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Objective We describe a severe case of vaccine-induced immune thrombotic thrombocytopenia (VITT) after the first dose of the ChAdOx1 nCoV-19 vaccine leading to massive ischemic stroke. Methods A 42-year-old woman developed acute left hemiparesis (NIHSS 12) 9 days after the first vaccine dose. Results The blood tests revealed low platelets (70 103/μL) and severe increment of D-dimer (70,745 ng/mL FEU). Brain non-contrast computed tomography and multiphasic CT angiography demonstrated a right middle cerebral artery occlusion. The patient was treated with primary thrombectomy, steroids, immunoglobulin, and fondaparinux. Despite the treatment, the neurological status deteriorated and underwent decompressive hemicraniectomy. She was transferred to the rehab’s unit 52 days after the onset. Discussion Healthcare providers should be aware of the possibility of ischemic stroke as a manifestation of VITT. Awareness on this very rare and possibly fatal complication should be reinforced on both the vaccine recipients and general practitioners. Supplementary Information The online version contains supplementary material available at 10.1007/s10072-021-05800-3.

The association of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) with usually low level of serum IgM monoclonal paraprotein is well recognized. We describe a rare case of a patient who developed overt IgM-related hyperviscosity syndrome after treatment for a diagnosis of CLL that was unresponsive to immunochemotherapy and to targeted therapies. Hyperviscosity syndrome, related to CLL-associated IgM paraprotein, is a very rare finding. High levels (> 3 g/dl) of serum IgM are mostly found in lymphoplasmacytic lymphoma-Waldenstrom macroglobulinemia (LPL/WM). In this patient, LPL was ruled out and diagnostic findings were consistent with only one clonal B cell population: CLL. It could be interesting understanding if ibrutinib therapy triggered IgM increase.

Acquired Hemophilia A (AHA) is a rare disease caused by anti-factor VIII autoantibodies. It is usually characterized by clinically significant bleeding at the onset and requires prompt hemostatic and immunosuppressive therapies. Due to its rarity and the lack of randomized trials, its treatment is a great challenge, especially in the relapse/refractory setting. This report presents the case of a patient diagnosed with chronic lymphocytic leukemia who developed a steroid-resistant AHA, successfully managed with aggressive immunosuppressive therapy.

R-Bendamustine is an effective treatment for follicular lymphoma (FL). Previous large trials demonstrated the prognostic role of the molecular minimal residual disease (MRD) during the most frequently adopted chemotherapeutic regimens, but there are not yet conclusive data about the effect of combination of rituximab (R) and bendamustine in terms of MRD clearance. Thus, the aim of this retrospective study was to assess if and in what extent the combination of rituximab and bendamustine would exert a significant reduction of the molecular disease in 48 previously untreated FL patients. The molecular marker at baseline was found in the 62.5% of cases; no significant differences were observed between patients with or without the molecular marker in respect of the main clinical features. Moreover, the quantization of the baseline molecular tumor burden showed a great variability: the median value was 1.4x10-2 copies, ranging from 3x10-5 to 4x104. The initial molecular tumor burden did not correlate with clinical features and did not impact on the subsequent quality of response. After treatment, 93% of cases became MRD-negative; the median reduction of the BCL2/JH load was 4 logs. The 2-years PFS was 85%; it was significantly longer for patients in complete than for those in partial response (91% vs 57%; p=0.002), and for cases with lower FLIPI-2 score (88% vs 60%; p=0.004). On the contrary, PFS did not differ between patients with or without the molecular marker at baseline; a molecular tumor burden 15 times higher was observed in the relapsed subgroup in comparison to the relapse-free one, but this difference did not change the PFS length. The 2-years OS was 93.6%; the only variable that significantly impacted on it was the FLIPI-2 score; the presence of the molecular marker at baseline or its behavior after treatment did not impact on survival. This study, even if retrospective and conducted on a small series of patients, would represent a proof of concept that R-bendamustine is able to so efficaciously eradicate MRD that it could be able to by-pass the prognostic significance of MRD already demonstrated for other chemotherapeutic regimens in follicular lymphoma.

