ALBERT

Description: SGN-30 is a monoclonal antibody directed against the CD30 antigen expressed on some hematologic malignancies. Based on encouraging phase I data, a multicenter phase II study was conducted treating patients with refractory or recurrent CD30-positive ALCL with an ECOG performance status of ≤ 2. Thirty-nine patients (24M, 15F) with ALCL were enrolled, with a median age of 57 (range 23–82) and a median of 3 prior therapies (range 2–5). Nine patients had previously received a stem cell transplant. Eighty-five percent of tumors were negative for ALK, a poor prognostic factor. SGN-30 was administred at 6 mg/kg/wk (90 minute infusion, premedications were not required) for 6 consecutive weeks. After 24 patients were enrolled, the dose was escalated to 12 mg/kg/wk in subsequent patients. (Patients with stable disease or objective response were eligible to receive additional cycles of SGN-30. Five patients received ≥ 2 cycles of SGN-30.) Response assessments, as determined by CT scans, were performed 2 weeks after the last infusion. Best response is shown below: CR PR SD PD Pending Eval ORR *Both CRs have ongoing durations of 〉365 days; both patients received additional cycles of SGN-30. **PRs had durations of 27, 53, 139 and 167 days; two additional patients have ongoing durations of 86+ and 25+ days. ***Three SDs have ongoing durations of 96+, 365+, and 365+ days. Two additional patients had SD for 71 and 174 days. 2* 6** 5*** 24 2 21% Three drug-related toxicities ≥ Grade 3 were reported (each was considered possibly related to SGN-30): 1) lymphopenia, 2) catheter related infection and 3) urticaria. No other significant hematologic or biochemical toxicities have been observed. There was one definitely related serious adverse event (Grade 2) in a patient who experienced a transient exacerbation of his cutaneous lesions after 2 doses of SGN-30 but achieved a partial response after continuing on study. This phase II study represents one of the largest prospectively designed trials in relapsed/refractory ALCL and demonstrates good tolerability and clinically meaningful antitumor activity of SGN-30, especially in ALK negative patients who have a particularly poor prognosis.

Description: Unmethylated CpG DNA activation of naive CD27− B cells has been reported to require B-cell–receptor (BCR) cross-linking. We describe a culture system using CpG DNA with sequential steps for T-cell–independent activation of naive CD19+CD27− human peripheral blood B cells that induces efficient CD138+ plasma-cell differentiation. CD27+ and CD27− B cells were cultured in a 3-step system: (1) days 0 to 4: CpG, IL-2/10/15; (2) days 4 to 7: IL-2/6/10/15 and anti-CD40L; (3) days 7 to 10: IL-6/15, IFN-α, hepatocyte growth factor, and hyaluronic acid. Both CD27+ and CD27− B cells up-regulated intracytoplasmic TLR-9 following CpG DNA activation. CD27− B-cell activation required cell-cell contact. Both naive and memory B cells progressed to a plasma-cell phenotype: CD19lowCD20lowCD27+CD38+HLA-DRlow. Seventy percent of the CD27−-derived CD138+ cells demonstrated productive V chain rearrangements without somatic mutations, confirming their origin from naive precursors. Plasma cells derived from CD27+ B cells were primarily IgG+, while those from CD27− B cells were IgM+. Our results indicate that under certain conditions, naive B cells increase TLR-9 expression and proliferate to CpG DNA stimulation without BCR signaling. In addition to its immunologic significance, this system should be a valuable method to interrogate the antigenic specificity of naive B cells.

Description: Key Points Clinical responsiveness to imexon represents the first demonstration of efficacy with modulating cellular redox in B-cell NHL. Antioxidant-related gene expression predicted for response to imexon.

