Summary
The safety and activity of the multikinase inhibitor sorafenib were investigated in patients with relapsed or refractory lymphoproliferative disorders who received sorafenib (400 mg) twice ...daily until disease progression or appearance of significant clinical toxicity. The primary endpoint was overall response rate (ORR). Biomarkers of sorafenib activity were analysed at baseline and during treatment. Thirty patients (median age, 61 years; range, 18–74) received a median of 4 months of therapy. Grade 3–4 toxicities included hand/foot skin reactions (20%), infections (12%), neutropenia (20%) and thrombocytopenia (14%). Two patients achieved complete remission (CR), and two achieved partial remission (PR) for an ORR of 13%. Stable disease (SD) and progressive disease (PD) was observed in 15 (50%) and 11 patients (37%), respectively. The median overall survival (OS) for all patients was 16 months. For patients who achieved CR, PR and SD, the median time to progression and OS was 5 and 24 months, respectively. Compared with patients with PD, responsive patients had significantly higher baseline levels of extracellular signal‐regulated kinase phosphorylation and autophagy and presented a significant reduction of these parameters after 1 month of therapy. Sorafenib was well tolerated and had a clinical activity that warrants development of combination regimens.
Background: Patients with R/R HL, failing to achieve a complete remission (CR) or a good partial remission (PR) after conventional dose salvage chemotherapy as well as those having severe ...comorbidities or advanced age, are generally ineligible for a transplant procedure. Furthermore approximately 50% of the patients able to proceed to ASCT, will eventually relapse and will need effective treatment to proceed to alloSCT. BV is a safe and highly effective treatment in R/R HL after ASCT and 75% objective remissions have been reported . Limited data exist regarding BV in transplant naive R/R HL or in R/R HL after ASCT. The aim of our retrospective study was to assess the efficacy and tolerability of BV in R/R HL patients, treated at a single institution, the Istituto Nazionale Tumori of Milan Italy (INT-MI).
Methods: Patients with R/R CD30-positive HL, treated with BV between January 2011 and April 2014 for failure of at least two prior therapies, when ASCT was not considered a treatment option (Group A), or for failure following ASCT (Group B), were included in this retrospective analysis. BV was given at the standard dose of 1.8 mg/kg iv every 21 days. The study protocol was approved by the ethical committee of INT-MI. The primary endpoint of this study was to evaluate efficacy of BV in obtaining FDG-PET remission and in enabling patients to proceed to ASCT or alloSCT. Secondary endpoints included BV toxicity, Progression-free Survival (PFS) and Overall Survival (OS).
Results: Sixteen R/R HL patients for Group A (ASCT-ineligible) and 10 patients for Group B (ASCT failures) were identified. Main characteristics at start of BV were as follows: TableCharacteristicsGroup A (n=16)Group B (n=10)Males/Females7/92/8Median age (range) yrs40 (22-72)43 (13-63)B Symptoms54Stage III-IV87Extra ± nodal involvement85³ 3 involved sites63Bulky disease (>7 cm)4 (1 na)2ECOG PS 0/1/27/7/24/4/1 (1 na)Refractory/relapsed after front-line therapy11/57/3Median number prior regimens (range)4 (2-12)4 (3-9)
Median time from HL diagnosis to BV therapy start was 19 months (range, 8-330) in Group A and 24 months (range, 16 to 254)in Group B, respectively. A median of 6 BV cycles (range, 3 to 19) were administered. Overall response rate in Group A and B was 87.5% and 60%, respectively; CR was documented in 8 patients (50%) in Group A and 2 patients (20%) in Group B. Best response was reported after a median of 3 cycles (range, 2-9). Three patients in Group A and 1 in group B, achieving a negative PET scan, by continuing BV therapy, had PD and were considered transplant ineligible. BV enabled 3 patients in Group A and 1 patient in Group B, achieving CR , to receive a transplant procedure. Moreover two complete responders in Group A underwent ASCT, although PET scan before transplant documented the reappearance of FDG-avid lesions; they are both alive in CR after 14 and 7 months from ASCT, respectively. Two pts in Group B, achieving a PR, underwent alloSCT and relapsed 6 and 11 months after transplant, respectively. Six patients (23%) had grade 3 or higher adverse events (1 sensory peripheral neuropathy, 5 hematological toxicities), no patient discontinued treatment due to toxicity. After a median follow-up of 15 months (range, 3 to 36) since the first BV cycle, median PFS was 5 months and median OS was still not reached.