INTRODUCTION Multiple myeloma (MM) is considered an incurable disease. Despite the introduction of novel agents allowed deeper response, high-dose chemotherapy and autologous stem cell transplantation (ASCT) remain the standard of care for patients (pts) in good clinical conditions. The most used strategies to mobilize stem cells from bone marrow (BM) into peripheral blood are high-dose cyclophosphamide (HD-CTX) plus G-CSF and G-CSF plus plerixafor (G-CSF+P). The goal of this retrospective study is to investigate whether the two different mobilization strategies have an impact on the clearance of monoclonal PCs in the apheresis products and on pts' outcome. PATIENTS AND METHODS We analyzed 62 pts (median age 61, range 41-75, 37 males and 25 women) diagnosed with MM and treated with ASCT between Mar 2014 and Mar 2018 at our Hematology Division (Pisa, Italy). All pts received induction therapy with at least 4 cycles of bortezomib, thalidomide and dexamethasone (VTD). 9/62 pts obtained a less than partial response (PR) and received lenalidomide-based regimens. After induction, 8 (12,9%) pts achieved complete remission (CR), 26 (41,9%) were in PR, 28 (45,2%) obtained a very good partial response (VGPR). 43/62 fit pts received HD-CTX (2-3 g/sqm) on day 1 followed by G-CSF (30 MU/day) started on day 4 until day 7, increased to 60 MU/day from day 8 until the end of apheresis. In 19/62 pts, after 4 days of G-CSF (60 MU/day) administration and not sufficient mobilization, we added plerixafor (0,24 mg/kgbw) for up to 4 consecutive days. In 43/62 pts we collected apheresis samples (10μl) analyzed through flow citometry to enumerate clonal residual PCs. The panel used to asses clonality included: CD138 Per-Cp, CD38 APC, CD19 PE-Cy7, CD45 APC-Cy7, cytoplasmic immunoglobulin K chain and L chain. RESULTS At the end of the peripheral blood stem cell (PBSC) collection, pts treated with HD-CTX presented a higher CD34+ absolute count (p=0.0489) and achieved the threshold of 5x106 CD34+ cells/kgbw in a significantly (p=0.006) higher percentage. We found a nearly significant (p=0.0517) lower count of CD34+ PBSCs in pts who received lenalidomide-based regimens before the mobilization. Performing flow citometry on apheresis samples, we observed that the number of the harvested clonal PCs showed a significant correlation (p=0.0115) with the occurrence of post-ASCT relapse. ROC curve analysis investigating the predictive effect of the number of pathological PCs on disease relapse showed an area under the curve of 0,6978 (95% CI 0.5392-0.8564; p=0.0267). Neither BM residual PCs detectable on BM biopsies performed before apheresis (r=-0.1323; p=0.609) nor the type of mobilization scheme (p=0.707) had an impact on the proportion of clonal PCs in the graft. Additionally, we did not observe any statistically significant difference in progression free- (PFS) (p=0.8276) and overall survival (OS) (p=0.2475) between the HD-CTX and G-CSF+P groups. DISCUSSION PBSC mobilization has a succession rate > 85%. Despite the use of HD-CTX to increase PBSC yields and decrease tumor burden, there is not clear evidence of a superior mobilization strategy. Additionally, HD-CTX has a not negligible toxicity and approximately 10% of the pts require hospitalization. Conversely, G-CSF+P is a safe and effective approach also in poor mobilizers. In our study, we observed a significative difference in the apheresis yields (p=0.0489) and in the percentage of pts who achieved the threshold of 5x106 CD34+ cells/kgbw (p=0.006) in favor of HD-CTX. Additionally, the detection of harvested residual clonal PCs could be a promising strategy to recognise pts more likely to relapse after ASCT. Nonetheless, we failed to demonstrate a superior effect of HD-CTX in the clearance of harvested clonal PCs, in agreement with the absence of a different pts' outcome amongst the two mobilization strategies. In conclusion, the choice between the two regimens is challenging and requires careful consideration of multiple factors. Overall, young fit pts, especially in the high-risk setting, should be treated with all appropriate modalities including chemiomobilization followed by double-ASCT. Conversely, in pts candidate to a single-ASCT it is reasonable to use G-CSF+P, since HD-CTX does not improve PFS and OS and add toxicity. The absence of an in-vivo purging effect on apheresis products of chemiomobilization further strengthens a chemotherapy-free mobilization. Disclosures Galimberti: Roche: Speakers Bureau; Celgene: Speakers Bureau; Novartis: Speakers Bureau.

Splenic marginal zone lymphoma (SMZL) is an indolent disease that typically affects elderly patients. Thanks to its outcome, most patients don't need any specific therapy and 'a watch and wait' policy is frequently employed. Treatment is required in symptomatic cases. Splenectomy remains one of the first line options in patients fit for surgery. The best pharmacological strategy has not yet been identified for poor surgical risk cases. Amongst different possible chemotherapeutic approaches, alkylating agents, alone or in association with Rituximab, could employ in 'frail' patients. In the present study, the role of oral cyclophosphamide (100 mg per day for 15 consecutive days, every 30 for a total of six cycles) associated with anti-CD20 monoclonal antibody has been evaluated in 30 newly diagnosed SMZL patients, not fit for splenectomy or more toxic chemotherapic regimens. Overall response rate was 87% (CR 70%; PR 17%). Median PFS was 20 months (range, 1-53), with better outcome for low-risk cases according to IIL score prognostic index. Toxicity profile resulted mild.

Background: Splenic marginal zone lymphoma (SMZL) with or without villous lymphocytes is an indolent lymphoma that typically affects elderly patients. Treatment is required in symptomatic cases. Splenectomy remains one of the first-line options in patients fit for surgery. The best therapeutic strategy has not yet been identified. Among different possible chemotherapeutic approaches, purine analogues, alone or in association with rituximab, seem to be a valid therapeutic choice. Patients and methods: Fifty SMZL patients were treated with cladribine with or without anti-CD20 mAb. Results: Forty-six of 50 patients were assessable for response. Overall response rate was 87%: 24 of 46 patients (52%) achieved a complete hematological response (CR), 16 of 46 (35%) a partial response and 6 (13%) were unresponsive. Interestingly, 15 of 24 cases (62%) in CR also achieved a molecular remission. Conclusions: The present results indicate that this schedule is a valid therapeutic approach in SMZL. Addition of rituximab significantly improved quality of response and consequently the outcome of the disease.