Description: Abstract 1658 There is great interest in repurposing drugs currently available in the pharmacopeia to other indications like cancer as such an approach would significantly shorten the time needed and cost encumbered to provide new and effective cancer therapeutics. One such drug is the gold compound Auranofin (AF), which is FDA approved as a treatment for rheumatoid arthritis (RA). We demonstrate that AF induces MCL cell death with an LD50 of 1000 nM, 500 nM and 90 nM for Granta and Jeko cell lines, and cells derived from a patient biopsy, respectively. The increased sensitivity of primary MCL patient specimens to AF is confirmed on 4 additional patient samples tested. AF similarly induced DLBCL cell death with an LD50 of 500 nM, 500 nM and 1000 nM for OCI Ly-10, SUDHL-6 and −4 cell lines, respectively. Exposure of Granta cells to an AF concentration that induced cell death resulted in the generation of reactive oxygen species (ROS). Pre-treatment of these cells with N-acetyl-cysteine (NAC) or glutathione (GSH) abrogated both ROS generation and the induction of cell death supporting the notion that AF induces NHL cell death through a redox dependent pathway. Although AF does increase mitochondrial membrane permeability (although not through the classical permeability transition pore), the major mechanism through which AF induces NHL cell death is activation of the extrinsic apoptotic pathway. In this regard, AF induces the activation of caspases 7 and 8 and results in PARP cleavage, all of which are blocked by NAC. Despite the fact that AF is a known inhibitor of thioredoxin reductase (TR), its cytotoxic effect is independent of TR inhibition, as we observe no difference in the response to AF in U266 multiple myeloma cells transfected with an expression vector which results in the over-expression of TR. Given the redox dependence of AF-induced cytotoxicity we hypothesized that inhibition of the glutathione system with buthionine sulphoximine (BSO) would further augment AF induced cell death. To test this hypothesis, Granta cells were exposed to both AF and BSO. Significant synergistic interactions of these drugs were seen when tested in a Laska analysis of synergy. For example, whereas the LD50 for AF alone in Granta cells was 1000 nM, the LD50 for AF in combination with 5 μM BSO was 200nm; for Ly-10 cells, the LD50 for AF±BSO was 400 nm vs. 190 nM, respectively, and for SUDHL-6, 411 nM vs. 185 nM, respectively. Similar results were seen in MCL cells flow cytometrically sorted from patient biopsy specimens. As observed in studies using AF alone, the cytotoxic effects of the combination were blocked with both NAC and GSH. Similar to results with AF alone, the synergistic effects of AF and BSO on NHL cytotoxicity were independent of their effects on TR. Exposure of Granta cells to AF resulted in NF-κB inhibition. NF-κB was further inhibited with concomitant exposure to BSO over-expression of relA in Granta cells, however, had no effect on AF and BSO induced cell death, suggesting the synergistic effects of AF and BSO on NHL cell death may be NF-κB-independent. Finally, we demonstrate that AF and BSO modify free thiols on the plasma membrane. As we have recently shown that the redox agent parthenolide induces NHL death in part by modifying surface protein thiols, AF and BSO may induce NHL cell death through a similar mechanism. In summary, AF induces both MCL and DLCL cell death through a redox-dependent pathway that involves the extrinsic apoptotic pathway. Profound synergy is seen with concomitant depletion of glutathione by BSO. The data presented above, along with the fact that AF is a drug having a favorable safety profile in patients, and is an FDA-approved drug for the treatment of RA makes it an attractive candidate for further study as a single agent and in rational combination with other redox active drugs. Disclosures: No relevant conflicts of interest to declare.

