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Background: In patients with relapsed/refractory acute myeloid leukaemia (R/R AML) who received salvage chemotherapy, limited and not updated studies explored the incidence of invasive aspergillosis (IA) and the role of antifungal prophylaxis (AP). The aims of this multicentre retrospective 'SEIFEM 2016-B' study were as follows: (1) to evaluate the current rate and the outcome of proven/probable IA and (2) to assess the efficacy of AP, in a large 'real life' series of patient with R/R AML submitted to salvage chemotherapy. Results: Of 2250 R/R AML patients, a total of 74 cases of IA (5.1%) were recorded as follows: 10 (0.7%) proven and 64 (4.3%) probable. Information about AP were available in 73/74 (99%) patients. Fifty-eight (79%) breakthrough infections occurred, mainly during AP with posaconazole [25 (43%)]. The patients who received AP during salvage chemotherapy showed a benefit from antifungal therapy (AT) than patients who did not received AP [43 (86%) vs 7 (14%); p&nbsp

Favorable acute myeloid leukemia (AML) patients (pts.) demonstrate a relatively good outcome with standard induction; thus, pts. are generally not addressed to allogeneic transplant in first remission. However, it is not clear if also in a real-life setting, the outcome is homogeneous in the different favorable molecular groups and which are the parameters significantly associated to an increased relapse risk, useful to suggest the need of an intensified approach. In order to clarify this point, we collected clinical data on consecutive unselected AML pts. assigned to favorable category (modified ELN 2010 due to the inclusion of double-mutated CEBPA-positive cases), diagnosed and treated in six centers of the Italian network Rete Ematologica Lombarda (REL) from 2007 to 2015. We assessed response (CR, mCR), relapse rate (CIR), and outcome (OS, DFS) after first-line treatment. A total of 201 pts. was studied and the analysis was performed globally and in each molecular group: t(8;21)(q22;q22)/RUNX1-RUNX1T1 (30 pts., 14.9%), inv. (16)(p13q22) or t(16;16)(p13q22)/CBFB-MIH11 (35 pts., 17.4%), normal karyotype and mutated NPM1 and negative FLT3-ITD (116 pts., 57.7%) or double-mutated CEBPA (CEBPAdm) (20 pts., 10%). Complete remission (CR) was obtained in 188 pts. (93.5%), molecular CR (mCR) in 114 (67.5%); After a median follow-up of 2.4 years, cumulative incidence of relapse (CIR) was documented in 78 of 188 responding pts. (41%) after a median time of 11.3 months. CIR was higher in the CBFB-MIH11 group, in pts. achieving only a hematological response without mCR (72.1 vs 28.1%, p

The epidemiology of invasive fungal infections (IFI) among patients with hematologic malignancies who are undergoing either conventional chemotherapy or hematopoietic stem cell transplantation (HSCT) is changing due to the introduction of new, effective antifungal agents for both prophylaxis and

The electronic surveillance system Hema e-Chart allowed us to prospectively collect data and to perform an analysis of invasive fungal infections (IFI) diagnosed in febrile patients as well as the procedures allowing their diagnosis and outcome according to the treatment given. Every patient admitted to 26 Italian Haematology Units with a new diagnosis of haematological malignancy and who was a candidate for chemotherapy was consecutively registered between March 2007 and March 2009. In all, 147 haematological patients with mycoses were identified. Yeasts were found in 23 infections; moulds were diagnosed in 17 proven, 35 probable and 72 possible mycoses. Galactomannan (GM) antigen was the most important test to diagnose probable mould infection; it was positive (cut-off >0.5) in 27 (77%) probable and in nine (53%) proven mould infections. Among patients with probable/proven mould infection who received no prophylaxis or non-mould-active prophylaxis with fluconazole, more patients (n = 26, 78.8%) had GM antigen positivity compared with patients (n = 10, 52.6%) given prophylaxis with mould-active drugs (p

Summary Objectives To describe the clinical characteristics and prognostic factors of hematological patients affected by Nocardia spp infections. Methods We retrospectively evaluated all the cases diagnosed in four Italian institutions. Results Between 2002 and 2012, 10 cases of nocardiosis were recorded. The median age of the patients was 66 years (range 24–85 years). The underlying hematological disease was a lymphoproliferative disorder in all but two patients. Eight patients (80%) showed active underlying hematological disease, relapsed or refractory in five (50%); one patient had a history of previous allogeneic bone marrow transplantation. Eight patients (80%) were on steroid therapy; lymphopenia was present in 8/10 (80%) patients. All patients showed lung involvement. Six patients were affected by disseminated nocardiosis. Three patients (30%) were nocardemic and three (30%) showed central nervous system involvement. Skin, lymph nodes, and bone were involved in one patient each. The median overall survival was 65 days. Older age, a longer period between hematological diagnosis and Nocardia spp infection, and relapsed/refractory hematological disease were associated with a worse prognosis. Conclusions Although rare, nocardiosis should be considered in the differential diagnosis of pulmonary and central nervous system lesions among hematological patients. Lymphoproliferative disorders, prolonged steroid treatment, lymphopenia, and active hematological disease are the conditions that are worth considering as predisposing factors for the development of this disease.

Acute myeloid leukemia (AML) with deranged core-binding factor beta (CBFβ) is usually associated with a favorable prognosis with 50–70% of patients cured using contemporary treatments. We analyzed the prognostic significance of clinical features on 58 patients with CBFβ-AML aged ≤60 years. Increasing age was the only predictor for survival (P

Blast phase (BP) may occur as a late event in essential thrombocythemia (ET). This study includes 19 patients with post-ET BP diagnosed and followed in a single institution. At BP, 63% of patients had leukocytosis (white blood cell count >10 x 10(9)/L), 74% had anemia (hemoglobin value

We used intermediate doses of Ara-C (IDAra-C) in the treatment of 15 patients with chronic myelogenous leukemia (CML) in blast crisis and, combined with hydroxyurea, in 20 CML patients in accelerated phase. Patients with blastic CML received intensive 5-day courses of IDAra-C 600 mg/m2 every 12 h as a 2-h infusion. Of 15 patients, three achieved complete response (CR) and three partial response (PR), for an overall response rate of 40 per cent. All patients developed severe leukopenia and thrombocytopenia, and two died in hypoplasia. Except nausea and vomiting requiring medication, other nonhematologic toxicities were uncommon. Median response duration was 4 months (range 1 to 7 months). Survival was 5 months for responders and 1.5 months for nonresponders. Patients with CML in accelerated phase were treated with two-day courses of IDAra-C 600 mg/m2 every 12 h by 2-h infusion, every two-three weeks. Daily hydroxyurea 1-1.5 g/day was administered between courses. Of 20 patients, 15 (75 per cent) achieved a good PR with rapid improvement of the symptoms of disease acceleration. The median duration of response was 11 months (range 3 to 38 months); duration was over 24 months in five patients. The median survival from the start of IDAra-C was 13 months for responders and 3.5 months for nonresponders. We conclude that IDAra-C is an effective approach for CML in terminal phase. Its use in 5-day induction courses for blast crisis CML has a response rate comparable to that achieved with high-dose Ara-C. In patients in accelerated phase, the combination of short courses of IDAra-C with hydroxyurea is a well-tolerated treatment able to improve substantially the clinical and hematologic symptoms of disease progression.

