Board of Directors or advisory committees; Astra Zeneca: Membership on an entity's Board of Directors or advisory committees; Lilly: Honoraria; Janssen: Honoraria; Roche: Honoraria; Astra Zeneca: Honoraria; Amgen: Honoraria; Gilead: Honoraria; Beigene: Honoraria; Beigene: Membership on an entity's Board of Directors or advisory committees. de Guibert:Gilead Sciences: Consultancy, Honoraria; AbbVie: Consultancy, Honoraria; Janssen: Consultancy, Honoraria. Garcia-Sanz:Amgen: Membership on an entity's Board of Directors or advisory committees; BMS: Honoraria; Gilead: Honoraria, Research Funding; Incyte: Research Funding; Janssen: Honoraria, Research Funding; Novartis: Honoraria; Pharmacyclics: Honoraria; Takeda: Consultancy, Research Funding. Gomes da Silva:roche: Consultancy; abbvie: Consultancy; BMS: Consultancy; MSD: Consultancy; Janssen: Consultancy; Gilead: Consultancy. Morel:Janssen: Honoraria.Bortezomib in combination with DRC in Waldenström's Macroglobulinemia

Background:

Introduction:

Background: The randomized phase-2 trial SAKK 35/10 was conducted by the Swiss Group for Clinical Cancer Research (SAKK) and the Nordic Lymphoma Group (NLG) to compare the activity of single-agent rituximab versus rituximab plus lenalidomide in the first-line treatment of symptomatic follicular lymphoma (FL). The results of primary endpoint (complete remission [CR/CRu] at week 23) assessment were previously reported, showing that addition of lenalidomide to rituximab results in a significantly higher CR/CRu rate at the expected cost of increased but manageable toxicity (Kimby et al. Blood 2014.124 (21):799; Zucca et al. Hematol Oncol 2015. 33(s1): 105). Here we report the first analysis of secondary endpoints, progression-free survival (PFS), time to next anti-lymphoma treatment (TTNT), CR duration, as well as CR/CRu rate at 30 months (CR30).

Off Label Use: Lenalidomide was used together with rituximab in a randomized clinical trial.. Kimby:Gilead: Membership on an entity's Board of Directors or advisory committees; Jansen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Roche: Honoraria, Research Funding; Pharmacyclics: Membership on an entity's Board of Directors or advisory committees; Pfizer: Research Funding.

Cheson: Celgene: Consultancy, Research Funding; AstraZeneca: Consultancy; Gilead: Consultancy, Research Funding; Spectrum: Consultancy; MedImmune: Research Funding; Teva: Research Funding; Pharmacyclics: Consultancy, Research Funding; Ascenta: Research Funding; Roche/Genentech: Consultancy, Research Funding; Astellas: Consultancy. Off Label Use: Obinutuzumab (GA101; Gazyva/Gazyvaro) is a CD20-directed cytolytic antibody and is indicated, in combination with chlorambucil, for the treatment of patients with previously untreated chronic lymphocytic leukemia). This abstract reports on bendamustine with or without obinutuzumab in patients with CD20+ R-ref, indolent non-Hodgkin lymphoma.. Trask:Genentech: Employment. Gribben:Janssen: Honoraria; Pharmacyclics: Honoraria; Celgene: Consultancy, Honoraria; Gilead: Honoraria; Roche/Genentech: Honoraria. Dimier:Roche: Employment. Kimby:Pfizer: Research Funding; Pharmacyclics: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Roche: Honoraria, Research Funding; Gilead: Membership on an entity's Board of Directors or advisory committees; Jansen: Honoraria, Membership on an entity's Board of Directors or advisory committees. Lugtenburg:Mundipharma: Consultancy; Servier: Consultancy; Janssen-Cilag: Consultancy; Celgene: Consultancy; Roche: Consultancy. Thieblemont:St. Louis Hospital, Paris, France: Employment. Wassner Fritsch:Roche: Employment. Sehn:Roche/Genentech: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Gilead: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Lundbeck: Consultancy, Honoraria.

Kimby: Roche: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding. Off Label Use: Lenalidomide, not approved for follicular lymphoma. Mey:Celgene: Membership on an entity's Board of Directors or advisory committees. Ferreri:Celgene: Research Funding. Bargetzi:Celgene: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees. Krasniqi:Roche, Takeda: Membership on an entity's Board of Directors or advisory committees. Zucca:Roche, Mundivarma, Novartis: Consultancy, Honoraria, Research Funding.

No relevant conflicts of interest to declare.

