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In multiple myeloma (MM) patients, various T-cell abnormalities, such as a marked reduction in the proportions of CD4 and CD8 cells expressing co-stimulatory molecules, signal transduction components, Th1/Th2 imbalance and alterations of regulatory T cells/T helper 17 cells (Treg/Th17 ratio), have been observed. The inducible T-cell co-stimulator (ICOS) has been implicated in the induction and regulation of Th1, Th2, and Treg/Th17 immunity. Therefore, we postulate that variations in ICOS gene might be associated with susceptibility and clinical course of MM. We analyzed ICOSISV1+173T>C (rs10932029), ICOSc.1624C>T (rs10932037), ICOSc.602A>C (rs10183087), ICOSc.1564T>C (rs4404254) and ICOSc.2373G>C (rs4675379) polymorphisms in 205 MM patients and 325 controls with TaqMan® SNP Genotyping Assays. None of the investigated ICOS gene polymorphisms were associated with susceptibility to the disease. However, in a multivariate Cox analysis which included the age of diagnosis, ISS, time to the clinical response to the treatment, gender, immunoglobulin classes, ICOS gene variations, we found that time to the response to treatment, ISS stage 3 and possessing of ICOSc.2373G>C [C+] allele were independently associated with the overall survival (HR: 1.35, 2.86 and 3.77, respectively). Although the result of the present study does not confirm the association of the investigated polymorphisms with risk of MM, they indicated that variations in ICOS gene might influence overall survival.

Background It is well established that expression of multi-drug resistance (MDR) proteins (MDR1, BCRP, MDR3, MRP1 and LRP) in leukemic blasts correlates with AML patients clinical response. Assuming that leukemic stem cells (LSC) are resistant to chemotherapy and responsible for relapse it might be clinically relevant to evaluate the expression level of MDR proteins in LSC and relate it to the clinical outcome. Methods Bone marrow samples from 26 patients with de novo AML were labeled with antibodies to distinguish CD34+CD38-CD123+ LSC population and with antibodies against MDR1, BCRP, MDR3, MRP1 or LRP proteins. Multicolor flow cytometry was applied to evaluate the expression of MDR proteins in blasts and LSC. Results Nine of 26 patients with AML attained CR (30%). High negative correlation was found between MDR1 and LRP expression in blasts and the patients remission. MDR proteins were expressed more frequently in LSC than in leukemic blasts. High negative correlation was also observed between remission achievement and MRP1 expression in LSC. Conclusions Our data presents for the very first time the high negative correlation between MRP1 protein expression in LSC and AML patients’ remission. It does strongly suggest that MRP1 expression in LSC is an adverse prognostic marker in patients with de novo AML. This article is protected by copyright. All rights reserved.

The association of single-nucleotide polymorphisms (SNPs) of B-cell activating factor (BAFF)/a proliferation-inducing ligand (APRIL) system with B-cell chronic lymphocytic leukemia (B-CLL) have been suggested, therefore, we investigated 20 SNPs of BAFF, APRIL, BAFF-R, transmembrane activator and calcium modulator and cyclophilin-ligand interactor (TACI), B-cell maturation antigen (BCMA) genes and the risk and outcome of B-CLL in 187 patients and 296 healthy subjects as well as ligand-receptor gene × gene interactions. Although the obtained P-values for all 20 SNPs did not reach statistical significance for this study (α = 0.003), the high value of the global chi-squared statistic (χ(2) df = 38 = 52.65; P = 0.0586), and obtained values of odds ratio indicate that rs9514828 (BAFF), rs3803800 (APRIL) and rs4985726 (TACI) may be associated with the risk of B-CLL. We observed that the B-CLL patients with the genotype rs9514828CT/rs11570136AA were diagnosed with the disease 12 years later than the whole group of patients in this study.

CHEK2 plays a key role in cellular response to DNA damage, and also in regulation of mitosis and maintenance of chromosomal stability. In patients newly diagnosed with myelodysplastic syndrome (MDS, n = 107) or acute myeloid leukemia (AML, n = 117) congenital CHEK2 mutations (c.444 + 1G A, c.1100delC, del5395, p.I157 T) were tested by PCR and sequencing analysis. The karyotype of bone marrow cells of each patient was assessed at disease diagnosis using classical cytogenetic methods and fluorescence in situ hybridization. The CHEK2 mutations were strongly associated with the risk of MDS (p0.0001) but not with the risk of de novo AML (p = 0.798). In CHEK2-positive MDS patients, two times higher frequency of aberrant karyotypes than in CHEK2-negative patients was found (71% vs. 37%, p = 0.015). In CHEK2-positive patients with cytogenetic abnormalities, subtypes of MDS: refractory anemia with excess blasts-1 or 2, associated with unfavorable disease prognosis, were diagnosed two times more often than in CHEK2-negative cases with aberrations (78% vs. 44%). In conclusion, the congenital CHEK2 inactivation is strongly associated with the risk of MDS and with a poorer prognosis of the disease. However, the chromosomal instability in AML is not correlated with the hereditary dysfunction of CHEK2.

The differentiation-inducing potential of side-chain modified analogs of vitamins D, compared to the reference compound, 1,25-dihydroxyvitamin D 3 , was studied in blast cells from patients with acute myeloid leukemia and in cell lines. Analogs PRI-1906 and PRI-1907 showed increased cell-differentiation activities, PRI-1907 even at a very low concentration. Our study revealed a high variability of individual patients’ blasts in their susceptibility to vitamin D analogs. The blasts of the patients with normal karyotype and with mutated NPM1 reacted to analogs with stronger differentiation than the blasts of the remaining patients, while the blasts with mutated FLT3 receptor reacted with weaker differentiation than the remaining blasts.