We report a case of a patient with myelofibrosis with myeloid metaplasia (MMM) who presented with progressive dyspnea of unexplained origin. Splenomegaly, blood smear, and bone marrow findings allowed diagnosis of MMM. High-resolution CT chest scan revealed diffuse septal thickening, while echocardiography and electrocardiogram showed no indirect evidence of pulmonary hypertension. Finally, lung biopsy revealed irregularly distributed interstitial fibrosis with islands of erythroblasts, immature granulocytic elements, and dysplastic megakaryocytes, allowing diagnosis of pulmonary extramedullary hematopoiesis (EMH). The patient received hydroxyurea as cytoreductive agent, obtaining a good hematologic response and an improvement of dyspnea. Note that, in this patient, dyspnea was the first clinical symptom of MMM; the dyspnea was not associated with pulmonary hypertension and improved following cytoreductive treatment. This case points to the importance of suspecting pulmonary EMH when unexplained progressive dyspnea occurs in a patient with MMM. Early recognition of pulmonary EMH may prevent PH and favor a better response to therapy.

ABL1 amplification, due to a cryptic episomal translocation NUP214/ABL1, is a novel finding in T-cell acute lymphoblastic leukemia (ALL). Here we report on the incidence and clinical features of this genetic defect in a series of 30 consecutive adult T-cell ALL patients. Multiple copies of the ABL1 gene were detected in two patients (6.6%), one with the karyotype 46,XY,t(1;3)(p36;p21),del(6)(q23)/46,XY and the other without analyzable metaphases. Metaphase/interphase fluorescence in situ hybridization (FISH) detected multiple uncountable signals corresponding to ABL1 in mitotic cells and nuclei from both patients. In one patient, no signals corresponded with the 9p21 chromosomal region, which contains the p16INK4a gene, and in the other one signal was observed. Quantitative reverse-transcriptase polymerase chain reaction (RT-PCR) demonstrated that in these patients ABL1 gene expression was 14- and 18-fold greater than in normal controls, and returned to normal levels only when complete remission was achieved. We reached the following conclusions: (1) FISH is the only technique that promptly identifies T-cell ALL patients with ABL1 amplification, (2) quick identification with FISH is fundamental in the clinic because this T-cell ALL subset is imatinib sensitive but may become resistant due to development of additional mutations, and (3) ABL1 quantitative RT-PCR may be easily applied to monitor minimal residual disease.

BACKGROUND Acute leukemia (AL) may occur as rare and late event of polycythemia vera (PV). METHODS The current study included 23 patients who developed acute leukemia in a cohort of 414 consecutive PV patients with long-term observation (3208 person years of follow-up). Kaplan–Meier Product-Limit method was used to estimate the cumulative probability of survival; Gehan–Wilcoxon test was applied to compare survival in different groups of patients. RESULTS Median age was 68 years, and 18 patients (78%) were > 60 years of age. At diagnosis of AL, most patients had a white blood count > 10 × 109/L (n = 17; 74%), Hgb 50 × 109/L (n = 17; 74%). Of 14 patients in whom cytogenetic analysis was available at leukemic transformation, 12 showed high-risk abnormalities including complex karyotype (n = 10), del (7)(q22) sole (n = 1) and del (X)(q26) sole (n = 1), whereas 2 had a normal karyotype. In patients whose karyotype was available at diagnosis of PV, cytogenetic evolution was documented at progression to AL. Treatment consisted of supportive care and/or low-dose chemotherapy (n = 15), or induction chemotherapy (n = 8). This included idarubicin plus cytarabine (n = 3), high-dose cytarabine (n = 4), and fludarabine-based regimen (n = 1). Allogenic stem cell transplantation was offered to a single patient, who is alive at Day + 70. The outcome of patients was poor, with a median survival of 2.9 months (range, 0.6–20.1 mos), with no significant differences between palliation and intensive treatments. CONCLUSIONS AL following PV has distinct clinical and biologic features. Outcome of patients is poor irrespective of the treatment employed. Cancer 2005. © 2005 American Cancer Society.

Objectives To investigate the incidence, treatment and outcome of breakthrough invasive fungal infections (IFIs) in adult acute myeloid leukaemia (AML) patients after posaconazole prophylaxis. Methods From January 2010 to April 2012, all consecutive patients with newly diagnosed AML were prospectively registered at 33 participating Italian centres. All cases of IFIs occurring within 30 days after the end of the first induction chemotherapy were recorded. The strategy of antifungal treatment (empirical, pre-emptive or targeted) and the drugs used were analysed. ClinicalTrials.gov code: NCT01315925. Results In total, 1192 patients with newly diagnosed AML were enrolled in the study, of whom 510 received posaconazole prophylaxis and were included in the present analysis. Of these patients, 140 (27%) needed systemic antifungal treatment. Among the 127 evaluable cases, an empirical approach was utilized in 102 patients (80%), a pre-emptive approach in 19 patients (15%) and targeted therapy in 6 patients (5%). Only five patients died of IFIs (three in the empirical group and two in the targeted group; 4%). A critical review of IFI diagnoses at 30 days demonstrated that among the patients treated empirically, ∼30% were not affected by IFIs but rather only by fever of unidentified origin. A comparison between the empirical and the pre-emptive groups showed no significant differences regarding the attributable and overall mortalities. Conclusions This study confirms that posaconazole prophylaxis reduces the incidence of breakthrough IFIs and does not modify the efficacy of subsequent systemic antifungal treatment, regardless of the approach (empirical or pre-emptive) or the antifungal drug used.

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We describe a 73-year-old man diagnosed with acute myelomonocytic leukemia (AML-M4) following myelodysplasia with trisomy 11 and with a t(11;11;22). This is the first case with both abnormalities present in the same cells and with the t(11;11;22) involving a chromosome 11 already duplicated at 11q23. This band contains the MLL gene that undergoes partial tandem duplication in patients with +11, which is "promiscuous," being translocated with a large number of genetic partners. Our patient had a complex karyotype that was completely defined by in situ hybridization. This technique demonstrated that the t(11;11;22) derivative with a duplication of band 11q23 carried from three to four copies of MLL. Two copies of the gene were close to each other and centromeric to the break-point region. Therefore, a partial tandem duplication of the MLL gene might have happened before the occurrence of t(11;11;22). Considering the associated chromosome defects, the monosomy for the long arm of chromosome 7, due to an unbalanced translocation t(7;17), further underlines the possibility that a partial tandem duplication of the MLL gene might have taken place.

