This 9p21 locus, encode for important proteins involved in cell cycle regulation and apoptosis containing the p16/CDKN2A (cyclin-dependent kinase inhibitor 2a) tumor suppressor gene and two other related genes, p14/ARF and p15/CDKN2B. This locus, is a major target of inactivation in the pathogenesis of a number of human tumors, both solid and haematologic, and is a frequent site of loss or deletion also in acute lymphoblastic leukemia (ALL) ranging from 18% to 45% 1. In order to explore, at high resolution, the frequency and size of alterations affecting this locus in adult BCR-ABL1-positive ALL and to investigate their prognostic value, 112 patients (101 de novo and 11 relapse cases) were analyzed by genome-wide single nucleotide polymorphisms arrays and gene candidate deep exon sequencing. Paired diagnosis-relapse samples were further available and analyzed for 19 (19%) cases. CDKN2A/ARF and CDKN2B genomic alterations were identified in 29% and 25% of newly diagnosed patients, respectively. Deletions were monoallelic in 72% of cases and in 43% the minimal overlapping region of the lost area spanned only the CDKN2A/2B gene locus. The analysis at the time of relapse showed an almost significant increase in the detection rate of CDKN2A/ARF loss (47%) compared to diagnosis (p = 0.06). Point mutations within the 9p21 locus were found at very low level with only a non-synonymous substition in the exon 2 of CDKN2A. Finally, correlation with clinical outcome showed that deletions of CDKN2A/B are significantly associated with poor outcome in terms of overall survival (p = 0.0206), disease free-survival (p = 0.0010) and cumulative incidence of relapse (p = 0.0014). The inactivation of 9p21 locus by genomic deletions is a frequent event in BCR-ABL1-positive ALL. Deletions are frequently acquired at the leukemia progression and work as a poor prognostic marker.

Background: Nilotinib is a potent and selective BCR-ABL inhibitor. The phase 3 ENESTnd trial demonstrated superior efficacy nilotinib vs imatinib, with higher and faster molecular responses. After 24 months, the rates of progression to accelerated-blastic phase (ABP) were 0.7% and 1.1% with nilotinib 300mg and 400mg BID, respectively, significantly lower compared to imatinib (4.2%). Nilotinib has been approved for the frontline treatment of Ph+ CML. With imatinib 400mg (IRIS trial), the rate of any event and of progression to ABP were higher during the first 3 years. Consequently, a confirmation of the durability of responses to nilotinib beyond 3 years is extremely important. Aims: To evaluate the response and the outcome of patients treated for 3 years with nilotinib 400mg BID as frontline therapy. Methods: A multicentre phase 2 trial was conducted by the GIMEMA CML WP (ClinicalTrials.gov.NCT00481052). Minimum 36-month follow-up data for all patients will be presented. Definitions: Major Molecular Response (MMR): BCR-ABL/ABL ratio <0,1%IS; Complete Molecular Response (CMR): undetectable transcript levels with ≥10,000 ABL transcripts; failures: according to the revised ELN recommendations; events: failures and treatment discontinuation for any reason. All the analysis has been made according to the intention-to-treat principle. Results: 73 patients enrolled: median age 51 years; 45% low, 41% intermediate and 14% high Sokal risk. The cumulative incidence of CCgR at 12 months was 100%. CCgR at each milestone: 78%, 96%, 96%, 95%, 92% at 3, 6, 12, 18 and 24 months, respectively. The overall estimated probability of MMR was 97%, while the rates of MMR at 3, 6, 12, 18 and 24 months were 52%, 66%, 85%, 81% and 82%, respectively. The overall estimated probability of CMR was 79%, while the rates of CMR at 12 and 24 months were 12% and 27%, respectively. No patient achieving a MMR progressed to AP. Only one patient progressed at 6 months to ABP and subsequently died (high Sokal risk, T315I mutation). Adverse events were mostly grade 1 or 2 and manageable with appropriate dose adaptations. During the first 12 months, the mean daily dose was 600-800mg in 74% of patients. The nilotinib last daily dose was as follows: 800mg in 46 (63%) patients, 600mg in 3 (4%) patients and 400mg in 18 (25%), 6 permanent discontinuations. Detail of discontinuation: 1 patient progressed to ABP; 3 patients had recurrent episodes of amylase and/or lipase increase (no pancreatitis); 1 patient had atrial fibrillation (unrelated to study drug) and 1 patient died after 32 months of mental deterioration and starvation (unrelated to study drug). Two patients are currently on imatinib second-line and 2 on dasatinib third-line. With a median follow-up of 39 months, the estimated probability of overall survival, progression-free survival and failure-free survival was 97%, the estimated probability of event-free survival was 91%. Conclusions: The rate of failures was very low during the first 3 years. Responses remain stable. The high rates of responses achieved during the first 12 months are being translated into optimal outcome for most of patients.