Although recommendations for assessing prognosis in patients with CLL have been formulated (IWCLL, 2008; ESMO, 2013; NCCN, 2013), the actual use of prognostic and predictive markers in patients with CLL seen in daily practice is unknown.To ascertain the use of prognostic and predictive markers in patients with CLL not included in trials.Three-hundred and eighty-two members included in the ERIC database were invited to participate in a survey which included a comprehensive list of parameters potentially useful to evaluate patients with CLL at three different steps: 1. At diagnosis; 2. During clinical course; 3. Before therapy.One-hundred sixteen out of the 382 ERIC members (30%), mainly from academic institutions (91%), participated in the survey. Here we present a summary of this study which can be seen at its full length at www.ericll.orgThe most frequently evaluated parameters (by > 80% of the participants) are: age, disease stage, ECOG, B-symptoms, WBC count, LDT, tumor bulk, DAT, LDH and B2M; CIRS is evaluated by 45% and only 7% measure sTK routinely. CD38 is assessed by virtually all investigators, but not ZAP-70 (58%) nor CD49d (24%). Imaging studies are frequently employed: ultrasonography (US) (51%), CT (21%). PET/CT is never investigated at diagnosis. FISH for 13q-, 11q-, 17p-, and +12 is required by > 70%. Among biomarkers, those more frequently used are IGHV mutational status (54%) and TP53 mutations (25%). As per the newly described gene mutations around 20% of the participants would like to determine mutations of NOTCH1, SF3B1, MYD88, and BIRC3 should they be available.Sixty percent of participants re-assess prognostic parameters over the course of the disease. Bone marrow (aspirate/biopsy), lymph node biopsy and imaging studies are performed in subjects with progressive disease. However, 72% of the participants never use PET/CT, which does not seem to be related to the technique availability since only 3% of the participants would use PET/CT if available.Beside standard clinical parameters, other features frequently evaluated include ECOG (96%), DAT (77%), CIRS (66%) and bone marrow (45%). US, CT scans, and PET/CT are routinely (or occasionally) assessed by 45% (52%), 39% (42%), and 3% (42%) of the investigators, respectively. IGHV mutational status is repeated by a few participants (19%). 17p- and 11q- are studied by 79% and 68% of the investigators, respectively. Likewise, TP53 mutations are routinely (or occasionally) investigated by 40% (27%), NOTCH1 by 6% (13%), SF3B1 by 6% (12%), MYD88 by 4% (10%), and BIRC3 by 4% (9%).Most (89%) investigators consider pre-treatment findings to select therapy, the clinical parameters frequently considered toward that end being age (80% of investigators), ECOG (43%) and CIRS (37%). Biologically, 17p- (79%) and TP53 mutations (40%) along with 11q- (48%) and 13q- (26%) are the most frequently investigated markers. Novel mutations are investigated by 9%-15% of participants and around 20% would use them if possible.Although international recommendations are generally followed, the evaluation of patients with CLL at diagnosis includes in many cases parameters (e.g., 17p-, TP53 mutations) more useful as predictive (i.e., predicting response to therapy) than prognostic (i.e., predicting disease progression) factors, as well as ancillary studies (e.g., imaging studies) only recommended within clinical studies. In many instances prognostic markers are repeated over the course of the disease. Finally, treatment decisions are mainly based on clinical features and consolidated biomarkers (i.e., FISH cytogenetics, TP53 mutations). The results of this study need to be taken cautiously because of potential investigator-related biases and its relatively small sample size. However, it could be useful as a basis for refining, based on what is actually done in daily practice, recommendations about evaluation and prognostication of patients with CLL.Montillo: Roche: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; GSK: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Mundipharma: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Janssen: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding.

Chemoimmunotherapy with purine analogues and the anti-CD20 antibody rituximab is the standard of care as initial therapy in younger and physically fit patients with chronic lymphocytic leukemia (CLL). However, most CLL patients are elderly and/or have comorbidities, meaning that fludarabine-containing regimens are often inappropriate, carry greater toxicity, and treatment of these patients remains challenging. Most randomized studies in previously untreated CLL have been conducted in younger or fit patients and results cannot necessarily be extrapolated to older, less fit patients. While chlorambucil (CHL) remains a standard of care for this patient population, more effective but tolerable treatment choices are still needed. Ofatumumab (O) demonstrated superior preclinical activity, compared to rituximab, against cells with low CD20 density like CLL and showed clinical activity as monotherapy, with high overall response rates (ORR) in patients with refractory CLL. Therefore, the addition of O to CHL could provide superior clinical outcomes than CHL alone, while being tolerable, for patients who are elderly and/or have comorbidities and currently have limited treatment options.Patients with CLL who required therapy (2008 NCI-WG guidelines) and were considered inappropriate for fludarabine-based therapy due to advanced age and/or co-morbidities were randomized (1:1) to receive either O+CHL or CHL. CHL was given orally (10mg/m2 at days 1-7 of each 28 day cycle) and O was administered as intravenous infusions (Cycle 1: 300mg day 1 and 1000mg day 8, subsequent cycles: 1000mg at day 1). O premedication included acetaminophen, antihistamine and glucocorticoid. Treatment duration was a minimum of 3 cycles, until best response up to a maximum of 12 cycles. The primary endpoint was progression-free survival (PFS) assessed by an Independent Review Committee (IRC) and secondary endpoints included overall response rate (ORR), overall survival (OS) and safety.447 patients from 16 countries were randomized. Baseline demographics and disease characteristics were well balanced between the 2 arms. Median age was 69 years with 82% ≥65 years and/or having ≥2 comorbidities. All modified Rai stages were represented (Low 8%, intermediate 51%, high 40%). 56% of patients had unmutated IgVH, 6% showed 17p deletions and 75% had β-2-microglobulin levels ≥3500μg/L.PFS as assessed by an IRC was significantly prolonged in the O+CHL arm (22.4 months) compared to CHL alone (13.1 months, p<0.001). ORR was higher for O+CHL vs CHL (82% vs 69%, p=0.001), with a superior CR rate (12% vs 1%). 37% of O+CHL subjects with an IRC-assessed CR were MRD negative. With a median follow-up of 29 months, median OS was not reached for O+CHL or CHL. Median duration of treatment for both arms was 6 cycles and 82% of patients received 6 or more cycles of O+CHL.Grade ≥3 AEs that occurred from start of treatment until 60 days after the last dose were experienced by 50% of patients receiving O-CHL and 43% of patients on CHL with the most common being neutropenia (O+CHL: 26%, CHL: 14%). Grade ≥3 infusion-related AEs were reported in 10% of patients. No fatal infusion reactions were reported. Grade ≥3 infections were reported in 15% (O+CHL) and 14% (CHL) of patients, with the most common infection being pneumonia (O+CHL: 4%, CHL: 3%). Deaths during treatment occurred in 2% of subjects in both arms.Ofatumumab added to chlorambucil (O+CHL) demonstrated clinically important improvements with a manageable side effect profile in patients with CLL who have not received prior therapy and who are considered inappropriate for fludarabine based therapy.Hillmen: Roche Pharmaceuticals: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Pharmacyclics: Research Funding; Celgene: Honoraria; GlaxoSmithKline: Honoraria, Research Funding. Off Label Use: The use of ofatumumab in combination with chlorambucil in previously untreated CLL. The reported trial will support the extension of the ofatumumab licence. Robak:GlaxoSmithKline: Honoraria, Research Funding. Janssens:GlaxoSmithKline: Speakers Bureau; Roche: Speakers Bureau; Mundipharma: Speakers Bureau; Amgen: Speakers Bureau. Mayer:Glaxo: Consultancy, Research Funding; Roche: Consultancy, Research Funding. Panagiotidis:Novartis: Consultancy, Honoraria; Roche: Consultancy, Honoraria; GSK: Consultancy, Honoraria. Kimby:Pharmacyclics: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Teva: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Mundipharma: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Roche: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Emergent: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding. Schuh:GSK: Honoraria, Research Funding. Montillo:Janssen: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Mundipharma: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; GSK: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Roche: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding. McKeown:GSK: Employment. Carey:GlaxoSmithKline: Employment. Gupta:GSK: Employment. Chang:GSK: Employment. Lisby:Genmab: Employment, hold stock options Other. Offner:Lilly: Membership on an entity’s Board of Directors or advisory committees.

