Sézary syndrome (SS) is a rare and aggressive T-cell lymphoma with a poor prognosis in advanced stages. Allogeneic hematopoietic cell transplantation (allo-HCT) offers a potential cure, but complications such as graft-versus-host disease (GvHD) remain a clinical challenge.Mogamulizumab, a humanized anti-CC chemokine receptor 4 (CCR4) antibody, is sometimes used as a bridge to transplantation, but its potential interactions with allo-HCT are unclear. This report describes the case of a 37-year-old man with advanced SS who received mogamulizumab therapy followed by allo-HSCT from an HLA-identical sibling donor. The patient developed severe gastrointestinal acute GvHD, which was treated with steroids and infliximab. However, the condition rapidly progressed to severe intestinal symptoms and life-threatening haemorrhagic shock, ultimately resulting in the patient's death. This case highlights a potential link between mogamulizumab and severe acute GvHD promoted by drug-induced suppression of regulatory T cells. Further research is required to fully understand the interaction between mogamulizumab and allo-HCT and to determine whether it is an optimal approach as a bridge to transplant therapy. This paradigmatic case suggests the need of personalizing transplant strategies by selecting appropriate conditioning therapy and GvHD prophylaxis to minimize potential toxicity.

Background: JACIE (Joint Accreditation Committee ISCTEurope & EBMT) standards define continuous training as a requirement for nurses working in accredited transplant units. Obtaining continuous education can be difficult, so our center decided to implement their own accredited training course. Since 2008 a specific training course, accredited by regular authorities, free of charges in the workplace and held by staff nurses, has been organized. Through all these years, the structure has been modified according to the needs and opinions of the attending nurses. Currently, it consisted of 10 sessions that take place through the year;each session was held at two or three different times (depending on the availability of the speaker), and so nurses from all shifts could attend. At the beginning of the pandemic caused by SARS-COVID 2, in March 2020, we had to suspend the program and reconsider how we could maintain the educational sessions. Methods: From June to November we reinitiated the course. Now, several options were offered to participate: (a) in person, since in our country meetings were restricted to ten people, with previous registration required, (b) synchronously through the Zoom platform, and (c) deferred, as all sessions were recorded so nurses were able to access through the internal training platform of our center. To justify attendance and get the accreditation, when the session was viewed in a delayed manner through the platform, three questions about the viewed session were required to be answered. The course has been accredited by our national system of accreditation. Results: 91 nurses participated in the course. 63.8% of the attendance was virtual. At the end of the course, a satisfaction survey was carried out among the participants. The average score of the questions was 9,25. The lowest score was 8,57 and, the highest, 9,53. There was also a final question in an open format to make comments and suggestions for future editions. Conclusions: Offering quality and up-to-date training to nurses in hematological transplantation wards is one of the JACIE's standards that sometimes is difficult to achieve due to the difficulty of combining nursing schedules and shifts, and the lack of economic resources. The appearance of the pandemic has been an added challenge in order to be able to maintain continuous training as it was established in our center. It was not easy initially to organize it, but it helped us that our center already had a training platform, the availability of online streaming platforms and our background in offering training courses. The high participation and satisfaction of the attendance nurses encourage us to explore and continue new training formats for highly specialized nurses.

The introduction of agents inhibiting the BCR-associated kinases such as ibrutinib has dramatically changed treatments algorithms of chronic lymphocytic leukaemia (CLL) as well as the role of different adverse prognosticators. We evaluated the efficacy of ibrutinib as single agent, in a real-life context, on 180 patients with CLL mostly pre-treated, recruited from three independent cohorts from Italy. Patients received 420 mg oral ibrutinib once daily until progression or occurrence of unacceptable side effects. Seventy-three patients discontinued ibrutinib for progression or for adverse events. NOTCH1 mutations (M) were correlated with a reduced redistribution lymphocytosis, calculated at 3 months on ibrutinib (p=0.022). Moreover, NOTCH1 mutated patients showed inferior nodal response at 6 months on ibrutinib compared to NOTCH1 wild type patients (p<0.0001). Significant shorter progression free survival (PFS) and overall survival (OS) were observed in NOTCH1 mutated patients (p=0.00002 and p=0.001). Interestingly, NOTCH1 M plus lower bax/bcl-2 ratio identified a CLL subset showing the worst PFS and OS (p=0.0002 and p=0.005). In multivariate analysis of PFS and OS, NOTCH1 M were confirmed an independent prognosticator (p=0.00006 and p=0.0039). In conclusion, NOTCH1 M are strongly associated with lower bax/bcl-2 ratio, consistent with a defective apoptosis, lower redistribution lymphocytosis and lower nodal shrinkage under ibrutinib treatment, this last responsible for partial responses, subsequent relapses, shorter PFS and OS. The therapeutic options for NOTCH1 mutated patients could be represented by either new small molecules combination approaches or from antibodies targeting NOTCH1.