Dear Editor, Invasive fungal sinusitis is a rare, severe infection, typically occurring in immunocompromised patients who have impaired neutrophil function or who have received longterm immunosuppressive therapy [1]. Haematological patients and among them, those affected by acute leukaemia and myelodysplastic syndrome are at higher risk [2]. The occurrence of this complication often compromises the therapeutic programme for the underlying haematological condition, necessitating a delay or cessation of chemotherapy with a subsequent high risk of relapse or progression. The acute fulminant form is characterised by its speed of evolution and is associated with a high mortality rate that reaches 100% in cases of intracranial mycotic dissemination [3]. The clinical onset is generally subtle and insidious; facial swelling or pain with or without fever must be promptly considered as possible signs of invasive sinusitis. Computed tomography (CT) evidence of pronounced thickening of the mucosa of the nasal cavity strongly suggests the diagnosis, which can be confirmed by identification of the pathogenic fungus in sinus tissues. Surgical debridement of the affected sinus is a necessary diagnostic and therapeutic procedure and must be combined with systemic antifungal therapy. The fungi most frequently involved are Aspergillus and Zygomicetes. Prognosis is related to various factors, such as the speed of diagnosis and treatment, the type of fungal infection [3], dissemination to the central nervous system, and complete neutrophil recovery [4]. The scarce information in the literature on invasive fungal sinusitis in immunocompromised patients highlights the importance and efficacy of a combined surgical and medical approach [5]. However, the factors with a major role in the evolution of the infection have not been discussed. We describe here seven cases of invasive fungal sinusitis, observed at our institution between November 2006 and December 2008, in patients affected by acute leukaemia (five patients with acute myeloid leukaemia and two with acute lymphoblastic leukaemia). These seven cases occurred among a total of 130 patients with acute leukaemia newly diagnosed in the same period. Table 1 summarises the characteristics of these seven patients and their infections. In all cases, the infection developed while the patients were severely neutropenic (neutrophil count< 500/mmc); the neutropenia was chemotherapy-related in six patients, while in one case of acute leukaemic transformation of a myelodysplastic syndrome, it was an expression of the patient’s haematological disease. This last patient had never been treated before; two out of the other six patients had received only induction chemotherapy, while the other four patients had a prior history of more chemotherapy (1–8 lines of chemotherapy). Facial pain with or without facial swelling was the initial symptom in all cases, associated with fever in six out of the seven patients. CTscanning, which P. Zappasodi (*) :M. Rossi : C. Castagnola :A. Corso : M. Bonfichi :M. Lazzarino Division of Haematology, Foundation IRCCS Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy e-mail: p.zappasodi@smatteo.pv.it

Between July 1992 and June 1996, 901 new cases of adult acute lymphoblastic leukaemia were recorded in the GIMEMA Archive of Adult Acute Leukaemia; 21 of them (2.3%) had a previous primary malignancy (PM). We found that secondary acute lymphoblastic leukaemia cases (sALL) presented with older age, a high incidence of pre-pre-B immunophenotype and a significantly higher prevalence of cancer among relatives compared to de novo ALL. The leukaemogenic activity of the cytotoxic drugs employed for the treatment of PM may have played a potential role in only a proportion of patients, opening the possibility that some sALL patients may have developed two or more malignancies due to individual predisposing factors.

Complete or partial monosomy for the long arms of chromosomes 5 or 7 or both is frequently observed in therapy-related myelodysplastic syndromes and acute nonlymphocytic leukemia. Sporadic cases have been reported in which partial monosomy is due to unbalanced translocations. The patient described herein carries one such rearrangement. 46,XY,t(1;2) (q32;p23),del(5)(q13),der(7)(5qter-->5q22::7p15-->7 q21:),del(12)(p12), resulting in partial monosomy for the long arms of chromosomes 5 and 7 and in partial monosomy for the short arm of chromosome 7.

One hundred and five consecutive primary high-risk myelodysplastic syndromes (MDS) or secondary acute myeloid leukaemia (sAML) evolving from MDS (performance status 0–3, ECOG) entered this study. Induction chemotherapy (CT) consisted of idarubicine 12 mg/m2 i.v. on days 1 and 2, etoposide 60 mg/m2/12 h i.v. for 5 d, Ara-C 120 mg/m2/12 h i.v. for 5 d (one or two courses). Patients were randomized to receive or not G-CSF (5 μg/kg/d subcutaneously 48 h after the end of CT). 52 cases underwent CT alone and 53 CT+G-CSF. The CT + G-CSF patients had a significantly shorter duration of neutropenia (8 v 16 d) with a lower incidence of infections and significantly better responses (CR+PR: 74% v 52%, P

The clinical and hematological characteristics of 5 patients affected with both acute myeloid leukemia (AML) and diabetes insipidus (DI) are described. Banded chromosomal analysis demonstrated monosomy 7 in 2 patients and a complex cytogenetic rearrangement in another. No patient entered complete remission with standard induction chemotherapy. These data confirm that in patients with AML, the association of DI (with or without monosomy 7) is an unfavorable prognostic factor.

Introduction: The European Leukemia Net (ELN) stratification classifies as favorable prognosis four different subgroups of acute myeloid leukemia (AML) with specific cytogenetic/molecular abnormalities. These forms are potentially curable with standard chemotherapy, even though about 30% of patients (pts) still relapse. Overall survival (OS) of 60% at 5 years is reported but it is not clear if all different subgroups show an homogeneous outcome. The purpose of this study was to assess, in a real life setting, the response rate and the outcome of newly diagnosed AML patients with favorable prognosis based on ELN classification. Data were collected from six hematological centers of the regional network REL (Rete Ematologica Lombarda). Methods: Between 2007 and 2014 we analyzed adult AML patients with t(8;21)(q22;q22)/RUNX1-RUNX1T1(group1), inv(16)(p13q22) or t(16;16)(p13q22)/CBFbeta-MIH11(group 2), normal karyotype and mutated NPM1 and negative FLT3-ITD (group 3) or double mutated CEBPA (CEBPA dm) (group 4). All patients received induction, mainly standard 3+7 chemotherapy (or reduced 1+5 in older pts) in 66% of cases, followed by high dose cytarabine based consolidation in 77% of pts. Clinical and molecular data were analyzed at diagnosis and at different time points during treatment and follow up with qualitative and quantitative PCR. The Kaplan-Meier product-limit method was used to estimate survival curves, and the log-rank test was adopted to evaluate differences between groups of pts. Results: We studied 177 AML pts (96 males and 81 females) with a median age of 55 years (range 20-80): 27 of group 1, 35 of group 2, 98 of group 3 and 17 of group 4. Complete hematological response (CHR), assessed in 176 pts, was achieved in 161 pts (92%): 23(85%), 32(91%), 90(93%), 16(94%) respectively in group 1, 2, 3, 4 without significant difference (p=0.26). Molecular complete remission (mCR), evaluated in 152 pts out of 161 in CHR, was documented in 102 pts. Forty pts entered mCR after induction and 62 pts at the end of consolidation or later (1-40 months); therefore, mCR rate was 67%. Considering the type of the method, 48 pts resulted in mCR with qualitative PCR, the remaining 54 (53%) with qualitatitive and quantitative PCR. Median time to mCR was 4 months and was different among groups (p=0.03); in particular, t(8;21) pts obtained mCR later than NPM1 pts (8 versus 2.6 months) (p=0.01). The relapse rate was 41% and the median time to relapse was 10.2 months, without any difference among groups (respectively p=0.5 and p=0.8). Five years overall survival (OS) and disease free survival (DFS) were 65% and 47% with no significant difference among groups (respectively p=0.3 and p=0.9). Age ( Conclusion: This study, conducted in a non selected population of favorable risk AML patients, confirms high CR rate and the prognostic value of age, favoring patients younger than 60 years. Our data confirm that the ELN classification identifies a clinically homogeneous group of good risk AML patients sharing comparable outcome even outside clinical trials setting. Molecular complete remission is associated with better outcome, in particular when assessed by quantitative PCR. Disclosures No relevant conflicts of interest to declare.