Autophagy is a process that is involved in the pathogenesis of cancer but also in the development of resistance or sensitivity to cytostatic treatment applied. Until now, the issue is still unresolved if we should stimulate or inhibit the process of autophagy in cancer treatment through the use of appropriate anticancer therapy so that it is beneficial for the patient and induce remission of the disease. On the one hand autophagy as a mechanism of programmed cell death may also cause the death of tumor cells. On the other hand, as a defense mechanism is the process of cell survival strategy in stress situations such as hypoxia in the peripheral parts of the tumor or using cytostatic drugs. It would be good to find an answer if the autophagy is the process increasing the effectiveness of therapy or increasing resistance to treatment in a case of specific tumor.

We characterized a structure-function relationships of four analogs of vitamin D(2) with extended and branched side-chains. We tested their ability to induce differentiation of human acute myeloid leukemia (AML) cells both in vitro and ex vivo. Our experiments on five human cell lines revealed substantial differences among tested analogs. Analogs with side-chains extended by one (PRI-1906) or two carbon units (PRI-1907) displayed similar or elevated cell-differentiating activity in comparison to 1,25-dihydroxyvitamin D(3) (1,25D), whereas further extending side-chain resulted in substantially lower biological activity (PRI-1908 and PRI-1909). Similar pattern of cell-differentiating activities to that observed in human cell lines has also been shown in blast cells isolated from patients diagnosed with AML. The ability of the analogs to activate expression of CYP24A1 gene has been studied in HL60 cell line. The analog PRI-1906 activated expression of CYP24A1 similarly to 1,25D, while PRI-1907 weaker than 1,25D. In addition, the analogs PRI-1906 and PRI-1907 were able to moderately inhibit proliferation and significantly activate expression of CYP24A1 mRNA in prostate cancer cells PC-3. Finally, we examined the molecular actions triggered by these analogs and found that their biological activity was related to their ability to induce expression and nuclear translocation of VDR and C/EBPβ.

The aim of this study was to analyze the association between gene polymorphisms of killer-cell immunoglobulin-like receptors (KIRs) and their human leukocyte antigen (HLA) ligands and susceptibility to B-cell chronic lymphocytic leukemia (B-CLL) and the clinical course of disease. The distribution of individual KIR genes in 197 B-CLL patients and 200 controls was similar, except for a tendency for lower frequencies of the KIR2DS3 and KIR2DL5 genes among B-CLL patients (26.9% vs 35.5%, P = 0.06, 46.2% vs 55.5%, P = 0.06). The associations between KIR2DS3 and B-CLL reached statistical significance in women (P = 0.05). Moreover, we found a trend toward a lower frequency of genotypes with the presence of five or six activating KIR genes in B-CLL patients compared to controls (20.8% vs 29.0%, P = 0.06), and a significantly higher frequency of individuals possessing genotypes with a prevalence of inhibitory over activating KIR genes (ratio < 0.71) among B-CLL patients (P = 0.04). The HLA-Bw4 specificity was significantly reduced among B-CLL patients (48.7% vs 63.0%, P = 0.005), which resulted from a decreased frequency of HLA-Bw4(Thr80) (21.6% vs 32.0%, P = 0.02). Moreover, among HLA-Bw4-positive individuals, progression-free survival (PFS) tended to be higher in the presence of KIR3DS1 (77% ± 9% vs 39% ± 13%, P = 0.07). However, in B-CLL patients, the presence of HLA-C2 was associated with decreased PFS (49% ± 9% vs 75% ± 7%, P = 0.02), and among HLA-C2-positive patients, the probability of PFS was significantly reduced in the absence of KIR2DS1 (34% ± 11% vs 77% ± 7%, P = 0.007). Our results indicate that the pattern of inhibitory/activating KIR genes, together with their HLA ligands, is associated with susceptibility to B-CLL and affects the clinical course of this disease.

Various phenotype and functional T-cell abnormalities are observed in multiple myeloma (MM) patients. The aim of this study was to investigate the association between polymorphisms in the gene encoding cytotoxic T-lymphocyte antigen-4 (CTLA-4), a negative regulator of the T-lymphocyte immune response and susceptibility to multiple myeloma in a Polish population. Two hundred MM patients and 380 healthy subjects were genotyped for the following polymorphisms: CTLA-4c.49A>G, CTLA-4g.319C>T, CTLA-4g.*642AT(8_33), CT60 (CTLA-4g.*6230G>A), Jo31 (CTLA-4g.*10223G>T). Our study is the largest and most comprehensive evaluation to date of the association between genetic polymorphisms in the CTLA-4 molecule and multiple myeloma. It was found that CTLA-4c.49A>G[G], CT60[G], and Jo31[G] alleles were more frequently observed in MM patients than in controls (0.50 vs. 0.44, p = 0.03, 0.65 vs. 0.58, p = 0.04, and 0.63 vs. 0.57, p = 0.03, respectively). Moreover, the haplotype CTLA-4c.49A>G[G], CTLA-4g.319C>T[C], CTLA-4g.*642AT(8_33) [8], CT60[G], Jo31[G] including all susceptibility alleles increases the risk of MM about fourfold (OR: 3.79, 95%CI: 2.08–6.89, p = 0.00001). These findings indicate that genetic variations in the CTLA-4 gene play role in susceptibility to multiple myeloma and warrant further investigation through replication studies.