Background CD69 is expressed in several hemopoietic cells and is an early activation marker in chronic lymphocytic leukemia. Chronic lymphocytic leukemia is a clinically heterogeneous disease which needs novel prognostic parameters which can be easily and efficiently managed. Design and Methods We investigated CD69 by flow cytometry in a series of 417 patients affected by chronic lymphocytic leukemia and compared this to other biological and clinical prognosticators. Results CD69 was associated with Rai stages (P=0.00002), β2-microglobulin (P=0.0005) and soluble CD23 (P<0.0001). CD69 and ZAP-70 (P=0.018) or CD38 (P=0.00015) or immunoglobulin variable heavy chain gene mutations (P=0.0005) were also significantly correlated. Clinically, CD69 positive chronic lymphocytic leukemias received chemotherapy more frequently (74%; P<0.0001), and presented a shorter duration of response after fludarabine plus rituximab (P=0.010) as well as shorter progression free survival and overall survival (P<0.0001). CD69 demonstrated true additive prognostic properties, since the CD69+ plus ZAP-70+ or CD38+ or immunoglobulin variable heavy chain gene unmutated patients had the worst progression free survival and overall survival (P<0.0001). Interestingly, low CD69 expression was necessary to correctly prognosticate the longer progression free survival of patients with a low tumor burden of β2-microglobulin (P=0.002), of soluble CD23 (P=0.020), or of Rai stages 0-I (P=0.005). CD69 was confirmed to be an independent prognostic factor in multivariate analysis of progression free survival (P=0.017) and overall survival (P=0.039). Conclusions Our data indicate that CD69 is significantly correlated with poor clinical and biological prognostic factors and is confirmed to be an independent disease prognosticator. This supports its introduction in a routine laboratory assessment and, possibly, in a prognostic scoring system for chronic lymphocytic leukemia, after an adequate standardization process.