No relevant conflicts of interest to declare.

Ofatumumab was given a conditional approval in the EU on April 2010 for the treatment of CLL refractory to fludarabine (F-ref) and alemtuzumab (A-ref), encouraging the retrieval of further data in patients treated in a “daily life” setting and to investigate treatment safety.The main objective of this study was to obtain information on the safety profile of ofatumumab given outside clinical trials in patients with previously treated CLL. The secondary endpoints were efficacy, progression-free-survival (PFS), and overall survival (OS).This was an observational, retrospective study. Patients were eligible regardless of prior treatments or disease status and provided they had not been included in ofatumumab clinical trials. Data on patients’ characteristics at diagnosis, prior treatment, adverse events response rate, PFS and OS were recorded.One-hundred and twenty patients were screened of which 103 from 25 centers in 10 European countries were eventually eligible for the study. There were 71 males; median age at initiation of ofatumumab was 64 years (range, 38-84); 66% patients were in advanced clinical stage (Rai III-IV/Binet C) and 33 patients presented bulky lymphadenopathy. Number of prior lines of therapy was 4 (range, 1-13). 94% had received prior F-based therapy, 54% received A-based therapy and 51% received both. Eighty-one percent had been previously exposed to rituximab-combination regimens. Fifty-four percent were F-ref, 70% A-ref and 41% were both F- and A-refractory. Cytogenetics within 3 months prior therapy was available in 52 patients of which 34 presented abnormalities (11 patients: 17p-; 9 patients: 11q-; 2 patients: 13q-; 1 patient: trisomy 12; 11 patients: two or more abnormalities including 17p- or 11q-). Forty-two of 50 patients showed unmutated IGHV genes. The median number of cycles of ofatumumab given was 9 (range, 0-16) and the median percentage of given/planned cycles was 83.3% (range, 0-133). In most patients the treatment dose and schedule were as follows: 300 mg 1st infusion followed by 2000 mg for subsequent infusions (8 weekly followed by 4 doses monthly). One hundred and sixty-one adverse events were reported in 68 patients, with 28 (17%) of them being considered as ofatumumab-related. Infusion related-reactions occurred in 19 (28%) patients (III-IV: 6%). Neutropenia was reported in 26% (III-IV: 19%), thrombocytopenia in 15% (III-IV: 12%) and anemia in 15% (III-IV: 7%). The non-hematological adverse events, included infection 44% (III-IV: 36%), fatigue 10% (III-IV: 4%), fever 10% (III-IV: 6%), rash 10% (III-IV: 3%), cough 7% (III-IV: 1%), diarrhea 6% (grade III-IV: 0%) and nausea 1% (III-IV: 0%). Hematologic toxicity correlated with the number of prior lines of therapy. Autoimmune hemolytic anemia and Richter syndrome were reported in one patient each. Two heavily pre-treated patients (5 and 6 prior lines of therapy, respectively) developed progressive multifocal leukoencephalopathy. The overall response rate (ORR) was 23% and the median PFS and OS were 5 and 12 months, respectively. The main causes of death were disease progression (61%) and infection (28%).The safety profile of ofatumumab given outside clinical trials to patients with poor-prognosis and heavily pre-treated CLL was consistent with that observed in clinical trials. Although not unexpectedly the ORR was lower in this study, PFS and OS were in line with those reported in phase II trials.Montillo: Roche: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; GSK: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Mundipharma: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Janssen: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding. Bloor:GSK: Consultancy, Honoraria, Paid speaker Other. Schuh:GSK: Honoraria; Celgene: Honoraria; Mundipharma: Honoraria. Geisler:Roche: Consultancy; GSK: Consultancy. Hillmen:GlaxoSmithKline: Honoraria, Research Funding. Stilgenbauer:GSK: Honoraria, support Other. Smolej:GSK: Consultancy, Honoraria, travel grants Other. Jaeger:GSK: Honoraria, Research Funding. Leblond:Roche : Consultancy, Honoraria, Membership on an entity’s Board of Directors or advisory committees, Speakers Bureau; Janssen: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Mundipharma: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Speakers Bureau. Kimby:Roche: Consultancy, Honoraria, Research Funding; celgene: Consultancy, Honoraria, Research Funding; Teva: Consultancy, Honoraria, Research Funding; Emergent BioSolutions: Consultancy, Honoraria, Research Funding; Gilead Sciences: Consultancy, Honoraria, Research Funding; Jansen: Consultancy, Honoraria, Research Funding; Pharmacyclics: Consultancy, Honoraria, Research Funding.

