We evaluated the safety of adding rituximab 375 mg/m2 only on days +1 and +8 following allo-HCT in 18 patients (M=12, F=6), median age 56 (41–66) years, with advanced CD20+ lymphoid malignancies ...CLL=9 (CR2=3, PR2=3; ≥PR3=3); Mantle cell lymphoma (MCL)= 5 (CR1=1, PR2=2, ≥PR3=2); follicular (FL)=3 (CR3=2, ≥PR3=1); DLBC NHL=1 (≥PR3=1). Source of stem cells consisted of matched-related (MRD)=11 (61%), matched-unrelated (MUD)=5 (28%), or mismatched-unrelated (MMUD)=2 (11%) donors. Conditioning regimens consisted of fludarabine plus targeted doses of IV busulfan (FLU-BU) (N=11) or 200 cGy TBI (N=4), or cyclophosphamide (FLU-CY) (N=1). ATG was administered on days −3 and −1 in 2 MMUD cases (FLU-BU-ATG). Fifteen patients received rituximab on day +1 (±3) and all on day +8 (±3). GVHD prophylaxis was tacrolimus plus mycophenolate mofetil (N=11) or methotrexate (N=7). Non-relapse mortality at 100 days was 6%. Median time to neutrophils and platelets engraftment was 15 (6–27) days and 12.5 (9–18) days, respectively. Eight patients never dropped platelets below 20,000/uL. Median CD3 and CD33 chimerisms at day +90 (±10) were 89% (50%–100%) and 100% (15%–100%), respectively. DLI was required in 2 patients (FLU-BU=1, FLU-TBI=1) due to poor CD3 engraftment. Response rates after 90 days post allo-HCT, according to diagnosis, were as follows: CLL (evaluable=8/9; CR=7/8; PR=1/8); MCL (evaluable=4/5; CR=4/4); FL (CR=3/3); DLBC (PD=1/1). Twelve (67%) patients remain alive in remission at a median follow up of 9.4 (2.3–42.3) months. The incidence of grade 0,I, II, and III–IV acute GVHD (aGVHD) was 6%, 33%, 50%, and 11%, respectively. Time to onset of aGVHD was 29 (16–77) days. The incidence of chronic GVHD (cGVHD), per NIH consensus criteria, was as follows in 15 evaluable patients: no cGVHD= 27%, mild= 33%, moderate= 13%, and severe=27%. These findings suggest that administration of rituximab 375 mg/m2 only on days +1 and +8 is safe. Response rates are encouraging; but controlled studies will be needed to conclusively determine the effect of post-transplant rituximab on efficacy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Richter syndrome (RS) represents an aggressive disease resulting from transformation of chronic lymphocytic leukemia (CLL) to diffuse large B-cell or Hodgkin lymphoma. In 80% of cases, RS is clonally ...related to CLL. New therapies like ibrutinib have limited efficacy in RS with anticipated median overall survival (OS) of 3.5 months from the time of CLL transformation. Adriamycin-based regimens combined with rituximab represent the standard induction treatment for RS; and those who demonstrate responsive disease are generally offered an allogeneic hematopoietic cell transplant (allo-HCT) despite the lack of randomized controlled studies. Outcomes following allo-HCT in RS are limited to single-institution case series or registry data. We performed a systematic review of the medical literature to assess the totality of evidence pertaining to the efficacy (or lack thereof) of allo-HCT in RS.
We performed a comprehensive search of the medical literature using PubMed/Medline and EMBASE on September 28, 2018. We extracted data on clinical outcomes pertaining to the benefits (complete remission CR, OS and progression-free survival PFS) and harms (relapse and non-relapse mortality NRM), independently by two authors. Our search identified a total of 240 references. Four studies (n= 72 patients) were eligible for inclusion in this systematic review/meta-analysis (Figure 1). Three single-institution studies were from the United States and one data registry study from the European Society for Blood and Marrow Transplantation.
