Abstract: Mantle cell lymphoma (MCL) is an aggressive B-cell non-Hodgkin lymphoma (NHL) which is characterized by the t(11;14)(q13;q32) translocation leading to overexpression of cyclin D1 that consists of around 3% of NHL. Most cases are diagnosed at advanced stage and despite the progress in the treatment, the prognosis remains poor. Appropriate prognostification of the disease is essential to consider risk stratified treatment to improve the outcome. Although MCL international prognostic index (MIPI) has been reported as the specific prognostic index of MCL, most of the patients included in the study received chemotherapy without rituximab. Validation of MIPI in rituximab era has been done by several studies but the result remains controversial. Patients and Methods To evaluate the treatment outcome and prognostic factors of MCL in Japan, we conducted a multicenter retrospective study. Medical records of 633 patients with MCL newly diagnosed and treated from 63 hospitals between 1992 and 2012 were reviewed and analyzed. Pretreatment characteristics and treatment regimens were evaluated for their association with overall survival (OS) and progression free survival (PFS) by hazard ratio (HR). Since the patients received various chemotherapy regimens, treatment were adjusted to analyze prognostic factors. Results The median age of patients was 66 years old (range 22-92). Ninety percent of the patients were in stage III/IV, 70% had bone marrow involvement and 12% had poor performance status. According to the simplified MIPI (s-MIPI), 191 patients (32%) were classified as low risk, 233 patients (39%) were classified as intermediate risk and 169 patients (29%) were classified as high risk. Among the patients, 504 patients (82%) received rituximab containing chemotherapy, 55% received CHOP-like regimen, 32% received high-dose Ara-C containing regimen (HDAC) and 17% received autologous stem cell transplantation (ASCT) at the first-line treatment. With a median follow up duration of 43.4 months, overall 3-years PFS and OS was 36% and 73%, respectively. By limiting the analysis to the patients who received rituximab at the first-line treatment, s-MIPI was still a valid prognostic index for both PFS and OS even in the rituximab era (Figure), with 3-years PFS for low, intermediate and high MIPI of 62%, 36% and 14%, respectively. Multivariate analysis by Cox model revealed that Hb 〈 12mg/L (HR: 1.4 [1.0-2.0]), beta 2-microglobulin≥4.0 µg/L (HR: 2.4 [1.4-4.0] ) and total protein 〈 6.0g/dl (HR: 1.8 [1.2-2.9]) were significantly associated with shorter OS independent to s-MIPI. With the stratification by s-MIPI at the analysis, treatment regimen was significantly associated with the outcome in rituximab era that 3-years PFS for CHOP, CHOP+ASCT, HDAC, HDAC+ASCT of 21%, 54%, 52% and 76%, respectively. HDAC regimen was significantly associated with longer PFS than CHOP regimen (HR: 0.40 [0.31-0.52] ). With focusing on ASCT, upfront-ASCT were associated with longer PFS both in CHOP (HR: 0.39 [0.19-0.81]) and HDAC regimen (HR: 0.66 [0.42-1.1] ). Conclusion s-MIPI is a valid prognostic index even in the rituximab era. We also identified three prognostic factors independent to s-MIPI including anemia, high beta 2-microglobulin and low total protein. Upfront ASCT showed survival benefit both in CHOP and HDAC regimen. Disclosures: No relevant conflicts of interest to declare.

