Clonal hematopoiesis of indeterminate potential (CHIP) is suspected of being a risk factor for patients with cancer. This study aimed to assess the clinical consequences of CHIP in patients with ...lymphoma intended for high-dose chemotherapy and autologous stem-cell transplantation (ASCT) in a population-based setting. We identified 892 lymphoma patients who had undergone stem cell harvest at all transplant centers in Denmark. A total of 565 patients had an available harvest sample, which was analysed for CHIP by next-generation sequencing, and the median follow-up was 9.1 years. Of the patients who were intended for immediate ASCT, 25.5% (112/440) carried at least one CHIP mutation. In contrast to previous single-center studies CHIP was not associated with inferior overall survival (OS) in multivariate analyses. However, patients with mutations in genes of the DNA repair pathway (PPM1D, TP53, RAD21, BRCC3) had a significant inferior OS (HR after 1 year of follow-up 2.79, 95% confidence interval 1.71-4.56; p < 0.0001), which also was evident in multivariate analysis (p = 0.00067). These patients had also increased rates of therapy-related leukemia and admission to intensive care. Furthermore, in patients who did not undergo immediate ASCT, a significant inferior OS of individuals with DNA repair mutations was also identified (p = 0.003).
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Background:
Somatic driver mutations in hematopoietic cells may lead to clonal hematopoiesis of indeterminate potential (CHIP). In patients with lymphoma CHIP has been associated with increased ...risk of therapy-related myeloid neoplasms (tMN) and inferior survival after autologous stem cell transplantation as demonstrated in a large single center study and in a case-control study (Gibson CJ et al., JCO 2017 and Berger G et al., Blood 2018). Here, we investigated the clinical impact of clonal hematopoiesis in a nation-wide population-based cohort of Danish lymphoma patients undergoing autologous transplant with prospective data from four national patient registries.
Methods:
Patients with lymphoma who had undergone leukapheresis at all danish transplant centers from 2000 to 2012 were identified. DNA and RNA was extracted from mobilized peripheral blood products. Targeted sequencing of all samples was performed using an Illumina TruSeq Custom Amplicon panel (Illumina, San Diego, CA, USA) designed to cover >95% of mutations associated with CHIP (ASXL1, ASXL2, BCOR, BRCC3, CBL, CREBBP, DNMT3A, ETV6, GNB1, IDH1, IDH2, JAK2, KRAS, NRAS, PPM1D, RAD21, SF3B1, SRSF2, TET2, TP53). To allow detection of low-level mutations and secure variant calling, unique molecular identifiers (UMI's) were used. Filtering of variants was done by stringent criteria consistent with earlier studies. Assessment of mutations was performed blinded to the patients' clinical data.
Prospective clinical patient data was obtained for all patients from four national registries, including the Danish Lymphoma Registry (diagnosis, involvement, lymphoma treatment, relapse and death), the Danish National Patient Registry (hospital admission diagnoses and treatments), the Danish Cancer Registry (primary and secondary cancer diagnoses) and the Danish Pathology Database (histopathological examinations and diagnoses), respectively.
Results:
Samples from 574 patients were included. The median age was 55.5 years (IQR: 45.3 - 62.2) and the median follow-up time for survivors was 9.2 years (IQR: 7.1 - 11.2). The lymphoma subtypes were typical of patients selected for autologous transplantation; diffuse large B-cell lymphoma (191 pts), follicular lymphoma (102 pts), mantle cell lymphoma (88 pts), Hodgkin's lymphoma (80 pts), peripheral T-cell lymphoma (77 pts) and other histologies (36 pts). Of the 574 patients analyzed, 191 (33.3%) of the patients had somatic mutations meeting CHIP criteria (total mutations called=210). The most commonly mutated genes were DNMT3A (n=59, 28%), TET2 (n=48, 23%), PPM1D (n=34, 16%), ASXL1 (n=21, 10%) and TP53 (n=18, 8%). As expected CHIP mutations were more frequent in patients above 60 years (p=0.002). Prevalence of CHIP was associated with an inferior overall survival (p=0.004) and event-free survival (p=0.03). It was also associated with increased risk of biopsy-confirmed tMN (p=0.03) and higher probability of receiving blood transfusions after autologous transplant (p=0.027).