Herpes zoster (HZ) incidence is higher in patients with hematologic malignancies (HM) (25-100 cases/1000 person-years) than in the general population (3-5 cases/1000 person-years). This immunocompromised population can experience significant morbidity and occasional mortality from complications associated with reactivation of the varicella-zoster virus (VZV). In general, there is limited data in the literature regarding the effect of anti-CD20 monoclonal antibodies, used in treatment of HM patients, on vaccine-related cell-mediated immune response. Due to the potential negative impact of anti-CD20 monoclonal antibodies on vaccine immunogenicity and efficacy, HM patients receiving anti-CD20 monoclonal antibodies have been excluded from prior inactivated VZV vaccine (inactivated-ZV) studies. This study evaluated the safety and immunogenicity of inactivated-ZV in HM patients receiving anti-CD20 monoclonal antibody therapy.This was an open label, single arm, multicenter Phase I study of a 4-dose inactivated-ZV regimen (∼30 days between each dose) in patients ≥18 years old with HM receiving anti-CD20 monoclonal antibodies either as a single agent or in a combination chemotherapy regimen and not likely to undergo HCT (n=80). Blood samples were collected at baseline prior to dose 1 and 28 days postdose 4 to measure VZV-specific T-cell responses using interferon-gamma enzyme-linked immunospot (IFN-γ ELISPOT). The primary hypothesis was that inactivated-ZV would elicit significant VZV-specific immune responses at ∼28 days postdose 4, with the statistical criterion being that the lower bound of the two-sided 90% confidence interval (CI) on the geometric fold rise (GMFR) be >1.0. All vaccinated patients were evaluated for adverse events (AE), including VZV-like rashes, through 28 days postdose 4.The 4-dose inactivated-ZV regimen elicited a statistically significant VZV-specific immune response measured by IFN-γ ELISPOT at 28 days postdose 4 in the per-protocol population (GMFR = 4.34 [90% CI: 3.01, 6.24], p-value <0.001). As the lower bound of the 2-sided 90% CI for GMFR was >1.0, the pre-specified primary immunogenicity success criterion was met.Overall, 85% (68/80) of patients reported ≥1 AEs, 44% (35/80) reported ≥1 injection-site AEs, and 74% (59/80) reported ≥1 systemic AEs. The most common injection-site AEs were pain (32%), erythema (31%), and swelling (26%). The most common systemic AEs were pyrexia (25%) and diarrhea (14%). Twelve patients (15%) experienced serious AEs, including one event determined by the investigator to be vaccine-related (convulsion: day 8 postdose 1). One patient experienced a fatal serious AE (Richter’s transformation to Hodgkin’s disease; day 34 postdose 1) assessed as not vaccine-related by the investigator. In general, the frequencies of AEs did not increase with subsequent doses of vaccine. No inactivated-ZV recipient had a rash that was PCR positive for VZV vaccine strain.In adults with HM receiving anti-CD20 monoclonal antibodies, inactivated-ZV was well tolerated and elicited statistically significant VZV-specific T-cell responses ∼28 days postdose 4.McNeil: Merck: investigator Other, Research Funding. Betts:Merck: investigator Other, Research Funding. Lawrence:Merck: investigator Other, Research Funding. Velardi:Merck: investigator Other, Research Funding. Kimby:Merck: investigator Other, Research Funding. Pagnoni:Merck: Employment, Equity Ownership. Stek:Merck: Employment, Equity Ownership. Zhao:Merck: Employment, Equity Ownership. Chan:Merck: Employment, Equity Ownership. Lee:Merck: Employment, Equity Ownership. Parrino:Merck: Employment, Equity Ownership.

The role of both autologous (autoSCT) and allogeneic stem cell transplantation (alloSCT) in the management of patients with mantle cell lymphoma (MCL) remains to be clarified. In the absence of prospective comparative trials decision making for clinicians remains challenging. We have conducted a consensus project to provide guidance on how stem cell transplantation should be employed in MCL.

The optimal treatment schedule and best order of therapies are not well established for patients (pts) with indolent lymphoma. The aim of this trial was to evaluate the effect of adding interferon-alpha (IFN) to first-line rituximab (R) monotherapy, with extended dosing, in pts with CD20+indolent lymphoma and to define pts with no need of initial chemotherapy.Pts with symptomatic, advanced indolent lymphoma (previously untreated or at first relapse after a short course of chlorambucil) were randomized to R (MabtheraR) 375 mg/m2 once-weekly for 4 consecutive weeks or R with 5 weeks IFN (Roferon-AR) as priming. Patients achieving either a complete response (CR), partial response (PR) or a minor response (MR) at evaluation 6 weeks after last R in this first cycle, were planned to receive a second cycle with four infusions of R alone or combined with IFN, according to the initial randomization. Primary endpoint was time to treatment failure (TTF), defined as the time period from randomization to one of the following events: progressive disease during treatment, death of any cause or initiation of new therapy.In total, 313 patients were randomized. The median age was 59 years, 51% were females, 90% Ann Arbor stage III or IV and 31% showed elevated LDH. The clinical characteristics were well-balanced between the treatment groups. Pathology review showed 127 follicular lymphoma (FL) grade I, 110 grade II and 9 grade IIIA. In total, 4 pts in each arm did not fulfill inclusion criteria: 5 DLBCL/ transformed, 2 MCL and one Hodgkin. Most patients were previously untreated, but 10 pts in the R group and 13 with R+IFN had had a previous response to chlorambucil and 18 and 9 had had local radiotherapy. respectively. After cycle 1, response rates among all 313 randomized pts were 8.6 % CR/CRu, 47.9 % PR, 22.4 % MR and 16.9 % of pts were considered resistant (SD/PD). In total 244 pts were qualified for cycle 2. Overall response rates after cycle 2 were 82% and 74%, in the R+IFN- and the R-group, respectively (n.s), but the CR/CRu rates were higher with the combination (41% vs 22.4%, p< 0.01). Also pts with FLIPI 3–5 (45% of all pts) showed a deeper response with R+IFN (CR/Cru 38.0% compared to 23.1%). More patients in the combination arm improved their responses from PR/MR in cycle 1, to CR after cycle 2. In the intention–to treat (ITT) population (n=313), median time to TTF was 21 and 28 months in the R and R+IFN group, respectively. Most events consisted of initiation of new therapy including chlorambucil, COP or CHOP, but in 7 patients in the R group, relapse treatment was single R (in one case with the addition of IFN) and in the R+IFN group 10 pts had R (3 with IFN). Two pts in the R-group and 12 pts in the R+IFN group had late relapses treated with local irradiation. After a median follow-up time of 60.7 months, for surviving pts, 35 % of the ITT patients were still event-free with 90% survivors, but with no difference between the treatment groups. Patients with FL grade II and IIIA showed a longer TTF than pts with grade I (p=0,05).This randomized phase III trial demonstrates that extended rituximab therapy is safe and effective as first-line therapy in patients with symptomatic low-grade B-cell lymphoma, with improved responses and a delayed time to early failure if combined with IFN. The long term FU suggests that more than 1/3 of this patient population does not need initial chemotherapy, but predictive markers for response to R and new biological combinations are needed.Kimby: Roche: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; GSK: Membership on an entity's Board of Directors or advisory committees; Gilead: Membership on an entity's Board of Directors or advisory committees.