Abstract: [Background] Mantle cell lymphoma (MCL) is an aggressive B-cell lymphoma, characterized by the overexpression of cyclin D1 derived from t(11;14)(q13;q32) and poor prognosis. Most MCLs show nodal presentation, but also accompany extranodal involvement, such as bone marrow, peripheral blood or gastrointestinal tract. As a result, many MCLs present with advanced stage disease. Since only a small portion of patients show limited-stage disease, minimal data exist on treatment of patients diagnosed with limited stage disease. Nevertheless, the treatment strategy of MCL is recommended according to the clinical stage of limited- (stage I or non-bulky II) vs. advanced-stage, as well as other types of lymphoma. [Patients and methods] We recently collected 633 patient data of MCL (Chihara, et al. Ann Oncol 2015). Information of clinical stage was available in 626 patients. The patient data were retrospectively analyzed the by the clinical stage at initial presentation. [Results] The clinical stage was I in 24 patients (4%), II in 33 (5%), III in 70 (11%), and IV in 499 (80%). Only one patient presented with bulky stage II. Detailed demographic information by the clinical stage are listed in Table. Age and sex were not significantly different by clinical stage. Limited stage patients were associated with better performance status (PS), less B symptoms, no extranodal involvement, and lower lactate dehydrogenase (LDH) level and white blood cell (WBC) count. Most patients in any stage were treated with cytotoxic chemotherapy, but more patients in limited stage received radiotherapy. The proportion of high-dose cytarabine (HDCA)-containing regimen over CHOP/CHOP-like was higher in advanced stage patients. Complete and overall response rates were 92% and 96% in stage I, 58% and 94% in stage II, 66% and 86% in stage III, and 52% and 82% in stage IV, respectively (P = 0.02). However, the higher response rate in limited stage patients did not translate into better prognosis. The median survival was 11.0 years in stage I, 13.4 years in stage II, 11.5 years in stage III, and 5.6 years in stage IV (Figure). The prognosis was not significantly different among patients with stage I, II, and III (P = 0.33). [Conclusion] Prognosis of limited-stage MCL was almost similar to that of stage III MCL. Although the present study includes several limitations including a retrospective nature and limited number of patients, prognosis of patients with limited-stage MCL was not satisfactory. The significance of radiotherapy, as well as the optimal choice of chemotherapy, for limited-stage MCL needs re-evaluation. Table Table. Figure Figure. Disclosures Suzuki: Chugai: Honoraria; Kyowa Hakko kirin: Honoraria; Bristol-Myers Squibb: Honoraria. Asano:Jannsen: Honoraria; Chugai: Honoraria. Kinoshita:Ono: Research Funding; Gilead: Research Funding; Zenyaku: Honoraria, Research Funding; Takeda: Research Funding; Chugai: Honoraria, Research Funding; Eisai: Honoraria, Research Funding; Solasia: Research Funding; Janssen: Honoraria; Kyowa Kirin: Honoraria. Suzumiya:Chugai: Honoraria, Research Funding; Astellas: Research Funding; Eisai: Honoraria, Research Funding; Takeda: Honoraria; Toyama Chemical: Research Funding; Kyowa Hakko kirin: Research Funding. Ogura:SymBio Pharmaceuticals: Consultancy, Honoraria; Celltrion, Inc.: Consultancy, Honoraria.

Abstract: Abstract Background: CNS relapse is uncommon but challenging complication in patients with mantle cell lymphoma (MCL). Survival after CNS relapse is extremely poor that identification of high risk population is therefore critical in whom prophylactic chemotherapy may play a role. Patients and Methods: A total of 405 patients (median age, 66 years; range 22-85) with MCL newly diagnosed between 1994 and 2012 at 48 institutions in Japan were analyzed.Pathological specimens were centrally reviewed in all patients. We evaluated risk factors for CNS relapse in patients with MCL using competing risk regression analysis. Patients were excluded if they had evidences of CNS involvement at initial diagnosis. Overall, 81% of the patients received rituximab containing regimen with 222 patients received CHOP, 133 patients received high-dose cytarabine containing regimen and 50 patients received other regimen such as fludarabine. At a median follow up duration of 40.4 months, 25 patients (6.2%) experienced CNS relapse. Five patients presented with brain parenchymal mass, 13 patients presented with leptomeningeal disease, and 7 patients presented with both. The median time from initial diagnosis to CNS relapse was 18.5 months. Two-year cumulative incidence of CNS relapse was 4.7% (95%CI: 2.8-7.3). No difference was seen in the incidence of CNS relapse between the treatment with or without rituximab. Univariate analysis revealed blastoid or pleomoriphic variant, Ki-67 ≥ 30, serum total protein 〈 6.0g/dl, leukemic presentation and high risk group in simplified-MIPI at diagnosis as significant risk factors for CNS relapse. Within these five factors, Ki-67 was the strongest predictive factor for CNS relapse with hazard ration of 8.7 (95%CI: 3.4-22.2). Two-year cumulative incidence of CNS relapse in patients with Ki-67 ≥ 30 was 25.4% (95%CI: 13.5-39.1), while that in patients with Ki-67 〈 30 was 1.5% (95%CI: 0.2-2.9) (Figure). Ki-67 ≥ 30 was a significant risk factor for CNS relapse both in patients who received CHOP and hyper-CVAD/MA. Survival after CNS relapse was dismal with median survival time of 5.7 months. Summary: We identified four risk factors for CNS relapse in patients with MCL. Within these factors, Ki-67 ≥ 30 is the strongest predictive factor with 2-year cumulative incidence of 25.4%. Evaluation for CNS involvement at the diagnosis and assessment for value of prophylactic IT chemotherapy is mandatory in patients with Ki-67 ≥ 30. Figure 1: Cumulative incidence of CNS relapses by Ki-67 Figure 1:. Cumulative incidence of CNS relapses by Ki-67 Disclosures No relevant conflicts of interest to declare.