Especially patients with mutations in DNA damage response genes PPM1D and TP53 (found in 48 pts, 8.3%) had a significantly increased risk of adverse outcomes. Both overall survival and event-free survival were significantly poorer with the presence of DNA damage pathway mutations (p<0.0001 for both, Figure 1A), as well as risk of tMN (p=0.01). In addition, PPM1D/TP53 mutations were associated with increased rates of any secondary cancer (p=0.004), including non-hematological cancer, and hospital admissions with severe infections (p=0.01, Figure 1B).
The impact of low-level mutations and statistical modelling of interactions between parallel outcomes will be presented at the meeting.
Conclusion:
To our knowledge this is the first population-based study of clonal hematopoiesis in patients with lymphoma. We find that CHIP and particularly mutations in DNA damage response genes (PPM1D/TP53) are associated with increased mortality, which confirms findings from single center studies. These data support the evaluation of CHIP for risk assessment in lymphoma patients before high-dose chemotherapy. Our study also identifies increased rates of several clinically relevant adverse outcomes (severe infections, blood transfusions and secondary cancers) in lymphoma patients with clonal hematopoiesis.
Grønbæk:Janssen Pharma: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Otsuka Pharma: Membership on an entity's Board of Directors or advisory committees.
Background: Aggressive non-Hodgkin lymphoma (aNHL) relapsing after high-dose therapy or, in not transplant-eligible patients, after 1st-line chemotherapy represents an unmet clinical need. Therefore, ...we aimed at evaluating a salvage combination regimen based on pixantrone, an aza-anthracenadione recently approved in Europe for patients with multiply relapsed aNHL. Etoposide and bendamustine were chosen as companion compounds due to available feasibility data in combination with anthracenadions, and a well-documented efficacy in salvage regimens for relapsed aNHL. Rituximab was added, if the relapse tumor biopsy was CD20+.
Aim: The aim of the present analysis was to summarize the preliminary clinical experience with the PREBEN/PEBEN regimen gathered, on a compassionate need basis, at different European sites and representing the platform for a currently ongoing Nordic phase 1/2 trial in relapsed aNHL.
Methods: The adopted schedule consisted of pixantrone 50 mg/m2 i.v. day 1+8, etoposide 100 mg i.v. day 1, bendamustine 90 mg i.v. day 1 with or without the addition of rituximab 375 mg/m2 i.v. day 1 (PREBEN/PEBEN). If feasible, each cycle was given at 3-weekly intervals for a maximum of 6 cycles. All patients were assessed for chemosensitivity with PET/CT, already after cycle 1 or 2. G-CSF support was applied and administered according to local practice.
Results: A total of 30 heavily pre-treated patients (19 males and 11 females, age range 49-81 yrs; mean N of previous regimens: 3, range 1-7) with aNHL were treated according to the PREBEN/PEBEN schedule. Seventeen had diffuse large B-cell (DLBCL), six transformed indolent (tIND), and seven peripheral T-cell lymphoma (PTCL). All patients had intermediate or high risk IPI prior to start of salvage therapy. Eight patients (27%) had a complete metabolic response (CMR) and seven (23%) a partial one (PMR), resulting in an overall response rate (ORR) of 50%. Among the histological subtypes, the patients with DLBCL, PTCL and tIND had an ORR of 53% (CMR 35%), 57% (CMR 14%), and 33% (CMR in one out of two responders), respectively. Most responses were achieved early (prior to course nr. 4). Response durations ranged between 2 and 23+ months. Among the 17 patients with DLBCL, nine were frail, non transplant-eligible with relapsed disease, six had primary refractory lymphoma progressing through anthracycline-containing 1st line and platinum-containing salvage therapies, and two had relapses occurring after a post-transplant remission period. While most of the relapsed patients with DLBCL responded , i.e. seven (five CMR and two PMR) of the nine (78%) frail relapsed patients and one of the two (50%) patients with post-transplant relapses, only one out six (17%) primary refractory patients exhibited some chemosensitivity. Interestingly, four out of seven PTCL patients achieved a PMR or CMR allowing them to undergo non-myeloablative allogeneic transplant with subsequent sustained response durations. The treatment schedule was feasible and most patients received it on an out-patient basis. The most common grade 3-4 toxicity was of hematological type (mainly neutropenia and thrombocytopenia), occurring in 52% of the patients. Grade 3-4 infections were observed at a frequency of 21%. No septic deaths were recorded. A previously anthracycline exposed, heavily pre-treated 60-year old female PTCL patient developed symptomatic congestive heart failure effectively reversed by angiotensin converting enzyme inhibitors with normalization of the myocardial ejection fraction. One previously ibritumomab tiuxetan exposed, heavily pretreated patient with tIND developed acute myeloid leukemia with therapy-related cytogenetic features.
