Abstract The aim of the study was to assess the risk of infections in the first 100 days in patients grafted from haploidentical donors (HAPLO) (n=116) or HLA-matched donors (MATCHED) (Related, n=29; unrelated n=39): all patients received graft-versus-host disease (GvHD) prophylaxis with post-transplant cyclophosphamide (PTCy), mycophenolate, and cyclosporine. The two groups had comparable age, intensity of conditioning, and disease status; the stem cell source was bone marrow for HAPLO and peripheral blood for MATCHED transplants. HAPLO patients had an increased risk of bloodstream infections (BSI) (HR 2.54; 95% CI 1.39-4.62; p=0.002), in particular gram-positive BSI (HR 4.42; 95% CI 1.57-12.5; p=0.005). HAPLO patients also had increased CMV infection/reactivation (HR 3.51; 95% CI 1.79-6.87; p<0.001) and a trend for increased invasive fungal infections (HR 1.80; 95% CI 0.90-3.57; p=0.10) and EBV infection/reactivation (HR 2.07; 95% CI 0.44-9.70; p=0.35). Overall, post-transplant infections were more likely to result in infection-related mortality in HAPLO grafts (p=0.03). In this single-center study, patients with HAPLO grafts had an increased risk of BSI and CMV infection/reactivation and a trend for increased IFI and EBV infection/reactivation, compared with MATCHED grafts. These findings call for diligent monitoring of infections in patients undergoing a HAPLO transplant.

Background: Background: The efficacy of spike messenger RNA vaccines against SARS-COV2 in immunocompetent population is about of 94-95%, while in immunocompromised patients no precise value has been established. Most of patients with Chronic Lymphocytic Leukaemia (CLL) present a consistent immunological defect, which increases the risk of mortality and morbidity from infections, including SARS-COV2. Moreover, they have shown a highly heterogeneous response to vaccination, depending on many factors including baseline features, disease and treatment status, types of therapy, vaccine administered, and immunoglobulin level at time of vaccination. Aims: Aims: We tried to evaluate the efficacy of vaccine, stratifying them according to treatment status (naïve, on treatment, off therapy) and of type of treatment, including chemo-immunotherapy (CIT), BTK or anti-Bcl2 inhibitors, monoclonal antibodies a to both and at the time of vaccination, were either naïve or off therapy yielded better probably due to a lower disease burden. The timing of MoAb administration strongly influences the response the receptors impair the humoral response of vaccination to any and behave accordingly for SARS-COV2. Data show that, in these patients, the third dose confers higher rates of response and a effect. In conclusion, vaccination is strongly recommended to all CLL patients. Due to the higher risk, by immune dysregulation typical of CLL, it is important to evaluate the timing of vaccination maintain safety any time.

Obinutuzumab (G) in combination with chlorambucil (Chl) has been approved in Italy in 2017 as frontline treatment for patients with chronic lymphocytic leukemia (CLL) and comorbidities, following results of the CLL11 trial 1 and real-life studies. 2-4 Few studies have focused on reduction of relative dose intensity (RDI) in CLL. 5,6 The aim of this study was to evaluate the impact of reduced RDI of G-Chl on the overall response rate (ORR), progression-free survival (PFS), time to next treatment (TTNT), and overall survival (OS); we also wanted to identify patients at higher risk for dose reductions. We collected and retrospec-tively analyzed data of 130 patients diagnosed with CLL and comorbidities from the Italian centers with the highest use of the G-Chl regimen outside clinical trials between 2017 and 2020. Patients ’ characteristics are shown in supplemental Table 1. The study was conducted according to the Helsinki Declara-tion, Good Clinical Practice, and the applicable national regulations; all patients provided written informed consent, and the study was approved by the Institutional Ethical Committee of the Fondazione Policlinico Agostino Gemelli IRCCS. The RDI was calculated as the ratio between the dose actually delivered over time and the expected correct dose: a dose reduction of 20% was considered the best