The treatment of the pulmonary toxicity induced by carmustine is nowadays based on the use of corticosteroids that generally lead to a rapid resolution of pneumonitis. On the contrary, no therapeutic alternatives are reported for those patients who do not respond to steroids. We describe a case of non-Hodgkin's lymphoma in a patient who developed a severe interstitial pneumonitis after an autologous transplantation including carmustine in the conditioning regimen. He was successfully treated with an association of steroids and cyclosporine A with a rapid improvement of symptoms and a complete resolution of pneumonitis. This is, to our knowledge, the first case of carmustine-induced pneumonitis, resistant to steroids alone, successfully treated with cyclosporine A. This suggests an immunoallergic mechanism in the pathogenesis of the damage, which can be reversed with prompt therapy.

TET2 haplo-insufficiency occurs through different molecular mechanisms and is promptly revealed by array comparative genomic hybridization, single nucleotide polymorphism (SNP) array, and next-generation sequencing (NGS). Fluorescence in situ hybridization (FISH) can effectively demonstrate TET2 deletions and is often used to validate molecular results. In the present study 41 MDS patients with and without 4q abnormalities were analyzed with a series of bacterial artificial chromosome (BAC) probes spanning the 4q22.3-q25 region. On conventional cytogenetic (CC) studies, a structural defect of the long arm of chromosome 4 (4q) was observed in seven patients. In three, one each with a t(1;4)(p21;q24), an ins(5;4)(q23;q24qter), and a t(4;17)(q31;p13) as the sole chromosomal abnormality, FISH with the RP11-356L5 and RP11-16G16 probes, which cover the TET2 locus, produced one signal only. Unexpectedly, this same result was achieved in 3 of the remaining 34 patients. Thus, a TET2 deletion was observed in a total of six patients (14.6%). TET2 deletion was not correlated with any particular clinical findings or outcome. These findings demonstrate that 1) FISH is an effective and economical method to reveal cryptic abnormalities of band 4q22-q24 resulting in TET2 deletions; 2) in these patients, TET2 deletion is the unifying genetic event; and 3) the different breakpoints within the 4q22-q25 region suggest that deletions are not mediated by repetitive sequences.

Background. Given the good penetration of systemic high-dose cytarabine (HDara-C) into the cerebrospinal fluid (CSF), this approach was used to treat patients with central nervous system (CNS) leukemia, either isolated or with concurrent extraneurologic disease (END). Methods. From 1983 to 1991, 46 adults with CNS involvement were treated with systemic HDara-C: 25 had acute lymphoblastic leukemia (ALL), 15 had high-grade non-Hodgkin lymphoma (NHL), 5 had acute myelogenous leukemia (AML), and 1 had lymphoid blast crisis of chronic myelogenous leukemia. Induction consisted of HDara-C 3 g/m2 every 12 hours, by 3-hour infusion, for 8 doses (30 patients), or 6 doses (16 patients), followed by 4 doses at day 21. Results. Of 46 patients, 29 (63%) achieved complete remission (CR): 15/15 with isolated CNS leukemia, and 14/31 (45%) with CNS and concurrent marrow or lymph node disease. Of 17 patients not meeting CR criteria because of persistent END, 11 showed complete CNS response. The first 10 remitters were consolidated with monthly 4-dose courses of HDara-C. The remaining 19 received postinduction multidrug chemotherapy (including vincristine, doxorubicin, cyclophosphamide, Lasparaginase, etoposide plus intermediate-dose ara-C, mitoxantrone plus HDara-C) and intrathecal methotrexate (MTX) ± cranial radiation therapy. One patient underwent autologous and one allogeneic bone marrow transplant. Median CR duration was 7 months (range, 2–56+): 8 months for patients with isolated CNS leukemia, and 4 months for those with concurrent END. In only two patients was CNS the primary site of relapse. Three patients with isolated CNS leukemia are disease-free at 23, 40, and 56 months. The main toxicity was myelosuppression. No patient showed dose-limiting neurologic toxicity. Conclusions. Systemic HDara-C appears effective therapy for CNS leukemia, maximally in cases with isolated CNS involvement. HDara-C may be combined safely with cranial radiation therapy and intrathecal MTX. This approach for CNS leukemia, however, needs to be combined with additional treatments to eradicate residual disease in extraneurologic compartments.

In this report, we present images from a patient with acute promyelocytic leukemia who experienced several central nervous system relapses.

Treatment and outcome of 103 consecutive patients aged greater than or equal to 60 with de novo acute nonlymphocytic leukemia (ANLL) were reviewed. Twenty-three cases (22%) were not suitable for induction chemotherapy because of very poor presenting general conditions and could receive supportive care alone. The majority of them died within 1 month. Twenty-eight patients (27%) aged greater than or equal to 70 and/or with concurrent nonhematologic disorders underwent mild induction chemotherapy, which produced 3 complete remissions. The median survival for this group was 2 months. Only 52 patients (50%) were considered eligible for conventional induction chemotherapy. For this group, response rate was 34.5%, the median survival was 3.5 months, and median survival for responding patients was 13 months. Only intensive chemotherapy seems capable of substantially improving prognosis for older ANLL patients. This approach, however, is feasible only in a minority of patients, due to a high incidence of life-threatening complications.