Conclusions: The PREBEN/PEBEN salvage regimen was feasible in a heavily pre-treated cohort of elderly patients with high-risk aNHL. In individual patients it elicited substantial and durable responses early in the course of therapy. In some younger patients, it proved useful as bridging strategy to a non-myeloablative allogeneic transplant. A phase 1/2 study in relapsed (non-refractory) aNHL was launched in June 2016 (ClinicalTrial.gov identifier: NCT02678299; EudraCT number: 2015-000758-39) and is currently accruing (N=5 pr. Aug 1st, 2016).
Clausen:Takeda: Research Funding; Novartis: Other: Travel expences; Abbvie: Other: Travel expences. Leppa:Mundipharma: Research Funding; Roche: Honoraria, Other: Travel expenses, Research Funding; Bayer: Research Funding; Janssen: Research Funding; Takeda: Honoraria, Other: Travel expenses; CTI Life Sciences: Honoraria; Amgen: Research Funding; Merck: Other: Travel expenses. Willenbacher:Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; European Commision: Research Funding. d'Amore:Servier: Honoraria, Other: Advisory Boards; CTI LIfe Sciences: Honoraria, Other: Advisory Boards.
Abstract 4413
Granulocyte colony-stimulating factor (G-CSF; Neupogen) is by far the most commonly used agent for mobilization of stem cells for autologous peripheral blood stem cell transplantation ...(ASCT) of non-Hodgkin lymphoma (NHL), Hodgkin lymphoma (HL), and multiple myeloma (MM) patients. However, up to 30% of the patients will fail to mobilize the targeted amount of CD34+ cells. The addition of plerixafor has been shown to mobilize the stem cells when G-CSF fails to do so. However, no reports have hitherto addressed and compared the biology of the CD34+ stem cells obtained from an inadequate G-CSF mobilization and a subsequent plerixafor administration. Given these considerations, this study was aimed at assessing the proportion of stem cells by means of phenotype and colony-forming potential. Given that CD34 is at best only a surrogate marker for stemness, we here included the aldehyde dehydrogenase (ALDH) activity, an emerging crucial marker in stem cell biology, to evaluate the stem cell pool in paired samples obtained after G-CSF and plerixafor administration.
Cryopreserved samples of peripheral blood mononuclear cells (PBMC) from patients diagnosed with NHL (n=3), MM (n=4), and HL (n=1,) were directly compared. All patients were heavily treated with at least 3 cytoreductive regimens prior to the decision to proceed with ASCT. Different mobilizing regimens were applied, but all received one dose of plerixafor (0.24mg/kg sc) as a result of failed G-CSF mobilization (12mg/kg sc twice daily for 3–5 days). The PBMCs were obtained from the morning CD34+ screening sample taken 1) during G-CSF mobilization, typically 1–2- days before it was substituted with plerixafor, and 2) the morning after the plerixafor injection. The percentages of CD34+CD38+ and CD34+CD38- cells and the percentage of ALDHbright CD34+ cells in the samples of the suboptimal G-CSF mobilization and the matched plerixafor/G-CSF mobilization were analyzed and calculated as percentage of PBMC. These samples were also subjected to semisolid culturing and colonies were quantified after 14 days, where CFU-GEMM, BFU-E, and CFU-GM were enumerated.