Abstract: Introduction Aggressive natural killer cell leukemia (ANKL) is a rare leukemic form of mature natural killer cell neoplasms that is closely associated with Epstein-Barr virus. ANKL presents a fulminant clinical course, resulting in a poor prognosis with a median overall survival of approximately 2 months. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is currently the only curative treatment, but the long-term outcomes after allo-HSCT remain unclear. Methods Using the national Japanese transplant registry database, the outcomes of 59 ANKL patients who underwent first allo-HSCT between 1997 and 2016 were analyzed. Correlation between groups was examined by the c2 test, Mann-Whitney U test, and Kruskal-Wallis test. Patient survival data were analyzed using the Kaplan-Meier method and compared by the log-lank test. The cumulative incidence of relapse and non-relapse mortality were calculated considering competing risks. Results The median patient age was 37 years (range, 9 to 66), and males accounted for 68%. The median time from diagnosis to allo-HSCT was 3.7 months (range, 1.1 to 13.9). Twenty-nine patients received stem cells from cord blood (CB), 18 received them from peripheral blood (PB), and 12 received them from bone marrow (BM). Two patients had a prior history of autologous HSCT. Twenty-one patients (36%) had a complete response (CR) and 7 (12%) had a partial response (PR), but 31 (52%) were not responding at the time of allo-HSCT. Forty-four patients received myeloablative conditioning and 15 received non-myeloablative conditioning. Thirty-two patients received tacrolimus-based GVHD prophylaxis, including 1 with additional post-transplant cyclophosphamide as part of haploidentical HSCT, whereas 26 received cyclosporin-based GVHD prophylaxis. The median follow-up of survivors was 62 months (range, 0.9 to 193). The median OS and relapse-free survival were 3.9 months and 2.6 months, respectively. The probability of OS and relapse-free survival, and cumulative incidence of relapse and non-relapse mortality 1 year after HSCT were 33.9%, 32.4%, 55.5%, and 12.1%, respectively. The probability of OS was significantly higher for patients with CR or PR at allo-HSCT than for those without a response (40.6% vs 16.1% at 5 years; P = 0.046). Among the 24 patients with primary induction failure (PIF) at allo-HSCT, 15 achieved CR after allo-HSCT. The prognosis of these 15 patients was almost equivalent to that of those who received allo-HSCT in CR or PR, as shown in the Figure (P = 0.95). Regarding the stem cell source, the probability of OS was significantly higher for patients who received stem cells from CB than for those who received them from PB or BM (CB 37.3% vs PB 15.8% and BM 16.7% at 5 years; P = 0.04). Seventeen patients (59%) of those who received stem cells from CB were CR at HSCT, whereas only 4 patients (13%) of those who received stem cells from PB or BM were CR at HSCT. In addition, 5 (83%) of 6 patients who received stem CB transplantation in PIF achieved CR after allo-SCT, whereas 10 (56%) of 18 patients who received PB stem cell transplantation or BM transplantation in PIF achieved CR. The age and year at HSCT were not different between the groups. The time from diagnosis to allo-HSCT did not differ among stem cell sources (median CB 3.3 months, PB 3.7 months and BM 4.1 months; P = 0.31). Regarding the conditioning regimen, the probability of OS was not different between myeloablative and non-myeloablative conditioning regimens (P = 0.58). Patients who developed acute GVHD grade 1/2 had a significantly better prognosis than those with grade 3/4 or without GVHD (P 〈 0.001). In contrast, chronic GVHD development did not affect the prognosis (P = 0.60). At the last follow-up, 42 patients (71%) had died. The most common cause of death was primary disease (62%), followed by infection (14%) and organ dysfunction (7%). Conclusion Allo-HSCT can lead to long-term survival even for patients with PIF at HSCT. CB is useful as a stem cell source, providing