Conclusions: These data confirm that BV is highly effective in R/R transplant ineligible HL patients, who have generally limited conventional treatment options and a low median OS. BV may overcome chemorefractoriness and enable patients to receive ASCT or allo-SCT, while omitting the significant toxicity of multiagent chemotherapy regimens.
Viviani:Takeda: Consultant for 40th EBMT Symposium Other.
Adenovirus-transduced CD34+ cells expressing membrane-bound tumor necrosis factor–related apoptosis-inducing ligand (CD34-TRAIL+ cells) exert potent antitumor activity. To further investigate the ...mechanism(s) of action of CD34-TRAIL+ cells, we analyzed their homing properties as well as antitumor and antivascular effects using a subcutaneous myeloma model in immunodeficient mice. After intravenous injection, transduced cells homed in the tumor peaking at 48 hours when 188 plus or minus 25 CD45+ cells per 105 tumor cells were detected. Inhibition experiments showed that tumor homing of CD34-TRAIL+ cells was largely mediated by vascular cell adhesion molecule-1 and stromal cell–derived factor-1. Both CD34-TRAIL+ cells and soluble (s)TRAIL significantly reduced tumor volume by 40% and 29%, respectively. Computer-aided analysis of TdT-mediated dUTP nick end-labeling–stained tumor sections demonstrated significantly greater effectiveness for CD34-TRAIL+ cells in increasing tumor cell apoptosis and necrosis over sTRAIL. Proteome array analysis indicated that CD34-TRAIL+ cells and sTRAIL activate similar apoptotic machinery. In vivo staining of tumor vasculature with sulfosuccinimidyl-6-(biotinamido) hexanoate-biotin revealed that CD34-TRAIL+ cells but not sTRAIL significantly damaged tumor vasculature, as shown by TdT-mediated dUTP nick end-labeling+ endothelial cells, appearance of hemorrhagic areas, and marked reduction of endothelial area. These results demonstrate that tumor homing of CD34-TRAIL+ cells induces early vascular disruption, resulting in hemorrhagic necrosis and tumor destruction.
INTRODUCTION: Secondary central nervous system (CNS) dissemination is a lethal event in patients (pts) with aggressive lymphomas. A few studies focused on the treatment of this condition are ...available, confirming the dismal prognosis and the high rate of severe neurotoxicity in pts managed with radiotherapy-based induction. Thus, the most effective treatment for secondary CNS lymphoma remains an important, unmet clinical need. Herein, we report the final results of a multicenter phase II trial addressing a new treatment in pts with aggressive B-cell lymphoma and CNS involvement (NCT00801216). Experimental treatment is based on the encouraging experiences with high doses of antimetabolites in pts with primary CNS lymphoma (Ferreri et al. Lancet 2009), and with high-dose sequential chemotherapy combined with rituximab (R-HDS) and supported by autologous stem cell transplant (ASCT) in pts with relapsed aggressive B-cell lymphoma (Tarella et al. JCO 2008).
METHODS: Selection criteria were: 1) histological diagnosis of diffuse large B-cell lymphoma (DLBCL), mantle cell lymphoma blastoid variant (MCLb) or grade-3 follicular lymphoma (FL); 2) secondary CNS involvement at diagnosis or relapse; 3) age 18-70 years; 4) ECOG PS ≤3; 5) absence of HIV infection; 6) adequate organ functions. Pts with primary CNS lymphoma (exclusive CNS disease at diagnosis) were excluded. Experimental treatment consisted of an induction phase with 2 courses of methotrexate 3.5 g/m2 d1 + cytarabine 2 g/m2 x2/d d2-3, followed by an intensification phase with R-HDS (cyclophosphamide 7 g/m2 d1; cytarabine 2 g/m2 x2/d d22-25; pts with residual extra-CNS disease received also etoposide 2 g/m2 d43) and a consolidation phase with BCNU-thiotepa conditioning + ASCT (figure). Treatment included 8 doses of rituximab and 4 of intrathecal liposomal cytarabine. The primary endpoint was 2-year PFS; the planned accrual was 38 pts.