Hypoxia-inducible factor-1 alpha (HIF-1α) plays a critical role in survival and is associated with poor prognosis in solid tumors. The role of HIF-1α in multiple myeloma is not completely known. In the present study, we explored the effect of EZN2968, an locked nucleic acid antisense oligonucleotide against HIF-1α, as a molecular target in MM. A panel of MM cell lines and primary samples from MM patients were cultured in vitro in the presence of EZN2968 . Under normoxia culture condition, HIF-1α mRNA and protein expression was detectable in all MM cell lines and in CD138+ cells from newly diagnosed MM patients samples. Significant up-regulation of HIF-1α protein expression was observed after incubation with IL6 or IGF-I, confirming that HIF-1α can be further induced by biological stimuli. EZN2968 efficiently induces a selective and stable down-modulation of HIF-1α and decreased the secretion of VEGF released by MM cell. Treatment with EZN2968 gave rise to a progressive accumulation of cells in the S and subG0 phase. The analysis of p21, a cyclin-dependent kinase inhibitors controlling cell cycle check point, shows upregulation of protein levels. These results suggest that HIF-1α inhibition is sufficient for cell cycle arrest in normoxia, and for inducing an apoptotic pathways.. In the presence of bone marrow microenvironment, HIF-1α inhibition blocks MAPK kinase pathway and secretion of pro-surviaval cytokines ( IL6,VEGF,IL8) In this study we provide evidence that HIF-1α, even in the absence of hypoxia signal, is expressed in MM plasma cells and further inducible by bone marrow milieu stimuli; moreover its inhibition is sufficient to induce a permanent cell cycle arrest. Our data support the hypothesis that HIF-1α inhibition may suppress tumor growth by preventing proliferation of plasma cells through p21 activation and blocking pro-survival stimuli from bone marrow microenvironment. / Nonostante l’introduzione nella terapia del mieloma multiplo (MM) di nuovi farmaci, quali inibitori del proteasoma ed agenti immunomodulanti come talidomide e lenalidomide, il MM è a tutt’oggi una malattia incurabile, e nuove strategie terapeutiche sono necessarie per migliorare la risposta alla terapia e superare le resistenze indotte del trattamento. In questo ambito, l’evidenza di una dis-regolazione di geni coinvolti nella risposta ipossica ha aperto la possibilità di testare l’attività antineoplastica di specifici inibitori di fattori di trascrizione coinvolti nella regolazione dell’ipossia identificando una nuova classe terapeutica che attualmente è in fase di sperimentazione clinica in pazienti con neoplasie solide. Recenti studi hanno suggerito che Hypoxia inducible factor 1 α (HIF1-α) sia coinvolto nella patogenesi del MM. Obiettivo del nostro studio è stata la valutazione del ruolo biologico e terapeutico di inibitori di HIF1-α nel mieloma multiplo (MM). Lo studio è stato effettuato su linee cellulari e su campioni biologici di pazienti affetti da MM tramite l’utilizzo di metodiche standard di analisi di laboratorio quali saggi di tossicità e proliferazione cellulare, analisi citofluorimetrica, studi di proteomica e biologia molecolare, saggi d funzionalità mitocondriale e microscopia elettronica. L’inibizione dell’espressione di HIF1-α, che nelle linee di MM (MM1S, U266, OPM2, RPMI8226) è costituzionalmente espresso ed ulteriormente inducibile determina una riduzione della sopravvivenza, superando inoltre il vantaggio proliferativo indotto dal microambiente midollare, con induzione della morte cellulare per necrosi ed attivazione dell’ ER stress come principale meccanismo di risposta. Associata all’inibizione di HIF1-α è stata osservata macroscopicamente una alterazione sia della morfologia cellulare che di alcuni organuli citoplasmatici, fra cui il reticolo endoplasmatico e i mitocondri che sono stati ulteriore oggetto di studio. In conclusione, l’inibizione di HIF1-a in vitro determina una alterazione della omeostasi cellulare nelle linee di mieloma multiplo e suggerisce quindi un suo ruolo come target per la terapia del mieloma.