Description: Rituximab (Rtx) has shown significant therapeutic activity in follicular lymphoma (FL) patients, yet it’s exact mechanism of action has not been fully defined. Although killing of FL cells through complement dependent cytolysis, antibody dependent cellular cytotoxicity or direct induction of apoptosis may contribute to its effectiveness, these mechanisms are unlikely to be the only ones as; the clinical and molecular responses to Rtx may continue for months after the last dose and; the median duration of the second response to Rtx is longer than that of the first, findings that cannot be explained solely by the above mechanisms. Rtx induced FL cell death likely results in the release of tumor antigens in a pro-inflammatory environment which we hypothesize may provoke a cell-mediated lymphoma specific immune response. Indeed, others have suggested that such a “vaccinal” effect may be an additional mechanism of action but to our knowledge there has been no direct evidence to support this in Rtx treated patients. Methods: To provide support for this hypothesis we examined lymphoma idiotype (Id) specific T-cell responses in peripheral blood mononuclear cells (PBMC) from three patients with relapsed FL. PBMC were obtained prior to and 4–6 weeks after the last of 4 weekly doses (375mg/m2 q week) of Rtx. A lymph node biopsy was obtained prior to Rtx to generate the patient’s Id protein. Dendritic cells (DC) were generated from pre-Rtx PBMC and pulsed with; no protein (control); the patient’s Id protein (Id); or an irrelevant (Irr) protein (Id from another patient). For patient 1, pre- and post-Rtx PBMC were stimulated with the DC for 1 week, while for patients 2 and 3, PBMC were stimulated for 1 week then re-stimulated for another week with fresh DC. Effectors were then assayed in triplicate for IFN-γ producing cells by Elispot. A second independent experiment was conducted in patients 2 and 3 (ie. this study describes data from 3 patients, 5 separate experiments). Results: Pre-Rtx: There was no consistent increase in the number of Id specific or Irr protein specific T-cells as compared to that of control T-cells. Post-Rtx: Whereas there was no consistent increase in the number of Irr protein specific T-cells as compared to that of control T-cells, in all three patients (including both replicates for patients 2 and 3) there was a consistent increase in the number of Id specific T-cells as compared to that of control T-cells. When composite data from all three patients were analyzed using a mixed ANOVA, the following p-values were obtained: Comparison Pre-Rtx Post-Rtx Control vs. Id 0.03 0.0003 Id vs. Irr 0.3 0.0005 Control vs. Irr 0.2 0.9 Comparison Pre-Rtx Post-Rtx Control vs. Id 0.03 0.0003 Id vs. Irr 0.3 0.0005 Control vs. Irr 0.2 0.9 Conclusions: These data provide, to our knowledge, the first support for the hypothesis that Rtx treatment results in an increase in Id specific T-cell responses in FL patients. If indeed this is a mechanism of Rtx activity, then clinical strategies to augment this postulated vaccinal effect, such as anti-CTLA-4 antibodies or Id vaccination post Rtx, may further increase the clinical potential of this agent and change the way we develop combination therapies. Further study of immune responses in a larger number of FL patients treated with Rtx is warranted and ongoing.

Description: ASCT is the standard therapy for relapsed HL. However, the majority of published studies suggesting benefit of ASCT for relapsed HL include relatively young patients (pts) with favorable prognostic features, and have relatively short follow-up. Moreover, very little data exists on the outcome of pts who experience progression of HL after ASCT. To determine the long-term outcome of ASCT in the modern, “ABVD-era”, and the impact of allogeneic transplantation in pts who fail ASCT, we reviewed all pts with HL who were treated with ASCT between 1990 and 2005 at the University of Rochester. 117 pts (44% female; 89% Caucasian) with documented HL were treated with ASCT for relapsed or refractory HL. At ASCT, median age was 34 years (range 19–66). 75% of these pts were treated initially with ABVD or MOPP-ABVD hybrid therapy. Histology was: NS (n=82), mixed cellularity (n=20), LP (n=6), LD (n=3), and classical NOS (n=6). 32% of pts had relapsed within 1 year of initial therapy, and 25% were refractory to therapy prior to ASCT. Conditioning regimens at ASCT were BEAC (n=80); BEAM (n=28); CBV (n=1); Cy/TBI (n=8). 49% of pts received XRT following ASCT. Median follow-up of entire cohort exceeded 5 years. At 5 years, overall survival (OS) for entire population was 50%, and event-free survival (EFS) was 38%. As expected, pts older than 45 yrs of age (n=21, p=0.06) and pts who relapsed within 1 year of initial therapy (p=0.0004) had an inferior OS after ASCT. In total, 49 pts have died; of these, 30 pts died of HL. 19 deaths occurred in remission: 9 were conditioning-related within the first 100 days of ASCT; 3 were from secondary malignancies (2 AML, 1 NHL), 1 from colitis, 1 from pulmonary fibrosis, and 5 with unknown cause. 9 of the deaths occurred more than 5 yrs after ASCT. 54 pts had progression of HL post ASCT; median survival for this group was 2.1 years after ASCT. 14 of these pts (26% of pts who failed ASCT) underwent allogeneic transplantation. 8 of these patients have died: 5 from progression of HL, 2 from pulmonary toxicity, and 1 from GVHD. Of the 5 remaining pts, 1 has progression of HL after allogeneic transplantation, and 3 have chronic GVHD. We conclude that ASCT remains a curative option for patients relapsing after ABVD, as there is a clear plateau on the relapse free survival curve after 5 years. Primary refractory disease and older age at ASCT dramatically affects outcome. In this modern era, deaths in remission after ASCT remain a significant problem due to both short-term and long-term toxicities of therapy. The risk of progression of HL persists until 5 years after ASCT, emphasizing the importance of prolonged follow-up. Although some pts who progress with HL after ASCT may live for years with a seemingly indolent form of HL, there is no plateau on the survival curve, and the majority of pts who progress after ASCT are not alive 2 years post ASCT. Allogeneic transplantation has not yet had a significant impact on OS for this group of pts. Novel approaches are clearly needed for the majority of pts who progress after ASCT, particularly older patients at ASCT and patients with primary induction failure.