Reduced intensity conditioning (RIC) regimens were more commonly prescribed (n=50, 69.4%) and the cell source was predominantly peripheral blood stem cells (n=54, 75%). Post-allograft pooled CR rate (3 studies, n=47 patients) was 33% (95%CI=4-71%) with high heterogeneity among studies (I2=84.2%). Pooled OS rate (3 studies, n=52 patients) was 54% (95%CI=28-79%) with high heterogeneity among studies (I2=69.8%) (Figure 2); and these 3 studies reported OS at 4-years, 3-years and 2-years, respectively. Pooled PFS (3 studies, n=52 patients) was 30% (95%CI=18-44%) with no heterogeneity among studies (I2=0). Pooled relapse rates (3 studies, n=52 patients) was 28% (95%CI=9-52%) with high heterogeneity (I2=62.7%). Pooled NRM associated with allo-HCT was 24% (95%CI=29.4%) with low heterogeneity (I2=29.4%).
Allo-HCT is an effective treatment for RS with a resulting pooled OS rate (between 2-4 years) of 54%. One study identified age (< 60 years), chemosensitive disease and use of RIC regimens to be associated with better relapse-free survival. Feasibility and efficacy of combining novel therapies +/- donor lymphocyte infusion(s) should be studied to help reduce the risk of post-transplant relapse.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
CD20 is a 33-kD B-cell antigen that is expressed from the early pre–B-cell stage of development and is lost on differentiation of B cells into plasma cells. Because CD20 is expressed strictly by B ...cells, it is an attractive target for B-cell lymphoma therapy. Monoclonal antibodies to CD20 have been used successfully in the treatment of B-cell lymphomas. We hypothesized that a vaccine consisting of CD20 peptide sequences might be capable of inducing an active, specific, humoral immune response to the protein. Vaccine therapy would have the advantage of generating a polyclonal response to the antigen in contrast to the monoclonal response of an infused antibody. Balb/c mice were vaccinated with prototype vaccine constructs that consisted of peptides representing the human or mouse CD20 extracellular sequences conjugated to carrier proteins and mixed with QS21 adjuvant. Sera from the vaccinated mice demonstrated high-titer, specific antibodies to various epitopes on the immunizing peptides in enzyme-linked immunosorbent assay, weaker antibody binding to native CD20 on cells by flow cytometry, and antibody-mediated complement killing of CD20+ cells in some cases. Specific proliferation and secretion of interleukin 4 and interferon γ by mouse spleen cells in response to the immunizing peptides were also demonstrated. Mice vaccinated with the CD20 peptide keyhole limpet hemocyanin conjugates had a 25% decrease in CD19+ splenic B cells relative to control mice. These data indicate that a biologically active, specific immune response to CD20 can be elicited in mice vaccinated with CD20 peptide conjugates.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Hypofibrinogenemia can occur after Chimeric Antigen Receptor (CAR) T-cell therapy and is sometimes associated with cytokine release syndrome. Hypofibrinogenemia is associated with increased risk of ...bleeding as well as thrombosis. Limited literature exists on the incidence, complications and management of hypofibrinogenemia after CAR T-cell therapy.
We analyzed medical records on 148 patients who received CD19-directed CAR T-cell therapy for large B-cell lymphomas between 05/2015 and 09/2019. All patients who had at least one serum fibrinogen level measured in the first 30 days after CAR T-cell infusion were included in the analysis. All patients with serum fibrinogen < 200 mg/dL lowest normal value had data collected on abnormalities in other coagulation parameters including PTT, PT, INR at the time of nadir serum fibrinogen level.
Out of 148 patients, 35 had at least one serum fibrinogen level measured in the first 30 days after CAR T-cell infusion. Nadir serum fibrinogen was < 200 mg/dl in 15/35 patients: 0-100 mg/dl in 9/15 and 100-200 mg/dl in 6/15. At the time of nadir fibrinogen level, 2/15 patients had abnormalities seen in the other 3 coagulation parameters. Of the 15 patients that had serum fibrinogen level < 200 mg/dl, four had a bleeding event and one had a thrombotic event within first 30 days after CAR T-cell infusion but none of these patients had a low fibrinogen level at the time of the bleed. Given concern for increased risk of bleeding, patients with serum fibrinogen level less than 100 mg/dl were given cryoprecipitate infusions. Details of the abnormalities in the coagulation parameters are highlighted in the table.
