Valdez, Riccardo

Chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) are essentially different manifestations of the same disease that are similarly managed. A number of molecular and cytogenetic variables with prognostic implications have been identified. Undetectable minimal residual disease at the end of treatment with chemoimmunotherapy or venetoclax-based combination regimens is an independent predictor of improved survival among patients with previously untreated or relapsed/refractory CLL/SLL. The selection of treatment is based on the disease stage, presence or absence of del(17p) or TP53 mutation, immunoglobulin heavy chain variable region mutation status, patient age, performance status, comorbid conditions, and the agent’s toxicity profile. This manuscript discusses the recommendations outlined in the NCCN Guidelines for the diagnosis and management of patients with CLL/SLL.

Abstract Context. —Lymphoepithelial lesions (LELs) are a useful diagnostic feature of extranodal marginal zone B-cell lymphoma (EMZL); however, there is scant literature comparing their frequency and morphology at various sites. Objective. —To evaluate any diagnostically useful, site-specific, morphologic patterns in EMZLs. Design. —In this retrospective review, we evaluated 136 EMZLs from different sites for LEL pattern and other pathologic differences, including CD43 coexpression and plasma cell component features. Results. —Prominent and destructive LELs were most common in salivary and thyroid gland cases, and LELs were rare to absent in breast, skin, and ocular adnexa cases. An LEL pattern with lymphocytes “stuffing” glandular lumina was seen in lung, thyroid, and salivary gland cases. Monoclonal plasma cells were most common in breast, upper aerodigestive tract, skin, and salivary gland cases. CD43 coexpression was seen in 36% of cases, most commonly in salivary gland, stomach, and upper aerodigestive tract. Conclusions. —The relative importance of LEL pattern, CD43 coexpression, and clonal plasma cell component in EMZLs is site-dependent, and the differences may aid in the diagnosis of EMZLs at different anatomic sites.

Abstract Waldenström’s macroglobulinemia (WM) is an incurable low-grade lymphoproliferative disorder characterized by bone marrow (BM) infiltration of a clonal population of small B-lymphocytes, plasmacytoid lymphocytes and plasma cells that secrete monoclonal IgM antibody. Because it is difficult to obtain tumor metaphases for karyotype studies, few recurrent chromosomal abnormalities have been reported and the genetic basis of the disease remains poorly defined. Therefore, we performed a comprehensive high-resolution study to identify genomic abnormalities involved in WM pathogenesis. Fifty-seven WM patients were analyzed using a combination of array-based comparative genomic hybridization (aCGH)(N=42); gene expression profiling (GEP)(N=22), DNA sequencing (N=24) and cIgM-FISH (N=57). Agilent 244A and Affymetrix U133 platforms were used in the aCGH and GEP experiments, respectively. An NF-κB index was calculated from GEP data, as a surrogate marker of NF-κB transcription activity. NFKB2 sub cellular localization was determined by immunofluorescence staining. Overall, 83% of samples have aCGH defined chromosomal abnormalities, with a median of 3 abnormalities per patient (range 0 to 27). We identified 16 recurrent regions of copy number change found in >5% (3 or more patients); 10 deleted and 6 amplified regions. The most common abnormality was the entire or partial deletion of 6q, identified in 40% of cases. Four nonoverlapped minimal deleted regions were identified on 6q (MDR1 to MDR4), each of them being present in at least 14 of 17 patients with the abnormality. Gain of 6p was the second most common abnormality (17%) and its presence was always concomitant with 6q loss. Other recurrent deletions were 13q14 (10%) and 7q22, 8p, 11q22-q23, 11q23-q24 and 17p11-p13 (7% each). Copy gains were identified as partial or entire gains of chromosomes 18 (17%), 4 (12%) and 3 (10%), 8q (10%) and Xq27.1-q28 (10%). Three patients had either homozygous deletions or LOH with mutations affecting both alleles of TRAF3 on 14q32. TRAF3 inactivation was correlated with an increased NF-kB transcriptional signature and it was associated with activation of the non-canonical NFkB pathway. Additionally, we identified the inactivation of TNFAIP3, another negative regulator of the NF-kB pathways, in one of 24 patients. Finally, interstitial deletions identified in 4 patients at 13q14 identified a 1.1 Mb MDR, including MIRN15A and MIRN16-1. These findings confirm that focal 13q14 deletion is not restrict to B-CLL and that the MIRN15A/MIRN16-1 abnormalities might be common to several indolent B-cell diseases. Overall, we identified TRAF3 and TNFAIP3 inactivation in 5.3% and 2.4%, respectively. To our knowledge, this is the first study showing the inactivation of bona fide tumor suppressor genes in WM patients. Furthermore, these genes are negative regulators of NF-kB signaling pathway, highlighting its biologic importance in sustaining and limiting growth in WM. Mutational activation of this pathway, which is normally activated by ligand-receptor interactions within the BM microenvironment, suggest a therapeutic role for inhibitors of NF-KB pathway activation in the treatment of WM.