OBJECTIVES Aim of this prospective study was to evaluate the risk of invasive fungal infection (IFI) in patients (pts) with acute promyelocytic leukemia (APL) and to compare APL pts with patients affected by non promyelocytic acute myeloid leukemia (npAML) in order to evaluate factors potentially linked to IFI in these two subsets of acute myeloid leukemia. PATIENTS AND METHODS From January 2010 to April 2012 all pts with newly diagnosed AML were registered in 33 Italian participating centers. A minimum follow up of 90 days after 1st induction chemotherapy was requested for all pts. A prolonged follow up until June 2014 was made only for APL. Data were collected about age, gender, AML subtype, treatment and also about post chemotherapy risk factors for IFI (duration of neutropenia, mucosal damages, vomiting, diarrhea, presence of medical devices), antifungal prophylaxis, onset of IFI, level of certainty (possible/probable/proven), and antifungal treatment. Only for APL the survey was prolonged for at least 3 months in order to analyze if these pts have an IFI risk during other than first induction phases. RESULTS 1,192 consecutive newly diagnosed adult AML pts (npAML:1,086/APL:106) were enrolled in the study. Among npAML pts, those receiving low dose chemotherapy and/or palliative treatment were excluded from the analysis; in the remaining 881 pts 214 cases (24%) of IFI were recorded. Considering APL, 3 pts were excluded from the analysis due to early death (1 pt) or bad performance status (2 pts). The remaining 103 pts received APL treatment according to local protocols: all trans retinoic acid (ATRA) plus chemotherapy (90 pts) or ATRA plus arsenic trioxide (ATO)(13 pts). Only 8 (8%) APL pts developed an IFI after the induction phase: 1 proven, 3 probable and 4 possible IFI. All cases were caused by molds. All APL were followed for a median follow up of 36 months (range 3-54). During this time only 2 other cases of IFI were observed: 1 possible IFI during consolidation at 16 weeks from APL diagnosis and 1 probable aspergillosis in a rare case of APL relapse at 132 weeks from APL diagnosis. All the IFI occurred in pts treated with ATRA plus chemotherapy. IFI was fatal in only 1 case (cerebral aspergillosis), all the other pts recovered after antifungal treatment. A comparison between npAML and APL was made in order to analyze the risk of IFI within 90 days after induction treatment among these 2 groups of patients (see table). A significantly lower number of overall IFI and systemic antifungal treatment was observed in the APL group, in spite of the fact that systemic anti mold prophylaxis was significantly less frequently utilized. | | || | | APL | npAML | p | | Number of pts | 103 | 881 | | | Mean age | 51 | 55 | 0.01 | | m/f | 50/53 | 448/433 | N.S. | | Performance status (WHO) 0-1 >1 | . 76 27 | . 284 597 | .

From 2000 to 2004, 152 patients with multiple myeloma agedor=65 years, enrolled in high-dose programs, were treated with two schedules of DCEP (dexamethasone, cyclophosphamide, etoposide, and cisplatin): 106 patients (group I) were mobilized with the infusional version of DCEP (infusional-DCEP), and 46 patients (group II) with a shorter version (DCEP-short). The median number of CD34(+) cells collected was similar in the two groups as was the percentage of patients yieldingor=4 x 10(6) cells/kg. The proportion of patients in whom mobilization failed was similar in the two groups. The incidence of WHO grade III neutropenia was higher in group II, although the difference was not statistically significant; the percentage of patients requiring hospitalization for severe infections was similar in the two groups. The incidence of WHO grade IV thrombocytopenia did not differ between the two groups. The response rate was 72% in group I and 80% in group II with similar percentages of patients achieving good responses. DCEP-short is a good mobilizing regimen, sharing the same characteristics as infusional-DCEP: high mobilizing efficacy, low toxicity and good antitumor activity. This new schedule of DCEP does, however, allow complete outpatient management and so could be advantageously included in any high-dose therapy program.

Background and Objectives: In adult acute lymphoblastic leukaemia (ALL), unlike in childhood ALL, the percentage of long-term remitters and survivors has not improved significantly over the last decades. In the present analysis, we describe a series of adult ALL patients consecutively treated with the same regimen in order to analyse prognostic factors and treatment outcome as well as to define new risk-oriented strategies. Design and Methods: From 1990 to 1998, 102 newly diagnosed ALL patients were referred to our division, 83 of them were eligible for the present study. Median age was 31 years (range 13–76); 77.1% had B-lineage ALL and 22.9% T-lineage ALL; 36.1% showed associated myeloid markers. All patients received an induction phase treatment, consisting of a 4-week cycle with vincristine, daunorubicin, L-asparaginase and desametasone; the consolidation phase included cyclophosphamide, cytarabine, 6-mercaptopurine and central nervous system (CNS) prophylaxis, followed by three of months maintenance (methotrexate + 6-mercaptopurine), re-induction (4-week cycle with vincristine, adriamicin, desametasone), and 2-year maintenance with methotrexate + 6-mercaptopurine. Results: Complete remission (CR) was achieved in 66 patients (79.5%); 20.5% of patients were resistant. The relapse rate was 60.2%. There were 10 CNS relapses (accounting for 12% of all patients, 15% of all CRs and 20% of all relapses). One patient had an ovarian and 2 had a breast relapse. Eleven patients remained in first continuous CR after chemotherapy. Median overall survival (OS) and disease-free survival (DFS) were 1.8 and 1.0 years, respectively, with a median follow-up of 5.6 years (range 0.3–12.1). Initial white blood cell count ≤30 × 109/l, age Interpretation and Conclusions: In our cohort, we were able to define a small subgroup of adult ALL patients with a better outcome. However, the majority of patients is at a high risk of failure when treated with standard protocols. There is a need for new, more active regimens for these patients.

Several trials have suggested that intensive post-remission therapy may prolong the duration of complete remission (CR) in acute myeloid leukemia (AML). The purpose of this study was to evaluate the feasibility and the efficacy of high-dose cytarabine (HiDAC) consolidation chemotherapy followed by high-dose therapy and autologous infusion of peripheral blood progenitor cells (PBPC) mobilized by G-CSF in adult patients with AML in first CR. Fifteen consecutive AML patients underwent HiDAC consolidation chemotherapy, used as a method of in vivo purging, followed by G-CSF for the purpose of autologous PBPC collection. Eleven patients collected a median of 6.9x10(8)/kg peripheral blood mononuclear cells (MNC) (range 2.9-23) and a median of 6.67x10(6)/kg CD34+ cells (range 1.8-33.5) with a median of two aphereses (range 1-3). Two patients did not mobilize and two obtained an inadequate number of progenitor cells. The 11 patients with adequate collections received myeloablative chemotherapy followed by the infusion of PBPC. The median number of days to recover neutrophils and platelets was 12 and 13, respectively. After a median follow-up of 28.7 months (range 17.2-43.4), five out of 11 patients who underwent PBPC transplantation are still in CR, five have died in first relapse and one is alive in CR after relapse treated with salvage therapy and second PBPC infusion. These results demonstrate that HiDAC consolidation chemotherapy followed by autologous PBPC transplantation is a feasible procedure with minimal toxicity. Randomized studies should be performed to evaluate whether this form of consolidation may produce a significant improvement in leukemia-free survival.

Growth factors (GF) are reported to play an important role in the therapy of myelodisplastic syndromes (MDS). After in vitro administration a consistent group of MDS may respond to GF but the possibility of differentiation, regulation or expansion of myelodisplastic clones following GF therapy is still a question to be answered as their optimum dose and combinations. To validate if in vivo treatment with GF, may promote the regulation or the recovery of myelopoiesis and/or modify the clonality of the responses, we gave G-CSF after intensive chemotherapy in high risk MDS and acute leukemia evolving from MDS patients. According to our data the use of G-CSF after intensive chemotherapy may improve the CR rate without increase of leukemic transformation. However the answer were clonal and the remission duration remained very short so we suggest to utilize this time to perform other therapeutic strategies such as, when possible, the BMT.