Goy: Milennium: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Membership on an entity's Board of Directors or advisory committees; Pharmacyclics: Membership on an entity's Board of Directors or advisory committees; J & J: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees.

The World Health Organization (WHO) classification allocates indolent follicular lymphoma to grades 1, 2 or 3A according to the proportions of small centrocytes and large centroblasts in the neoplastic follicles. The prognostic value of the WHO's grading system in indolent follicular lymphoma has not been investigated in patients given the anti-CD20 monoclonal antibody rituximab without chemotherapy.We prospectively reviewed the follicular lymphoma grades in 276 grade 1–3A patients who received upfront rituximab without chemotherapy in two randomized trials. Flow cytometry analyses of malignant and nonmalignant lymphocyte subsets in lymph nodes and blood were also assessed.In these patients given upfront rituximab-containing therapy, increasing grades of 1, 2, and 3A correlated with longer time to treatment-failure (P =0.002) and overall survival (P =0.045), independently of clinical factors (including the follicular lymphoma international prognostic index). The grades' impact was also independent of the levels of CD3+, CD4+, and CD8+ T cells in lymph nodes and in blood.Increasing grades of indolent follicular lymphoma correlate with better outcome in patients treated upfront with rituximab without chemotherapy, independently of clinical and immunologic factors. This suggests that treatment with rituximab acts differentially in tumors depending on the centrocyte/centroblast ratio.No relevant conflicts of interest to declare.

Mantle cell lymphoma (MCL) constitutes 3–10% of non-Hodgkin lymphomas and affects predominantly middle-aged to elderly men. The median survival is 3–5 years and seems to improve with new therapeutic regimens. The MCL International Prognostic Index (MIPI) has been proven useful for predicting survival in MCL patients included in clinical trials, but its value in unselected population based MCL cohorts is less well known. Biological markers are increasingly used for prognostication of MCL patients, especially for defining indolent cases.All 186 patients diagnosed with MCL, confirmed by IHC for cyclinD1 and/or by FISH for t(11;14), between January 1998 and June 2010 in the Stockholm region, were included in a retrospective analysis. Clinical data from patient files, diagnostic biopsies and flow cytometry data were reviewed. Last follow-up was in May 2011.The prognostic value of the following variables, evaluated at the time of diagnosis, were analyzed: age, sex, Ann Arbor stage, ECOG, B-symptoms, Hb, LDH, albumin, lymphocytosis, leukocytosis, splenomegaly, nodal, extranodal and bone marrow involvement, blastoid morphology, expression of CD23, light chain, Ki 67, p53 and nuclear SOX11.The median age at diagnosis was 68.8 years (range 36.2 – 89.9); 67.4 in males and 72.1 in females, respectively. The male: female ratio was 2. Thirty patients had a known malignancy of other type before the MCL diagnosis and 12 acquired a cancer later. In 13 patients the other malignancy was the cause of death. Median overall survival (OS) time was 43 months in the whole cohort and 38 months, when excluding 39 patients receiving ASCT as part of first-line therapy. No statistically significant difference in OS was seen with respect to whether the lymphoma was diagnosed before or after 2005.In the non-transplanted patients (n=149), univariate analysis showed the following clinical variables to be negatively correlated to overall survival: age >65 years, B-symptoms, splenomegaly, ECOG >2, low albumin, and high LDH. The median survival was not reached in the low risk MIPI group, and was 79 and 34 months, in the middle and high risk MIPI group, respectively. Blastoid morphology and p53 positivity (>20%), were negatively correlated to overall survival (both with p<0.0001), as was increasing tumor cell proliferation (measured as a continous variable or using the cut-offs >50%, both with with p<0.0001), but not with cut-off >30% (p=0.061), while SOX11 positivity was related to a prolonged survival (p=0.015). Multivariate analyses showed that age >65 (HR 6.1, p<0,002), ECOG >2 (HR 63, p<0.001), high LD (HR 3.7, p< 0.001), and p53 positivity (HR 5.6, p< 0.0001) remained significant.Clinically indolent MCL, defined as in retrospect not requiring treatment within two years from diagnosis, was seen in 17 patients. In two of these patients the proliferation was >30%, in one >50%, two had a p53 expression >20% and two were SOX11 negative. Therapy was never required in 9 of these initially indolent patients and only one had an autologous transplantion later in the disease course. The median OS was 72 months for the 17 indolent MCL compared with 34 months in patients requiring treatment earlier in their disease (p=0.003). The follow-up time did not differ significantly between the two groups.Compared to data from published clinical trials of advanced MCL, our population-based cohort of 186 cyclin D1 positive MCL patients were diagnosed at an older age, which may contribute to a shorter overall survival. Certain well-established prognostic variables seem to loose significance outside study populations.In the group of 147 non-transplanted patients multivariate analysis showed that only age, ECOG, LDH and p53 positivity were independently associated with overall survival. Leukocytosis as a variable of MIPI had no impact. Neither SOX11, CD23 or other biological markers applied at the time of diagnosis could predict for clinically indolent disease.No relevant conflicts of interest to declare.

