The benefit of high-dose chemotherapy with autologous stem-cell transplantation (ASCT) as first-line treatment in patients with diffuse large B-cell lymphomas is still a matter of debate. To address this point, we designed a randomized phase III trial to compare rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP)-14 (eight cycles) with rituximab plus high-dose sequential chemotherapy (R-HDS) with ASCT. Patients and Methods From June 2005 to June 2011, 246 high-risk patients with a high-intermediate (56%) or high (44%)International Prognostic Index score were randomly assigned to the R-CHOP or R-HDS arm, and 235 were analyzed by intent to treat. The primary efficacy end point of the study was 3-year event-free survival, and results were analyzed on an intent-to-treat basis. ResultsClinical response (complete response, 78% v 76%; partial response, 5% v 9%) and failures (no response, 15% v 11%; and early treatment-related mortality, 2% v 3%) were similar after R-CHOP versus R-HDS, respectively. After a median follow-up of 5 years, the 3-year event-free survival was 62% versus 65% (P = .83). At 3 years, compared with the R-CHOP arm, the R-HDS arm had better disease-free survival (79% v 91%, respectively; P = .034), but this subsequently vanished because of late-occurring treatment-related deaths. No difference was detected in terms of progression-free survival (65% v 75%, respectively; P = .12), or overall survival (74% v 77%, respectively; P = .64). Significantly higher hematologic toxicity (P , .001) and more infectious complications (P , .001) were observed in the R-HDS arm. ConclusionIn this study, front-line intensive R-HDS chemotherapy with ASCT did not improve the outcome of high-risk patients with diffuse large B-cell lymphomas.J Clin Oncol 34.

Background. The role of normal lymphocytes in the development of malignancies is investigated with increasing interest, with particular focus on lymphoproliferative disorders. A few recent reports, including a large study from our group, have shown that the lymphocyte/monocyte ratio (LMR) is often altered in diffuse large B cell lymphoma (DLB-CL) and a reduced LMR at diagnosis is associated with a poor response to therapy and a marked reduction in the overall survival expectancy. Reduction of LMR is primarily due to decreased levels of circulating lymphocytes, although an increase of circulating monocytes may also concur in reducing the LMR value. The present study was undertaken to further characterize the lymphocyte subpopulations in DLB-CL and in the other germinal-center derived Follicular Lymphoma (FL). In particular, the aim was to investigate possible abnormalities of either B or T-lymphocytes that might be present in patients with DLB-CL or FL at disease onset. Patients and Methods. Peripheral blood (PB) samples were obtained at diagnosis from 23 DLB-CL and 15 FL without leukemic involvement; among them 11/23 DLB-CL and 12/15 FL did not display disease involvement also in their bone marrow (BM). In addition, 25 PB and 20 BM were obtained as controls from age matched healthy donors or from subjects undergoing diagnostic procedures without any evidence of hematological or solid malignancy. Multicolor flow cytometry (MFC) was used, to evaluate the PB distribution and the absolute value of the main cell categories, i.e.: CD3+ T cell, CD3-CD56+ NK cells, and CD19+CD20+ B cells; among these latter, the following subsets were investigated: transitional (CD38+high/CD24+high/IgD+/CD27-), naive (CD38+/CD24+/IgD+/CD27-), memory IgD+ (CD38-/+CD24+/IgD+/ CD27+), and memory IgD- (CD38-/CD24+high/IgD-/CD27+). Similarly, MFC was used to identify B-lymphocyte subsets in BM samples (B cell precursors as CD19+CD20-CD10+ and mature B cells as CD19+CD20+CD10-). Results. The absolute number of circulating B cells was significantly reduced in both FL (median 86 cell/ul) and DLB-CL (median 72 cell/ul) compared to normal age-matched controls (median 233 cells/ul), as detailed in the Figure 1. The low absolute number of circulating B cells did not correlate with a low LMR or with bone marrow involvement. Despite the generalized reduction in absolute number, the proportion of transitional and naïve B cell subsets was similar or slightly increased in B-NHL, while the percentage of memory B cell was deeply reduced in both FL and DLB-CL compared to normal controls. The amount of BM CD19+ B cells, evaluated as percentage on the whole lymphocyte population, was similar in both FL and DLBCL (15% and 15.9% respectively) and not significantly different from normal controls (18.9%). Interestingly, the percentage of B cell precursors (CD19+CD20-CD10+) within the B cell compartment was similar in FL and normal BM (50% vs 43.1%, p=ns), while it was marginally reduced in DLB-CL (23.7% vs 43.1%, p=ns). T and NK cells were not significantly different in DLB-CL and FL and in normal controls. Conclusions. Our data suggest that the homeostasis of normal B-cell compartment is impaired in FL and DLBCL, mainly at the peripheral level. The circulating memory B cells seem to be the B-cell subset affected in FL and DLB-LC. The mechanism underlying the reduction of circulating B lymphocyte number remains unknown. It might be hypothesized that FL and DLB-CL affect the microenvironment in which normal B cell differentiation occurs, resulting in the hampered production or increased elimination of differentiating B-cells. This hypothesis seems supported by the observation that the B cell population is not significantly altered in BM. Further study should be addressed to verify the impact of B-cell reduction on the long-term outcome of DLB-CL e FL and whether increasing circulating B-cells may improve the response to therapy. In addition the results here reported should be considered in relation with the prolonged B-cell impairment associated with the widely employed chemo-immunotherapy treatments for B-cell lymphoma. Figure 1. Absolute count values of total PB B lymphocyte in normal control (dottet bar), DLBCL (vertical line bar) and FL (diagonal line bar). Figure 1. Absolute count values of total PB B lymphocyte in normal control (dottet bar), DLBCL (vertical line bar) and FL (diagonal line bar). Disclosures No relevant conflicts of interest to declare.