Background: COVID-19 disease have strongly hit patients with hematological diseases and the ones receiving haematopoietic stem cell transplantation (HSCT) are a particularly vulnerable group. However, the effectiveness of vaccination in self-transplanted patients seems to be variable. The article by Chiarucci et al compared serological data of 38 autologous recipient and 45 healthy subjects, collected 30 days after their vaccination against SARS-CoV-2. In patients receiving high-dose therapy and auto-HSCT, prior administration of Rituximab was associated with a lower rate of immunization against SARS-CoV-2 (54%) and a significantly lower IgG antibody. Aims: Confirm and implement the data found out by Chiarucci et al. with a wider database derived from our four centers. Methods: This multicenter retrospective observational study included 82 patients who underwent aHSCT from January 2020 to October 2021, with 58 vaccinated after the autologous procedure (group A) and 24 patients before getting transplantation (group B). We divided patients of group A in 2 subgroups according to the hematological disease: 29 patients affected by plasma cell neoplasms (28 multiple myeloma MM and 1 plasma cell leukemia) and 29 affected by lymphomas (26 non Hodgkin lymphoma, NHL, and 3 Hodgkin lymphoma, HL). Than, we compared patients according to the conditioning regimen and the previous treatment. In group B, twelve patients were tested the first day of hospitalization, the day of discharge and one month after the transplantation. Results: In group A, 39 (67%) patients had a positive serology and 19 (33%) did not develop any antibody response. In particular, we noticed that the rate of positivity increased with the distance from the aHSCT. When vaccinated within 6 months after the procedure, only 57% of patients were positive, but it increased to 89% after 12 months. The subgroup of patients affected by lymphomas had a lower rate of positivity (52%). In this group, indeed, the distance from the aHSCT was particularly significant in terms of response: in fact, the positivity registered was 30% when the vaccination was done within 6 months, 54% after 6 and within 12 months and 83% after 12 months. When considering NHL the distance from the administration of RTX had a particular impact on the vaccination response: patients receiving the monoclonal antibody within 6 months had a poorer response to the vaccination (13% of positivity) than those who were treated with RTX after 6 and within 12 months (50%) and after 12 months (87%). This result was statistically significant (p= 0.01). In the plasma cells neoplasms subgroup, the rate of positivity was higher (83% overall), and it was not particularly affected by the distance from the transplant. In group B, 15 (63%) were positive at least 1 month after the procedure, while 9 (37%) were negative. We also noted that, in the subgroup of patients tested also at the hospitalization and at the discharge, no initially positive patient became negative after the transplantation. Image:Summary/Conclusion: Our data on 82 patients affected by lymphoproliferative disorders who underwent aHSCT confirmed the role of rituximab as negative predictor of response to anti-SARS-CoV-2 vaccination, as already reported by Chiarucci et al. We therefore showed the scanty importance of conditioning and transplantation procedure to the response of vaccination. According to this data, it would be more fruitful consider the vaccination at least 6 months from the last rituximab administration, even though it’s necessary to take into account patient conditions and the epidemiological context.