8053 Background: Lenalidomide (LEN) is an immunomodulatory agent that has shown significant single-agent anti-lymphoma activity in patients with relapsed disease and in combination may enhance the efficacy of rituximab by various mechanisms. There is limited data on the role of LEN in combination regimens for treatment-naïve patients. This phase II single arm trial was designed to evaluate tumor response, toxicity (AE) and survival with a combination of LEN, rituximab, cyclophosphamide (CTX) and dexamethasone (DEX) (LR-CD) in symptomatic untreated patients with low grade B-cell non-Hodgkin lymphoma. Methods: Eligibility required age ≥18, ECOG PS ≤2, confirmed diagnosis of low-grade B-cell lymphoma (FL1-2, SLL, MZL or LPL/WM), measurable nodes ≥2cm or IgM ≥400mg/dL(LPL/WM), ANC ≥1400/mm3, platelets ≥100,000/mm3, creatinine ≤2mg/dL, signed informed consent and in need of therapy. Treatment consisted of IV rituximab 375mg/m2 D1, oral LEN 20mg D1-21, CTX 250mg/m2 D1, 8, 15, DEX 40mg D1, 8, 15, 22 and ASA 325 mg daily in a 28 day cycle. Treatment continued 2 cycles beyond best response (max 12). Toxicity was assessed by NCI CTCAE v3.0. Results: 28 patients have enrolled at Mayo Clinic with 25 evaluable for toxicity and 21 for response: Median age 65(43-83), 72% male, FL 24%, MZL 28%, LPL/WM 38%, and SLL 4%. Median number of cycles given was 5. Overall response in 21 patients with response data is 95% (95% CI 76-100%) with 19% CR (95% CI 5-42%), and 76% PR (confirmed and unconfirmed, 95% CI 53-92%). The ORR in 8 patients with LPL/WM with response data was 88%, all PR (95% CI 47-100%). At a median f/u of 14.7 months 96% are alive without progression. 1 death (unrelated) occurred 7.7 months after completing 12 cycles of treatment. The most common grade ≥3 AEs were neutropenia (37.5%), leukopenia (16.7%), anemia (12.5%) and fatigue (12.5%). Conclusions: The combination LR-CD with the novel agent LEN is feasible, well tolerated and produces high response rates in symptomatic patients with low grade B-cell NHL. Toxicities are manageable and similar to reported data of single agent LEN.