We have compared the CFU-GM growth observed in 29 PBSC samples (8 HL, 21 NHL) to that obtained with 30 bone marrow (BM) “buffy coats” harvested for an autologous BMT program in pts without BM involvement (25 AML, 3 HL, 2 NHL). The CFU-GM tests were performed before cryopreservation, made without noncontrolled heat fusion, and after thawing. The collections of PBSC were made with a CS3000 Plus (Baxter). The apheresis were performed after mobilisation with HD CTX 4 g/m2 and administration of G-CSF (6–15 days). The cultures of CFU-GM were made in methylcellulose for PBSC and in agar monolayer for BM cells, using a conditioned medium from 5637 cell line as source of CSF. Before freezing a mean the CFU-GM growth of from BM cells were higher than in PBSC (35.5 vs 26: P

Abstract 4867 Background: A monosomal karytype (MK) is defined by the presence of at least two or more distinct autosomal monosomies or an autosomal monosomy along with a structural defect. In AML this cytogenetic pattern has a very well-known poor prognostic significance independently of the specific chromosome involved. Currently, in MDS this negative prognostic influence is also emerging as recent data suggest that any monosomy in a complex karyotype (≥3 abnormalities) may have the same poor prognostic impact as monosomy 5 and 7 (−5,−7). Objectives: Thus, the principal goal of the present study was to test whether a MK further worsen the already poor prognostic influence of a complex karyotype and to establish whether autosomal monosomies have the same unfavourable prognostic impact on OS and progression free interval (PFI) as −5/−7. Methods: The eighty-five consecutive MDS patients with a complex karyotype analysed by the present study were included in a series of 631 patients who came at our observation in the period January 2000-December 2010. They were thirty-two females and fifty-three males with a median age of 65 years (range 25–85). Fifty-five patients were diagnosed as MDS and were subdivided in 3 RARS, 6 RA, 6 RCMD, 2 RCMDS, one MDS-u, 13 RAEB-1 and 24 RAEB-2. The IPSS score was intermediate-1 in 5, intermediate-2 in 23 and high in 27. During the follow-up 31 MDS patients died and 41 experienced disease progression (3 RARS, 5 RA, 4 RCMD, one MDS-u, 9 RAEB-1 and 19 RAEB-2). Thirty patients were diagnosed as AML evolved from MDS. Fifteen of them received supportive treatment only, the remaining single agent chemotherapy to control leukocytosis. Nineteen of these thirty patients died of disease related complications. Results: On conventional cytogenetics 37 patients (4 RA, 5 RCMD, one MDS-u, 8 RAEB-1, 12 RAEB-2 and 7 AML) presented a complex karyotype without monosomies and 48 (3 RARS, 2 RA, 2 RCMDS, one RCMD, 5 RAEB-1, 12 RAEB-2, 24 AML) a complex karyotype with monosomies. These two patients subgroups were comparable in terms of age, sex distribution, haemoglobin level, leukocyte or platelet counts, bone marrow blast cell percentage and IPSS score. However, median survival was 8 months (range 1–131) for patients with a complex karyotype without monosomies and 5 months (range 1–81) for those with a complex karyotype with monosomies (p=0.001). Twenty patients (54.0%) without monosomies died after a median time of 6 months (range 2–35), whereas 30 patients (62.5%) with monosomies died after a median time of 5 months (range 1–24). Disease progression was observed in 22 (59.4%) and 19 (39.5%) patients respectively (p=0.001). The 48 patients with a MK were further subdivided in those with −5/−7 versus those with other autosomal monosomies. The 23 patients with −5/−7 presented a median survival of 4 months (range 1–15) and the 25 with other monosomies presented a median survival of 5 months (range 1–81) (p=Not Significant). Fourteen −5/−7 patients died after a median time of 4 months (range 1–15) and 13 patients with autosomal monosomies died after a median time of 6 months (range 1–24). Disease progression occurred in 12 (52.1%) and 7 (28%) respectively. Conclusions: i) a MK further refines the prognostic stratification of MDS with a complex karyotype as it identifies a subgroup of patients with an extremely poor clinical outcome; ii) autosomal monosomies have an impact on disease outcome as detrimental as −5/−7. Disclosures: No relevant conflicts of interest to declare.

The t(10,11)(p12;q23) translocation is a recurrent and rare chromosomal abnormality in AML, especially associated with the M5 cytotype. An heterogeneity in 10p breakpoints has been revealed by cytogenetic studies even if molecular analysis have demonstrated that the AF10 gene is constantly involved in this translocation. Up to now, two types of chimeric transcripts the MLL-AF10 in the t(10;11)(p12;q23) and the CALM-AF10 in the t(10;11) (p13;q14) have been isolated. In 1998 the Abl-interactor 1 (ABI1) gene was identified as a new MLL partner in the t(10;11) translocation. In addition, it was demonstrated that this chromosomal rearrangement is significantly associated with complex translocations including invins(10;11) and inv(11)t(10;11). However, a duplication of the chromosome 10 derivative has never been reported. Herein we describe an additional female patient with a complex t(10;11) rearrangement and a M2 AML. She was forty-seven years old. Her blood count was the following: haemoglobin 9,4g/dl, WBC 34,2×109/l (blast cells 88%), Plts 7.0×109/l. Induction chemotherapy determined a complete remission (CR) which lasted six months. A second CR was achieved and subsequently the patient was submitted to an allogeneic bone marrow transplant. Now she is alive and well twelve months posttransplant. On clinical diagnosis cytogenetic studies on bone marrow cells revealed the following karyotype: 46,XX/46,XX,t(10;11)(p14;q23), −10, +der(10)t(10;11). FISH studies were performed with the following probes: LSI MLL and LSI ATM from Vysis, Whole Chromosome Painting (WCP) 11 and Arm Chromosome Painting (ACP) 10p from Q-Biogene. In order to better define the rearranged chromosomal region the RP11-47P2 (mapping at 10p15.1), the RP11-79F9 (corresponding to 10p14), the RP11-13C4 and the RP11-36M5 (covering the PLZF3 gene at 11q23.2), the RP11-19S45 and the RP11-48M23 (covering the ABI1 gene at 10p12.1), the RP11-46N13 and the RP-140P12 (covering the AF10 gene at 10p12.31) BAC probes were applied. Other genes investigated with the same approach were the SLC39A12 at 10p12.33, the PLXDC2 at 10p12.33-p12.32, the ARMETL1 at 10p13 and the PIP5K2A at 10p12.31. The WCP 11 and the ACP 10p probes confirmed the t(10;11) translocation, the loss of the normal chromosome 10 and the duplication of der(10)t(10;11). When analysing chromosome 11, the ATM and the PLZF3 probes were in a normal position so neither gene was rearranged. Instead, both the signals (red and green) corresponding to MLL were translocated to chromosome 10 and split by an additional rearrangement. So, we hypothesized that the t(10;11) translocation occurred first and was followed by an additional defect. This possibility was confirmed by the presence of chromosome 10 material inserted between the two MLL signals, an event which was interpreted as either an inversion or an insertion. When analysing chromosome 10, the RP11-79F9 green probe remained in the correct position, whereas the RP11-47P2 red probe was translocated to chromosome 11. Thus, in the initial t(10;11) the breakpoints on chromosome 10 fell within the region delimited by these two BAC probes. Based on the fact that either the AF10 or the ABI1 gene, located at 10p12, are MLL partners in the usually complex t(10;11) translocations we checked whether these genes were involved in the secondary rearrangement on chromosome 10. FISH studies excluded any ABI1 rearrangement. Instead, they demonstrated that the RP11-46N13 (green) and RP-140P12 (red) BAC probes, covering the AF10 gene, were still located on 10p but separated by the chromosomal material belonging to chromosome 11 carrying the two MLL signals at its extremities. Since the two signal corresponding to the AF10 gene were located in the same position of MLL split signals a AF10/MLL translocation had occurred in our patient, who is the first one up to now reported to present a duplication of the rearranged chromosome 10.