Abstract Abstract 2870 Chronic lymphocytic leukemia (CLL) is a very heterogeneous disease ranging from rapid disease progression leading to death to a nearly normal life expectancy and therefore it is mandatory to find valid prognostic markers. Recent studies showed that activating mutations of NOTCH1 proto-oncogene occur in about 10% CLL at diagnosis and are associated with an unfavorable clinical outcome (Rossi et al, 2012). About 85% of NOTCH1 mutated CLL cases displayed a DCT7544–7545 frameshift deletion (hereafter NOTCH1 mutation), that has been demonstrated to predict NOTCH1 degradation impairment through the truncation of the C-terminal PEST domain. Given the possibility of targeting NOTCH1 with drugs currently under development, the primary endpoints of our research were: 1) to correlate NOTCH1 mutation with other clinical and biological prognostic factors; 2) to determine time to first treatment (TTFT) and overall survival (OS) upon NOTCH1 mutation in univariate analysis; 3) to validate NOTCH1 mutation as an independent prognostic factor. We investigated 463 pts, median age 65 years (range 33–89), 256 males and 207 females. With regard to modified Rai stages at diagnosis, 159 had a low stage, 290 an intermediate stage and 14 a high stage. NOTCH1 mutation was investigated by amplification refractory mutation system (ARMS) PCR at diagnosis or before any chemotherapeutic approach. The ARMS PCR approach was set up in order to identify NOTCH1 mutation when present in at least 10% of the alleles. Using this approach, NOTCH1 mutated pts were 45/463 (9.7%). Considering the association with markers of tumor burden and proliferation, NOTCH1 mutation correlated with intermediate/high Rai stages (37/45; P=0.002), multiple thoracic/abdominal lymphadenopathies and/or splenomegaly (26/45, P=0.003), beta-2 microglobulin >2.2 mg/ml (27/45; P=0.02), lymphocyte doubling time <12 months (19/45; P=0.0006) and soluble CD23>70 U/ml (26/39; P=0.00001). Significant associations were also found with the main biologic prognostic markers in CLL. In this regard, NOTCH1 mutation was associated with an unmutated IGHV status (available for 446 total cases, 30/43; P<0.0001), CD38>30% (26/45, P<0.0001), ZAP-70>20% (33/45; P<0.0001), and CD49d>30% (22/34; P=0.009). Finally, considering associations with specific chromosomal aberrations defined by FISH cytogenetics (available in 417 cases), significant correlations (P=0.003) were found between NOTCH1 mutation and trisomy 12 (14/41; 25%), and del11q (7/41;16% ), whereas only 2/43 NOTCH1 mutated cases presented 17p deletion. With regard to clinical outcome, 30/45 (67%) NOTCH1 mutated pts received chemotherapy vs 193/418 (46%) among NOTCH1 germ line CLL (P=0.01), with 15/45 (33%) vs 48/418 (11%) cases, belonging to the same subgroups, undergoing at least two lines of treatment (P=0.001). Moreover, both significant shorter TTFT and OS were observed in NOTCH1 mutated pts (7% vs 35% at 12 years, P=0.0006 and 34% vs 78% at 14 years, P<0.0001; Figures A, B). To further test the clinical value of NOTCH1 mutation in CLL, we investigated its prognostic impact in bivariate analyses with the main clinical/biological prognosticators. According to these analyses, pts with NOTCH1 mutation showed shorter OS both within the ZAP-70 positive (>20%, 188 pts) and unmutated IGHV (<2%, 144 pts) subsets (24% vs 50% at 14 years; P=0.006, and 18% vs 52% at 14 years, P=0.04, respectively; Figures C, D). In multivariate analysis of OS, NOTCH1 mutation (P=0.02) together with age (P=0.001), FISH cytogenetics (P=0.001) and CD38 (P=0.002) was confirmed to be an independent prognostic factor, after correcting for colinearity with IGHV status. Therefore, NOTCH1 mutation, as determined by ARMS PCR, is a novel important prognostic parameter in CLL to be considered in drawing prognostic scores. In addition, NOTCH1 might represent a commendable therapeutic target for specific inhibitors to be employed especially in NOTCH1 mutated CLL. Disclosures: No relevant conflicts of interest to declare.

Dear Sir, High-dose chemotherapy, with or without radiotherapy, followed by autologous haematopoietic stem cell transplantation (HSCT), has a key role in the treatment of haematological malignancies. Granulocyte colony-stimulating factor (G-CSF) seems to reduce the duration of neutropenia and related infectious complications, although recent data1 have challenged some of the evidence of the previously reported advantage of G-CSF use in this setting. Pegylated filgrastim (Peg-G-CSF) has been shown to be as safe and as effective as daily filgrastim or lenograstim (daily-G-CSF) for mobilisation of progenitor cells from the bone marrow into the peripheral blood and for the management of standard chemotherapy-induced neutropenia, as well as high-dose chemotherapy followed by autologous2,3 or allogeneic HSCT4; however, a recent paper by Romeo et al.5, while presenting the comparison between different lenograstim doses for peripheral blood progenitor mobilisation with regards to both target CD34+ cell dose and autologous HSCT outcome, mentioned a delay in platelet recovery after Peg-G-CSF-stimulated transplantation compared with lenograstim-stimulated transplanation. We started to use Peg-G-CSF in our centre in October 2004 and an initial analysis in October 2006, published in the form of Poster at the 2007 Italian Society of Haematology (SIE) annual congress, revealed a delay in platelet recovery among 17 Peg-G-CSF- treated patients when compared with a matched historical control group treated with daily G-CSF (median day for platelet recovery >20 ×109/L: day +12 versus day +15 for patients treated with daily-G-CSF and Peg-G-CSF, respectively; p=0.03). Nevertheless, starting from January 2008, patients undergoing high-dose chemotherapy and autologous HSCT were assigned to receive either Peg-G-CSF (6 mg sc day +6) or daily-G-CSF (5 mg/kg/day sc or iv also starting on day +6). From January 2008 to August 2010, 49 patients were treated. Their median age was 58 years (range, 21–69 years). The diagnosis was non-Hodgkin's lymphoma in 14 patients, Hodgkin's lymphoma in 6 patients and multiple myeloma in 29. The median dose of infused CD34+ cells was 4.2×106/kg, collected after mobilization with chemotherapy (IEV, IGEV, DHAP, CTX) and daily-G-CSF. The conditioning regimen was BEAM in 19 patients, high-dose melphalan in 24 and other regimens in the remaining 6 patients. The groups of patients receiving Peg-G-CSF or daily G-CSF were matched for sex, age, diagnosis, state at transplantation, conditioning regimen and infused CD34+ cell dose. No differences were found between the two groups with regards to median time to reach an absolute neutrophil count greater than 0.5×109/L, platelet count greater than 20×109/L or platelet count greater than 50×109/L (Table I). Transfusion requirements, episodes of infection, duration of antibacterial or antifungal therapy and time to discharge were similar in the two groups. Table I Engraftment after autologous HSCT in the two groups of patients. These data, although limited, suggest that both Peg-G-CSF and daily G-CSF can support haematopoiesis after autologous HSCT with similar engraftment outcomes. A delay in platelet reconstitution, as reported from our preliminary experience and in the paper by Romeo et al.5, was not confirmed. Larger, randomised studies are needed to definitely detect the hypothesised differences between the outcomes of the two approaches.