7047 Background: In addition to secondary AML (sAML), important lifestyle and environmental exposures associated with increased risk of AML development have been identified in recent case-control studies including obesity (BMI>30kg/m2), smoking, regular acetaminophen use, and rural/farm habitat. The association of these exposures with AML cytogenetic risk groups is unknown. We therefore evaluated relevant exposures in a cohort of 301 AML patients with confirmed central cytogenetics analysis diagnosed and treated at Mayo Clinic FL and AZ since 1995. Methods: Documented patient exposures were extracted from central electronic medical records, including: prior chemotherapy/radiation or hematologic malignancy, occupation, select medications, “toxins” (esp. benzene) and solid organ transplantation (SOT). Standard cytogenetic risk categories (including intermediate abnormal) were applied. The association of epidemiologic exposures with cytogenetic risk was evaluated on multivariable analysis using logistic regression models. Results: sAML was significantly associated with cytogenetic risk groups, as was prior SOT, healthcare occupation, farm habitat and toxin exposures [see Odds Ratios (OR), Table). In contrast, prior radiation for epithelial malignancies, smoking and BMI were not independently associated with specific cytogenetic risk categories. Conclusions: Specific epidemiologic exposures are significantly associated with AML cytogenetic risk categories suggesting a unique clinical phenotype. This supports a link to leukemogenesis and requires validation in a controlled prospective therapeutic study. [Table: see text]

Abstract Introduction: The clinical phenotype of patients with myeloproliferative neoplasms (MPNs) including primary myelofibrosis (PMF), polycythemia vera (PV), and essential thrombocytosis (ET) who manifest WHO grade 1 (on a 0-3 scale) for intramedullary fibrosis is poorly defined, and may represent MPN patients in a transitional state. We have specifically observed patients with existing PV and ET who manifest clinical progression towards a post PV/ET phenotype (IWG-MRT criteria) yet fail to progress to a 2+ marrow fibrosis. In contrast, the 2008 WHO definition of PMF does not require a minimum fibrosis threshold as long as patients meet the diagnostic criteria. In this study, we retrospectively analyzed the clinical characteristics and outcomes of MPN patients with 1+ marrow fibrosis. Methods: MPN patients with WHO grade 1 (scale 0-3) fibrosis within two institutional databases were identified. The clinical characteristics, laboratory, and outcome data were collected. Data were compared between PMF and PV/ET patients. 2008 IWG-MRT criteria were applied to PV/ET patients with exclusion of fibrosis component. Results: 91 MPN patients with WHO grade 1 fibrosis were identified, PMF in 33 patients (36%), PV in 37 (41%), ET in 20 (22%), and MPN-U in 1 (1%). The population characteristics are reported in Table 1. The majority (56%) of patients exhibited one or more symptoms (weight loss, night sweats, early satiety, bone pain, fatigue). The presence of symptomatic disease was similar between groups, with 52% PMF versus 57% PV/ET exhibiting at least one symptom. Symptoms were more severe in the PMF group with DIPSS risk of intermediate 2 or higher being present in 39%(PMF) versus 29% (PV/ET). Erythrocyte transfusion dependence occurred in a small percentage of overall population (9%), and was seen primarily in the PMF group (6/8 patients). Incidence and severity of splenomegaly was higher in the PMF group, with 55% having splenomegaly versus 43% of the PV/ET group. A higher incidence of a leukoerythoblastic blood smears was seen in PMF (45%) than PV/ET (38%). Two or more prior medical therapies were utilized in 45/90 (49%) of patients, with the most common prior therapies including hydroxyurea (71%), pegylated interferon (28%), anagrelide (18%), Jak inhibitor (13%), lenalidomide (4%), and prednisone (4%). At the time of this analysis, 78/91 patients (86%) were alive. When IWG-MRT criteria were applied to the PV/ET group, 38/58 (66%) of patients fulfilled criteria for diagnosis of post-PV/ET myelofibrosis (except for the 2+fibrosis requirement). Table 1 Patient characteristics UPN Age (yrs) Sex System Risk Activity Tx BRAFV600E (%) 1 56 F Multi High Inactive Yes 0 2 38 F Single High Inactive Yes 0 3 65 F Multi High Active Yes 2.59 4 48 M Single High Inactive Yes 0 5 41 F Single High Inactive Yes 0 6 28 M Multi High Inactive Yes 0 7 29 M Multi High Active No 1.00 8 47 F Multi High Active Yes 6.16 Discussion and Conclusion: PV and ET patients with WHO grade 1 marrow fibrosis manifest a phenotype that suggests progression to post-PV/ET myelofibrosis, and clinically overlap with PMF phenotype; however, these patients currently fail to meet 2008 IWG-MRT diagnostic criteria for this diagnosis on basis of sub-threshold fibrosis. MPN progression represents a biological spectrum and definitions of progression in ET/PV may benefit from other criteria not restricted by degree of fibrosis. Disclosures Mesa: Incyte, CTI, NS pharma, Gilead, Celgene: Research Funding.