Purine analogues have dramatically improved the outcome of patients affected by hairy cell leukemia (HCL), although complete eradication of disease was achieved in few cases. The purpose of this study was to evaluate the role of Rituximab in eradicating minimal residual disease (MRD) in HCL patients after a pre-treatment with 2-chloro-deoxy-adenosine (2-CdA). Ten patients received four cycles of Rituximab after administration of Cladribrine. Before starting anti-CD20 antibody, two patients were in complete remission, six in partial remission and two showed no significant response to Cladribrine. All cases resulted IgH-positive. Median time from the last 2-CdA infusion was 5.7 months. Eight of 10 patients [four in partial remission (PR), two in complete remission (CR) and two unresponsive after 2-CdA] were evaluable for response. Two months after the end of anti-CD20 therapy, all evaluated patients presented a complete haematological remission. Moreover, Rituximab increased percentage of molecular remission up to 100% 1 yr after the end of treatment. Interestingly, in all cases but one, including those persistently polymerase chain reaction (PCR)-positive, semi-quantitative molecular analyses showed MRD levels lower than those found before Rituximab administration. Toxicity was very mild. The present results not only confirm the therapeutic effect of Rituximab, but also show its relevance in eradicating MRD in HCL.

Liposomes used for delivering antineoplastic drugs to sites of disease are able to minimize side effects and enhance therapeutic efficacy. Liposomal Daunorubicin (Daunoxome; DNX) has a selective and higher accumulation in neoplastic tissues and seems to be able to escape Multi-Drug Resistance (MDR). We treated 35 elderly patients with aggressive non-Hodgkin's lymphoma (NHL) with PVBECDNX, a regimen analogue to P-VABEC in which doxorubicin is replaced with DNX at a dose of 50 mg (first 13 patients) and thereafter 50 mg/m2. Twenty-six out of 35 patients were evaluable for response; 15 obtained a CR, 5 a PR (overall response rate of 77%). After a median follow-up of 13 months the 2-years actuarial overall survival was 75% and the failure-free survival was 71%. Two patients out of six no responders died because of progression of disease, and one died in CR because of pre-existing cardiovascular disorders. Eight patients did not tolerate DNX infusion (back pain). Non-haematological toxicity was mild. This study confirms that PVABEC-like regimens are able to induce a high overall response rate in a percentage of patients affected by aggressive lymphoma and shows that DNX is as effective as Daunorubicin in these disorders, but its acute toxicity is reduced.

We report here a patient with relapsed follicular lymphoma who developed secondary acute myeloid leukaemia 15 months after radioimmunotherapy (RIT) with (90)Y-ibritumomab tiuxetan, the fifth described case to date. We review the literature for the potential causal relationship between RIT and secondary myelodysplastic syndromes/acute myeloid leukaemia.

The pharmacology of liposomal doxorubicin gives rise to a compound with major advantages that could potentially improve response and decrease toxicity. The lower toxicity, especially less cardiotoxicity, is also related to the encapsulation of doxorubicin into microscopic liposomes, which preferentially penetrate and accumulate in tumour vasculature. In addition, because myeloma cells divide slowly, the increased exposure of these cells to doxorubicin has the potential of overcoming resistance and increasing tumour cell killing capacity, theoretically resulting in improved response rates. In our hospital we treated 40 patients (24M/16F, see Table I) with of a combination regimen of lenalidomide, non pegylated liposomal doxorubicin (NPLD, Myocet®) and dexamethasone (RMD). All the patients had relapsed multiple myeloma and the majority of them were heavily pretreated (23/40 were resistant to ≥ 2 previous therapies). RMD was administered for a median of six 28-day cycles. Lenalidomide (25mg d 1-21), NPLD 40 mg/m2 d4, Dex 40 mg d1-4 and 17-20. The median age of patients was 61 years and the ORR of the combination was 58%, with 10% of patients achieving a complete or very good partial remission. In particular a high ORR (52%) resulted also in very refractory patients in third line of treatment or more. The median progression-free survival was 9.4 months, while the median overall survival was 21 months (see Table II). The most common side effect was haematological toxicity with grade neutropenia (33%), thrombocytopenia (33%) and anaemia (18%). Under thrombosis prophylaxis with aspirin 100 mg per day we observed thrombembolic complications in only in one patients. Other non haematological side effects were pain (8%), diarrhoea (8%). Neither neurotoxicity nor constitutional symptoms of grade 3/4 were found. In our study, lenalidomide in combination with NPLD and dexamethason has shown encouraging activity in heavily pretreated patients with relapsed or refractory multiple myeloma. These schemes can be additional standard of care in the treatment of patients with relapsed or refractory multiple myeloma. The addition of NPLD can play a key role in overcoming anthracycline resistance and improving the quality of response without limiting toxicity. The pharmacology of NPLD gives rise to a compound with major advantages that could potentially improve response and decrease toxicity. Because increased angiogenic activity occurs in the bone marrow of patients with multiple myeloma, this non-pegylated formulation can enhance the delivery of doxorubicin to the tumour site. In addition, because myeloma cells divide slowly, the increased exposure of these cells to doxorubicin has the potential of overcoming resistance and increasing tumour cell killing capacity, theoretically resulting in improved response rates without limiting toxicity, especially in patients who have already received at least one prior therapy. Table . Characteristics of MM Patients undergoing RMD therapy Characteristics Cases Age at diagnosis (median and range) 61 (30-73) Number of patients 40 (26 M, 14 F) Stage at diagnosis Durie-Salmon (II/III) 31/40 (78%) Number of previous therapies 1 17 (42,5%) 2 10 (25%) 3 8 (20%) 4 5 3 (7,5%) 2 (5%) Prognostic Markers b2-microglobulin (m/L.) 2.2 (1.1 – 35)a Creatinin (mg/dl.) 0.9 (0.5 – 4.4)a Albumin (g/dl)) 4.0 (2.1 – 4.9)a Hemoglobin (mg/dl) 11.3 (5.7 – 16.4)a .aMedian (Range) Download : Download high-res image (21KB) Download : Download full-size image Figure 1 . Download : Download high-res image (21KB) Download : Download full-size image Figure 2 . Table II Progression Free Survival and Overall Survival (in months) Disclosures No relevant conflicts of interest to declare.