We found no significant difference in the percentage of CD34+CD38+ and CD34+CD38- cells in the cell pools recovered from G-CSF (mean 0.68%, SD 0.281 and mean 0.183%, SD 0.095, respectively) and plerixafor mobilization (mean 1.123%, SD 1.143 and mean 0.361%, SD 0.316, respectively) (n=8, Wilcoxon matched-pairs signed rank test, p=0.46 and p=0.15, respectively). Importantly, when comparing the percentage of ALDHbright CD34+ cells (G-CSF: mean 0.071%, SD 0.048. Plerixafor: mean 0.261%, SD 0.298) in the same matching samples the difference between them was not significant (p=0.11). Finally, the numbers of CFU-GEMM (G-CSF: mean 12.13, SD 16.65. Plerixafor: mean 12.5, SD 14.23), BFU-E (G-CSF: mean 2.375, SD 3.926. Plerixafor: mean 4.125, SD 7.06), and CFU-C colonies (G-CSF: mean 9, SD 13.68. Plerixafor: mean 10.5, SD 11.45) originating from the matching G-CSF and plerixafor-mobilized cells were not significantly different (p=0.93, p=0.29, p=1, respectively).
Collectively, these data reveal that in poor G-CSF mobilizers, the ratios of CD34+CD38+ and CD34+CD38- cells to PBMCs were equal in the matching samples recovered from G-CSF and plerixafor mobilization clearly suggesting that successful plerixafor mobilization is the consequence of increased cell release only in otherwise poor mobilizers. Notably, plerixafor and G-CSF caused the release of stem cells with equal degrees of stemness and commitment as measured by ALDH activity, percentages of CD34+ cells, and colony forming potential.
No relevant conflicts of interest to declare.
Abstract Background aims In the autologous setting, granulocyte colony-stimulating factor (G-CSF) (G), or, when failing, G plus plerixafor (G+P), are common regimens for mobilization of stem cells ...into peripheral blood. To delineate mobilization effects on graft composition and hematopoietic recovery, we compared contents of stem cells and progenitor cells in products of G+P- and G patients. Paired samples of G+P patients and prior insufficient G mobilization were available for analyses. Methods Subset analyses of grafts were performed by flow cytometry and myeloid colony-forming assay. In search of new markers to ascertain graft quality, we determined the fractions of aldehyde dehydrogenase bright (ALDHbr ) cells. Results G grafts contained higher percentages of CD34+ cells, CD34+CD38- cells, and committed progenitors (CD34+CD38+) compared with G+P grafts. A detailed characterization of the mobilized CD34+ cell subset showed higher percentages of CD38– among the CD34+ cells of the G+P group ( P = 0.032). In contrast, the CD34+ cell subset in G grafts was characterized by a higher percentage of ALDHbr cells ( P < 0.0001). Studying engraftment and day +100 graft function the G and G+P transplanted patients were comparable with respect to neutrophils, whereas in platelets they differed. In the prediction of engraftment and hematopoietic recovery, the dose of infused ALDHbr cells correlated best to both platelet ( r = 0.565, P = 0.002) and neutrophil reconstitution ( r = 0.366, P = 0.06). Conclusions Besides showing dissimilar distributions of CD34+CD38– cells and progenitors in G and G+P grafts, this study further designated ALDHbr as a promising marker in determination and prediction of graft quality and hematopoietic recovery.
Abstract 1559
Lymphocytopenia and absolute leukocytosis are included in the seven prognostic factors of the International Prognostic Score (IPS) for advanced Hodgkin's lymphoma (HL). Recent studies ...suggest that a high number of tumor-associated macrophages (TAMs) in pre-therapeutic tumor biopsies correlate with poorer outcome in classical HL. TAMs are derived from circulating monocytes and are thought to play a role in the tumor microenvironment of HL by promoting tumor growth. Therefore, the aim of the present study was to investigate whether a complete blood count (CBC) and counts of white blood cell (WBC) subpopulations could predict outcome also in patients with relapsed/refractory HL. For the purpose of the present study, we limited our analysis to younger HL patients undergoing high dose therapy (HDT) followed by autologous hempoietic stem cell transplantation (ASCT) as part of their salvage treatment strategy.
The data from 68 relapsed/refractory HL patients (classical HL n=63; nodular lymphocytic predominance HL n=5) diagnosed and treated at the Department of Hematology, Aarhus University Hospital, in the period 1989 to 2009 were analyzed. The cohort had a median age at relapse/progression of 31 years (range 16–67 years). All patients received HDT and ASCT due to biopsy-verified relapse or primary refractory disease occurred after standard treatment regimen with adriamycin, bleomycin, vinblastin, dacarbazin. CBC and WBC differentials were performed on all patients at time of first relapse or just prior to salvage chemotherapy in cases of refractory disease. Using the log rank test and univariate analysis we studied the effect of CBC and WBC differentials on overall survival (OS) and progression-free survival (PFS). PFS was calculated from the date of autologous stem cell re-infusion to the date of relapse or death by any cause. Due to a limited number of events a backward stepwise selection model was used to select covariates for a multivariate analysis (significance level p≤0.05).