Mantle cell lymphoma (MCL) constitutes 3–10% of non-Hodgkin lymphomas and has a median survival of 3–5 years. A small number of patients are characterized by a clinically indolent disease and may not require treatment for several years. However, these are difficult to identify at the time of diagnosis due to lack of reliable predictive markers. Recently, the nuclear expression of the transcription factor SOX11 has been suggested to be of prognostic value in MCL.All 186 patients diagnosed with MCL in the Stockholm region between January 1998 and June 2010 were included. Diagnosis was according to the WHO criteria and all cases were cyclin D1 positive by IHC and/or for t(11;14) by FISH. Clinical data from patient files, diagnostic biopsies and flow cytometry data were reviewed. Patients not requiring treatment within the first two years after diagnosis were retrospectively defined as indolent disease.Patients were further categorized in nuclear SOX11 negative (n=13) and nuclear SOX11 positive (n=160) cases and in cases with indolent (n=17) versus non-indolent disease course (n=169). The following variables were evaluated at the time of diagnosis: age, sex, Ann Arbor stage, ECOG, B-symptoms, Hb, LDH, albumin, lymphocytosis, leukocytosis, splenomegaly, nodal and bone marrow involvement, MIPI, indolent disease, blastoid morphology, expression of CD23, light chain, Ki 67, SOX11 and p53. Overall survival was analyzed, excluding patients receiving ASCT (n=37). Baumgartner, S. et al presents further data on the entire cohort in the accompanying abstract.The following variables were significantly more common in SOX11 negative cases (Table 1): Lymphocytosis (p=0,045), high LDH (p=0,029) and p53 positivity (p<0,000). MIPI high risk was more frequent among SOX11 negative patients but did not reach statistical difference. There were no statistically significant differences in the frequency of splenomegaly or indolent disease among SOX11 negative and positive cases. Median overall survival time was 36,7 months in the whole cohort; 16,5 months in patients with SOX11 negative tumors and 39,3 months in patients with SOX11 positive tumors (p=0,015), excluding 37 patients (1 SOX11 negative, 38 SOX11 positive) receiving ASCT as part of first-line therapy. Patients with an indolent clinical course had significantly less often B symptoms (p=0,002), nodal presentation (p=0,019) and elevated LDH (p=0,040) than patients with a non-indolent disease, while none of the other factors analyzed reached statistical significance. Median overall survival time of patients with indolent disease was not reached (median follow-up time 41,7 months). 15/17 of the MCL cases with indolent clinical course expressed SOX11.In a population-based cohort of 186 cyclin D1 positive MCL, 8% lacked expression of nuclear SOX11 at diagnosis. There was no enrichment of patients with an indolent disease among SOX11 negative MCL. Instead patients with SOX11 negative MCL had a higher frequency of lymphocytosis and elevated LDH at diagnosis and a shorter overall survival. MCL lacking nuclear SOX11 expression at diagnosis were more frequently p53 positive which may contribute to shorter survival in the SOX11 negative MCL subset.No relevant conflicts of interest to declare.

In CLL unmutated immunoglobulin heavy chain (IGH) genes, deletions of chromosome 17p or 11q and trisomy 12 are associated with an unfavorable outcome. At the outset of the present trial, phase II studies had shown promising results of immunochemotherapy with FC + rituximab, but the optimal immunochemotherapy regimen was not known, especially not for high-risk CLL patients. The aim of this trial was to improve the outcome of high-risk CLL by the addition of the monoclonal antibody alemtuzumab to the currently best known chemotherapy FC. Because of the recognized immunosuppressant activity of both treatment modalities, a low-dose alemtuzumab approach was chosen and vigilance and prophylaxis towards infection upheld throughout the study.Patients and methods: Previously untreated, fit patients up to 75 years of age with high-risk CLL in need of treatment according to the NCI/IWCLL guidelines were randomized to either oral FC (F 40 mg/m2 D1-3 and C 250 mg/m2 D1-3) or AFC: oral FC + subcutaneous (sc.) alemtuzumab 30 mg, in cycle 1 day -1 to +1, in cycles 2–6 30 mg day 1 only. Responses and endpoints were defined according to NCI/IWCLL guidelines. The primary endpoint was progression-free survival (PFS) on intent-to-treat with progression defined as no response after three cycles of induction treatment, progression of disease, relapse or death whichever occurred first. Secondary endpoints included the rate of complete remission (CR) and the rate of MRD – negative CR (by PCR or flow cytometry), overall survival (OS) and toxicity. We assumed that the addition of alemtuzumab to FC could increase the CR rate from the estimated 20% to 40% and the median PFS from 30 to 42 months.The study population of 281 patients was included 2006–2010. As of July 2011 262 patients (93%) were evaluable, 129 in the AFC arm and 133 in the FC arm with a median follow-up of 30 months (range 2–63 months). The median age was 60 years (range 27–75) and 75% were males. Twelve % had Binet stage A, 54% stage B and 34% stage C. Beta-2-microglobulin was increased in the majority of the patients (median 3.7 g/ml). Eighty-nine % had unmutated IGH genes and FISH revealed 27% with del11q, 18% with trisomy 12 and 11% with del17p according to the hierarchical model. All risk parameters were well balanced between the two arms. Sixty-three% completed all six cycles in each arm, 73% completed at least 5 cýcles AFC while 66% completed 5 cycles FC.The overall response to AFC and FC was 88% and 80% respectively (NS), the CR rates were 57% and 45% respectively (P=0.049), and the rates of MRD-negative CR were 29% and 17% respectively (P<0.02. The median PFS following AFC and FC was 37 and 31 months respectively (P=0.08). The median OS has not been reached. In the subgroups with 17p deletions, 11q deletions, trisomy 12 or unmutated IGH genes a trend of improved PFS following AFC was seen, but this did not reach significance due to small numbers. There were no differences in response or PFS between treatment arms according to Binet stage or beta-2-microglobulin level.Severe adverse events, mostly grade 3, were significantly more frequent following AFC than FC: 145 vs 90 (P<0.0001), including flu-like syndrome due to the antibody (27 vs. 2), opportunistic infections (25 vs 11), and organ affection (34 vs 14). The numbers of neutropenic and other infections did not differ. Six treatment related deaths were reported in each arm to a total treatment related mortality of 4%.In this selected high-risk CLL population, the addition of low-dose sc. alemtuzumab to FC induced a higher rate and higher quality of complete remission than FC alone, which, however, in this early analysis, did not yet translate into significantly prolonged PFS or OS. As expected, the combination is more immuno-suppressant than chemotherapy alone, leading to a higher number of opportunistic infections. With proper vigilance and prophylactic measures, these infections were manageable and did not lead to any excess mortality.The members of the Data Management and safety Board, Peter Hillmen, Stephan Stilgenbauer and Harald Anderson are thanked for their advice. The NovoNordisk Foundation, The Danish Cancer Society and Genzyme Corporation are thanked for research support.Geisler: Roche: Consultancy; Genzyme: Research Funding; Celgene: Consultancy; GSK: Consultancy. Walewski:4SC AG: Consultancy.