Nel 1997 venne isolata una popolazione cellulare con caratteristiche appartenenti a cellule endoteliali mature e a cellule progenitrici ; le cellule appartenenti a queste popolazione furono denominate EPCs (cellule endoteliali progenitrici circolanti) e fu messa in evidenza la loro capacità di dare origine a vasculogenesi postnatale. Lo scopo dello studio è stata la caratterizzazione di tale popolazione cellulare in termini biologici e la valutazione delle differenze delle EPCs in soggetti sani e nefropatici in emodialisi. È stata infine valutata l’eventuale capacità della Vitamina D di influenzare le capacità delle Late EPCs in termini di formazione di colonie in vitro e di attività anticalcifica in soggetti in insufficienza renale cronica.

La diagnosi di linfoma non Hodgkin B della zona marginale si basa su criteri morfologici e sulla sostanziale negatività per marcatori immunoistochimici espressi in altri sottotipi di linfoma B. L’ obiettivo di questo lavoro è stato, quindi, quello di ricercare una molecola specifica associata ai linfomi della zona marginale. Materiali e Metodi. Sono stati esaminati 2.104 linfomi periferici di entità nosologia eterogenea mediante un anticorpo monoclonale, diretto contro la molecola IRTA1, che riconosce la zona marginale nei tessuti linfoidi umani. Risultati. Si è riscontrata espressione di IRTA1 nel 93% dei linfomi della zona marginale ad insorgenza extranodale e nel 74% di quelli primitivi linfonodali suggerendo la possibilità che questi linfomi possano originare dalle cellule perifollicolari o monocitoidi IRTA1+ riscontrabili nei linfonodi reattivi. La valutazione immunoistochimica mediante doppia colorazione (IRTA1/bcl6), ha inoltre dimostrato come vi sia una modulazione fenotipica nelle cellule marginali neoplastiche nel momento in cui esse colonizzano i follicoli linfoidi e durante la loro circolazione nei centri germinativi. Le cellule marginali neoplastiche che differenziano in senso plasmacellulare perdono l’ espressione di IRTA1 Discussione. In conclusione, tali evidenze hanno permesso di ampliare la conoscenza sulla biologia dei linfomi marginali e sottolineano come IRTA1 sia il primo marcatore diagnostico positivo per queste neoplasie. / Diagnosis of marginal zone lymphomas (MZLs) is based on morphological criteria and negativity for markers characteristically detectable in other B-cell lymphomas. Searching for a molecule specifically associated to MZLs, we immunostained 2,104 peripheral lymphomas of various types with a monoclonal antibody against IRTA1 that recognizes the equivalents of marginal zone in human lymphoid tissues other than spleen. IRTA1 expression was mostly restricted to extranodal (93%) and nodal MZLs (73%) and to lymphomas with marginal zone differentiation. Extranodal MZL cells with the strongest IRTA1 expression were usually located adjacent to epithelia, mimicking the IRTA1 expression pattern of normal and acquired mucosa-associated lymphoid tissue (MALT). The cytological features, growth pattern and IRTA1 positivity we observed in nodal MZLs suggest they may derive from the IRTA1+ perifollicular B-cells or monocytoid B-cells detectable in reactive lymph nodes. Double immunostaining for IRTA1/BCL6 allowed to track colonization of B-cell follicles by MZL cells and to document modulation of their phenotype (e.g. acquisition of BCL6) during recirculation through germinal centers. MZL cells differentiating to plasma cells usually lost IRTA1. These results further expand our knowledge on the biology of MZLs and highlight IRTA1 as the first positive marker for MZLs, enabling more accurate diagnosis of these neoplasms.