Acquired hemophilia is a severe, potentially life-threatening condition usually involving elderly patients, caused by an auto-antibody against factor VIII of coagulation. We describe the case of a 92-years-old woman who came to our attention for severe acute anemia associated with many spontaneous diffuse skin bleedings secondary to a prolonged aPTT 110 sec, factor VIII < 1% with a titer of factor VIII inhibitor of 5.5 Bethesda Units. A diagnosis of chronic lymphocytic leukemia was determined. We treated the patient with a blood transfusion and intravenous corticosteroids with prompt reduction of aPTT and inhibitor factor VIII titer. The present case report involving a very old patient could represent an example of acquired hemophilia as a first manifestation of a lymphoproliferative syndrome.

Background: Splenic marginal zone lymphoma with or without villous lymphocytes (SLVL/SMZL) is an indolent lymphoma that typically affects elderly patients and that has a median survival >10 years. It presents with marked splenomegaly. Treatment is required in symptomatic cases. Splenectomy remains one of the first-line options in patients fit for surgery. The best pharmacological strategy has not yet been identified for poor surgical risk cases. Among different possible chemotherapeutic approaches, purine analogs, alone or in association with Rituximab, seem to be a valid therapeutic choice. Patients and methods: Fifty SMZL patients were treated with Cladribine ± anti-CD20 monoclonal antibody. Results: Forty-seven of 50 patients were evaluable for response. ORR was 87%: 24 of 47 patients (51%) achieved a complete hematological response (CR), 17 of 47 (36%) a partial response (PR) and 6 (13%) resulted unresponsive. Interestingly, 15 of 24 cases (62%) in CR achieved also a molecular remission. After a median follow-up of 48 months, 7 of 41 responsive cases relapsed and the 5-year PFS was 80%. Conclusions: These data confirm the efficacy of this schedule emphasizing the impact of minimal residual disease even in the outcome of SMZL patients.

A 14-year follow-up of 153 haemophilic patients treated with clotted factor concentrates was made to assess liver function. Investigations included measurement of alanine amino transferase (ALT), immunoglobulins, HIV antibody, HBsAg, antibody to HBs and HBc antigens, antibodies to HCV (assayed by ELISA-2 and by RIBA-2) and HCV viraemia assessed by PCR. Assessment of liver function also included liver ultrasound scan and oesophageal X-ray. A positive correlation was found between abnormal liver function and age, HIV infection, HBV infection, HCV infection and hepatomegaly. However, there was no correlation between abnormal liver function and annual clotting factor concentrate use. The increasing incidence of liver insufficiency with increasing age is likely to result in substantial morbidity and mortality amongst haemophilic patients.

The described report deals with the case of a patient with diagnosis of ischemic-hypertensive cardiomyiopathy based on the history of angina and inducible myocardial ischemia with normal coronary arteries. However, after cardiac magnetic resonance, the typical amyloidotic pattern is found and the final diagnosis of multiple myeloma is made at osteomedullary biopsy.

Granulocyte function may be altered after in vivo G-CSF administration and this has been related to both an immaturity of mobilized cells and to a defect in F-actin polymerization. In this paper we show that in resting Filgrastim (non-glycosylated G-CSF)-pulsed cells, F-actin polymerization, membrane-linked RhoA and cell polarization are enhanced compared to those found in resting Lenograstim (glycosylated G-CSF)-cells. The basal hyper-activation of RhoA could be responsible for the morphological and functional modifications of Filgrastim-mobilized cells. Moreover, Filgrastim-mobilized cells, but not Lenograstim-mobilized cells, are unable to correctly respond to LPS stimulation, as demonstrated by minor further RhoA activation and cell elongation.

Aim of the present study was to assess the effect of epirubicin-based chemotherapy on QT interval dispersion in patients with aggressive non-Hodgkin lymphoma (NHL), and the effect of dexrazoxane supplementation. Prolongation of QT dispersion may not only represent a sensitive tool in identifying the first sign of anthracycline-induced cardiotoxicity, but it may serve also in identifying patients who are at risk of arrhythmic events.Twenty untreated patients,or=60 years of age with newly-diagnosed aggressive NHL, eligible for a treatment with epirubicin-based chemotherapy were selected for the study. The patients were randomly allocated in two subgroups (N=10) to receive or not dexrazoxane hydrochloride (400 mg/m(2)) after epirubicin infusion. The patients underwent 12-lead electrocardiogram (ECG) before and after epirubicin infusion and after dexrazoxane supplementation. QT dispersion was defined as the difference between the maximum and the minimum QT interval occurring in any of the 12 ECG leads, corrected (QTc) for heart rate.All the 20 patients showed increased QT dispersion (44.3 +/- 8.4 vs. 68.4+/-11.4 ms, P0.001) and QTc dispersion (46.2 +/- 6.2 vs. 72.2 +/- 8.4, P0.001) after chemotherapy infusion. The 10 patients who underwent supplementation with dexrazoxane exhibited a significant reduction of QT dispersion (67.4 +/- 8.1 vs. 49.5 +/- 4.2 ms, P0.001) and QTc dispersion (71.2 +/- .7 vs. 51.4 +/- 4.3 ms, P0.001), while the 10 patients not supplemented with dexrazoxane did not (QT dispersion: 69.3 +/- 7.6 vs. 64.2 +/- 6.9 ms; QTc dispersion: 72.8 +/- 8.1 vs. 67.3 +/- 7.2 ms, ns).Epirubicin-based chemotherapy causes an early increase of the QT and QTc dispersion, which is attenuated by dexrazoxane supplementation. Therefore, dexrazoxane can reduce the arrhythmic risk in patients treated with epirubicin.