Patients who relapse after fludarabine-based treatments have poor prognosis. These patients have deteriorating immune functions with high infection rates resulting from progressing disease complicated further by ineffective and often immunosuppressive therapies. Two phase II studies in patients with relapsed or refractory (rel/ref) CLL at starting doses of 10 mg or 25 mg daily of lenalidomide (Len) demonstrated promising responses. A phase II/III study was initiated to assess Len 10 mg/d vs 25 mg/d given continuously for 21 days of a 28-day cycle. Four cases of serious tumor lysis syndrome (TLS) prompted an independent data monitoring committee to amend the protocol into a phase I trial (de Parseval et al., JCO 2007) Here we present results from this amended study.Eligible patients had rel/ref CLL, received prior treatment with an alkylating agent and fludarabine, and progressed during or ≤ 12 months after completing fludarabine-based treatment. Primary objective was to determine whether Len 2.5 mg was a safe starting dose and the maximum tolerated dose escalation level (MTDEL). Prophylaxis with allopurinol and hydration were employed as part of an aggressive monitoring plan for TLS prevention. All patients initiated Len at 2.5 mg/d with subsequent dose escalation to 5 mg/d after 28 days with further dose escalations in 5 mg increments performed every 28 days until MTDEL was defined, or the maximum targeted 20 mg/d dose level attained. The first 6 patients at 10, 15 and 20 mg/d dose levels were considered a cohort and could not escalate beyond that dose level for the duration of treatment. Treatment continued until disease progression or unacceptable toxicity.The redesigned phase I study enrolled 52 patients with a median age of 65 years (range, 37–80) and bulky disease (> 5 cm) in 70%. Cytogenetic data was available for 46 patients, of whom 22 (48%) had high-risk disease: 8 (17%) had del(17p), 12 (26%) had del(11q), 2 had both. Patients were heavily pretreated with a median of 4 prior therapies (range, 1–14); 54% were fludarabine refractory (no-response/relapse ≤ 6 mo), 42% had prior FCR or PCR and 21% had prior alemtuzumab. The TLS prevention strategy resulted in only 2 (3.8%) cases of TLS, both observed at 2.5 mg/d (1 patient with Gr.2 and another with lab TLS). Gr.3/4 tumor flare occurred in 5 (9.6%) patients and was managed with NSAIDs or low-dose steroids. The most common Gr.3/4 adverse events (AEs) included neutropenia (65%) and thrombocytopenia (33%). Febrile neutropenia occurred in 4 (8%) patients. Gr.3/4 infections were observed in 21 (40%) patients; 10 (19%) patients developed pneumonia and 3 developed sepsis; 2 cases of sepsis-related death at day 37 and 94 of therapy were also noted but deemed unrelated to study drug by the investigators. Reasons for study discontinuation included disease progression (37%), AEs (29%), consent withdrawal (15%), death (4%), and other reasons (10%). For 16 (31%) patients, 2.5 mg/d was the maximum dose reached and 22 (42%) patients were unable to escalate beyond 5 mg/d. Gr.4 neutropenia was the primary reason for delay in dose escalation. By intent-to-treat (ITT) analysis, 6 patients (12%) had a partial response (NCI-WG 1996), 30 patients (58%) had stable disease and 13 patients (25%) progressed; 3 patients were non-evaluable. Median duration of treatment was 3.1 months (range, 0.07–18.4) and the median time to response was 4.3 months (range, 2.8–7.4). Responses were observed at 10 mg/d (n=3), at 15 mg/d (n=1), and at 20 mg/d (n=2); Median PFS (ITT) was 5.5 months and median PFS for responders was 12 months. Three patients still remain on therapy.We conclude that a Len starting dose of 2.5 mg/d appears safe, feasible and can be safely titrated to 20 mg/d (maximum intended dose). The MTDEL was not reached at 20 mg/d. Based on the response rate reported in this study, a higher starting dose, such as previously reported by Chanan-Khan et al (JCO 2006) and Ferrajoli et al (Blood 2008), may be needed to achieve clinical efficacy, particularly for patients with high-risk disease. Adequate TLS prophylaxis and monitoring allows for higher starting doses to be investigated. To identify a safe and clinically active starting dose, the CLL-009 study is evaluating Len at starting doses of 5 mg/d, 10 mg/d, and 15 mg/d in the setting of rel/ref CLL.Wendtner: Celgene, BayerSchering, Roche, Mundipharma: Consultancy, Honoraria. Off Label Use: off-label use of lenalidomide. Hillmen:Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Alexion Pharmaceuticals: Consultancy; Bayer Schering: Consultancy. Mahadevan:Pfizer, millenium, Amgen: Honoraria. Stilgenbauer:Roche, Bayer, Celgene, GSK, Amgen, Mundipharma: Consultancy, Honoraria, Research Funding. Frankfurt:Bayer, Celgene: Research Funding, Speakers Bureau. Kimby:Roche, Bayer-Schering, Mundipharma: Membership on an entity's Board of Directors or advisory committees, lecturer. Gobbi:Novartis, Jansen Cilag, Roche, Celgene, Amgen: Consultancy, Research Funding, Speakers Bureau. Hurd:Celgene: Research Funding. Sekeres:Celgene: Research Funding, Speakers Bureau. Ferrajoli:Celgene: Honoraria, Research Funding. Shah:Celgene: Employment, Equity Ownership. Zhang:Celgene: Employment. Moutouh de Parseval:Celgene: Employment, Equity Ownership.

