This preliminary clinical experience seems to confirm the possibility of using SonoVue enhanced US to make a differential diagnosis between infectious and neoplastic lesions based on a qualitative and quantitative assessment, by evaluating the enhancement pattern (homogeneous or inhomogeneous), arrival time of the contrast agent in the lesion, the possibility to identify the pulmonary arteries and time of contrast agent elimination.

Ultrasound (US) imaging of the spleen was considered of little use in the past and was performed only to distinguish between cystic and solid lesions. However, in the last decade due to experience acquired and the introduction of second-generation contrast agents, this technique has been re-evaluated as contrast-enhanced US (CEUS) allows detection and characterization of most focal lesions of the spleen with a high sensitivity and a good specificity. Gray-scale US presents a low specificity in splenic infarctions with a high rate of false negative cases, whereas specificity reaches 100 %, if the examination is performed using US contrast agents. Gray-scale US can provide a correct diagnosis in simple cysts, whereas CEUS is useful when cystic lymphangioma is suspected. In the study of splenic lesions, the most important problem is to differentiate between angioma, hamartoma, lymphoma, and metastasis. CEUS reaches a good specificity in the differentiation of benign from malignant splenic lesions, as hypo-enhancement in the parenchymal phase is predictive of malignancy in 87 % of cases. In conclusion, Gray-scale US and particularly CEUS are at present widely indicated in the study of focal splenic lesions.Keywords Focal splenic lesion Á Splenic angioma/ hamartoma Á Splenic cysts Riassunto L'ecografia splenica è stata considerata nel passato poco utile ed indicata solo nella diagnosi differenziale tra lesioni cistiche e solide. Nell'ultimo decennio grazie alla maggior esperienza ed all'utilizzo dei mezzi di contrasto ecografici di II generazione (CEUS), questa metodica è stata rivalutata, in quanto consente di evidenziare e caratterizzare con elevata sensibilità e buona specificità la maggior parte delle lesioni focali della milza. Negli infarti splenici l'ecografia B-Mode ha una bassa specificità con elevata percentuale di falsi negativi, mentre questa risulta il 100 %, quanto l'esame è eseguito con i mezzi di contrasto ecografici. Nelle cisti semplici l'esame ecografico è sufficiente per porre una corretta diagnosi, mentre la CEUS può risultare utile nel sospetto di linfoangioma cistico. Il problema più importante a livello splenico è quello di definire con la maggior accuratezza possibile la diagnosi differenziale tra Angioma/Amartoma e Linfoma/Metastasi. La CEUS presenta nella lesioni spleniche una buona specificità nel differenziare una lesione benigna da una maligna, in quanto la presenza di ipoehnancement in fase parenchimale è predittiva nell'87 % dei casi di malignità. In conclusione l'ecografia B-Mode ed ancor più la CEUS trova al momento attuale ampie indicazioni nelle lesioni focali spleniche.

Introduction: Mediastinal syndrome is suspected on the basis of clinical symptoms and is generally confirmed by chest radiography or computed tomography (CT). However, also grey scale ultrasound (US) and contrast enhanced US (CEUS) are useful in this hematologic emergency as they provide the possibility to perform US-guided biopsy and histological diagnosis. Materials and methods: 15 Patients affected by mediastinal syndrome were prospectively studied using B-mode US and CEUS; 13 of these patients, who had no other lesions, were proposed for US-guided biopsy of the mediastinal mass, but only in 12 patients biopsy was technically possible. Results: In this study, B-mode US reached an excellent sensitivity (100%) in evidencing the lesions but a low specificity which did not exceed 30e40%. CEUS reached an elevated specificity identifying neoplastic pathologies if both the early and the late phases are considered (90e86.6%). US-guided biopsy was possible in 92.3% of lesions showing a diagnostic adequacy of 91.66%. Conclusions: B-mode US associated with CEUS and US-guided biopsy reached an elevated accuracy in the diagnosis of mediastinal masses. If these results are confirmed by further studies, this diagnostic procedure could be included in the routine management of mediastinal syndrome.Sommario Introduzione: La diagnosi di sindrome mediastinica viene sospettata dai sintomi