Il trapianto allogenico di cellule staminali emopoietiche è spesso l’unica soluzione per la cura di diverse malattie ematologiche. La aGVHD è la complicanza più importante che si può avere a seguito del trapianto allogenico ed è causata dai linfociti T del donatore che riconoscono gli antigeni del ricevente presentati dalle APC. Eliminare o inattivare la APC del ricevente prima del trapianto potrebbe prevenire la aGVHD. Ad oggi non esistono farmaci specifici diretti contro le APC, sono però noti i meccanismi molecolari coinvolti nella sopravvivenza cellulare come la via di segnale di PI3K. In questo lavoro abbiamo testato l’attività di due farmaci, che colpiscono target molecolari della via di PI3K, la rapamicina e la perifosina, sul differenziamento dei monociti a differenti popolazioni di cellule dendritiche (DC), in vitro. La rapamicina riduceva il recupero cellulare delle DC derivate da monociti coltivate in presenza di IL-4 aumentando l’apoptosi, mentre i monociti coltivati in presenza di GM-CSF con o senza IFN-α risultavano resistenti alla rapamicina. Inoltre la rapamicina riduceva l’espressione della molecola costimolatoria CD86 e incrementava l’espressione della molecola CD1a solo nei monociti coltivati con GM-CSF e IL-4. Nelle DC derivate dai monociti in presenza di IL-4 la rapamicina bloccava la produzione di IL-12 e TNF-α e ne alterava la capacità allostimolatoria. La rapamicina non alterava la sopravvivenza e la funzione delle DC circolanti. Il trattamento con perifosina provocava un incremento di apoptosi nei monociti coltivati sia con GM-CSF che con GM-CSF e IL-4. La perifosina bloccava la produzione di TNF-α nelle DC derivate da monociti coltivati nelle diverse condizioni. Questi risultati dimostrano che l’azione della rapamicina è strettamente dipendente dalla presenza dell’IL-4 nel terreno di coltura, in vitro, rispetto alla perifosina e suggeriscono un possibile ruolo della perifosina nella prevenzione della GVHD prima del trapianto allogenico di cellule staminali. / Allogeneic transplantation of hematopoietic stem cells (HTSC) is the most effective curative option for many neoplastic hematological disease. Acute graft versus host disease (aGVHD) is the most feared complication following HTSC and is caused by donor lymphocytes recognizing recipient histocompatibility antigen presented by antigen-presenting cells (APC). Removal or inactivation of APC before transplantation prevents GVHD. Nowadays there are no drugs specifically targeting APC. The molecular mechanisms involved in cell growth of these cells are well known and mostly involve the activation of the PI3K signaling pathway. In this study we tested the effects of two drugs targeting the PI3K pathway, rapamycin and perifosine on the differentiation of monocytes to distinct DC subtypes in vitro. Rapamycin decreased the recovery of monocyte-derived DC cultured in presence of IL-4 due to increased apoptosis, while monocytes cultured in GM-CSF with or without IFN-α were not affected. Rapamycin decreased the expression of the costimulatory molecules CD86 and increased the expression of CD1a in monocyte-derived DC, only in presence of IL-4. Moreover, rapamycin blocked the secretion of IL-12 and TNF-α and altered the allostimulatory capacity only in monocytes cultured with IL-4. Rapamycin didn’t alter the survival and function of circulating DC. Treatment with perifosine was associated with increased apoptosis of monocytes cultured both with GM-CSF only or with GM-CSF and IL-4. Perifosine blocked the secretion of TNF-α by monocytes cultured with GM-CSF only and with GM-CSF and IL-4 after 3 days of culture. These results suggest that the action of rapamycin is more strictly dependent on IL-4 than perifosine, suggesting a possible use of perifosine in the prevention of GVHD before HSCT.