This study describes in detail, hypofibrinogenemia seen in patients treated with CD19-directed CAR T-cell therapy in lymphoma. None of the patients experienced a major bleeding or thrombotic event with low serum fibrinogen level. These descriptive data may be used by clinicians to inform their management of hypofibrinogenemia seen in CAR T-cell patients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
In patients with lymphoma, third space fluid accumulations may develop or worsen during cytokine release syndrome (CRS) associated with chimeric antigen receptor (CAR) T-cell therapy. Pre-existing ...symptomatic pleural effusions were excluded by the ZUMA-1 trial of axicabtagene ciloleucel (axi-cel) for large B cell lymphoma (LBCL) and variants. The optimal management of effusions that develop before or after axi-cel infusion in LBCL is unknown.
We performed a single center retrospective study evaluating 148 patients receiving CD19 CAR T-cell therapy for LBCL between 05/2015 and 09/2019. We identified all patients who developed pleural, pericardial and peritoneal effusions before (pre-CAR-T) or during the first 30 days after CAR T-cell infusion (post-CAR-T). Clinically relevant effusions were considered symptomatic based upon physician documentation.
Total effusions and symptomatic effusions were noted in 24% (36/148) and 18% (27/148) of patients, respectively. Among 27 patients with symptomatic effusions, 59% (16/27) were pre-CAR-T effusions, 52% (14/27) persisted after day 30, and 44% (12/27) were malignant effusions. Overall, 67% of symptomatic effusions (18/27) were managed with diuretics, 44% (12/27) with a therapeutic thoracentesis or paracentesis and 33% (9/27) were observed with only supplemental oxygen provided. Six patients required pleural or abdominal catheters with a median indwelling duration of 54 (range, 29, 202) days, although 2 of these patients passed away with these indwelling catheters. Among symptomatic effusions developing only post-CAR-T (n=11), time to onset of effusion was median of 5 (range, 2-11) days and none of these patients required interventional drainage. Table 1 differentiates between effusions based on whether they were present (n = 19) or not (n = 17) prior to CAR T cell infusion.
Nearly half of all effusions diagnosed in patients receiving CAR T cell therapy develop after infusion but most can be medically managed. Patients with pre-CAR-T effusions may require procedural drainage or indwelling catheters, as these effusions may persist beyond the acute CRS period.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Cancer associated venous thrombo-embolism (VTE) constitutes major cause of mortality and morbidity in patients with hematological malignancies. There is limited data on the incidence and management ...of VTE in patients receiving chimeric antigen receptor (CAR) T-cell therapy.
We performed a single center retrospective study of 148 patients receiving CD19-directed CAR T-cell therapy for aggressive B-cell lymphomas between 05/2015 and 09/2019 to evaluate the incidence and management of known and new VTE phenomenon between day 0-100 after CAR T-cell infusion.
Prophylaxis with anticoagulation (AC) was utilized in 4% (6/148) of patients between day 0-100 after CAR T-cell infusion. 19% (28/148) had known VTE prior to CAR T-cell infusion and 50% (12/28) of these were still on AC at the time of infusion. Of those on AC for prior VTE at the time of infusion, 50% (6/12) had it held between day 0-100 after CAR T-cell infusion due to low platelet count or risk of bleeding, while the remainder continued without interruption.
A new episode of VTE, between day 0-100, occurred in 11% (16/148) of patients. None of these patients had previous known VTE. Of these, 75% (12/16) started therapeutic AC, however 42% (5/12) had AC held before day 100 after CAR T-cell infusion due to low platelet count or risk of bleeding. None of the patients that continued therapeutic AC in the 2 cohorts had a bleeding event. Details of the thrombotic events and management with AC are shown in the table.