Purine analogues have dramatically improved the outcome of patients affected by hairy cell leukemia (HCL), although complete eradication of disease was achieved in few cases. The purpose of this study was to evaluate the role of Rituximab in eradicating minimal residual disease (MRD) in HCL patients after a pre-treatment with 2-chloro-deoxy-adenosine (2-CdA). Ten patients received four cycles of Rituximab after administration of Cladribrine. Before starting anti-CD20 antibody, two patients were in complete remission, six in partial remission and two showed no significant response to Cladribrine. All cases resulted IgH-positive. Median time from the last 2-CdA infusion was 5.7 months. Eight of 10 patients [four in partial remission (PR), two in complete remission (CR) and two unresponsive after 2-CdA] were evaluable for response. Two months after the end of anti-CD20 therapy, all evaluated patients presented a complete haematological remission. Moreover, Rituximab increased percentage of molecular remission up to 100% 1 yr after the end of treatment. Interestingly, in all cases but one, including those persistently polymerase chain reaction (PCR)-positive, semi-quantitative molecular analyses showed MRD levels lower than those found before Rituximab administration. Toxicity was very mild. The present results not only confirm the therapeutic effect of Rituximab, but also show its relevance in eradicating MRD in HCL.

Splenic Marginal Zone Lymphoma (SMZL) is a rare clinicopathological entity among marginal zone lymphomas. SMZL is an indolent lymphoma usually treated by splenectomy. A subset of patients is characterized by a more aggressive clinical course and poor prognosis. Treatment of these cases and second-line therapy for relapsed patients have not been yet identified. We report 10 cases treated with cladribrine (5 mg/m(2)/week) for six courses. Six patients (60%) achieved partial response, two patients (20%) achieved a complete response and the two remaining patients did not respond and died as a result of progression of the disease. The treatment was well tolerated. A total of 60% of the patients had an overall survival rate of 48 months and 24 months progression-free-survival was achieved by 37% with a median time of progression-free-survival of 17 months. Interestingly, in addition to a relevant percentage of hematological remission, some patients also experienced a molecular remission. We conclude that this treatment is safe and well tolerated and is able to induce a substantial number of responses. Our results suggest that this schedule is well tolerated and could be an useful alternative to splenectomy.

Cladribrine (2-CdA), a purine analogue active on both dividing and resting lymphocytes, plays an important role in the treatment of indolent lymphoproliferative malignancies such as Hairy Cell Leukemia (HCL), Chronic Lymphocytic Leukemia (CLL), Lymphoplasmocytic Lymphoma (LPL), Waldenström's Macroglobulinemia (WM). With the aim of evaluating the efficacy and toxicity of low dose 2-CdA, 15 lymphoplasmocytic lymphoma patients, not eligible for more aggressive or standard therapies, because of age or poor performance status, were treated with the drug at a dose of 5 mg/m2, once a week for six total courses. All patients showed disease progression. Fourteen patients were valuable for response. In eleven out of these 14 (85.7%) disease progression stopped, with 21% having good hematological responses (one CR and two PR). The treatment was generally well tolerated, without serious infectious events. This schedule may be appropriate for the management of patients where the aim of the treatment is control of disease progression.

The front-line therapy for CLL young and fit patients is chemo-immunotherapy with Fludarabine-Cyclophosphamide and Rituximab (FCR). However, around three quarter of the patients with a newly diagnosed CLL are 65 years or older, with approximately 42% being older than 75 years and with age-related comorbidities. FCR regimen results in a significant myelosuppression and high rates of early and late infections. Hence, other less toxic regimens are under evaluation. Recently the German CLL study group reported an interim analysis of the CLL10 trial, who compared FCR vs Bendamustine-Rituximab (BR). The response rates to the 1st-line treatment with BR or FCR were comparable, and BR could be an alternative 1st-line treatment for medically fit pts. Notably, this study showed that pts treated with BR were often older (median 71 vs. 65 yrs; p 7). All patients had an ECOG performance status ranging from 0 to 2. Twenty-nine of 70 patients had Binet stage C, 12 patients were Binet A, 29 Binet B. Thirty-nine patients showed karyotype abnormalities at FISH analysis (data available in 54/70 patients). High risk FISH karyotype according to Dohner´s hierarchical model was detected in 17 patients (14 with del 11q, 3 with del 17p). Ten of them had del(13q14), 12 had trisomy 12 and 15 had normal karyotype. The analysis of the IGHV status, available in 50 patients, showed 25 patients with somatic mutation and 25 patients with germ-line sequences. Zap-70 data were available for 37/70 pts, 19 of them (51.3%) were Zap-70 positive. CD38 was available for 52 patients: it was positive in 27/52 pts (51.9%). (Table 1) A mean number of 5.46 courses of BR were given and the Bendamustine dose was reduced by more than 10% in 39 patients (55,7%). The main reason for dose reduction was haematological toxicities. The ORR rate was 88,6%,with 22 patients (31.4%) obtaining a CR and 40 patients (57,2%) obtaining a PR. Progression Free Survival, Time To Retreatment and Overall Survival rates at 2-years were 79%, 90.3% and 89.6%, respectively. Only the presence of del17 resulted to affect the response rate (p= 0.023) and PFS (p7 | 8/70 pts (11.4%) | | PB lymphocytes | 33.203/mmc | | Binet stage A | 12/70 pts (17.2%) | | Binet stage B | 29/70 pts (41.4%) | | Binet stage C | 29/70 pts (41.4%) | | ZAP70>20% | 19/37 pts (51.3 %) | | CD38> 30% | 27/52 pts (51.9%) | | Beta2microglobulin increased | 51/59 pts (86.4%) | | IgVH homology < 98% | 25/50 pts (50%) | | Normal FISH | 15/54 pts (27.8%) | | del 13q | 10/54 pts (18.5%) | | +12 | 12/54 pts (22.2%) | | del 11q | 14/54 pts (25.9%) | | del 17p | 3/54 pts (5.6%) | | Bulky syndrome | 16/70 pts (22.9%) | Table 1: Patients’ clinical-biological characteristics. PB, peripheral blood; IgVH, immunoglobulin heavy chain variable genes; FISH, Fluorescent In Situ Hybridization. Disclosures No relevant conflicts of interest to declare.