Background: B-cell receptor (BCR) signalling controls B-cell survival and proliferation, and its deregulation has a pathogenic role in Chronic Lymphocytic Leukemia (CLL), a B-cell malignancy. Currently, several BCR signalling inhibitors are used in therapy, among them the Ibrutinib. We previously reported that the BCR-signalling inhibition mediated by Ibrutinib leads to miR-181a/b activation; those miRNAs are significant biomarkers of CLL progression, and their downregulation is associated to a poor prognosis; furthermore, low levels of miR-181a/b impair several anti-apoptotic proteins, contributing to cell survival. BCR signalling also controls c-Fos/AP-1 pathway in pre-B cells. Recently, we suggested the involvement of c-Fos in miR-181b expression, however the mechanism by which this regulation is exerted is still not explored. Moreover, the involvement of c-Fos in miR-181a/b transcription during Ibrutinib is still not clear. Aims: Assess the impact of Ibrutinib on c-Fos expression; assess the involvement of the transcription factor c-Fos in miR-181a/b transcription; assess the impact of miR-181a/b in CLL cells survival during Ibrutinib treatment. Methods: To assess the impact of Ibrutinb on c-Fos transcription, we evaluated its expression in CLL cells treated with Ibrutinib or vehicle. To assess the involvement of c-Fos in miR-181a/b transcription, we evaluated i) the expression of the miRs and of their primary transcripts in CLL cells overexpressing c-Fos, and ii) the ability of c-Fos to bind miR-181a/b host gene promoter by luciferase, ChIP and EMSA assays. To assess the impact of the miRs on CLL cells survival during Ibrutinib treatment, we performed MTT assay in CLL cells after miR-181a/b silencing and Ibrutinib treatment. Results: Considering that c-Fos was found to be controlled by BCR signalling in pre-B cells, we evaluated whether BCR signalling affect c-Fos also in CLL cells: we found that c-Fos expression increases in primary CLL cells after Ibrutinib treatment. Since miR-181a/b was up-regulated after Ibrutinib treatment in vitro and in vivo in CLL cells, and considering that a possible involvement of c-Fos in miR-181b expression was already suggested, we sought to identify if c-Fos was a direct regulator of miR-181a/b expression. We confirmed that c-Fos overexpression affects miR-181b levels in CLL patients, but not miR-181a; however, the dysregulation of the miR shows heterogeneity among patients. Indeed miR-181b expression increases in 3 and decreases in 2 of 7 patients. To better understand how c-Fos impact on miRs expression, we analysed both miR-181a and miR-181b at the transcriptional level in CLL and lymphoblastoid cell lines, finding that c-Fos negatively regulates the pri-miR-181a/b. To clarify the mechanism by which c-Fos regulates miR-181a/b transcription, we analysed the miRs host gene (MIR181A2HG) promoter. Since MIR181A2HG promoter shows two consensus sequences for the transcription factor c-Fos, we studied whether c-Fos binds these regions. We found that c-Fos binds at MIR181A2HG promoter by recognizing the two consensus sequences. Accordingly, after their deletion, the ability of c-Fos to recognize the promoter was overcome. Finally, since miR-181a and miR-181b are involved in cell death, we assessed whether those miRNAs participate in CLL cells death induced by Ibrutinib: we found that the silencing of both miRNAs improves CLL cell survival during Ibrutinib treatment. Summary/Conclusion: c-Fos is a downstream target of BCR signalling and a direct regulator of miR-181a/b transcription in CLL. MiR-181a/b are effectors of Ibrutinib-induced CLL cells death.

Background: Ibrutinib is a first-in-class covalent inhibitor of Bruton’s tyrosine kinase that has changed the treatment paradigm of chronic lymphocytic leukemia (CLL) in both treatment-naive (TN) and relapsed/refractory (R/R) setting. Clinical trials, in selected populations showed that the BTK inhibitor is manageble even in the elderly. Nevertheless, few studies are focused on the role of ibrutinib in unselected patients aged ≥80 years. Aims: We aimed to assess the activity and safety of ibrutinib in a cohort of patients with CLL aged ≥80 years at therapy start. The primary endpoint was safety evaluation. Key secondary endpoints were overall (ORR), complete (CR) and partial (PR) response rates according to iwCLL 