In CLL the prognostic importance of cytogenetic abnormalities in bone marrow or peripheral blood is well-known. However data is lacking on the frequency and importance of the aberrations in other tissues such as lymph nodes and spleens.To develop a method to assess the chromosomal aberrations commonly seen in CLL (13q-, 11q-, 17p- and +12) on paraffin-embedded tissue sections from spleens and to relate the findings to data on abnormalities found in bone marrow or peripheral blood.24 out of 61 CLL patients splenectomized between 1990–2009 have so far been analyzed. Paraffin-embedded sections were obtained from stored tissue material from spleen. Fluorescence in situ hybridization (FISH) was used to detect cytogenetic abnormalities and the results were compared with analyses made on blood or bone marrow. Monosomy 12, an abnormality rarely occurring in CLL was used as a surrogate marker to avoid false-positive results for deletions due to incomplete nuclei. In all but one case this was below 20%. Therefore the cut-off for the deletions (13q-, 11q- and 17p-) were set to 30%. For +12 we used 5%. Data on flow cytometry for quantification of the CLL clone in the spleen was available in 13 patients with a median of 71% clonal cells (range 11–86%). Indications for splenectomy were splenomegaly (n=13), AIHA (n=8) or ITP (n=3). All but five patients had received chemotherapy before splenectomy including purine analogs (n=7), alemtuzumab (n=1) or both (n=2) The remaining patients were treated with alkylators and/or anthracycline-containg regimens.In all but one patient, FISH results from the splenic sections could be obtained with cytogenetic aberrations detected in 18 of 23 patients (78%). In 11 patients a single abnormality was detected, whereas multiple aberrations were present in 7 cases. The most common aberration was 13q- (70%), followed by 17p- (22%), 11q- and +12 (17% each) (Table 1). In 8 cases FISH samples from blood/bone marrow were available from time points both pre- and post- splenectomy and 6 additional cases had FISH data before splenectomy. All FISH abnormalities affecting >20% CLL cells in blood or bone marrow were also found in the spleen. In contrast an additional 17p clone was found in one patient and in two patients the 13q- and 17p- clones were significantly larger in the spleen. Remarkably one patient had both homo- and heterozygous 13q- clones in blood and in the spleen. In repeated blood samples nine years after splenectomy only a heterozygous clone remained.FISH on paraffin-embedded sections is a useful tool for the evaluation of genetic abnormalities. Clonal evolution does appear to occur in the spleen in CLL and with splenectomy selected clones might be obliterated.Kimby: Roche, Bayer-Schering, Mundipharma: Membership on an entity's Board of Directors or advisory committees, lecturer.

Pettengell: Roche: Honoraria. Schmitz:Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Gisselbrecht:Roche: Research Funding. Walewski:Roche: Honoraria, Research Funding. Geisler:Roche: Research Funding. Kimby:Roche: Honoraria, Research Funding. Goldstone:Roche: Honoraria, Speakers Bureau.

Several studies concur that the microenvironment determines outcome in follicular lymphoma (FL), but they disagree regarding which components thereof are important. Our hypothesis was that several immune cell subsets are important for disease outcome and their individual prognostic importance should be demonstrable in the same analysis and in competition with clinical factors. Specifically, we hypothesized that (1) CD8+ cells are associated with good prognosis (presumably due to tumor cell killing), as are (2) cells positive for programmed death-1 (PD-1) or FOXP3 (due to diminished B-cell stimulation), while (3) CD4+ cells are associated with poor prognosis (due to B-cell stimulation).Seventy FL patients with extreme clinical outcome (“poor” and “good” cases) were identified in a cohort of 197 patients. The criterion for poor outcome was death from lymphoma <5 years after diagnosis (n=33). The general criteria for good outcome were absence of a lymphoma-related death and/or transplantation and one of the following three statements had to be true: (1) never treated against lymphoma and followed for ≥5 years (n=11); (2) never relapsed after first-line anti-lymphoma treatment and followed for ≥8 years (n=14); (3) relapsed but never received intensive or frequent (≥3 years between) treatments and followed for ≥10 years (n=12), rendering totally 37 good-outcome patients. A tissue microarray was constructed from diagnostic and relapse biopsies of these 70 patients. Sections of the microarray were stained for CD3, CD7, CD4, FOXP3, PD-1, CD8, TIA-1, granzyme B, perforin, CD57, CD56, CD68, and tryptase. The number of positive cells for each staining were quantified using computerized image analysis, separating cells inside and outside the follicles (follicular and interfollicular compartments).Between the two clinical extreme groups there were great differences in the FL International Prognostic Index (FLIPI), as expected (P<0.0001). In univariate analysis, the amounts of several immune subsets were different between the two groups with borderline or stronger significance. These subsets were taken to multivariate analysis together with the FLIPI. Independently of the FLIPI, CD4+ cells were associated with poor (Odds Ratio [OR] 1.26; P=0.025) but PD-1+ (OR 0.58; P=0.020) and CD8+ (OR 0.94; P=0.024) cells with good outcome. In a second multivariate analysis, where the subsets in the follicular and interfollicular comparments were analyzed (again in competition with the FLIPI), the prognostic values of CD4+ and PD-1+ cells were accentuated when they were follicular (OR 2.16; P=0.010 and OR 0.34; P=0.019, respectively), and that of CD8+ cells when interfollicular (OR 0.86; P=0.014). Follicular FOXP3+ cells were also associated with good outcome (OR 0.09; P=0.018) and interfollicular CD68+ cells with poor (OR 1.36; P=0.040).We conclude that there are many important immune cell subsets in the microenvironment of FL. Independently of the FLIPI, and of each other, PD-1+, FOXP3+, CD4+, CD8+, and CD68+ cells correlate with outcome. This suggests several different but not mutually exclusive mechanisms which all affect the course of the disease.No relevant conflicts of interest to declare.