Chronic Lymphocytic Leukemia (B-CLL) is the most prevalent adult leukemia in western countries, with a median age of onset of 65 years. Front-line therapy for B-CLL young patients is chemo-immunotherapy with Fludarabine-Cyclophosphamide and Rituximab (FCR). However, many B-CLL patients are elderly and with comorbidities. FCR regimen can result in a significant myelosuppression and a high rate of early and late infections, suggesting that it may be too toxic and therefore unsuitable for this large subpopulation of patients. Data from the CLL 5 phase III trial of the German CLL study group (GCLLSG) comparing Fludarabine vs Chlorambucil (Chl) in patients older than 65 years showed no differences in overall survival and progression free survival (PFS) between Fludarabine and Chl. Recently, Bendamustine as single agent showed superiority in comparison to Chl in terms of overall response rate (ORR) and PFS, with a good safety profile. Later, the addition of Rituximab (RTX) to Bendamustine (Benda-R) was shown to be efficacious and safe in the same treatment-naïve setting. Insufficient data are available in patients older than 70 years regarding the efficacy and safety, nevertheless increased incidence of extra-hematological toxicity was noted in this subgroup. Here we report our multicentre retrospective study focusing on responses and toxicities rate in elderly patients with B-CLL. We report data on 24 elderly patients with previously untreated B-CLL observed in 7 Italian Centers from November 2000 to June 2012. All patients were treated with a median of 6 cycles of Bendamustine (range, 3-6) at the median dose of 90 mg/m2 (range, 70-90 mg/m2) for 2 consecutive days every 28 days plus RTX (375 mg/m2 for the first course and 500 mg/m2 for subsequent cycles every 28 days). The median number of RTX cycles was 6 (range, 3-6). The mean dose of RTX was 4500 mg (range, 1500-6200 mg). The primary end points were the ORR (complete response CR and partial response PR) and hematological-extrahematological toxicities rate. Twenty male and four female with a median age of 72 years (range, 65-87 years) were included in the study. Only one patient was unfit with a CIRS score of 7. All patients had ECOG less than 2. Two B-CLL patients had A/I progressive stage according Binet and Rai, 10 patients had B/II and 12 patients had C/III or C/IV. The median lymphocytes count at diagnosis was 37.040/mmc (range, 2.200-140.000). FISH analysis was performed in 19/25 patients: 12 patients were classified as standard risk (normal karyotype, del13q14 or +12) and 7 patients as high risk (del11q and del17p). The analysis of the IgVH, available in 12 patients, showed 7 patients with somatic mutation and 5 patients with germ-line sequences. Only one patient was admitted to the hospital and one received reduced bendamustine dose for neutropenia. Fifteen patients received bendamustine at the dosage of 90 mg/m2 while 9 were treated with 70 mg/m2. The ORR rate was 87.5%: ten patients (41.7%) obtained a complete response and eleven patients (45.8%) obtained a partial response. Among biological features the presence of standard risk FISH karyotype showed a statistical significance in terms of better response to therapy (p= 0.013) and progression (p=0.034). Hematological toxicity was recorded in 7 patients (29%) (neutropenia grade III/IV), 5 of them required G-CSF. Extra-hematological toxicity grade I-III was noticed in 8 patients (3 skin reactions, 3 infusion related reactions, 2 nausea and vomiting). At the present only four patients showed a progressive disease with a PFS of 92% at 12 months. Only one unresponsive patient died from Richter disease 6 months after the end of therapy. When we stratified patients in two groups according to the age, we found that patients younger than 75 years (15 patients) showed a better response (p=0.004) and a delayed time to progression (p=0.027) in comparison to patients more than 75 years. Retrospective data from this group of elderly B-CLL patients indicate Benda-R front-line provide a high response rate and a good safety profile. Also in a subgroup of very elderly patients (age > 75 years) the association of bendamustine 90 mg/m2 and rituximab at standard dose is recommended because of a low rate of dose delay/reduction and acceptable hematological/extrahematological toxicities. Disclosures: No relevant conflicts of interest to declare.