In Leukemias, recent developments have demonstrated that the Hedgehog pathway plays a key-role in the peculiar ability of self renewal of leukemia stem cells. The aim of this research activity was to investigate, through a first in man, Phase I, open label, clinical trial, the role and the impact, mainly in terms of safety profile, adverse events and pharmacokinetics, of a Sonic Hedgehog inhibitor compound on a population of heavely pretreated patients affected by AML, CML, MF, or MDS, resistant or refractory to standard chemotherapy. Thirty-five patients have been enrolled. The drug was administered orally, in 28 days cycles, without rest periods. The compound showed a good safety profile. The half life was of 17-35 hours, justifying the daily administration. Significant signs of activity, in terms of reduction of bone marrow blast cell amount were seen in most of the patients enrolled. Interestingly, correlative biological studies demonstrated that, comparing the gene expression profyiling signature of separated CD34+ cells before and after one cycle of treatment, the most variably expressed genes were involved in the Hh pathway. Moreover, we observed that many genes involved in MDR (multidrug resistance)were significantly down regulated after treatment. These data might lead to future clinical trials based on combinatory approaches, including, for instance, Hh inhibitors and conventional chemotherapy.

L'outcome dei pazienti sottoposti a trapianto allogenico di cellule staminali emopoietiche è fortemente influenzato da graft versus leukemia (GvL) e graft versus host disease (GvHD) che sono mediate, almeno in parte, dagli antigeni minori di istocompatibilità (mHAgs). In letteratura sono stati identificati 26 mHAgs che sono stati correlati a GvHD/GvL con risultati incompleti e in alcuni casi contrastanti; inoltre manca una metodica che sia in grado di genotipizzare contemporaneamente un pannello così ampio. Il lavoro è stato finalizzato alla preparazione di un protocollo di laboratorio che permetta di studiare in modo efficace i 26 mHAgs identificati, per poi correlarli con GvHD/GvL all’interno di uno specifico gruppo di trapiantati. Utilizzando la metodica IPlex Gold Mass Array Sequenom e tecniche di biologia molecolare convenzionale sono stati genotipizzati 26 antigeni minori di istocompatibilità per 46 coppie full-matched. Tutti i pazienti inclusi nel progetto di studio erano stati sottoposti a trapianto allogenico di cellule staminali emopoietiche da donatore familiare o volontario full-compatibile per leucemia mieloide cronica (n=46) o leucemia acuta linfoblastica Philadelphia positiva (LAL-Ph+, n=24). Il progetto ha confermato l'efficienza (98.6%) e la fattibilità delle metodiche proposte. Dal lavoro è inoltre emerso che, le differenze tra donatore e ricevente a libello mHAgs ACC-1, ACC-4, ACC-5, LB-MTHFD1-1Q, UGT2B17, DPH1, LRH1 potrebbero essere fattori predittivi di GvHD (p<0.05). La seconda evidenza è legata a un trend secondo cui il mismatch per LB-ADIR1 protegge dalla recidiva di malattia, in particolare nei confronti della LAL-Ph+ che è scarsamente responsiva all'allo-immunoterapia. Questo lavoro pilota, la cui casistica deve quindi essere ampliata, ha dimostrato l’efficacia della genotipizzazione con IPlex Gold Sequenom e l’elevato potenziale degli mHAgs sia come fattori predittivi di GvHD che come driver di GvL. / The outcome of allogeneic stem cell transplantation (Allo-SCT) is closely related to graft versus host disease (GvHD) and graft versus leukemia (GvL) effects which, in part, are mediated by mHAgs. Twenty-six mHAgs have been