2018, median progression free survival (PFS) and overall survival (OS). Methods: Sixty consecutive patients (age ≥80 years) diagnosed with TN (20 patients) or R/R CLL (40 patients) who started ibrutinib were enrolled in this multicenter study from six Italian sites; data were retrospectively analyzed. Pre-existing cardiovascular risk factors were present in 66.7% of patients; 23.3% had experienced a cardiovascular event prior ibrutinib initiation. (Table 1) Results: After a median follow up of 27 months, at least one adverse event (AE) occurred in 68.3% patients, leading to treatment discontinuation in 23.3%. The most common grade ≥3 events were infections (23%) and neutropenia (6%). Cardiovascular events occurred in 31.6% of patients, with an incidence of atrial fibrillation (AF) and arterial hypertension both increasing over time and reaching 16% at 24 months. Although no significant increase in incidence of cardiovascular events was noted among patients with concomitant cardiovascular risk factors or previous events, baseline higher left atrial diameter at echocardiography was predictive of AF occurrence. OS did not differ between patients experiencing AF or not. During treatment, two patients experienced sudden cardiac death. Bleeding was the most frequent AE, occurring in 36.6% of patients, with a median time to event of 24 months and predominantly in patients assuming concomitant antiplatelet or anticoagulant drugs. A total of 23 infective events was registered, mostly in the first 12 months, leading to drug permanent discontinuation in 5 patients. Of note, the infectious rate was higher in del(17p) CLL (p=0.05). The obtained ORR was 88.3%, with 21.7% of patients achieving CR and 66.7% PR; median PFS was 51.8 months (95% CI: 47.4-56.2). No significant difference in PFS was observed comparing TN to R/R patients (p=0.83), or IGHV mutated and unmutated patients (p=0.45). Furthermore, no difference emerged comparing PFS data of patients with TP53 dysfunction (del17 and/or TP53 mutation) to patients without TP53 dysfunction (p=0.13). Patients achieving a response during ibrutinib experienced a prolonged PFS compared to patients achieving SD (p<0.0001). Drug withholding for more than 7 days due to ibrutinib-related toxicities affected patients’ outcome, translating in a shorter PFS with a trend to statistical significance (p=0.07). Median overall survival was 53.2 months (95% CI: 43.3-63.0). Image:Summary/Conclusion: A high proportion of patients had an overall response to ibrutinib and the risk-benefit profile was favourable, providing further evidence for use of ibrutinib in this subset of elderly and unselected patients. Safety profile remains consistent with literature data with no emergent adverse events, thus making ibrutinib an attractive therapeutic possibility even in patients with advanced age and multiple comorbidities.

Background: Secondary antibody deficiency (SAD) is a typical manifestation of haematological malignancies such as chronic lymphocytic leukaemia (CLL), or a side effect of their treatment. Immunological defects are observed in 25-85% of CLL patients (pts) and increases the risk of infections, with overall higher morbidity and mortality. Antibiotics administration and vaccinations are recommended as risk-reduction strategies in those pts. No real guidelines are available to recommend eligibility for prophylaxis, but many indications warrant immunoglobulins replacement therapy (IgRT) in selected pts with low IgG ( 600 mg/dl from 6 months onward. About cellular immunity, T-cells including CD4 and CD8 and NK cells displayed a stable fashion until 6 months. On the other hand, the CD19 B cells values reflect both the disease status and the ongoing treatment effects. Results were in Table 1. Finally we observed advantages on both QoL and costs, since pts did not need to go to the hospital with the help of a care-giver, rather they could comfortably get their SCIg at home without any assistance. Summary/Conclusion: SCIg administration in CLL pts is safe and efficacious as infectious prophylaxis, with higher median IgG levels, thanks to its pharmacokinetic advantages and improved adherence to treatment. Especially in the Covid-19 era, the subcutaneous route is preferred to the intravenous one, because of the self-administration at home and the granted availability to the drug itself.