Background : Polytransfused patients may be dually infected with hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Objectives : To assess the correlation of antibodies to HCV with viral RNA in serum as determined by polymerase chain reaction (PCR) in anti HIV-positive and -negative haemophiliacs. Study design : Serum from 150 Patients with or without HIV infection were examined for anti-HCV by second generation enzyme-linked immunosorbent assay (ELISA) and recombinant immunoblotting assay (RIBA). A sample was also tested in a nested-reverse transcription PCR for a conserved sequence of the 5′ untranslated region of HCV. PCR-positive specimens were titrated and a type-specific PCR using viral core gene sequences was used to determine distribution of HCV viral types. Results : Eighty-seven percent of the patients were positive in ELISA. All the positives but 2 were either positive of indeterminate in RIBA. The frequency of indeterminate RIBA results was 33% among HIV-positive subjects and less than 1% among HIV-negative ones. PCR was positive in 68% of 73 RIBA-positive or -indeterminate individuals and negative in all HCV-seronegative individuals examined. No significant differences were observed in HCV viral type, prevalence or titers of viraemia between HIV-positive or -negative patients. Conclusions : The majority (68%) of anti-HCV-positive haemophiliacs examined in this study had HCV RNA in their sera and anti-HCV profile determined by RIBA had no apparent influence on viraemia. The presence of HIV infection in these patients had no significant impact on HCV RNA prevalence, titer or HCV type distribution.

Abstract 1662 Poster Board I-688 Introduction Bendamustine is an alkylating agent with a nitrogen mustard group and a purine like benzimidazol group. Recently this drug was introduced in Italy. We analized all pts treated in sixteen haematological Italian centers with Bendamustine alone or in combination with anti-CD20 antibody. Patients and methods On an intention to treat basis pts who have received at least one complete cycle were evaluable for response and toxicity. The treatments consisted of: Bendamustine 60-90 mg/m2 days 1,2 alone or in combination with Rituximab 375 mg/m2 day 0, every 21 or 28 days. 173 pts were analized, median age was 67 (range 31-87), 114 were male, 63 chronic lymphatic leukaemia 41 indolent non-follicular lymphoma, 26 diffuse large B cell lymphoma, 26 follicular lymphoma, 15 mantle cell lymphoma, 2 Peripheral T cell lymphoma. Pts were heavily pretreated, the median number of previous treatments was 3,5 (range 1-8), 121 pts have experienced more than three chemotherapy schemes. One hundred and twenty-seven pts were previously treated with Rituximab and 24 performed an autologous peripheral blood stem cell transplantation. The Bendamustine pre-treatment condition was: 70 relapsed pts, 40 with refractory disease and 63 with a progressive disease after partial response. The median number of Bendamustine cycles was 4.3 (range 1-11). Results All patients were evaluable for response: 48 pts (28%) obtained a complete remission, 78 (45%) a partial response or stable disease with an overall response rate of 73% and 47 were non responders. According to histotype we observed that 10/15 pts (67%) with mantle cell lymphoma obtained a response (6 CR;4 PR), 37/41 (9 CR; 28 PR) indolent non follicular lymphoma and 25/26 (96%) follicular lymphoma obtained a response (12 CR;13 PR), 46/63 CLL obtained a response and 8/26 (31%) DLBCL obtained a response to therapy (4 CR;4 PR), none of the two T lymphoma pts responded to therapy. With a median period of observation of 12 months (1-46) 121 (70%) pts are alive and 83 pts are in complete remission or with stable disease without any other treatment. The overall survival was 82%, 72%, 68% and 27% respectively for indolent, CLL, mantle cell and diffuse large B cell lymphoma. The progression free survival was 31%, 27%, 15% and 10% respectively for indolent, CLL, mantle cell and diffuse large B cell lymphoma. Fifthy-two pts died, 47 for progressive disease, 11 due to infection and sepsis (6%) and 2 due to other causes not related with therapy or disease. In this group of heavily pretreated pts 760 cycles were performed. The extrahematological toxicity was mild the most important problem were infections (Herpes Zooster, pneumonia, enteritis) reported in 16 pts, hepatic in 4 and cardiologic in 2 pts. The hematological toxicity was trombocytopenia grade 3-4 in 20 pts (12%), neutropenia grade 3-4 in 40 pts (23%) and anemia grade 3-4 in 19 pts (11%). Discussion In conclusion this retrospective study shows that treatment with Bendamustine alone or in combination with Rituximab is a safe and efficacy regimen in a subset of pluriresistent patients. This data shows also that the best results could be obtained in indolent lymphoma and CLL incouraging data in mantle cell lymphoma are reported. Disclosures No relevant conflicts of interest to declare.