identified and reported to be differently and variably correlated with GVHD or GVL, but a simultaneous method to genotype a so large panel of mHAgs has never been employed. The aim of this work has been to develop a feasible method to genotype all the 26 mHAgs described so far and to test them for their correlation with GVHD and GVL in a group of donor/recipient pairs submitted to allo-SCT. For a multi-genotyping of 23 mHAgs we used iPlex Gold Mass Array technology (3 multiplex). For the other three mHAgs we designed other three assays based on conventional molecular biology. By these methods, we tested the 26 mHAgs in 46 donor/recipient pairs full-matched that underwent allo-SCT (sibling or MUD) because of Philadelphia positive CML (n=46) or ALL-Ph+ (n=24). Maldi-Tof IPlex Gold technology proved a high degree of efficiency (98.6%). As expected, sibling pairs showed most identity of MUD pairs. Notably, donor/recipient mismatch on ACC-1, ACC-4, ACC-5, LB-MTHFD1-1Q, UGT2B17, DPH1, LRH1 can drive GvHD effect (p<0.01). Next we identified that LB-ADIR1 can enhance (p=ns, but there is a trend) GvL effect specially on ALL-Ph+ that is otherwise un-responsible to allo-immunotherapy. Our data generated by a multi-genotype technique confirm the role of mHAgs in addressing GvL (in some cases without GvHD) and suggest that a study of mHAgs could be perfomed before transplant in order to better investigate the role of the known and new mHAgs involved in GvHD and GvL effects.

Sulla base delle evidenze della letteratura (Fenaux, 2009; Lyons, JCO 2009), a partire da Settembre 2004 nel Nostro Istituto sono stati trattati 57 pazienti affetti da Sindrome Mielodisplastica (MDS) mediante terapia demetilante con 5-Azacitidina. Sono stati utilizzati differenti regimi terapeutici a seconda della classe di rischio IPSS: i pazienti a rischio basso/intermedio-1 hanno ricevuto Azacitidina 75 mg/mq/die sottocute per 5 giorni/mese (schema 5) per 8 cicli; i pazienti a rischio alto/intermedio-2 hanno ricevuto Azacitidina 50 mg/mq/die sottocute per 10 giorni/mese (schema 5+2+5) o Azacitidina 75 mg/mq/die per 7 giorni/mese (schema 7) fino a perdita della risposta. Su una casistica totale di 57 pazienti (15 a rischio basso/int-1; 41 rischio alto/int-2), l’87.7% (50 pazienti) sono risultati valutabili. Tra questi le risposte osservate sono state del 68% (34 pazienti), di cui il 14% (7 pazienti) ha ottenuto una Remissione Completa (CR) ed il 54% (27 pazienti) ha ottenuto un Hematologic Improvement (HI). La valutazione della risposta è stata eseguita secondo i criteri dell’International Working Group 2006 (IWG, Cheeson 2006). Le principali tossicità osservate sono state rappresentate da reazioni cutanee locali nel sito d’iniezione, tossicità gastrointestinale (stipsi e/o diarrea), mielotossicità, neutropenia febbrile, sepsi (3 pazienti). Tra i pazienti trattati abbiamo osservato la presenza di risposta ematologica prolungata (≥ 20 mesi) in 10 pazienti (20% dei pazienti valutabili). Inoltre, grazie alla collaborazione con il Dipartimento di Anatomia Umana dell’Università di Bologna (Prof. L. Cocco, Dott.ssa M.Y. Follo), tutti i pazienti trattati sono stati valutati per i livelli di espressione genica e metilazione del gene della fosfolipasi PI-PLC-beta1. I dati biologici così ottenuti sono stati correlati con quelli clinici, evidenziando la presenza di una correlazione tra i livelli di espressione genica e mutilazione della PI-PLC-beta1 e la risposta alla terapia demetilante con 5-Azacitidina. / Based on the evidence of literature (Fenaux 2009; Lyons 2009), from September 2004, in our Institute, 57 