There is strong evidence that altered immunological function entails an increased risk of B-cell chronic lymphocytic leukemia (B-CLL). The main mechanism of an anti-tumor response depends on T-cell activation. Unlike the constitutively expressed CD28, inducible costimulatory molecule (ICOS) is expressed on the T-cell surface after activation. ICOS enhances all the basic T-cell responses to a foreign antigen, namely proliferation, secretion of lymphokines, the upregulation of molecules that mediate cell-cell interaction, and effective help for antibody secretion by B cells. ICOS is essential for both efficient interaction between T and B cells and normal antibody responses to T cell-dependent antigens. It does not upregulate the production of interleukin-2, but superinduces the synthesis of interleukin-10. Our previous results indicated the ICOS gene has a role as a susceptibility locus to B-CLL. Therefore an extended study was undertaken to evaluate the association between four ICOS polymorphisms (which were recently described as functional ones) and susceptibility to B-CLL in the Polish population. A case-control study of 296 individuals, including 146 B-CLL patients, was conducted on four polymorphisms in the ICOS gene. Genotyping of the polymorphisms ICOS ISV1+173T>C (rs10932029), ICOSc.1624C>T (rs10932037), ICOSc.2373G>C (rs4675379), and ICOSc.602A>C (rs10183087) was carried out using allelic discrimination methods with the TaqMan® SNP Genotyping Assay. There were no statistically significant differences in the allele, genotype, or haplotype distributions between B-CLL patients and healthy controls for any of the investigated polymorphic markers in the ICOS gene. However, we noted that patients carrying genotype ICOS ISV1+173T>C [TT], ICOSc.602A>C [AA], ICOSc.1624C>T [CC], and ICOSc.2373G>C [GG] have a decreased frequency of progression to a higher Rai stage during 60-month follow-up (21.35% vs. 40.8%, p = 0.013) compared to other individuals. This indicates that the investigated polymorphisms do not modulate the risk of B-CLL in the Polish population, but are associated with disease dynamics, in particular with the time to Rai stage progression. (Folia Histochemica et Cytobiologica 2011; Vol. 49, No. 1, pp. 49–54)

The aim of this study was to evaluate the phospholipid concentration in acute leukemia (AL) blast cells from peripheral blood (PBMC) and bone marrow (BMMC). In vitro 31P Nuclear Magnetic Resonance Spectroscopy (31P MRS) was used. The integral intensities of the resonant peaks and the phospholipid concentrations in PBMC and BMMC were analyzed. Differences in the phospholipid concentrations in cells from myeloblastic or lymphoblastic lines were also evaluated. This investigation was carried out on phospholipid extracts from PBMC and BMMC from 15 healthy volunteers and 77 patients with AL (samples taken at the moment of diagnosis). A significant decrease in sphingomyelin (SM) and phosphtidylserine (PS) was observed in the PBMC of patients with AL relative to the results for the healthy volunteers. For ALL, we found a significant decrease in the concentration of phosphatidylcholine plasmalogen (CPLAS), SM, PI+PE (phosphatidylinositol + phosphatidylethanolamine) and PS in comparison with the results for healthy volunteers and patients with AML. Experiments with BMMC cells revealed a significant decrease in the concentration of CPLAS, SM, PI+PE, and PS in ALL relative to AML. Additionally, a significant decrease in phosphatidylcholine (PC) concentration was observed in ALL compared to AML. If the phospholipid extracts were taken simultaneously from the same patient, there were no significant differences in the integral intensities and phospholipid concentrations between PBMC and BMMC.

To the editor: Internal tandem duplication in the FLT3 gene ( FLT3- ITD) has been recognized as a marker conferring poor outcome in patients with normal karyotype acute myeloid leukemia (NK-AML).[1][1] Because of the inferior outcome of FLT3- ITD+ NK-AML patients when treated with standard

1,25-Dihydroxyvitamin D3 (1,25D) regulates gene transcription through the nuclear vitamin D receptor (VDR) and initiates rapid cellular responses via an unknown mechanism. Here we report that 1,25D induces a rapid increase in synthesis of VDR protein and its transport to the nucleus. These results are similarly obtained in myeloid leukemia cell lines, and in blast cells from blood of patients diagnosed with acute myeloid leukemia, subtypes M2 and M4. Our results suggest that stability of unliganded VDR is LY294002- and PD98059-dependent, and that ligation of VDR leads to its increased translation and nuclear translocation. The receptor localized in the cell nucleus is not exported back to the cytosol by exportin 1. We also show that the cytosolic portion of VDR in leukemia cells is localized in the vicinity of the plasma membrane, close to the F-actin cytoskeleton.

Copy number variations (CNV) in CEBPA locus represent heterogeneous group of mutations accompanying acute myeloid leukemia (AML). The aim of this study was to characterize different CEBPA mutation categories in regard to biological data like age, cytology, CD7, and molecular markers, and identify possible factors affecting their etiology. We report here the incidence of 12.6% of CEBPA mutants in the population of 262 normal karyotype AML (NK-AML) patients. We confirmed that double mutant AMLs presented uniform biological features when compared to single CEBPA mutations and accompanied mostly younger patients. We hypothesized that pathogenesis of distinct CEBPA mutation categories might be influenced by different factors. The detailed sequence analysis revealed frequent breakpoint-associated microhomologies of 2 to 12bp. The analysis of distribution of microhomology motifs along CEBPA gene showed that longer stretches of microhomology at the mutational junctions were relatively rare by chance which suggests their functional role in the CEBPA mutagenesis. Additionally, accurate quantification of CEBPA transcript levels showed that double CEBPA mutations correlated with high-level CEBPA expression, whereas single N-terminal CEBPA mutations were associated with low-level CEBPA expression. This might suggest that high-level CEBPA expression and/or accessibility of CEBPA locus contribute to B-ZIP in-frame duplications.

The aim of this study was to prospectively evaluate the impact of early bone marrow response on complete remission (CR) rate and long-term outcome in adults with acute myeloid leukemia. Bone marrow cytology was assessed on day 6 of induction treatment in 164 patients, revealing the presence of ≥5% blasts in 61 cases. In this subgroup the CR rate was significantly lower compared to the remaining patients (P < 0.00001) resulting in decrease of the overall survival (P = 0.002). Persistence of ≥5% blasts in bone marrow on day 6 of induction is an easily available surrogate marker to be used for treatment decisions.