Introduction: Radioimmunotherapy (RIT) is a new treatment for B non Hodgkin’s lymphoma (NHL) patients. 90Y ibritumomab tiuxetan (Zevalin®) consists of a murine monoclonal antibody to CD20, conjugated to a metal chelator tiuxetan for retention of the beta emitter 90Y. Thus Zevalin® delivers radiation to B-NHL, combining the tumor targeting attributes of a monoclonal antibody and the beta radiation of 90Y. Zevalin® is approved for the treatment of follicular lymphoma (FL) refractory to or relapsed after rituximab, on the bases of clinical trials where it achieved a response rate as high as 83%. Several ongoing registrational trials are evaluating the efficacy of Zevalin® in other NHL, as diffuse large B cell (DLCL) and mantle cell lymphoma (MCL). We are here evaluating the effect of Zevalin® as consolidation therapy in NHL patients that achieved a complete clinical response (CCR) with chemotherapy. Methods: In B cell NHL patients that achieved a CCR after 1st or multiple lines anthracyclines based chemotherapy +/− Rituximab, minimal residual disease was evaluated by PCR on bone marrow samples, for the following rearrangements: JH, Bcl-1, Bcl-2. Patients received Zevalin® 6-9 weeks post chemotherapy. Evaluation of molecular response was assessed after a follow up period at 12 weeks. The aim of the study was the role of Zevalin® in inducing a complete molecular response (CMR). Results: 23 B-NHL patients (13 FL, 6 MCL, 4 DLCL; male:female 13:10, median age 63, range 42–73. See table) in a CCR after chemotherapy (documented by TC scan and/or PET-scan negative for abnormal lesions or glucose captation) have been enrolled. 10 patients had a pathological rearrangement before RIT, while 13 were already in a CMR condition. Zevalin® was completed in all 23 patients and the post infusion evaluation was performed after 12 weeks. In the follow-up period thrombocitopenia was commonly documented, but it was not associated to bleeding or need of platelet transfusion, but in one singular case. After 12 weeks from RIT a new molecular evaluation was performed on bone marrow samples. All the 23 patients have completed the 12 weeks follow-up: 8 of 10 (80%) patients positive before RIT achieved a CMR with Zevalin® administration. The 13 PCR negative patients maintained the CMR. The 21 PCR negative patients are now under follow-up to evaluate the molecular disease free survival after Zevalin® RIT. Conclusion: Zevalin® is an efficient consolidation therapy in B cell NHL patients after chemotherapy. In this series of patients Zevalin® administration allowed to convert 8 of 10 CCR to CMR. In the remaining 13 patients Zevalin® maintained the CMR. Zevalin® addition to medication treatment is feasible and associated with manageable hematological toxicity. Pts disease sex age previous chemotherapy lines molecular response before RIT molecular response after RIT 1 FL M 68 1 POS NEG 2 FL F 53 1 NEG NEG 3 FL M 54 1 NEG NEG 4 FL M 51 4 NEG NEG 5 DLCL F 66 2 POS NEG 6 DLCL F 67 1 NEG NEG 7 FL F 42 1 POS POS 8 FL M 52 1 POS NEG 9 FL F 54 3 NEG NEG 10 FL M 57 2 POS NEG 11 FL F 62 2 POS NEG 12 FL M 58 2 POS NEG 13 FL F 69 2 NEG NEG 14 MCL M 62 1 POS NEG 15 MCL M 66 1 POS POS 16 MCL M 66 2 NEG NEG 17 MCL M 67 1 POS NEG 18 FL F 67 2 NEG NEG 19 DLCL F 67 3 NEG NEG 20 MCL M 70 2 NEG NEG 21 FL M 61 4 NEG NEG 22 DLCL M 43 2 NEG NEG 23 MCL F 73 2 NEG NEG

A patient with copper deficiency and renal failure was suffering from pancytopenia. Marrow examination showed cytoplasmic and nuclear vacuolizations of the erythroid and myeloid series. These abnormalities disappeared after oral copper therapy. Possible mechanisms causing the pancytopenia are discussed. Copper supplementation is needed for patients receiving dietary changes.

Although novel therapies for chronic lymphocytic leukemia have resulted in higher hematologic response rates, the complete eradication of disease rarely occurs. Alemtuzumab (Campath-1H) seems to be extremely effective in this role in pretreated patients. The authors used a molecular semiquantitative polymerase chain reaction (PCR) method to assess the ability of alemtuzumab to induce PCR negativity in eight patients pretreated with fludarabine. IgH rearrangement was coamplified with a housekeeping gene and fluorescent PCR products were analyzed on a DNA automatic sequencer. Each patient was evaluated at diagnosis, after fludarabine, and after Campath-1H. The median interval between the last therapy course with fludarabine and the start of Campath-1H was 14 weeks. Patients received subcutaneous doses up to 10 mg, three times a week, for 12 weeks, with a median dose of 190 mg. After six cycles with fludarabine, only one patient (12.5%) achieved molecular remission, and in three other patients IgH levels decreased by 0.5 to 1 log. At the beginning of Campath-1H administration, all patients were PCR positive, including the one previously found to be negative. At the end of treatment, five patients achieved molecular remission (62.5%), four of them within 1 month after the end of therapy. Seventy-two percent of responses, with 43% of complete responses, were documented on bone marrow smears. A significant reduction of lymph node and spleen diameters was noted in 50% and 33% of patients, respectively. Four patients showed grade 2 skin reaction at the site of the subcutaneous injection and grade 1 or 2 fever. Two patients developed neutropenia (grade 2 and 3) and two hemolytic episodes. Three patients showed cytomegalovirus and one herpes zoster and Epstein-Barr virus reactivation. These results show that Campath-1H represents an efficacious in vivo purging tool with a safe profile.

Patients infected with hepatitis C virus (HCV) were examined with four commercial HCV immunoblotting assays and for anti-GOR antibody to ascertain whether serological findings varied with the genotype of the infecting virus. The results indicate that patients infected with different HCV genotypes tend to show different immunoblotting profiles, mainly due to a low prevalence of antibodies to the viral region NS4 in patients infected with genotypes III and IV. Differences were more evident with second- than with third-generation assays. Patients infected with genotype IV exhibited a lower prevalence of anti-GOR antibody than patients infected with other genotypes.