patients (pts) with Myelodysplastic Syndrome were treated (MDS) with demethylating therapy. We used 4 different regimens depending on the class of IPSS risk: patients at risk low/int-1 received Azacitidine 75 mg/sqm/day subcutaneously for 5 days/month (AZA 5) for 8 cycles, patients at risk high/int-2 received Azacitidine 50 mg/sqm/day subcutaneously for 10 days/month (AZA 5-2-5) or Azacitidine 75 mg/sqm/day for 7 days/month (AZA 7) until loss of response. On a series total of 57 pts (15 lower risk; 41 higher risk), 87 .7% (50 pts) were evaluable. Among these, responses observed were 68% (34 pts): 14% (7 pts) achieved complete remission (CR) and 54% (27 pts) had a Hematologic Improvement (HI). The assessment of response was performed according to the criteria of the International Working Group 2006 (Cheeson 2006). The main toxicities observed were represented by local skin reactions at the injection site, gastrointestinal toxicity (constipation and/or diarrhea), myelotoxicity, febrile neutropenia, sepsis (3 pts). Among the patients we observed the presence of prolonged hematologic response (≥ 20 months) in 10 pts (20% of evaluable patients). In addition, thanks to the collaboration with the Department of Human Anatomy, University of Bologna (Prof. L. Cocco, Dr. Follo MY), all patients were evaluated for levels of gene expression and gene methylation of phospholipase PI PLC- ß 1. The biological data obtained were correlated with clinical, highlighting the presence of a correlation between the levels of gene expression and mutilation of PI-PLC-ß1 and response to therapy with demethylating 5-Azacitidine.

Abnormal Hedgehog signaling is associated with human malignancies. Smo, a key player of that signaling, is the most suitable target to inhibit this pathway. To this aim several molecules, antagonists of Smo, have been synthesized, and some of them have started the phase I in clinical trials. Our hospital participated to one of these studies which investigated the oral administration of a new selective inhibitor of Smo (SMOi). To evaluate ex vivo SMOi efficacy and to identify new potential clinical biomarkers of responsiveness, we separated bone marrow CD34+ cells from 5 acute myeloid leukemia (AML), 1 myelofibrosis (MF), 2 blastic phases chronic myeloid leukemia (CML) patients treated with SMOi by immunomagnetic separation, and we analysed their gene expression profile using Affimetrix HG-U133 Plus 2.0 platform. This analysis, showed differential expression after 28 days start of therapy (p-value ≤ 0.05) of 1,197 genes in CML patients and 589 genes in AML patients. This differential expression is related to Hedgehog pathway with a p-value = 0.003 in CML patients and with a p-value = 0.0002 in AML patients, suggesting that SMOi targets specifically this pathway. Among the genes differentially expressed we observed strong up-regulation of Gas1 and Kif27 genes, which may work as biomarkers of responsiveness of SMOi treatment in CML CD34+ cells whereas Hedgehog target genes (such as Smo, Gli1, Gli2, Gli3), Bcl2 and Abca2 were down-regulated, in both AML and CML CD34+ cells. It has been reported that Bcl-2 expression could be correlated with cancer therapy resistance and that Hedgehog signaling modulate ATP-binding (ABC) cassette transporters, whose expression has been correlated with chemoresistance. Moreover we confirmed that in vitro SMOi treatment targets Hedgehog pathway, down-regulate ABC transporters, Abcg2 and Abcb1 genes, and in combination with tyrosine kinase inhibitors (TKIs) could revert the chemoresistance mechanism in K562 TKIs-resistant cell line.