Abstract Abstract 5093 A relative increase in proliferation is now accepted as the most important measure in risk stratification of myeloma. Attempts to include measures of proliferation in different stratification strategies have been met with obstacles largely influenced by their practicality and economic viability in the clinical setting. The plasma cell labelling index (PCLI) is the gold standard used in myeloma; however it is still only used in a minority of centers across the globe. New surrogate markers of proliferation, such as serum biomarkers and transcription-based methods, are under investigation but few have evolved to become part of a uniform strategy in the stratification of myeloma. The gene-expression based proliferation indices (gPI) described by Bergsagel et al, Shaughnessy et al and Hose et al all show similar correlation with PCLI. Studies comparing all currently available methods are lacking. In a cohort of 70 patients, PCLI and gPI were compared with two immunohistochemistry-based methods of measuring proliferation, Ki67 and a more specific measure of S-phase entry – phosphorylation of minichromosome maintenance protein 2 (pMcm2) at serine 40/41, combined with dual staining of CD138. We observed a similar correlation of gPI wth PCLI to that previously reported (r value; CI – 0.43;0.21–0.61). Both Ki67 and pMcm2 staining showed a stronger correlation with PCLI than with gPI and PCLI (r value; CI – 0.81;0.71–0.88 and 0.86; 0.78 – 0.91 respectively). PCLI and gPI have already been shown to be an independent predictor of time to progression and overall survival. Although this sample size was too small to test for time to progression or overall survival and thus independence, a logical extrapolation would indicate similar independence and predictions on survival and time to progression. As Ki67 is routinely used for more proliferative cancers in the clinic, the extension of its use as part of a new stratification system in myeloma provides interesting possibilities for further exploration. Disclosures: O'Dwyer: Novartis: Honoraria, Research Funding.

Abstract Primary central nervous system lymphoma (PCNSL) is an aggressive and incurable variant of non-Hodgkin lymphoma (NHL) that is confined to the central nervous system. Most PCNSL (90%) are part of the immune-privileged site-associated diffuse large B-cell lymphomas (DLBCL). Unlike nodal DLBCL, only a limited number of genetic studies have been performed in PCNSL, partly due to lack of available tissue specimens. Because of the fragmented knowledge of the genomic basis, it is still a matter of debate whether they differ from systemic DLBCL with respect to their molecular features and pathogenesis and also if there is a CNS specific signature. We performed a comprehensive genomic study in a cohort of 22 immunocompetent (HIV- and EBV-) PCNSL. DNA was extracted from FFPE tissues (N=15) and frozen tissue (N=7). Samples were analyzed using a combination of aCGH (N=18), exome sequencing (N=10), mate-pair genome sequencing (N=2) and targeted sequencing (N=8). We found a complex karyotype with a median of 21 copy-number abnormalities (range 10–47), 6 structural abnormalities, 6 frameshift indels and 67 nonsynonymous mutations. By integrating mutation and copy number data we found a group of genes recurrently mutated and/or deleted in PNCSL. Remarkable findings were the high prevalence of MYD88 activating mutations (L265P/M232T/V217F), found in 69% of cases and the biallelic loss of CDKN2A (60%). A subset of recurrent abnormalities was exclusively found in PCNSL, and not being previously identified in systemic DLBCL. Thus, 11% of PCNSL have biallelic inactivation of TOX (a regulator of T-cell development) and PRKCD (protein kinase C delta), while another 17% of cases show focal monoallelic deletions/mutations in these genes. Finally, recurrent mutations have been identified in ATM, which have not been found in nodal DLBCL. Several other genes affected have been previously identified in nodal DLBCL, such as biallelic loss of TNFAIP3 (16%), PRDM1 (16%), GNA13, TMEM30A, B2M and CD58 (11% each), activating mutations of CD79B (28%) and CARD11 (19%) and translocations of BCL6 (22%). Components of the NF-kB pathways were altered in >90% of PNCSL. Pathway analysis also showed an enrichment of networks associated with immune response, proliferation, regulation of apoptosis and lymphocyte differentiation and activation. Finally, we searched for associations between genetic alterations and clinical outcome. We showed that deletions of 6q21 (PRDM1) and 6q23 (TNFAIP3) were both associated with shorter overall survival (p=0.007 and p=0.03, respectively). In summary, we report a genomic background in PCNSL similar to post-GC DLBCL but reinforcing the existence of a subset of abnormalities specific to PCNSL, suggesting their potential relevance in the disease pathogenesis. Additionally, the results obtained from FFPE samples are encouraging and larger archival tissue collections can now be analyzed in order to complement the still fragmented knowledge we have of the genetic basis of the disease. Disclosures: Stewart: Onyx: Consultancy, Research Funding; Millenium: Honoraria, Research Funding; Celgene: Honoraria; BMS: Honoraria. Fonseca:Medtronic: Consultancy; Otsuka: Consultancy; Celgene: Consultancy; Genzyme: Consultancy; BMS: Consultancy; Lilly: Consultancy; Onyx: Consultancy, Research Funding; Binding Site: Consultancy; Millennium: Consultancy; AMGEN: Consultancy; Cylene: Research Funding; Prognostication of MM based on genetic categorization of the disease: Patents & Royalties.