The median follow up for the entire study cohort was 5 years. Consistent with the factors of the IPS in the pre-therapeutic setting, also in relapsed/refractory HL we found that absolute leukocytosis was associated with decreased OS (50% vs. 81%; HR 3,0; p=0,048) and PFS (27% vs. 72%; HR 3,7; P=0,005), and that lymphocytopenia also correlated with poorer outcome, however limited to OS (65 vs. 85%; HR 3,8; p=0,02). Interestingly, the analysis also revealed that both neutrophil granulocytosis and monocytosis (for both parameters: > normal upper limit) were significantly associated with higher risk of relapse/progression post-transplant and consequently poorer outcome in terms of lower OS and PFS. If present, neutrophil granulocytosis was associated with a 5-yr OS of 52% as opposed to 84% in patients with normal neutrophil count (HR 2,88; p=0,04); the corresponding values for PFS were 35% and 74% (HR 3,0; p=0,014). Similarly, patients with monocytosis at relapse/progression had a 5-yr OS post-transplant of 55% as opposed to 84% for patients with a normal monocyte count (HR 3,4; p=0,018); the corresponding PFS values were 39% and 74% (HR 3,4; p=0,006). A subsequent multivariate analysis showed that only monocytosis retained an independent predictive impact on both OS (p=0.02) and PFS (p=0.04). Lymphocytopenia was co-selected as independent factor for OS alone (p=0.02) and absolute leukocytosis for PFS alone (p=0.04).
The influence of monocytosis, along with lymphocytopenia and absolute leukocytosis, on post-transplant outcome in relapsed/refractory HL is a novel finding. If confirmed, it will provide a useful, cheap and readily available tool to optimize treatment strategies in this subset of HL patients.
No relevant conflicts of interest to declare.
Introduction: When lymphomas originally diagnosed as indolent (IL) transform to a more aggressive histology (TIL) the result is often an accelerated clinical course and a shortened survival. The ...purpose of this study was (i) to investigate whether autologous stem-cell transplantation (ASCT) performed at the time of transformation improved the outcome compared to rituximab-containing chemotherapy alone, (ii) to identify clinical pre-transformation factors influencing post-transformation outcome.
Methods: Patients aged 18-68 yrs with histologically verified sequential TIL diagnosed between 1999 and 2012 at 3 Danish tertiary lymphoma referral centers were identified using the National Danish Pathology Registry. Pre-therapeutic clinico-pathological features as well as treatment- and outcome data at baseline and follow-up were collected through the Danish lymphoma registry (LYFO) and patient records. The patient cohort was subdivided into 2 major subsets according to treatment strategy at transformation i.e. ASCT or no ASCT. Selected characteristics of potential clinical relevance, treatment background and response rates were compared using χ2 test, Fisher’s exact test or t test and tested in a multivariate analysis using a Cox proportional Hazards model. Treatment outcomes were estimated as 5-year overall (OS) and progression-free survival (PFS) and compared using the log-rank test.
Results: Fifty-seven patients with sequential TIL were included of which 39 patients received ASCT after initial immunochemotherapy and 18 did not. The two treatment cohorts (non-ASCT vs. ASCT) were comparable in all features including time to transformation (3.4 yrs vs. 6.5 yrs; p=0.10) and treatment with rituximab at IL-stage (n=5, 28% vs. n=7, 18%; p=0.49). Outcome determinants were tested at a median follow-up of 3.1 yrs (0.1-13.4 yrs) from the time of TIL diagnosis. The 5-yr OS was 57% if ASCT was performed and 36% if it was not (p=0.10). In terms of 5-yr PFS, ASCT treated patients had significantly higher values as compared to not transplanted ones (47% vs. 6%; p=0.003). This associated superior outcome was irrespective of prior rituximab treatment (Prior rituximab: 21% vs. 0%; p=0.02. No prior Rituximab 52% vs. 9%; p=0.03). However, the favorable impact of ASCT was greatest in patients who were rituximab-naïve at transformation (5-yr OS: 21% vs. 64%; 5-yr PFS: 21% vs. 52%). When comparing the outcome of sequential TIL patients based on the number of prior chemotherapy regimens, a higher number of prior regimens (>2) correlated with an inferior outcome (5-yr OS: 70% vs. 22%, p=0.05; 5-yr PFS: 64% vs. 23%, p=0.04) as did a high FLIPI-score. No influence on outcome was observed with regard to type of treatment at IL-stage, induction at TIL-stage (CHOP-like vs. platinum based), age or WHO-performance score at TIL diagnosis.