This is the first study to our knowledge that describes in detail the incidence and characteristics of VTE and use of AC in lymphoma patients receiving CAR T-cell therapy. Most patients were managed with AC without complications of recurrent VTE or bleeding.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Intracellular processing of the breakpoint products of the bcr-abl fusion gene may generate novel peptides that, if capable of binding to HLA class I molecules, would be potential targets for a ...cytotoxic T lymphocyte (CTL) response. In humans, peptides derived from the e1a2 p190 breakpoint have generated peptide-specific MHC class II proliferative responses. Short peptides have shown binding to MHC class I molecules, although processing and presentation of endogenous p190 protein has not been shown. In a Kd Balb/c mouse model, we tested the hypothesis that single, key amino acids near the breakpoint could be the reason of lack of immunogenicity of the p190 breakpoint peptides. We synthesized a native peptide from the 190 breakpoint (AFHGDAEAL) as well as a synthetic mutated peptide (AYHGDAEAL), which showed excellent predicted binding on the BIMAS algorithm (1152 and 2880 respectively), although in vivo experiments did not show any specific CTL response. In order to assess if the lack of immunogenicity in vivo was due to the absence of binding to the MHC class I molecule rather than to poor TCR interactions, we designed a series of peptides where neutral amino acid, alanine, substitutions were introduced at different potential binding sites in the synthetic peptide: at position three (AYAGDAEAL), position four (AYHADAEAL), position five (AYHGAAEAL) and position seven (AYHGDAAAL). The binding of these altered peptides to H2 class I was assessed using a MHC stabilization assay on T2-Kd cells (TAP deficient cells). In spite of the good computer prediction for binding the MHC stabilization assay did not show evidence of binding of the native and synthetic peptides (<1.9 over the background). In contrast, alanine substitution in position five resulted in the best binding (3.5x over the background). Alanine substitutions in positions three, four and seven also showed improved binding to Kd molecules (2.6x, 3.1x and 3x over the background respectively). These results were confirmed by immunization in vivo with these altered peptides. Only the peptide with the alanine substitution in position five generated a immune response in a CD8 gamma-IFN Elispot assay. Since the altered peptides with the alanine substitutions in positions three, four and seven have shown binding to the Kd molecules, but not a CTL response, change of the aspartic acid in position five near to the fusion breakpoint allows appropriate presentation and recognition of the sequence by the TCR.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Major Histocompatibility Complex class I (MHC-I) molecules present antigenic peptides to T cells on the cell surface as a prerequisite for stimulating cytotoxic T cell response. Thus, the ability to ...reliably identify the peptides that can bind to MHC molecules is of practical importance for rapid vaccine development. Several computer-based prediction methods have been applied to study the interaction of MHC class I/peptide binding. Here we have compared three of the most commonly used predictive algorithms BIMAS, SYFPEITHI and Rankpep with actual binding of HLA-A*0201 peptides in vitro. Forty six HLA-A*0201 peptides were selected from several target oncoproteins: Wilms' tumor (WT1), native and imatinib- mutated bcr-abl p210 and JAK2 protein. Experimental peptide binding to HLA-A*0201 was assessed using a MHC stabilization assay on T2, TAP deficient cells. Peptides were considered to show positive in vitro binding if the mean fluorescence was at least 50 % of the binding of a high affinity reference peptide. Peptides qualified as positive in vitro if the BIMAS score was ≥ 100, the SYFPEITHI score ranked ≥ 24 or the Rankpep was ≥ 50. Results are summarized below:
BIMASSYFPEITHIRANKPEPSensitivity84 %72 %60 %Specificity76 %71 %81 %Positive Predictive Value84 %72 %60 %Negative Predictive Value80 %68 %63 %
Combining two or more computer methods did not appear to improve the predictive value. In conclusion, of the three predictive algorithms, the best correspondence with the actual MHC binding was demonstrated with the BIMAS algorithm. Predictive computer algorithms are important for preselection of potential T-cell epitope candidates for the application in vaccine design.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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