Previous studies investigated the efficacy and the safety of bendamustine (B) vs. chlorambucil (Chl) associated with rituximab (R) in fludarabine-ineligible patients with treated and untreated chronic lymphocytic leukemia (CLL). We conducted a retrospective multicenter study in the Lazio region to further evaluate and compare the efficacy and the toxicity of Chl-R and B-R regimen in CLL patients over the age of 65. We enrolled 192 untreated CLL patients: 111 treated with B-R and 81 with Chl-R. The overall response rates (ORR; 93.6% in B-R and 86.5% in Chl-R) were not statistically different between the two groups, such as progression-free survival (PFS), time to retreatment (TTR), and overall survival (OS). The B-R group showed a higher hematological (p = 0.007) and extra-hematological (p = 0.008) toxicity. When comparing the toxicities according to age, we noted that the extra-hematological toxicity was higher in patients over the age of 75 who were treated with B-R than those treated with Chl-R (p = 0.03). This retrospective study confirms the feasibility of B-R and Chl-R in elderly untreated CLL patients. Currently, patients who are over 75 and unfit are usually treated with Chl-R. This scheme allows achieving the same ORR, PFS, TTR, and OS when compared with B-R because of hematological and extra-hematological toxicities due to B, in which a greater dose reduction has been shown in comparison to Chl.

Background:B‐cell receptor signaling inhibitors (BCRi), such as Ibrutinib (Ibr) and Idelalisib (Idela), have changed the treatment paradigm for chronic lymphocytic leukemia (CLL), and the BCL‐2 inhibitor Venetoclax (Ven) has shown promising efficacy across clinical studies in relapsed/refractory (R/R) CLL. To date, the exact timing on the use of new pathways inhibitors in the real life practice is not well established.Aims:In this multicenter retrospective real life study we evaluated the overall response rate (ORR), progression‐free survival (PFS), overall survival (OS) of CLL patients (pts) treated with Ven after one or two BCRi. Also the reasons for BCRi discontinuation ‐ adverse events (AE) vs progressive disease (PD) ‐ were evaluated.Methods:We report a multi‐center retrospective analysis that included 76 CLL pts from 18 different Italian centers treated with Ibr and/or Idela prior to Ven for progressive naïve CLL or with relapsed or refractory disease. Twenty‐four pts were treated with one BCRi, while 52 pts with both BCRi before Ven. Median age was 63 years (26–87); 78% pts had an unmutated IgVH status, 33% pts had 17p deletion and 32% pts had TP53 mutation. The sequence of the BCRi prior to Ven was the following: Ibr, Idela, Ven in 16 pts; Idela, Ibr, Ven in 8 pts; Ibr, Ven in 37 pts; Idela, Ven in 15 pts.Results:No statistically significant difference was found in terms of ORR to Ven in patients who had been exposed to one or two BCRi (p = 0.114). At the same time, we observed that pts who received only one BCRi prior to Ven showed a significantly better PFS and OS at 12 months: 76% vs. 35% (p = 0.011) and 88% vs. 57% (p = 0.015), respectively. BCRi treatment was stopped in 70% of pts because of PD and in 30% due to AE. When we considered the impact of the reasons of the first BCRi discontinuation ‐ AE vs PD ‐ on Ven response, we found that the ORR was significantly better in pts who stopped due to AE: 91% vs 49% (p = 0.03). PFS and OS were also significantly better in pts who discontinued treatment due to AE compared to PD, with a PFS of 84% vs 45% (p = 0.003) and an OS of 93% vs 62% (p = 0.028). When we considered the impact of discontinuation of both BCRi on Ven response, the PFS was similar in CLL patients who stopped BCRi due to AE (p = 0.31), while pts who experienced PD to both BCRi showed a worse PFS during Ven (p = 0.06).Summary/Conclusion:The number of BCRi received before BCL2i does not affect ORR to Ven. Single BCRi is better than double BCRi in terms of PFS and OS following Ven treatment, regardless of the BCRi used. Discontinuation of the first BCRi because of AE is associated with a better PFS and OS to Ven compared to pts who experienced PD. The discontinuation of double BCRi for AE did not impact on PFS to Ven. On the other hand, pts who stopped both BCRi for PD showed a tendency to a worse PFS on Ven, without reaching significance. Finally, these preliminary data seem to suggest the use of double BCRi before Ven for pts who discontinued due to AE; on the contrary, we suggest the use of Ven after single BCRi when the reason of discontinuation is disease progression.image