e confermata da una radiografia standard del torace ed ancor meglio dalla TC, ma anche l'ecografia con e senza mezzo di contrasto (CEUS) può essere utile in questa emergenza ematologica, permettendo oltre tutto una diagnosi istologica tramite biopsia ecoguidata. Materiali e metodi: 15 pazienti affetti da sindrome mediastinica sono stati prospetticamente studiati sia con l'ecografia B-Mode che utilizzando la CEUS. 13 di questi pazienti, senza altre lesioni sono stati proposti per una biopsia ecoguidata della massa mediastinica, che è stata tecnicamente possibile solo in 12. Risultati: L'ecografia B-mode mostra in questo lavoro un'ottima sensibilità (100%), nell'evidenziare le lesioni, ma una bassa specificità che non supera il 30e40%. La CEUS mostra invece una buona specificità per le patologie neoplastiche se viene valutata sia la fase precoce che quella tardiva (90e86,6%). La biopsia ecoguidata è stata possibile nel 92,3%, mostrando un'adeguatezza diagnostica del 91,66%. Conclusioni: L'ecografia B-Mode, associata all'ecografia con mdc ed alla biopsia ecoguidata delle masse mediastiniche, ha un'elevata accuratezza nella diagnosi delle masse mediastiniche, che se confermata da ulteriori lavori, può trovare indicazione nel management della sindrome mediastinica. ª

1371 Background: IGHV1-69 gene identifies the most frequent IGHV gene in chronic lymphocytic leukemia (CLL) and identifies the paradigm of unmutated CLL (U-CLL), being used in roughly 1/3 U-CLL. It is often rearranged to form subsets of stereotyped HCDR3 patterns, likely selected and transformed from the natural naïve B-cell repertoire (Blood. 2010; 115:71-7). Being unmutated, IGHV1-69 CLL are hypothetically expected to have competent tumor B-cell receptors (BCR) and to progress more rapidly. However, it has not been investigated if progression occurs similarly in all the subsets. Aims: we aimed to investigate the prognostic significance of mutational status and of stereotypic B-cell receptors in IGHV1-69+ CLL. Methods: Nucleotide sequences of the tumor IGHV1-69/D/J rearrangement, clinical and molecular prognostic parameters at diagnosis and clinical status at follow-up of 294 IGHV1-69+ CLL patients were obtained from 22 hematological Institutions in Italy. CLL B-cell derived IGHV1-69 rearrangements were scanned for HCDR3 stereotypic patterns and assigned to subsets according to the criteria by Murray et al (Blood. 2008; 111: 1524–1533). Enpoint of outcome was time to progression requiring first treatment according to NCI criteria (TTFT) in Rai stage 0 CLL. Results: Of 294 IGHV1-69+ CLL, 264 (89,8%) were unmutated, 168 (57,1%) were assigned to subsets, of which subsets 7 (n=23, 7,8%), 6 (17, 5,8%), 3 (13, 4,4%), 5 (10, 3,4%) and 9 (10, 3,4%) were the most frequent. CD38, ZAP70, normal or sole del13, +12, del11 and del17p scored positive in 109/264 (58,7%), 139/245 (56,7%), 128/248 (50,5%), 51/248 (20,6%), 43/248 (17,3%) and 34/248 (13,7%). CLLs were reclassified as 18 (6,1%) clinical MBL, 101 (34,4%) Rai 0, 155 (52,7%) Rai I-II and 20 (6,8%) Rai III-IV CLL. Subset 6 was also UM in 16/17 (94,1%) cases. Prevalence of CD38 (p<.001), ZAP70 (p=.016), normal or sole del13 (p<.001), +12 (p=.026), del11 (p=.011), and clinical high risk CLL (p=.025) were lower in IGHV1-69 M-CLL than in IGHV1-69 U-CLL. TTFT was significantly shorter in stage 0 IGHV1-69 U-CLL than in IGHV1-69 M-CLL (49 vs 144 months, p<.001, while it was not different between CLL assigned or not to subsets (65 vs 55 months, p=.346). However, specific analysis of individual subsets revealed differential outcomes (p=.005). Among all, it emerged that subset 6 had a TTFT equivalent to IGHV1-69 M-CLL (p=.29) and significantly longer than stage 0 IGHV1-69 U-CLL (median not reached vs 48 months, p=.017). Conclusions: our analysis documents and confirms that unmutated status of IGHV, and not stereotypy, is a relevant prognosticator of outcome (TTFT) in CLL. In the IGHV1-69 CLL it exclude a role of IGHV gene use for CLL progression. However, the good prognosis of Rai 0 U-CLL assigned to subset 6 suggests a differential clinical benign course of this particular subset, irrelevant of unmutated status. One possibility is that the IGHV1-69/D3-16/J3 rearrangements of subset 6 produce a tumor-specific BCR with stereotypic HCDR3 patterns that are anergized by antigen while circulating in the peripheral blood in early stage (Rai 0) CLL. Disclosures: No relevant conflicts of interest to declare.