Background: The cardiac left ventricle responds to pressure overloads with mechanisms culminating in irreversible structural/functional cardiac alterations (left ventricular hypertrophy and/or diastolic dysfunction), inducing myocardial cells to secrete natriuretic peptides (NT-proBNP) antagonists of the renin-angiotensin-aldosterone system. The aim of this study was to evaluate the diagnostic accuracy of serum NT-proBNP levels in order to detect structural/functional cardiac diseases assessed by echocardiography.Methods: A total of 126 consecutive newly diagnosed, never before treated, hypertensive patients (30-67 years) were enrolled, and clinical, echocardiography parameters and biochemical data were collected. Our reference was the presence of structural/functional cardiac disease (CSFD) and our index text was the serum NT-proBNP levels.Results: NT-proBNP levels in CSFD patients were -2 times higher than in non-CSFD subjects (median 61 vs 29 ng/L, n=50 and 76, respectively); in addition, 60% of CSFD subjects (only 14% of which with pathological levels, >125 ng/L), and 30% without CSFD showed NT-proBNP concentrations higher than 50 ng/L. However. ROC curves demonstrated a low specificity (38%) (calculated at 90% sensitivity at a cut-off of 22.5 ng/L).Discussion: NT-proBNP levels, as a screening tool for cardiac structural/functional disease, appear to be limited, because of the low specificity. However, the strong association between its concentration and the establishment of irreversible cardiac hypertrophy prompts successive studies aimed to ascertain the use of its serum levels as an early alert indicator of disease severity. (C) 2011 Elsevier B.V. All rights reserved.

Mucormycosis is a relatively rare, opportunistic, invasive infection caused by various members of the Phycomycetes class [from Greek phyko- seaweed; having a plant body], an extensive taxonomy introduced in 1956 to enlarge the class of Zygomycetes. These filamentous fungi have a worldwide distribution and are capable of rapid growth and thermotolerance of human body temperature. Infection typically occurs in seriously compromised patients (i.e. diabetic ketoacidosis, hematologic malignancies, immunosuppressive disorders, end-stage renal disease, solid-organ or bone-marrow transplantation) and can be acute or fulminant, as well as indolent and chronic. In this paper we describe a case of cutaneous mucormycosis that occurred in a 54-year-old diabetic woman and evolved into a disseminated form, leading to an uncommon spinal cord infarction and consequent paraparesis. Our case suggests the importance of suspecting a mucormycosis infection in patients with decompensated diabetes mellitus, even without ketoacidosis.

In chronic lymphocytic leukemia (CLL), inhibition of spontaneous apoptosis determines a worse prognosis and increasing evidences show that disease progression relies also upon cycling CLL cells. We investigated bcl-2, as measure of apoptosis, and CD71, as measure of proliferation, by flow cytometry in 265 patients with CLL. Combining bcl-2 with CD71 values, we defined three subgroups: (1) bcl2 - CD71-; (2) bcl2 + CD71+; and (3) bcl2 + CD71- or bcl2- CD71+. Both a shorter progression-free survival (PFS) and overall survival (OS) were observed in ZAP-70+ (p < 0.00001) and in patients with bcl2 + CD71+ (p < 0.00001 and p = 0.02). The patients with discordant in bcl2 + CD71- and bcl2- CD71+ showed an intermediate outcome. Noteworthy, patients with bcl2 + CD71+ showed a shorter PFS within ZAP-70 negative subgroup (p = 0.00009). In multivariate analysis of PFS, age (p = 0.005), beta-(2) microglobulin (B(2)-M) (p = 0.003), bcl-2 (p = 0.004), CD49d (p = 0.001), and ZAP-70 (p < 0.001) resulted to be significant prognostic factors. The independent prognostic significance of B(2)-M (p = 0.009) and bcl-2 (p = 0.03) was confirmed within ZAP-70 negative patients. Bcl-2 and CD71 can be considered as interesting progression indicators, which should be validated in an independent cohort of patients, to take timely therapeutic decisions in CLL.