Background: Dasatinib is a potent, oral inhibitor of the BCR-ABL, c-KIT and SRC kinase family, which has proven to be a more active inhibitor of BCR-ABL and c-KIT than imatinib in preclinical studies. Clinically, it has been shown to be effective in chronic myeloid leukemia and in Ph+ ALL patients resistant or intolerant to imatinib. Aims: The primary objective of the study was to assess the activity of dasatinib in de novo adult Ph+ ALL patients in terms of complete hematological remission (CHR); the secondary objectives were treatment toxicity, rate of immunophenotypic and molecular responses, disease-free survival (DFS), relapse rate and overall survival (OS). Methods: The GIMEMA LAL 1205 protocol was designed for patients ≥18 years (no upper age limit) who receive dasatinib po, 70 mg BID. A steroid pre-phase is started 7 days prior to dasatinib administration and continued up to day 31, and then tapered. The pre-phase allows identification of the BCR/ABL transcript. Dasatinib is given for 12 weeks. Two intrathecal methotrexates are administered at days +22 and +43. All cases are analyzed through a central handling of samples at presentation for morphology, immunophenotype, cytogenetics and molecular biology at the coordinating center in Rome. Minimal residual disease (MRD) is also centrally investigated by flow-cytometry and Q-RT-PCR at days +22, +43, +57 and +84. The protocol was designed for 48 patients. Results: Recruitment started in November 2006 and was completed in August 2008. The median age of the 48 enrolled BCR/ABL+ ALL patients was 54 years (range 24-76), 26 were females and 22 males. The median WBC count was 20.1 (range 2.2–133). The last analysis has been conducted on 36 patients. One patient stopped treatment after 14 days due to intestinal toxicity and 1 patient refused treatment. Thus, to date 34 patients are evaluable for response. Nineteen cases were p190+ and 15 p210+ (5 were p190/p210+). A >75% response to the steroid pre-phase was recorded in 82.7% of patients. All 34 patients (100%) have witnessed a CHR: 32 (94.12%) at the 1st determination at day +22, 1 at the 2nd at day +43 and 1 at the 3rd at day +57. No fatalities have been observed. In 13 patients, at least 1 severe adverse event (SAE) has been recorded, for a total of 26 SAEs. Overall, the compliance has been good; only 1 patient stopped treatment at day 67 due to toxicity while in CHR. The median follow-up is so far 11.2 months. The OS at 10 months is 80.7%. Immunophenotypic and BCR/ABL Q-RT-PCR monitoring of MRD has shown a very marked clearance of leukemic cells by day +22, progressively strengthened at the subsequent timepoints. In p190+ cases the minimal MRD value was reached at day +43, while in p210+ cases this was observed at day +84, documenting a lower susceptibility to dasatinib by this molecular subgroup. So far, 9 patients have relapsed, at a median of 72 days from the end of induction; in agreement with the MRD data, 7/9 relapses occurred within the p210+ cases and 2/9 within the p190+ cases. The presence of mutations has been investigated in 8/9 relapsed samples: 5 showed a T315I mutation, 1 an E255K mutation and 2 were wt. Cloning experiments allowed to detect in 2 cases low levels of T315I mutations already at presentation and on MRD cells at the end of the induction treatment. The first multivariate analysis has been conducted for DFS and the degree of PCR reduction − ≤10−3 vs ≥10−3 - has so far emerged as the only significant prognostic factor. Conclusions: This study demonstrates that in adult Ph+ ALL dasatinib monotherapy is capable of inducing a CHR in virtually all patients, irrespective of age, without important toxicities and with no fatalities. The hematological response is associated with a very marked and rapid debulking of the neoplastic clone documented at the MRD level, particularly for p190+ cases. The degree of PCR response is of prognostic relevance. No relapses have been observed during the induction phase. The optimal post-induction treatment strategy, which was not part of the study, remains to be defined, particularly in light of the genetic instability of Ph+ ALL and of the selection/induction of mutations. These results, together with those previously reported by our group with imatinib alone for elderly patients, question the use of chemotherapy, with or without a TK inhibitor, for the remission induction of Ph+ ALL.

Based on conventional cytogenetic studies, acquired losses of the whole or a part of chromosome 5, alone or in a complex karyotype (defined by the presence of ≥3 chromosome defects), are recurrent cyogenetic defects in MDS and AML. The size of the deleted material and the breakpoints vary among patients. Commonly deleted regions are bands 5q13, 5q31-q32, and 5q33-q34-q35. Monosomy 5 (−5), too, has always been considered a non-random chromosomal defect. However, recent evidence is changing this assumption since most patients with −5 on CC studies present a chromosome 5 fragmentation in more than two segments on FISH investigations (Herry et al, 2007). The present FISH study was aimed at establishing the incidence of true −5 and at refining chromosome 5 abnormalities in 9 patients, one MDS, classified as refractory anemia with excess of blasts type 1 and 8 AML (2 M2, 5 M4 and one M5). Monosomy 5 was the only karyotype defect in 2 patients and part of a complex karyotype in the remaining 7. CC and FISH studies were performed as already reported (Bernasconi et al, 2007). FISH analyses were carried out on mitotic figures with the following probes: the LSI CSF1R/D5S721:D5S23, mapped at 5q33 (spectrum orange) and 5p (spectrum green) from Vysis (Abbott Molecular/Vysis, North Chicago, IL, USA) and the WCP5SO probes from QBiogene (Qbiogene Inc., Carslbad, CA, USA). Additional FISH investigations were carried out with two BAC probes exploring the 5q segment comprised between the centromere and band 5q11 in order to check whether this chromosomal region was either maintained or deleted. The WCP5SO probe demonstrated that all the 9 patients presented an apparent monosomy 5 since chromosome 5 material was contained within marker chromosomes already identified by CC. In 3 patients the LSI CSF1R/D5S721:D5S23 probe provided three green signals (5p duplication) along with one red signal (5q33 monosomy). In these patients one green/red signals were mapped on the normal chromosome 5, the other two green signals were localized on marker chromosomes. In the remaining 6 patients the same probe demonstrated one green/red signal on the normal chromosome 5 and another green signal on a marker chromosome. Subsequently all the 9 patients were investigated with the 5q11 BAC probes. Five patients showed two signals revealing that band 5q11 was maintained. Considering the 4 patients with loss of band 5q11, 3 presented a fragmentation of chromosome 5 and one an internal chromosome 5 rearrangement. In conclusion our data show that true monosomy 5 is a very uncommon event in MDS/AML since in all our patients with −5 on CC 5p was either maintained or amplified. In addition, band 5q11 was maintained in 5/9 patients. In view of these results our future goal will be to check whether other 5q regions are maintained or deleted in these complex chromosome 5 rearrangements.