Purpose The goal of this study was to evaluate whether the addition of a purine analog, cladribine or fludarabine, to the standard induction regimen affects the outcome of adult patients with acute myeloid leukemia (AML). Patients and Methods A cohort of 652 untreated AML patients with median age 47 years (range, 17 to 60 years) were randomly assigned to receive one of three induction regimens: DA (daunorubicin plus cytarabine), DAC (DA plus cladribine), or DAF (DA plus fludarabine). Postremission treatment was the same for all arms. Results Complete remission rate in the DAC arm was higher compared with the DA arm (67.5% v 56%; P = .01) as a consequence of reduced incidence of resistant disease (21% v 34%; P = .004). There was no significant difference in early outcome between the DAF and DA arms. The probability of overall survival was improved for the DAC arm (45% ± 4% at 3 years) compared with the DA arm (33% ± 4%; P = .02), and leukemia-free survival was comparable. Long-term outcome did not differ significantly for the comparison of the DAF and DA arms. A survival advantage of the DAC arm over the DA arm was observed among patients age 50 years or older (P = .005), those with initial leukocyte count above 50 × 109/L (P = .03), and those with unfavorable karyotype (P = .03). DAF revealed a significant advantage over DA in patients with adverse karyotype (P = .02). Conclusion The addition of cladribine to the standard induction regimen is associated with increased rate of complete remission and improved survival of adult patients with AML.

This study was designed to compare the differentiation-inducing potential of 1,25-dihydroxyvitamin D 3 (1,25D) with some analogs (VDAs) in a panel of acute myeloid leukemia (AML) cell lines and in blast cells isolated from patients with AML. Of the cell lines studied, HL60 proved to be the most sensitive to each of the differentiation-inducing agents when compared to THP-1, NB-4 and U-937 cell lines. Three of the VDAs tested (PRI-1906, PRI-2191 and PRI-2201) were similarly effective as 1,25D in all the cell lines tested. However, blast cells from AML showed a varying sensitivity towards 1,25D. For example, blast cells isolated from patients in which the whole or part of chromosome 7 was deleted were extremely sensitive to 1,25D and its analogs. In contrast, 1,25D failed to increase the expression of differentiation markers in blast cells isolated from patients carrying activating mutations in Flt3 gene. Since, the expression of vitamin D receptor (VDR) in cells with Flt3 mutations was increased to the same extent as in other AML cells this suggests that failure of these cells to differentiate lies downstream of the receptor. That blast cells with different cytogenetic abnormalities have dissimilar responses to 1,25D and its analogs, may have implications in the use of 1,25D as a ‘differentiation therapy’ for myeloid leukemias. The analog PRI-2191 (tacalcitol) was found to be the most potent in inducing patient's cells differentiation.

The treatment of adults with Philadelphia-negative acute lymphoblastic leukaemia (ALL) depends on the presence of risk factors including age, white blood cell count, immunophenotype and time to complete remission. In recent years, status of minimal residual disease (MRD) has been postulated as an additional risk criterion. This study prospectively evaluated the significance of MRD. Patients were treated with a uniform Polish Adult Leukemia Group (PALG) 4-2002 protocol. MRD status was assessed after induction and consolidation by multiparametric flow cytometry. Out of 132 patients included (age, 17-60 years), 116 patients were suitable for analysis. MRD level >/=0.1% of bone marrow cells after induction was found to be a strong and independent predictor for relapse in the whole study population (P < 0.0001), as well as in the standard risk (SR, P = 0.0003) and high-risk (P = 0.008) groups. The impact of MRD after consolidation on outcome was not significant. The combination of MRD status with conventional risk stratification system identified a subgroup of patients allocated to the SR group with MRD

The aim of this investigation was to evaluate the changes in PAF concentrations in the plasma, PBMC and BMMC of patients with acute lymphoblastic leukemia (ALL) and acute myeloblastic leukemia (AML). The plasma was from 23 healthy volunteers (HV) and 44 patients with AL (16 ALL, 28 AML). The PBMC were from 15 HV and 55 patients with AL (18 ALL, 37 AML), and the BMMC from 40 patients with AL (11 ALL, 29 AML). Methanol-chloroform phospholipid extraction from 60 × 106 cells (PBMC or BMMC) was performed according to a modified version of Folch’s method. 31P MRS data was obtained on an AMX 300 Bruker spectrometer (7.05 T). The PAF concentration in the plasma of the patients with ALL or AML was lower than that for the healthy volunteers. The PAF concentration in the plasma of the patients with ALL did not differ significantly from that of the patients with AML. In the case of both the PBMC and BMMC, the PAF concentration was significantly diminished in patients with ALL relative to the concentration for those with AML and for the healthy volunteers. No differences were observed in the PAF concentrations for the AML patients and the healthy volunteers.

To assess the efficacy of an original DAC-7 regimen: daunorubicine (DNR) 60 mg/m2/day, days 1-3; cytarabine (AraC) 200 mg/m2/day, days 1-7; cladribine (2-CdA) 5 mg/m2/day, days 1-5, 400 untreated adult acute myeloid leukemia patients (including 63 with preceding myelodysplastic syndrome), aged 45 (16-60) years were randomized to either DAC-7 (n=200) or DA-7 (without 2-CdA, n=200). The overall CR rate equaled 72% for DAC-7 and 69% for DA-7 arm (P=NS). After a single course of DAC-7 induction, the CR rate equaled 64% and was significantly higher compared to 47% in the DA-7 arm (P=0.0009). Median hospitalization time during the induction was 7 days shorter for DAC-7 compared to the DA-7 group (33 vs 40 days, P=0.002). Toxicity was comparable in both groups. The probability of 3-year leukemia-free survival (LFS) for DAC-7 and DA-7 group equaled 43 and 34%, respectively (P=NS). There was a trend toward higher LFS rate for patients aged >40 years receiving DAC-7 compared with DA-7 regimen (44 vs 28%, P=0.05). This study proves that addition of 2-CdA increases antileukemic potency of DNR+AraC regimen, thus resulting in a higher CR rate after one induction cycle when compared to DA-7, without additional toxicity. It shortens hospitalization time and may improve long-term survival in patients aged >40 years.