The unbalance between anti-apoptotic (bcl-2) and pro-apoptotic mitochondrial proteins (bax) represents a critical mechanism explaining the high rate of resistance and treatment failure in acute myeloid leukemia (AML) (Del Poeta, 2003). Moreover, the availability of novel and effective pro-apoptotic compounds such as bortezomib (Attar, 2008) and gemtuzumab (Del Poeta, 2008) moved us to widely investigate the impact of mitochondrial proteins such as bcl-2, bax and 7A6 on AML prognosis. 7A6 antigen has been found to be exposed on the mitochondrial membrane during the early stages of apoptosis and is recognized by monoclonal antibody APO2.7. For this purpose, a large series of 420 non M3 AML patients (pts), median age 63 years, treated with intensive chemotherapy regimens, were tested. The aims of our research were:

The clinical course of B-cell chronic lymphocytic leukemia (B-CLL) is variable, and novel biologic parameters need to be added to the clinical staging systems to predict an indolent or aggressive outcome. We investigated the 70-kDa zeta-associated protein (ZAP-70), CD38, soluble CD23 (sCD23), and cytogenetics in 289 patients with B-CLL. Both a shorter progression-free survival (PFS) and overall survival (OS) were observed in ZAP-70(+) (P < .001), in CD38(+) (P < .001) and in sCD23(+) patients (P < .001 and P = .013, respectively). ZAP-70(+)CD38(+) or ZAP-70(+) patients with an unmutated IgV(H) status showed both a shorter PFS (P < .001) and OS (P < .001 and P < .001, respectively) as compared with ZAP-70(-)/CD38(-) or ZAP-70(-) patients with mutated IgV(H) genes. Discordant patients showed an intermediate outcome. Note, ZAP-70(+) patients even if CD38(-) or mutated showed a shorter PFS, whereas ZAP-70(-) patients even if CD38(+) or unmutated had a longer PFS. Furthermore, ZAP-70 positivity was associated with a shorter PFS both within normal karyotype (P < .001) and within the poor-risk cytogenetic subset (P = .02). The predictive value of ZAP-70 expression was confirmed in multivariate analysis. Thus, ZAP-70 protein determined by flow cytometry improves the prognostic significance of cytogenetics and appears to be a better predictor of outcomes than IgV(H) gene mutational status. On this line, we recommend and are also interested in conducting a prospective randomized trial of early intervention versus observation for ZAP-70(+) patients.

New genetic evidence strongly supports a role for the immune system in the pathogenesis of essential hypertension (EH) through chemokines and their receptors (CCR) involvement. The aim of the present study was to evaluate the possible relation between CCR2 and CCR5 alleles and blood pressure (BP) levels in hypertensive subjects. In all, 118 essential hypertensive outpatients (male 90, female 28; stage I and II; age 27-54 years; not previously treated with antihypertensive drugs) were selected for the study. All of the subjects underwent office BP measurement. Subsequently, 24-h ambulatory BP monitoring (ABPM) was performed with a Spacelabs 90207 monitor during a regular working day. CCR264I and CCR5Delta32 polymorphisms were determined by polymerase chain reaction (PCR), following the standard molecular biology protocols. Allelic frequencies were the following: CCR5Delta32= 0.097, CCR264I=0.101. Logistic regression analysis showed an association between the CCR5Delta32 allele and the following: 24-h systolic BP (SBP >140 mmHg; p = 0.027), values over the 50th percentile of 24-h SBP (p = 0.032), and the values over the 50th percentile of nighttime SBP (p = 0.039). Office BP showed an association with the Delta32 allele in a range over the 75th percentile of SBP (p = 0.087) and the 75th percentile of DBP (p = 0.085). No significant association was observed for CCR264I and BP levels or between physiological nocturnal BP decline and genotype. The observed results not only support the role of the immune system in the development and maintenance of hypertension, but they also indicate an influence of CCR5Delta32 polymorphism on the establishment of BP levels.