Dasatinib (SPRYCEL, formerly BMS-354825) is a potent, orally active inhibitor of the BCR-ABL, c-KIT and SRC family of kinases, which play a critical role in oncogenesis and persistence of malignant phenotypes. In preclinical studies, dasatinib has proven to be a more potent inhibitor of BCR-ABL and c-KIT than imatinib mesylate, and has been shown to be effective in the clinical setting in patients with all phases of chronic myeloid leukemia (CML) or Ph+ ALL resistant to or intolerant of imatinib. We present the first interim results of the GIMEMA protocol LAL 1205 designed to assess the efficacy, safety and tolerability of dasatinib in Ph+ ALL patients at the onset of the disease. The protocol enrolls patients ≥18 years who receive dasatinib p.o. at a dose of 70 mg BID. A steroid regimen (prednisone up to 60mg/m2 day po) is started 7 days prior to the first dasatinib administration and is continued until day 31. The 7-day prednisone pre-phase allows identification of the BCR/ABL transcript. Dasatinib is administered for a total of 84 days. Two intrathecal methotrexate infusions at days +22 and +43 are included. All cases are processed and analyzed through central handling of samples at presentation and are investigated for morphology, immunophenotype, cytogenetics and molecular biology. Minimal residual disease (MRD) is also centrally evaluated by flow-cytometry and Q-RT-PCR at days +22, +43, +57 and +84. A total of 23 patients with BCR/ABL+ ALL have been enrolled to date; median age 57 yrs (30–74), 15 females. All 23 patients have shown a complete hematological response by day +22. One patient relapsed after completing dasatinib administration and died of disease progression, while all other patients are at present alive and well after a median time of observation from diagnosis of 4.5 months (1.7 – 8.0). Monitoring of MRD documented that dasatinib plus prednisone was capable of inducing a very marked clearance of leukemic cells already at day +22, confirmed and strengthened in the subsequent steps of observation. The results of the immunophenotypic and BCR/ABL Q-RT-PCR monitoring are reported in the accompanying table: This interim analysis indicates that in adult and elderly Ph+ ALL induction monotherapy with dasatinib plus prednisone is capable of inducing a rapid hematological remission in all patients so far treated without important toxicity and no fatality. This is associated with a very marked and rapid debulking of the disease as documented by the close phenotypic and molecular monitoring of MRD. DAYS IMMUNOPHENOTYPE Q-RT-PCR (% of leukemic cells) (copy number) 1% 0.01% 1 x 10²

Chromosome 3q defects, namely inv(3)(q21q26)/t(3,3)(q21;q26), are revealed in about 2.5% of AML and in rare MDS patients (pts), are associated with a normal/high platelet count, tri-lineage dysplasia, resistance to intensive chemotherapy and poor survival. In these disorders ectopic EVI1 expression is the pathogenetically relevant molecular lesion. However, several pts with 3q21q26 rearrangements lack EVI1 expression and 9% of those without 3q21q26 defects present EVI1 over-expression. In addition, FISH, which can be used as an alternative tool for or an adjunct to RT-PCR to discover any EVI1 rearrangement, revealed an important breakpoint heterogeneity within this chromosomal region. Based on the above data, FISH was used to investigate 12 pts (7 MDS and 5 AML) with 3q21q26 rearrangements on conventional cytogenetics (CC). The goals of our study were to establish the incidence of EVI1 defects and to reveal any difference in morphological features and disease outcome between pts with and without EVI1 defects. The 12 pts were 4 females and 8 males with a median age of 60 years (range 35–80). Median follow-up was 22 months (range. 2–40). According to WHO classification, 2 MDS pts were diagnosed as Refractory Cytopenia with Multilineage Dysplasia (RCMD) and 5 as Refractory Anemia with Excess of Blasts type 2 (RAEB-2). Four of these 7 pts progressed into AML. Considering the 5 AML pts, 2 were diagnosed as M2 and 3 as M4. On clinical diagnosis CC showed a standard t(3,3)(q21;q26) in 5 pts, a translocation of 3p material onto band 3q26 in 2, a 3q21 deletion in 2, a complex rearrangement of band 3q26 in one, an inv(3)(q21q26) in one and a translocation involving 3p21 and 3q21 in one. FISH, carried out on cytogenetic preparation, used BAC probes obtained from Welcome Trust Sanger Institute (Cambridge, UK). The probes applied were those of the literature (Lahortiga et al, Genes Chrom & Cancer 2004; Poppe et al, Genes Chrom & Cancer 2006) and other probes covering the RPN1, EVI1, MDS1 genes. EVI1 defects had an incidence of 50%. EVI1 gene was translocated in 4 t(3;3) pts (3 RAEB-2 and one AML), amplified along with MLL in a RAEB-2 pt and deleted in the 2 AML pts with a 3q21 deletion on CC. Interestingly, no EVI1 defect was discovered in a t(3;3) RAEB-2 pt and in an inv(3)(q21q26) RCMD pt. Tri-lineage dysplasia was observed in all MDS pts independently of any EVI1 defect. Median survival of the 5 pts with either EVI1 translocation or amplification was 6 months (range 2–32), that of the 7 pts without any EVI1 defect was 26 months (range 4–40). A progression in AML occurred in all the 3 MDS pts with EVI1 defects and in one of the 4 MDS pts without any defect. A total of 8 pts, including 3 of the 4 AML progressed from MDS, were submitted to intensive chemotherapy. A complete remission (CR) was achieved in only one of the 4 pts with EVI defects and in 3 of the 4 pts without any defect. Two CR pts, one with and one without any EVI1 defect, were submitted to allogeneic bone marrow transplantation (allo-BMT). The pt with the EVI1 translocation relapsed, but succeeded in entering a second CR. In conclusion, EVI1 defects were revealed in 50% of pts, were not required for evoking the dysplastic changes associated with 3q21q26 rearrangements, were associated with a high risk of AML evolution in MDS pts, caused a short survival and resistant AML.