Abstract 4614 Introduction: There is strong evidence that altered immunological function entails an increased risk of B-cell chronic lymphocytic leukemia (B-CLL). The main mechanism of an antitumor response depends on T-cell activation. Unlike the constitutively expressed CD28, inducible costimulatory molecule (ICOS) is expressed on the T-cell surface after activation. ICOS enhances all the basic T-cell responses to a foreign antigen, namely proliferation, secretion of lymphokines, the up-regulation of molecules that mediate cell-cell interaction, and effective help for antibody secretion by B cells. ICOS is essential for both efficient interaction between T and B cells and normal antibody responses to T cell-dependent antigens. It does not up-regulate the production of interleukin-2, but superinduces the synthesis of interleukin-10. Our previous results indicated a role of ICOS gene as a susceptibility locus to B-CLL. Therefore an extended study was undertaken to evaluate the association between four ICOS polymorphisms (which were recently described as functional ones) and susceptibility to B-CLL in a Polish population. Methods: A case-control study of 296 individuals including 146 B-CLL patients was conducted on four polymorphisms in the ICOS gene. Genotyping of the polymorphisms ICOSISV1+173T>C (rs10932029), ICOSc.1624C>T (rs10932037), ICOSc.2373G>C (rs4675379), and ICOSc.602A>C (rs10183087) was done using allelic discrimination methods with the TaqManÒ SNP Genotyping Assay. Results: There were no statistically significant differences in the allele, genotype, and haplotype distributions between B-CLL patients and healthy controls for any of the investigated polymorphic markers in the ICOS gene. However, we noted that patients carrying genotype ISV1+173T>C [TT], ICOSc.602A>C [AA], ICOSc.1624C>T [CC], and ICOSc.2373G>C [GG] have a decreased frequency of progression to a higher Rai stage during 60-month follow-up (21.35 vs. 40.8%, p=0.013) compared with other individuals. Conclusion: This study showed that the investigated polymorphisms do not modulate the risk of B-CLL in the Polish population, but are associated with disease dynamics in particular with the time to Rai stage progression. Disclosures: No relevant conflicts of interest to declare.

Abstract 4402 Introduction Dysfunction in cellular and humoral immunity entails an increased risk of B-cell chronic lymphocytic leukemia (B-CLL). It has been suggested that innate immunity, especially natural killers cells play key role in antitumor cytotoxicity regulated by interaction between killer immunoglobulin-like receptors (KIRs) on NK cells and some T-cell subpopulations and their HLA-class I ligands on target cells. KIRs receptors have been divided into two functional groups: with long cytoplasmic tails (DL) - inhibitory and with short cytoplasmic tails (DS) - activating. Two broad haplotypes of KIR genes have been defined: the A haplotype characterized by presence of single activating KIR gene (2DS4) and the B haloptype characterized by two or more activating KIR genes (2DS1, 2DS2, 2DS3, 2DS5 and 3DS1).The 2DL2, 2DL3 and 2DS2 KIRs bind to HLA-C1 allotype (Asp80), while 2DL1 and 2DS1 KIRs bind to HLA-C2 allotype (Lys80). Due to lack of representative data in literature the study was undertaken to determine the association between polymorphism of KIR genes and HLA-C allotypes and susceptibility to B-CLL. Patients and methods The following KIR genes were typed: 2DL1, 2DL2, 2DL3, 3DL1, 2DS1, 2DS2, 2DS3, 2DS4fl, 2DS4del, 2DS5, 3DS1, in 200 B-CLL patients and 199 healthy individuals using PCR-SSP method. The HLA-C1 and HLA-C2 were determined using Olerup SSP typing kit in 187 B-CLL patients and 104 controls. Results Individual KIR gene content was similar in B-CLL cases and healthy controls although patients with KIR2DS3 gene were more common among cases compared to controls (36% vs. 27%, p=0.06) (Table1). The frequency of AA haplotype did not differ between studied groups (29% vs. 28%). Moreover no differences were found between incidence of HLA-C allotypes (HLA-C1: 74.3% vs. 76.0%, HLA-C2: 67.4% vs.70.2%), genotypes (C1/C1: 32.6% vs 29.8%, C1/C2: 41.7% vs 46,2% and C2/C2: 25.7% vs 24.1) and KIR genes in combination with genes for their HLA-C ligands in B-CLL patients and controls (Table 2). Conclusions The data obtain in this study imply that there may be not direct association between KIR and HLA-C gene content in the genome and the presence of B-CLL. Disclosures: No relevant conflicts of interest to declare.

Abstract 2055 Poster Board II-32 This trial is a continuation of earlier Polish Adult Leukemia Group (PALG) studies on the use of purine analogues for therapy of AML patients (Leukemia 2004,18:989–97, updated at 7 y: ASH 2006, Abstr.N#2003, Ann Hematol. 2008, 87:361–7). The goal of the present study was to evaluate the efficacy of combination including fludarabine – DAF (daunorubicine 60 mg/m2/d iv, d 1–3; cytarabine (AraC) 200 mg/m2/d ci, d 1–7, and fludarabine 25 mg/m2 iv d 1–5) in untreated adult patients with AML, based on head to head comparison with DAC (DNR, AraC, Cladribine), and standard DA regimens (preliminary results: ASH 2008, abstr.#133). Primary end-points were: complete remission rate (CR) and overall survival (OS); secondary objectives were: toxicity and leukemia-free survival (LFS). Patients achieving CR received two courses of subsequent intensive consolidation: HAM (HD AraC, mitoxantrone) and HD AraC. Reduction of consolidation was accepted in patients treated with early alloBMT. In case of partial remission (PR) after the first induction course the same regimen was repeated. Patients with no remission (NR) or with PR after 2 induction courses were withdrawn from the study. Between 09.2004 and 05.2008, 673 adult untreated AML patients aged 18–60 y, median 47 y, sex: male 49,5%, female 50,5%, treated in 18 co-operating PALG centers were centrally randomized to either DAF (n=225), DAC (n=224) or DA (n=224) arm (1:1:1). PML/RAR alfa positive - FAB M3 cases were excluded. The study groups were well balanced in respect of age, sex, FAB subtype, and WBC. The results are summarized in the table. Outcome DAC (n = 223) DAF (n = 219) DA (n = 210) P Value (DAC vs DA) P Value (DAC vs DAF) CR 68 59 56 .013 .08 CR after 1 cycle 62 55 50,5 .017 16 3-yr OS 46 30 31 02 .02 2-yr LFS 47 40 39 NS NS Both, the entire CR rate and the CR rate after a single induction course were significantly superior in the DAC arm if compared with DA and DAF subgroups. With a median follow-up of 34 months (the longest observation time 5y) the OS rate equaled 46% for the DAC treated subgroup and was higher in comparison to the standard DA arm and the DAF arm. There were no significant differences in the leukemia free survival rates. The early death rates of 8,5–11%. were similar in the studied treatment subgroups. All patients developed WHO grade IV thrombocytopenia and agranulocytosis. The frequency and severity of infections, mucositis, vomiting, diarrhoea, alopecia, polyneuropathy as well as of cardiac, liver or kidney dysfunctions were comparable in particular arms. In conclusion, this updated results of randomized study prove that the incorporation of cladribine to the standard DA induction regimen (DAC) improves CR rate and the overall survival in adults with AML aged up to 60 y, without additional toxicity. This beneficial effect was not observed in patients treated using the DAF protocol with fludarabine added to the standard “DA 3+7” schedule. Disclosures: Robak: Celgene: Consultancy; Roche: Honoraria, Research Funding; Genmab: Research Funding; Cambridge Antibody Technology: Research Funding; GlaxoSmithKline: Honoraria. Warzocha:BMS: Consultancy, Honoraria; Celgene: Consultancy; Roche: Honoraria; Pfizer: Honoraria; Amgen: Honoraria.