Conclusions: ASCT improved the outcome in sequential TIL. The beneficial impact of ASCT was greater in patients, who were rituximab-naïve at transformation. Factors with negative influence on outcome were a high FLIPI-score and the number of treatment regimens prior to transformation.
No relevant conflicts of interest to declare.
Background: With currently available therapies, relapsed/refractory aggressive non-Hodgkin lymphoma (NHL) after high-dose therapy or, in not transplant-eligible patients, after first-line ...chemotherapy represents an unequivocally unmet clinical need. Aim and Methods: Therefore, we aimed at evaluating a combination chemotherapy regimen based on pixantrone (Pix), a novel aza-anthracenadione recently approved by the European Medicines Agency in adult patients with multiply relapsed or refractory aggressive non-Hodgkin lymphoma (NHL). Etoposide and bendamustine were chosen as companion compounds due to available feasibility data in combination with Pix, as well as to their documented efficacy in salvage regimens in relapsed/refractory aggressive NHL and to a well-known feasibility profile when given alone or in combination. The monoclonal anti-CD20 antibody rituximab was added if tumor cells in the relapse biopsy specimen were CD20-positive. The adopted schedule consisted of Pixantrone 50 mg/m2 i.v. day 1+8, Etoposide 100 mg i.v. day 1, Bendamustine 90 mg i.v. day 1 with or without the addition of Rituximab 375 mg/m2 i.v. day 1 (PREBEN/PEBEN). If feasible, each cycle was given at 3-weekly intervals for a maximum of 6 cycles. All patients were assessed for chemosensitivity with PET/CT after cycle 1 or 2. G-CSF support was administered according to local guidelines. Results: A total of 8 evaluable patients with relapsed/refractory aggressive NHL were treated according to the PREBEN/PEBEN schedule. Abstract 5435. Table 1summarizes the clinico-pathological features of the patient cohort along with selected feasibility and efficacy parameters related to the PREBEN/PEBEN regimen (PET/CT status after 1 or 2 courses):Patient characteristicsPREBEN/PEBEN-related parametersPt #DxAgeSexCS at relapseN of prior Rx linesPrior TxN coursesTox grade 3-4Best responseDoR1DLBCL (ABC)70MIV3N6thrombocytopeniaCR*6 mo2DLBCL (ABC)49MIV3Y2-PD-3DLBCL (ABC)53MIV2N2neutropenic fevergoodPR4+ mo4DLBCL (ABC)64MIV2N2neutropenic fevergoodPR3+ mo5DLBCL (GCB)69FIV3N2-CR2+ mo6tFL62MIII3Y2neutropenic feverSD-7tCLL51FIV5Y2neutropenic feverPD-8PTCL-NOS57FIV2N6diarrhoeaCR4+ mo
Baseline (pt#1) after 1 x PREBEN (pt#1)
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Conclusion: The PREBEN/PEBEN schedule is feasible (out-patient regimen) and in individual patients it elicits profound responses early in the course of therapy. A phase 1-2 study in relapsed/refractory DLBCL and PTCL is in preparation.
d’Amore:Amgen: Research Funding; Sanofi Aventis: Research Funding; CTI Life Sciences: Advisory board, Advisory board Other, Speakers Bureau; Mundipharma: Advisory board, Advisory board Other, Speakers Bureau; Takeda: Advisory board, Advisory board Other, Speakers Bureau; Kyowa Kirin Pharmaceuticals: Advisory board Other, Speakers Bureau; Roche: Research Funding.
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