RESULTS: 39 pts were registered (age 32-70 ys, median 59; M/F ratio 1.5): 33 had DLBCL, 3 MCLb, 3 FL. CNS disease (brain 21, meninges 5, spinal cord 2, multiple 11) was detected at diagnosis in 16 pts (all with extra-CNS disease) and at relapse in 23 (8 with extra-CNS disease). The median TTP from the previous treatment line was 3 months (range 0-77 months).
Thirty-four pts completed the induction phase; 73 (93%) of 78 planned courses were actually delivered; G4 neutropenia, thrombocytopenia and anemia were recorded in 77%, 63% and 5% of courses, G3-4 febrile neutropenia in 16%, CMV reactivation in 3 pts. Transient G4 transaminases increase (3% of courses) was the only G4 non-hematological toxicity. Drugs dose reduction was indicated in 3 pts. Response after induction phase was complete in 11 pts and partial in 19 (ORR= 77%; 95%CI=64-90%).
Thirty pts were referred to intensification phase (figure); 58 (97%) of 60 planned courses were actually delivered; G4 neutropenia, thrombocytopenia and anemia were recorded in 67%, 60% and 7% of courses, G3-4 febrile neutropenia in 22%, G4 sepsis in 8%. CMV reactivation was diagnosed in 4 pts, pulmonary aspergillosis in 1. No cases of G4 extra-hematological toxicity were recorded. Response after intensification phase (before conditioning) was complete in 22 pts and partial in 2 (ORR= 62%; 95%CI=47-77%). ASCs were collected in 21/22 (95%) pts (median 9.5 x 106/kg; range 6-19); 20 pts underwent ASCT. Response at the end of the whole program was complete in 23 pts and partial in 1 (ORR= 62%, 95%CI= 47-77%), 1 pt had SD, 10 experienced PD (all in the CNS), and 4 died of toxicity (sepsis 2, stroke, acute tracheal obstruction). Importantly, no pt was irradiated to the brain to achieve lymphoma remission, and no evidence of neurotoxicity was recorded in pts with a survival longer than 3 years. One pt was referred to sibling-donor transplant due to sMDS, and is alive and NED at 91 months of follow-up.
At a median follow-up of 42 months, 16 pts remain relapse-free, with a 2-yr PFS of 42±8%. Sixteen pts are alive, with a 2-yr OS of 42±8%; 2-yr OS of transplanted pts was 72±11%. Extra-CNS and/or meningeal disease did not affect outcome, and survival was similar in both pts treated at presentation or at relapse.
CONCLUSION: This radiotherapy-free combination of high doses of antimetabolites, R-HDS and ASCT is feasible and effective in pts ≤70 ys with secondary CNS lymphoma. Toxicity is usually haematological and manageable. Survival benefit is attainable also in pts with meningeal and/or concomitant extra-CNS disease.
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No relevant conflicts of interest to declare.
Abstract 1562
Our previous findings have made it clear that the significant clinical efficacy attained by dendritic cell-based vaccination in relapsed B-cell non-Hodgkin lymphoma (B-NHL) patients is ...firmly associated with multifaceted immunologic responses, including the development of anti-heat shock protein (HSP)105 humoral immunity (Di Nicola et al., Blood 2009 113:18–27; Zappasodi et al., Cancer Res. 2010 70:9062–9072; Zappasodi et al., Blood 2011 118:4421–4430). Human HSP105 is a high-molecular-weight chaperone constitutively expressed at low levels within the cytoplasm, and can also be induced in the nucleus by various forms of stress. It is overexpressed in several solid tumors, including melanoma, breast, thyroid and gastroenteric cancers. We have recently shown that this is also true for B-NHLs, in which HSP105 levels increase in function of their aggressiveness and proliferation index (Zappasodi et al., Blood 2011 118:4421–4430). Accordingly, in normal lymph nodes HSP105 expression is confined to the hyper-proliferating germinal center (GC) B cells, suggesting its involvement in the potentially oncogenic GC reactions.