Abstract Abstract 4743 Background: BMBX procedures are traditionally performed by physicians, NPs, or PAs using a manual method. It is uncommon for nurses to perform these procedures, and even more rare for nurses to perform them using non-traditional techniques, such as the battery-powered system (OnControl, Vidacare, Shavano, TX). In this study, we report our nurse-led BMBX team experience using OnControl to collect diagnostic BMBX samples. Patient care and safety, team satisfaction, and specimen quality were evaluated. Methods: A team of nurses trained to perform BMBX procedures on sedated and non-sedated patients completed 94 procedures using OnControl and established SOPs. All nurses completed a questionnaire aimed at assessing the patient experience during and after the procedure and overall nurse satisfaction with OnControl. Specimen quality was graded by 3 physicians and compared to 25 specimens obtained by the same nursing team using traditional methods. Bone core specimens were graded based on core length and the presence/absence of artifacts. Biopsies had to be >1 cm or >1.5 cm to qualify good or excellent, respectively. Aspirates were similarly evaluated taking into account the presence/absence of spicules on stained smears. Results: Patient Care & Safety: The majority (86.2%) of patients who underwent a BMBX procedure during the study were outpatients, and minimal sedation was used in 94.7%. Most patients (76.6%) had a prior BMBX using the traditional method. In 94 patients evaluated, pre-procedure pain was 0 (0-10 scale) in 72 (76.5%) while 21 (22.3%) reported pain up to 5 just before the procedure (avg=2). The post-procedure pain score in the same patients was 0 in 78 (83%) and up to 4 in six (6%) (avg=1). No patients had post-procedure bleeding or complications requiring medical care. Seventy patients were reached 24 hrs post-procedure: 33 (47%) reported no pain and 37 (53%) reported pain up to 8 (avg=2.5). Nurse BMBX Team Satisfaction: Team members reported 100% satisfaction with the process of inserting the OnControl biopsy needle through soft tissues and acquiring a core biopsy. The nurses reported having satisfactory control of the depth of needle through the cortex and into the medullary space using the needle guide 95% of the time. Team members were satisfied with the ease of obtaining an aspirate 93% of the time. Nearly all (95%) nurses felt improved ergonomics using the battery-powered driver compared to the manual method. The nurses reported that OnControl was easy to use, with 83% of them obtaining a core biopsy on their first attempt. All nurses indicated they would use OnControl over the manual method if given the choice. Specimen Quality: H&E-stained bone core biopsy slides and W-G-stained aspirate smears from 83/94 specimens collected using OnControl were reviewed and graded. All but two (2.4%) of the bone core specimens were adequate for diagnosis. Of adequate samples, 45.8% were excellent, 12% good, and 39.8% fair. Aspiration artifact was seen in 18/83 (21.6%) of cores, and that artifact was the reason for a downgrade to fair quality in 17/18 (94%). Extra aspirate material for research was collected in 7/18 with fair quality bone core biopsies. Similar grading applied to 25 core biopsy samples collected using the manual method revealed 44% of cores to be excellent, 20% good, 32% fair, and 4% poor. The average core length using OnControl and the traditional method was 1.6 cm and 1.7 cm, respectively. Five of 83 (6%) aspirates obtained using OnControl were poor quality due to lack of bone marrow cells. Of the remaining aspirates, 54.2% were excellent, 20.5% good, and 19.2% fair. Factors related to bedside technique caused a downgrade in 10/16 samples graded as fair and 5/17 samples graded as good. Aspirates obtained by the standard method were graded as 52% excellent, 28% good, 12% fair, and 8% poor. Conclusions: Trained nurses can safely and effectively perform BMBX procedures using traditional methods as well as novel techniques such as the OnControl battery-powered driver system. In the hands of experienced individuals, OnControl can consistently yield high-quality BMBX specimens. Aspiration artifact was the most common flaw found in bone cores obtained with OnControl, but it was usually focal and did not hinder interpretation. When artifact associated with technical aspects out of the control of the BMBX operator was excluded, the OnControl needle produced good-excellent aspirate in 87% of patients. Disclosures: No relevant conflicts of interest to declare.