Our previous PALG study in 445 de novo AML patients has demonstrated that addition of cladribine to the standard daunorubicine-cytarabine (DA) remission induction regimen - DAC has a beneficial influence on both the CR rate after one induction cycle (p=0,0008) and on survival in patients older than 40 y (Leukemia2004,18:989–97, updated at 7 y: ASH 2006, Abstr.N#2003). The goal of this study was to evaluate the efficacy of original combination including another purine analogue fludarabine – DAF (daunorubicine 60 mg/m2/d iv, d 1–3; cytarabine (AraC) 200 mg/m2/d ci, d 1–7, and fludarabine 25 mg/m2 iv d 1–5) in untreated patients with AML, aged up to 60 y, based on head to head comparison with DAC - (DNR, AraC, Cladribine), and standard DA regimens. We evaluated earlier the DAF protocol in relapsed or refractory AML (PALG pilot study; Ann Hematol.2008, 87:361–7. Epub 2007 Dec 12); the tolerance was good, CR 44%, LFS 38%. Primary objectives of the presented trial were: complete remission rate (CR) and overall survival (OS); secondary objectives were: toxicity and leukemia-free survival (LFS). Additional analysis was planned for patients submitted to an early bone marrow allotransplantation (alloBMT) after CR. Patients achieving CR received two courses of subsequent intensive consolidation: HAM (HD AraC, mitoxantrone) HD AraC. Reduction of consolidation was accepted in patients treated with early alloBMT. In case of partial remission (PR) after the first induction course the same regimen was repeated. Patients with no remission (NR) or with PR after 2 induction courses were withdrawn from the study. Between 09.2004 and 05.2008, 673 adult untreated AML patients aged 18–60 y, median 47 y, sex: male 49,5%, female 50,5%, treated in 18 co-operating Polish Adult leukemia Group (PALG) centres were centrally randomised to either DAF (n=225), DAC (n=224) or DA (n=224) arm (1:1:1). PML/RAR alfa positive - FAB M3 cases were excluded. The study groups were well balanced in respect of age, sex, FAB subtype, and WBC. After a single induction course the CR rate for patients receiving DAC equalling 63% was significantly higher if compared with DA - 51% (p=0,01), whereas no significant differences were noted between DAC vs. DAF - 55% and DAF vs. DA subgroups. Also the entire CR rate of 68% in the DAC arm was higher in comparison with DA one - 57% (p=0,02). No significant differences were found between DAC vs. DAF - 60%, and DAF vs. DA. At median time of 24 months (longest observation time 3,5y) the OS rate equalled 51% for the DAC treated subgroup and was higher in comparison to the standard DA arm - 39% and the DAF arm - 36% (p=0,03). The leukemia free survival rates (LFS) in DAC, DA and DAF treated cohorts equalled 51%, 32% and 41% respectively (p=NS). The early death rates of 8–10%. were similar in the studied treatment subgroups. All patients developed WHO grade IV thrombocytopenia and agranulocytosis. The frequency and severity of infections, mucositis, vomiting, diarrhoea, alopecia, polyneuropathy as well as of cardiac, liver or kidney dysfunctions were comparable in particular arms. In conclusion, this randomised study proves that the addition of cladribine to the standard DA induction regimen (DAC) improves CR rate and the overall survival in adults with AML aged up to 60 y, without additional toxicity. This beneficial effect was not observed in patients treated using the DAF protocol with fludarabine added to the standard “DA 3+7” schedule