We have now set out to clarify the functional role of HSP105 in B-NHLs by stably silencing its expression in the Namalwa aggressive lymphoma cell line. Namalwa cells were infected by using a lentiviral vector carrying a HSP105-targeting pre-microRNA sequence and the Emerald Green Fluorescent Protein (EmGFP) gene, both under the human cytomegolovirus immediate early promoter, as well as the blasticidin resistance gene. Control cells were mock-infected with the empty vector. Infected cells were initially selected in the presence of blasticidin, and then single GFP+ cells were sorted on a flow cytometry device. In this way, we achieved 100% GFP+ subclones that displayed a specific constitutive down-regulation of HSP105, as there was no significant decrease in the expression of its cognate molecular homolog HSP70, or the other major cellular chaperone HSP90. Comparison of the in vitro proliferation rate of two silenced clones with that of the mock culture showed that the cell doubling time of both clones significantly increased and their in vitro growth was accordingly delayed (P= 0.01 and P= 0.04). Western blot analysis in 6 different silenced clones of the oncoproteins most frequently involved in B-NHLs revealed that BCL-6 and c-Myc were down-regulated in function of HSP105 knockdown levels, whereas in mock cells no modifications were detected with respect to their wild-type counterparts. Further strengthening the association between HSP105, BCL-6 and c-Myc expression, immunohistochemistry analysis of 50 primary human aggressive B-NHLs revealed that HSP105 expression, measured both as intensity and percentage of positive cells, was significantly higher in c-Myc- or BCL-6-dependent Burkitt (P= 0.0264) and diffuse large B-cell lymphomas (P= 0.0068) respectively than in other aggressive istotypes that do not overexpress these oncoproteins. These findings support the potential pro-tumorigenic cooperation of HSP105 with BCL-6 and c-Myc transcription factors. To find out whether counteracting HSP105 functions hampers in vivo lymphoma growth, we evaluated the tumor-forming capability of HSP105-silenced (siHSP105) or mock Namalwa cells subcutaneously injected into severe combined immunodeficient mice at serial 10-fold dilutions from 106 to 104 cells/injection (Figure 1). We found that HSP105 knockdown slightly delayed in vivo Namalwa tumor formation when 106 and 105 cells were injected. Noteworthy, no lesions appeared over 70-day observation in mice inoculated with 104 siHSP105 cells, whereas palpable tumors were present in 67% of the animals 24 days after injection of the mock cells (Figure 1).
Overall, these results indicate that HSP105 may be a per se nononcogenic molecule that contributes to lymphomagenesis by facilitating the tumorigenic functions of key oncoproteins. They equally provide the rationale for developing HSP105 inhibitors as a novel strategy for improving the treatment of aggressive B-NHLs.
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Gianni:Hoffmann-La Roche: Consultancy, Honoraria.
The introduction of high-dose (HD) chemotherapy (CT) and autologous stem cell (ASCT) or bone marrow transplant (ABMT) in the last two decades has improved the prognosis of patients with refractory or ...relapsed Hodgkin lymphoma (HL) over conventional-dose salvage CT. To evaluate the outcome of adult patients with HL treated with HD CT and ASCT or ABMT after failure or relapse from first-line treatment with CT ± radiotherapy, we report the results of a retrospective analysis in 82 consecutive patients given HD CT and autologous transplant as second-line therapy between October 1984 and December 2006. Thirty-two patients were given sequential high-dose cytoreductive therapy while 50 received other conventional induction regimens. Seventy-three patients with chemoresponsive disease underwent the myeloablative phase, while eight patients had progressive disease during cytoreductive CT. After a median follow-up of 73 months, the 10-year progression-free survival (PFS) and overall survival (OS) were 57% and 51%, respectively. According to response to first-line treatment, PFS and OS were, respectively, 54% and 82% for patients with complete remission (CR) lasting 12 months or more; 49% and 51% for patients with CR less than 12 months; and 47% and 50% for patients who never achieved CR or progressed during first-line CT (induction failure). Response to cytoreductive CT significantly influenced outcome, with PFS and OS being, respectively, 56% and 68% vs. 44% and 47% (p = 0.009) in patients in CR versus patients not in CR after induction therapy. Treatment was well tolerated, and therapy related mortality was only 3.7%. These long-term results confirm that HD CT and ASCT or ABMT was feasible, safe, and very effective. Therefore, this therapeutic strategy may represent an active salvage approach even in the unfavorable group of patients with induction failure.