BACKGROUND Follicular lymphoma (FL) is the most common indolent form of non-Hodgkin's lymphoma. However, FL is a heterogeneous disorder and in a proportion of patients, the disease is very resistant to standard frontline therapies. In the current analysis clinical features and outcome to primary treatment were evaluated in a large series of FL patients who were consecutively treated at the Hematology Centers of Bergamo and Torino, Italy between 1976 and 2012. The aim of the study was to define the rate of refractory disease and the long term survival of patients according to response to their primary treatment. METHODS Medical records of 597 FL patients were reviewed. In front line therapy, rituximab was employed in 330 patients (55%), front-line high dose therapy with autograft (HDS) was administered in 58 patients (9.7%). Primary refractory disease was defined as full refractoriness (stable or progressive disease) or progressive disease within six months after initial response. Univariate analysis was done for prognostic factors including gender, age at diagnosis (age≤60 and >60 years), histological grade, IPI score (low=0-2 versus high=3-5), bone marrow (BM) involvement, rituximab administration in 1st line treatment, lymphocyte to monocyte ratio at diagnosis (>2.6 vs ≤2.6), presence of primary refractory disease, and the administration of front-line HDS. Cox model was also used for multivariate analysis. RESULTS: A total of 375 patients (63%) were older than 60 years (range: 18-88) and 49% were males. There were 476 patients (79.7%) with stage III-IV, 286 patients (48%) with BM involvement, 185 (31%) had a high IPI score and 28 patients (5%) presented with high histological grade. Eighty-seven patients (13%) displayed primary refractory disease. At a median follow-up of 8 years, median overall survival (OS) was 25 years for all patients, 32.6 years for responsive patients compared to 5 years for primary refractory patients (p=<0.0001). Among primary refractory patients, those with fully refractory disease had a shorter survival (median OS: 2.7 years) compared to patients with early progressive disease (median OS: 5 years). The strikingly different outcome of primary refractory vs. responsive patients is shown in the Figure 1. A significant prolonged survival was observed in patients who were treated with rituximab in primary therapy. The median OS is not reached for rituximab treated patients compared to 19 years for those who did not receive rituximab. Median OS was 25 years for patients with low IPI and 14.6 years for the high risk group. By univariate analysis, age and BM involvement were also significant prognostic factors for OS. Median OS for patients 60 years old or younger compared to older patients were 32.6 versus 13 years, respectively. The median survival was not reached for patients without BM involvement vs 19 years for patients with BM involvement (p=0.001). By multivariate analysis high IPI, refractory disease and not receiving rituximab in first line regimens were independent negative prognostic factors for OS, as detailed in Table 1. CONCLUSION: FL patients who display responsive disease to their primary treatment have a very long life expectancy with median survival of 32.6 yrs. Similarly to the aggressive lymphoma subtypes, primary refractory disease is of major concern also for FL. Research studies should be focused on the early identification of primary refractory patients to promptly institute adapted therapy for this unfavorable subgroup, and possibly optimize treatment strategies for patients with high-risk FL. Table 1. Multivariate analysis for overall survival Parameter Hazard Ratio (95% Confidence interval) p-value Age (yrs): >60 vs. ≤ 60 1.54 (1.5-2.3) .03 Histologic grade: 1-2 vs 3 2.25 (0.5-9.1) .3 IPI *Score: low (0-2) vs high(3-5) 0.59 (0.4-0.9) .009 Primary Refractory: yes vs no 4.40 (3.0-6.5) < .0001 Rituximab 1st line: yes vs no 0.56 (0.4-0.8) .005 BM# involvement: yes vs no 1.44 (1.0-2.1) .06 *International prognostic index was used to have a uniform prognostic factors scoring system for patients treated over the three decades of the survey. # Bone marrow Figure 1. Overall Survival in 597 follicular lymphoma patients according to response to primary treatment Figure 1. Overall Survival in 597 follicular lymphoma patients according to response to primary treatment Disclosures No relevant conflicts of interest to declare.