Background: High expression of BAALC,MN1, ERG and low CEBPA have been shown to be an adverse risk factor in cytogenetically normal acute myeloid leukemia (CN-AML). However intermediate (IM) risk group of AML includes not only patients with normal karyotype, but also with other aberrations, of unknown clinical significance. That’s why it is important to evaluate prognostic impact of the above mentioned markers in the IM group of AML patients as total. So far, the prognostic significance of expression level of the studied markers has not been yet compared with each other, as well as evaluated in the context of other molecular biomarkers, such as FLT3 ITD (internal tandem duplication), MLL-PTD (partial tandem duplication) mutations, and EVI1 expression level. Aims: To evaluate the prognostic impact of BAALC,MN1, ERG, CEBPA expression in the context of FLT3-ITD, MLL-PTD and EVI1 expression on the complete response to induction therapy (CR), and the relapse rate in the patients group representing intermediate risk group of AML according to cytogenetics. Methods: 86 patients (16 to 60 years of age) with untreated primary IM-risk AML were included in this study: 55 with normal karyotype, and 31 with other aberrations. Patients were treated similarly according to the Polish Acute Leukemia Group (PALG) protocol (induction chemotherapy: daunorubicin, cytarabine plus fludarabine or cladribine, and two cycles of consolidation high-dose cytarabine with mitoxantrone and high- dose cytarabine). BAALC, MN1, ERG, CEBPA expressions were evaluated in the bone marrow cells from IM-AML patients by real-time RT-PCR technique, using TaqMan probes, as recently described. Results: High and low BAALC, as well asERGandMN1 expression was determined by dichotomizing delta Ct values at the median (high expression of ERG, MN1 referred further as negative or positive cases). High BAALC correlated significantly with the group positive for MN1 (p=0.01), ERG (p=0.01) as well as MLL-PTD (p=0.045), while no correlation was found between: high BAALC and FLT3-ITD, as well as CEBPA. There was a trend towards significance towards lower CR rates in the groups with high BAALC, positive MN1, positive EVI1 expression or MLL-PTD, while low CEBPA showed negative correlation with CR rate (p=0.02). Next we analysed cumulative presence of the subsequent markers: MLL-PTD, positive ERG, positive MN1, and positive EVI1. Cases negative for all of above markers presented 85 % of CR rate, patients with one or two markers present: 55% CR rate, and a group with more than three of them positive: only 20% CR rate. Further comparing DFS after 2nd and 3rd year of follow up, with each marker separately did not show significant correlation, although a trend towards significance was observed for most of them. However again, cumulative presence of high BAALC, positive MN1, positive ERG, positive EVI1, and MLL-PTD showed significant correlation with 2 and 3 years’ DFS (respectively 70% for the cases with 0 –2 markers, while 22% for the group with more than 2 markers present; p=0.035). Conclusions: In our study, we analysed a series of patients with intermediate risk according to the cytogenetics (NC and other aberrations). Cumulative presence of high BAALC, and positiveERG, MN1, EVI1 expression levels as well as MLL-PTD, showed their prognostic significance.

Background: Natural killer (NK)-cell receptors (NKRs) on CD8+ T cells can modulate antigen-specific T cell activity but their function and rules that govern their expression remain unclear. Among NKRs heterodimers CD94-NKG2 form either an inhibitory or an activating receptor, depending on whether CD94 associates with NKG2A or NKG2C, E or H, respectively. NKG2D is expressed on all naïve and activated CD8+ T cells. NKG2D ligands are distantly related to HLA class I molecules and up-regulated in virally infected cells, tumour cells or otherwise stressed cells. The expression of NKG2D ligands by target cells potently induces NK cells cytotoxicity. Although specific immunity mediated by cytolitic T-lymphocytes might have an anti-cancer role, tumours escape from T-cell-based immune surveillance using various mechanisms, such as downregulation, mutation, or loss of HLA class I molecules. Aims: In this study we tried to establish the expression significance of molecules stimulating (NKG2D) and inhibiting (CD94/NKG2A) NK cells cytotoxicity in lymphoid malignancies. Our aim was also to explore whether any influence of this expression on treatment response exists. It could be useful as remission predictive factor or a future target for therapeutic approaches. Patients: 23 patients (F/M -13/10, median age 57) with lymphoid malignancies (Non-Hodgkin Lymphoma (NHL), Myeloma multiplex (MM) and Hodgkin disease (HD) in 19, 3 and 1 case respectively) diagnosed in our unit in two recent years and 8 healthy volunteers were included. Eight patients were still untreated while involved into the study. In the previously treated group 4 of 15 patients achieved complete remission (CR), 5-partial remission (PR) and in 6 cases there were no response (NR) for chemotherapy. In all cases first line treatment was used. Methods: Mononuclear cells (MNC) were isolated from blood samples in Ficoll gradient. All used antibodies were conjugated: CD8 (DAKO Cytomation), CD94/NKG2A PE (Becton Dickinson) and NKG2D PE (Immunotech). MNC were stained for co-expression of CD8/NKG2D and CD8/CD94/NKG2A populations and then performed for flow cytometry. Results: We evaluated the diffreneces in CD94/NKG2A and NKG2D expression in blood deriving CD8+ population between lymphoid malignancies patients and healthy volunteers. There were no statistically significant difference in CD94/NKG2A and NKG2D expression between treated and untreated patients. CD94/NKG2A expression was significantly higher in the treated group than in healthy controls (p=0,01). In reverse, NKG2D expression was significantly higher in previously untreated group than in healthy controls (p=0,04). The only significant correlation we found was positive CD94/NKG2A and NKG2D correlation among the whole group of patients (r=0,57, p=0,004). Conclusions: As the expression of NKG2D ligands by target cells potently induces NK cells cytotoxicity and we have found NKG2D to be overexpressed in lymphoid malignancies comparing to healthy controls it may be just another proof for a natural anti tumour surveillance. On the other hand the opposite role of CD94/NKG2A heterodimer may be a premise for antiNKG2A immunotherapy of lymphoid malignancies to support the natural surveillance especially in the light of our results: CD94/NKG2A expression was significantly higher in the treated group than in healthy controls.