Abstract Abstract 2741 Background: The novel agent lenalidomide (LEN) has shown significant single-agent activity in patients with relapsed lymphoma through anti-proliferative and immunomodulatory mechanisms. In combination LEN may synergistically improve the efficacy of rituximab. However, there is limited data on the efficacy and safety of LEN in multi-drug combination regimens for treatment-naïve patients. We designed a phase II single arm trial to evaluate tumor response, toxicity (AE) and survival with a combination of LEN, rituximab, cyclophosphamide (CTX) and dexamethasone (DEX) (LR-CD) in symptomatic untreated patients with indolent B-cell lymphoma. (NCT00784927). Methods: Eligibility required age ≥18, ECOG PS ≤2, confirmed diagnosis of indolent B-cell lymphoma (FL1–2, SLL, MZL or LPL/WM), measurable nodes ≥2cm or IgM ≥400mg/dL (LPL/WM), ANC ≥1400/mm3, platelets ≥100,000/mm3, creatinine ≤2mg/dL, and signed informed consent. Only patients needing therapy were considered eligible. Treatment consisted of IV rituximab 375mg/m2 D1, oral LEN 20mg D1–21, CTX 250mg/m2 D1, 8, 15, DEX 40mg D1, 8, 15, 22 and ASA 325 mg daily in a 28 day cycle. Treatment continued 2 cycles beyond best response up to a maximum of 12 cycles. Toxicity was assessed by NCI CTCAE v3.0. Results: Thirty-one patients have enrolled at Mayo Clinic with 28 evaluable for toxicity and response (1 deemed ineligible, 1 withdrew before treatment, 1 treatment violation). Four patients continue on study at this time. Patient characteristics: median age 68.5(43–83), 71% male, stage IV 86%, FL 28%, MZL 25%, LPL/WM 39%, and SLL 4%. Median number of cycles given was 6 and 71% completed the study per protocol. The best overall response is 89% with 32% CR and 57% PR. In subgroup analysis, the response rates for LPL/WM was 91% (all PR) and for FL 88% (CR 63%, PR 25%). The most common grade ≥3 AEs were neutropenia (35.7%), leukopenia (17.8%), anemia (14.3%) and thrombosis (14.3%). The LPL/WM subgroup experienced more grade ≥3 anemia (36%) compared to the group as a whole. Patients (57%) required at least one dose reduction of LEN (n =10), CTX (n = 9) or DEX (n = 7). At a median f/u of 14.5 (1.8–36.5) months 86% are progression free (fig. 1) and the OS is 96% (fig. 2). One death unrelated to treatment occurred 7.7 months after completing 12 cycles of treatment. Conclusion: Lenalidomide can be safely combined with other active agents and in the combination LR-CD produces high response rates in symptomatic patients with indolent B-cell lymphoma. The regimen is well tolerated with manageable toxicities which are similar to that seen with single agent LEN. The encouraging results seen in patients with LPL/WM have led to expansion of this cohort for additional study. Disclosures: Reeder: Celgene: Research Funding. Off Label Use: lenalidomide use in non-Hodgkin lymphoma. Stewart:Celgene: Consultancy, Honoraria.