good outcomes and timely allo-HSCT for this rapidly progressive disease. To confirm our findings and evaluate the outcome of allo-SCT in more detail, further studies including patients who did not receive allo-SCT for ANKL are warranted. Figure Disclosures Ishida: Bristol-Meyers Squibb: Research Funding; Pfizer: Research Funding; Astellas Pharma: Research Funding; Eli Lily and Company: Research Funding; Celgene: Honoraria; Chugai Pharmaceutical: Consultancy, Research Funding. Izutsu:Celgene: Consultancy, Research Funding; Chugai: Honoraria, Research Funding; Daiichi Sankyo: Honoraria, Research Funding; Astra Zeneca: Honoraria, Research Funding; Eisai: Honoraria, Research Funding; Symbio: Research Funding; Ono: Honoraria, Research Funding; Bayer: Honoraria, Research Funding; Solasia: Research Funding; Zenyaku: Research Funding; Incyte: Research Funding; Novartis: Honoraria, Research Funding; Sanofi: Research Funding; HUYA Bioscience: Honoraria, Research Funding; MSD: Honoraria, Research Funding; Astellas Amgen: Honoraria, Research Funding; Abbvie: Honoraria, Research Funding; ARIAD: Research Funding; Takeda: Honoraria, Research Funding; Pfizer: Research Funding; Kyowa Kirin: Honoraria; Nihon Medi-physics: Honoraria; Janssen: Honoraria; Dainihon Sumitomo: Honoraria; Bristol-Byers Squibb: Honoraria; Mundi: Honoraria; Otsuka: Honoraria; Asahi Kasei: Honoraria. Suzumiya:Celgene, Kyowa Kirin, Chugai-Roche, Eisai, Takeda, Celltrion, SymBio, Astellas, Ono, AstraZeneca, Ootsuka, Taiho, Mundi, Dainihon-Sumitomo: Research Funding. Mitsui:MSD pharmaceutical: Research Funding; Maruho pharmaceutical: Research Funding; JCR pharmaceutical: Research Funding; Teijin pharmaceutical: Research Funding; Chugai pharmaceutical: Research Funding; Daiichi Sankyo pharmaceutical: Research Funding; Astellas pharmaceutica: Research Funding; Shionogi pharmaceutical: Research Funding. Kanda:Kyowa Hakko Kirin: Honoraria; Otsuka: Honoraria; Daiichi Sankyo Company: Honoraria; MSD: Honoraria; Chugai: Honoraria; Bristol-Meyers Squib: Honoraria; Novartis: Honoraria; Celgene: Honoraria; Astellas: Honoraria; JCR Pharmaceuticals: Honoraria; Takeda: Honoraria; NextGeM Incorporation: Patents & Royalties: 2019-011392. Atsuta:CHUGAI PHARMACEUTICAL CO., LTD.: Honoraria; Kyowa Kirin Co., Ltd: Honoraria. Suzuki:Celgene: Honoraria; Novartis: Honoraria; AbbVie: Honoraria; Kyowa Hakko Kirin: Honoraria; Chugai Pharmaceutical Co.,Ltd.: Honoraria; Meiji Seika: Honoraria; Bristol-Myers Squibb: Honoraria; Merck Sharp & Dohme: Honoraria; Takeda Pharmaceutical Co., Ltd.: Honoraria; Eisai: Honoraria; ONO Pharmaceutical Co., Ltd.: Honoraria; Janssen: Honoraria.

Abstract: Mantle cell lymphoma ( MCL ) is essentially incurable with conventional chemotherapy. The MCL International Prognostic Index ( MIPI ) is a validated specific prognostic index, but was derived from patients with advanced‐stage disease primarily in the pre‐rituximab era. We analysed 501 MCL patients (median age, 67 years; range 22–90) treated with rituximab‐containing chemotherapy, and evaluated the prognostic factors adjusted by the treatment. Five‐year overall survival ( OS ) in the low, intermediate and high MIPI groups was 74%, 70% and 35%, respectively. Additional to MIPI risk factors, multivariate analysis revealed that low serum albumin and bone‐marrow involvement were also significantly associated with a poor outcome. The revised‐ MIPI (R‐ MIPI ) was constructed using six factors, namely age, performance status, white blood cell count, serum lactate dehydrogenase, bone‐marrow involvement and serum albumin, which is divided into four prognostic groups. Five‐year OS in low, low‐intermediate (L‐I), high‐intermediate (H‐I) and high R‐ MIPI groups was 92%, 75%, 61% and 19%, respectively. Hazard ratio for OS of L‐I, H‐I and high risk to low risk patients were 5·4, 8·3 and 33·0, respectively. R‐ MIPI , a new prognostic index with easy application to the general patient population, shows promise for identifying low‐ and high‐risk MCL patients in the rituximab era.