701 Introduction: Hairy cell leukemia (HCL) is generally responsive to intravenous Cladribine (iv2CdA). Subcutaneous Cladribine (sc2CdA) is an alternative route with 100% bioavailability. In indolent non-Hodgkin lymphomas other than HCL, at the dose of 0.7 mg/kg/cycle, efficacy of sc2CdA is similar to iv2CdA and reduction to 0.5 mg/kg/cycle determines equivalent efficacy and lower toxicity. Aims: In a national multicentre clinical trial (protocol EudraCT code: ICGHCL 2004), we prospectively evaluated toxicity and efficacy of sc2CdA given 0.1mg/kg/die for 5 (total dose 0.5 mg/kg, arm A) or for 7 consecutive days (total dose 0.7 mg/kg, arm B) as a single course in classic HCL requiring first treatment. Method: Clinical data and diagnostic samples were collected from all patients for central revision of classical HCL diagnosis (WHO criteria) and for molecular analyses at the University of Siena, prior to study entry. Early grade 3–4 toxicity was assessed on days 7 to 30 after treatment, according to the 2003 NCI/CTCAE v3 criteria and occurrence of second tumors was assessed at every subsequent follow-up. Enpoints of sc2CdA efficacy were response to treatment, treatment free interval (TFI), relapse free survival (RFS), time to second tumor (TTST) and overall survival (OS). Responses to treatment were assessed on days 60 and 180 after treatment and defined according to the 1987 Consensus criteria. Complete Remissions (CR) and Partial Remissions (PR) were rated as beneficial responses (CR/PR), while minor Responses (mR) and No Responses (NR) were rated as treatment failures (mR/NR). TFI was measured as the time elapsed from sc2CdA initiation to second treatment because of new progression or failure to sc2CdA. RFS was measured in patients with a CR/PR from treatment inititation to relapse. OS was measured from sc2CdA initiation to death for any cause. Result: of 156 patients screened centrally, 148 scored as classical HCL and entered the study. Gender (male total 116/148, 78,4%; arm A: 62/77, 80,5% vs arm B: 54/71, 76,1%), age (total: median age 52 years, range 30–83; arm A: median 56, range 30–83; arm B: median 51, range 33–82), clinical and laboratory parameters prior to treatment (including spleen, hemoglobin, platelet, leucocyte and hairy cell counts) were equally balanced in the two arms. Dose reduction was required in no patients from arm A and in 2 patients from arm B due to concurrent infection. Overall hematological toxicity was no different among the two treatment arms. Requirement of platelet transfusions (total 7/148, 4,7%; arm A: 2/77, 2,6% vs arm B: 5/71, 7%), red blood cell transfusion (total 32/148; 21,6%, arm A: 15/77, 19,5% vs arm B: 17/71, 23,9%), or G-CSF (total 102/148; 68,9%, arm A: 55/77, 71,4% vs arm B: 47/71, 66,2%) was no different among the two arms. However, a significantly higher non hematological toxicity (total 28/148; 18,9%, arm A: 9/77, 11,7% vs arm B: 19/71, 26,8%) was observed in arm B (p=.019). Non haematological toxicity was mainly represented by infections or FUO (total 25/148; 16,9%) that were significantly more frequent in arm B (arm A: 8/77, 10,4% vs arm B: 17/71, 23,9%, p=.028). Higher prevalence of toxicity resulted in a higher hospitalization rate in arm B than in arm A (total 29/148; 19,6%, arm A: 9/77, 11,7% vs arm B: 20/71, 28,2%, p=.012) and one early death was experienced because of lung aspergillosis in arm B. Onehundred-forty patients (94,6%) had a beneficial response (101 CR, 68,2%; 39 PR, 26,4%) and 8 (5,4%) failed treatment (5 mR, 3,4%; 3 NR, 2%). Responses were equivalent in the two arms, with 72/77 (93,5%) beneficial responses (49/77 CR, 63,6%; 23/77 PR, 29,9%; 4/77 mR, 5,2% and 1/77 NR, 1,3%) in arm A versus 68/71 (95,8%) beneficial responses in arm B (52/71 CR, 73,2%; 16/71 PR, 22,5%; 1/71 mR, 1,4%; 2/71 NR, 2,8%). After a median follow-up of 36 months (range 12–66), 5 year TFI, RFS, TTST and OS were 67%, 71% 87% and 94%, respectively. Causes of late death were 2 cardiac events and 3 second tumors. No differences of TFI, RFS, TTST and OS were observed in the 2 arms of treatment. Conclusion: The present data indicate that overall activity of sc2CdA is similar to iv2CdA (Cheson, 1998). Furthermore, this study indicates that sc2CdA given at 25% reduced doses (0.5 mg/kg) has equivalent activity and significantly lower toxicity than sc2CdA at standard doses (0.7 mg/kg). The reduced infection rates and hospitalization rates of sc2CdA have important pharmaco-economic implications. Disclosures: No relevant conflicts of interest to declare.