Background. Early occurrence of the multidrug resistance (MDR) in de novo acute myeloid leukaemia (AML) may contribute to the treatment failure.The aim of this study was to investigate prospectively the clinical significance of the MDR proteins overexpression and their functional augmenting, in the context of other AML prognostic factors, such as age, immunophenotype and cytogenetic profile. We examined expression of MDR proteins: MDR1, MRP1, MDR3, BCRP, LRP and GSTπ and performed drug resistance functional assay in peripheral blood blasts of 25 patients with de novo AML at diagnosis and after the first chemotherapy cycle consisting of a 3 + 7 combination of DNR/Ara-C. MDR proteins presence and their functional activity (measured by fluorescent Rh123 dye efflux) were estimated by flow cytometry. Results: Thirteen out of the 25 AML patients (52%) attained a CR with induction treatment, one had PR and eleven did not achieve remission. Out of 10 patients without CR, 2 died in aplasia and 9 were classified as an early death due to disease progression. All patients who achieved remission were younger than 55 years. Among 11 patients without remission, 9 expressed CD34; 6 of them had intermediate and 5 unfovorable cytogenetic profiles. In 10 out of 25 patients (40%) overexpression od MDR1 was shown at diagnosis, and was irreversible in 9 of them, those with poor clinical outcome (6 did not achieve CR, 1 had PR and one who obtained CR relapsed), whereas one patient who reversed achieved CR. The functional MDR assay showed the increased Rh123 efflux, both at diagnosis and after the first chemotherapy cycle in 12 patients (48%) and it influenced patients’ outcome in similar manner as MDR1 expression. At diagnosis other MDR proteins were also elevated in some AML patients:GSTπin 19 (76%), LRP in 9 (36%), MRP in 4 (16%) and MDR3 in 2 (8%). Seven AML patients (20%), both at diagnosis and after the first chemotherapy cycle co-expressed MDR1 with other multidrug resistance proteins and had enhanced Rh123 efflux. This co-expression resultes in 6 of them in chemotherapy resistance; the remaining one who achieved remission was young and had favorable cytogenetic profile. The results obtained demonstrate that the advanced age, unfavorable cytogenetic profile, overexpression of MDR1 at diagnosis and co-expression of other MDR proteins together with their functional activity contribute to the treatment failure in de novo AML.

Multidrug resistance (MDR), connected with the overexpression of several proteins e.g. MDR1, MDR3, MRP1, LRP and BCPR, has been implicated in refractoriness to chemotherapy in acute myeloid leukemia (AML). The aim of this study was to evaluate their clinical significance and individual contributions to the drug resistant phenotype in AML We studied 22 untreated patients with de novo AML, 12 F and 10 M (aged from 20 to 74 years, mean 48.2 yrs) between Jan. 2002 and June 2004. Acc. to FAB classification 2 cases were M0, 2 M1, 10 M2, 6 M4, 2 M5. We performed rhodamine 123 (Rho123) accumulation and retention test and, simultaneously, evaluated MDR1, MDR3, MRP1, LRP and BCPR proteins, in flow cytometry analysis using specific monoclonal antibodies, with leukemic blasts gated with leukemia cell-specific antibodies. In all patients the examination was performed twice: at diagnosis time and 2 days after the first course of chemotherapy (daunorubicine and cytosine arabinoside). The sample was classified as a positive when the mean geometric canal of fluorescence intensity (FI) was 1.5-fold higher than that of the negative (isotypic antibody) control. 12 out of 22 pts are alive, 7 had CR and 5 had NR. Out of 7 CR pts 4 had all tests negative, both at diagnosis and after chemotherapy, in 1 case the positive tests at diagnosis were reversed after chemotherapy, and in 2 the Rho123 test was positive at diagnosis and after chemotherapy. Out of 5 who had NR, 4 were positive in both, the Rho 123 test and MDR1 prior to chemotherapy and thereafter, and all 5 NR pts expressed LRP after chemotherapy. Ten out of 22 AML pts died, in four due to disease progression and six in the septic shock. Out of 4 who died in relapse 3 had positive the Rho123 test and elevated MDR1, both at diagnosis and after chemotherapy, and the remaining 1 became positive after chemotherapy. In 6 who died in the septic shock the Rho 123 test was negative and the multidrug resistance proteins not expressed. Overexpression of MDR1 was detected in 7/22 pts at diagnosis, and was reversed after chemotherapy in 1 case (CR) and all 6 positive remained were refractory to chemotherapy (2 died, and the other 4 had NR). MDR1 appeared after chemotherapy in 3 pts and all of them died. In 9 out of 15 who did not respond to chemotherapy MDR1 was elevated after chemotherapy and 15 of them died. In six out of 22 AML elevated LRP was found at diagnosis and after chemotherapy; 5 were resistant to chemotherapy (3 died, 2 had NR) and only 1 achieved CR. And all five LRP -negative at diagnosis and further LRP- positive after chemotherapy, did not achieve remission (3 died and 2 had NR). 10 out of 15 resistant pts overexpressed LPR after chemotherapy and 6 of them died. In 4 AML pts MRP was elevated at diagnosis, and 3 of them in whom it reversed after chemotherapy are alive (1 CR and 2 had NR) and 1 in whom MRP remained positive died. Out of 2 AML pts in whom MRP became overexpressed after chemotherapy 1 died and 1 had NR. Elevated BCPR was found at diagnosis in 2 AML pts, after chemotherapy it was reversed in one (CR) and in one remained expressed (NR); in remaining 3 pts BCPR appeared after chemotherapy (2 of them died). We conclude, that the coexpression of several (at least two) multidrug resistance proteins is associated with an adverse prognosis and less CR.

Summary Objectives The addition of cladribine to the standard regimen consisting of daunorubicin and cytarabine has been reported to increase the efficacy of induction therapy in acute myeloid leukemia (AML). The goal of this study was to determine the effect of this modification on the incidence and spectrum of infectious complications. Methods Case report forms of 309 patients with newly diagnosed AML who had been enrolled in the prospective, randomized ‘DAC-7 vs. DA-7' trial were reviewed. The frequency, etiology, localization, severity, and outcome of infections were compared for patients receiving only daunorubicin and cytarabine (DA-7) and those additionally treated with cladribine (DAC-7). Results A total of 443 febrile episodes were reported with no significant difference between the treatment groups. A trend towards a higher frequency of bacteremias was observed among DA-7 patients compared to those in the DAC-7 group (31% vs. 21%; p =0.08). The treatment arms did not differ in terms of the distribution of the isolated Gram-positive, Gram-negative, fungal, and viral organisms. However, when bacteremias were considered, Gram-positive blood cultures tended to be more frequent in the DA-7 compared to the DAC-7 group (16% vs. 8.5%; p =0.07). This difference reached statistical significance when major blood bacteremias were analyzed separately (13% vs. 5%; p =0.02). Complete recovery from infections was observed in the majority of patients across both treatment arms and no significant difference was noted regarding infection-related mortality. Conclusions The addition of cladribine to standard induction chemotherapy has no impact on the incidence and spectrum of infectious complications in newly diagnosed AML patients.