We have evaluated, as a vector for gene transfer into human T lymphocytes, a recombinant adenovirus (rAd-MFG-AP) carrying a modified, membrane-exposed, alkaline phosphatase (AP) as reporter gene. ...CD3+ cells were selected from the buffy coat of healthy donors by the immunomagnetic technique. The positive cell population, comprising 96+/-2% CD3+ cells, was cultured with clinical-grade cytokine(s) for 3-7 days prior to rAd-MFG-AP transduction and the transgene expression was evaluated 48 hr later by indirect immunofluorescence flow cytometry assay with an anti-alkaline phosphatase antibody. The best efficiency of transduction was achieved on incubation of CD3+ cells with IL-2 plus either IL-12 (AP+ cells, 12+/-3%) or IL-7 (AP+ cells, 11+/-3%). To increase further the efficiency of transduction, we have combined LipofectAMINE and rAd-MFG-AP with the aim to enhance the uptake of viral particles into the target cells. The percentage of CD3+ cells transduced by rAd-MFG-AP-LipofectAMINE complex was 24+/-4% (range, 20-35%) after incubation with IL-2 plus IL-7 and 22+/-4% (range, 18-32%) after incubation with II-2 plus IL-12. Forty-eight hours after the incubation with rAd-MFG-AP, the transduced T lymphocytes were subjected to fluorescence-activated cell sorting and fractionated into AP+ and AP- cell subpopulations. The AP+ cell fraction, comprising 96.8% of AP+ cells, was evaluated by FACScan analysis for T lymphocyte surface antigens. The immunophenotyping of the transduced T lymphocytes has shown that there was not a particular subtype of T lymphocytes more susceptible to rAd-MFG-AP transduction. In addition, the transgene expression did not modify T lymphocyte functions, as demonstrated by results obtained by cytotoxicity assay before and after rAd-MFG-AP-LipofectAMINE complex transduction. In conclusion, human T lymphocytes can be efficiently transduced, under clinically applicable conditions, by adenovirus-LipofectAMINE complex after 7 days of culture with IL-2 and IL-12 or IL-7.
We compared a regimen of six chemotherapeutic agents administered sequentially at high doses, followed by myeloablative treatment and bone marrow transplantation, with a regimen of methotrexate, ...doxorubicin, cyclophosphamide, vincristine, prednisone, and bleomycin (MACOP-B) as initial or salvage treatment for adults with diffuse large-cell lymphoma.
Ninety-eight eligible patients with diffuse large-cell lymphoma of the B-cell type were randomly assigned to receive either MACOP-B (50 patients) or high-dose sequential therapy (48 patients). The study design allowed for patients in whom the assigned treatment failed to cross over to the other treatment group.
After a median follow-up of 55 months, the patients given high-dose sequential therapy, as compared with those treated with MACOP-B, had significantly higher rates of complete response (96 percent vs. 70 percent, P=0.001), freedom from disease progression (84 percent vs. 49 percent, P<0.001), freedom from relapse (88 percent vs. 70 percent, P=0.055), and event-free survival (76 percent vs. 49 percent, P=0.004). The difference in overall survival at seven years, which also favored the group assigned to high-dose sequential therapy, was marginally significant (81 percent vs. 55 percent, P=0.09).
High-dose sequential therapy is superior to standard-dose MACOP-B for patients with diffuse large-cell lymphoma of the B-cell type.
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