Description: The incorporation of rituximab, a chimeric anti-CD20 monoclonal antibody, into the therapeutic armamentarium for patients with follicular lymphoma (FL) has significantly improved treatment outcome for such patients. Despite the almost universal application of this therapy, however, its exact mechanism of action has not been completely defined. One proposed mechanism is that of a “vaccinal” effect, whereby FL cell kill by rituximab results in the elicitation of an FL-specific T-cell response. The demonstration that rituximab can even elicit such a response in patients has, to our knowledge, never been shown. We analyzed the response against the immunoglobulin expressed by the FL before and after rituximab monotherapy in 5 FL patients and found an increase in FL idiotype–specific T cells after rituximab in 4 of 5 patients. Our data thus provide “proof of principle” for the ability of passive immunotherapy with rituximab to elicit an active FL-specific cellular response.

Description: Abstract 2818 Background: The use of bortezomib-based therapy is known to be associated with an increased risk of HZ in patients (pts) with multiple myeloma, who have disease-related inherent immune defects. A 13% incidence of HZ occurrence in pts with relapsed/refractory MM who received single agent bortezomib has been previously reported (J Clin Oncol 2008; 26:4784-4790). However, the occurrence of HZ in bortezomib-treated pts with non-Hodgkin lymphoma (NHL) has not been previously examined. Methods: We reviewed clinical data from two phase II trials in which bortezomib therapy was administered to pts with relapsed/refractory mantle cell NHL or indolent B-cell NHL. The occurrence of HZ complicating their treatment course was delineated, and an analysis for potential predisposing risk factors was undertaken. Results: A total of 236 relapsed/refractory pts, median age 65 years (yrs), enrolled on these trials was examined. Mantle cell NHL pts (n=155) received single-agent bortezomib, 1.3 mg/m2, days (D) 1, 4, 8, 11, 21-D cycles; those with indolent B-cell NHL (n=81) received either bortezomib, 1.3 mg/m2, D 1, 4, 8, 11, 21-D cycles, plus rituximab, 375 mg/m2, D 1, 8, 15 (cycle 1) and D 1 (cycle 2) (n=41), or bortezomib, 1.6 mg/m2, D 1, 8, 15, 22, 35-D cycles, and rituximab, 375 mg/m2, D 1, 8, 15, 22 (cycle 1) (n=40). HZ occurred in 24 pts (10.2%) overall, with a comparable incidence in both disease subgroups. Median time to HZ occurrence was 39 (range, 11–206) days (〈 2 cycles). Overall, 11% of pts had had a prior episode of HZ. Baseline demographic and clinical variables were examined, including age, gender, disease stage, baseline absolute neutrophil and lymphocyte counts, hemoglobin, lactate dehydrogenase, prior HZ, and number and types of prior therapies, to determine if any may predict for subsequent development of HZ. With regard to age, 71% of pts with HZ were age ≥65 yrs, compared to 48% without HZ (p=0.03). 63% of pts with HZ had received ≥2 lines of prior therapy, compared to 47% in those without HZ (p=0.15). 4% of pts with HZ had undergone prior stem cell transplantation, compared to 13% of pts without HZ. Of the pts with HZ, 25% had received prior purine analog therapy, compared to 9% of pts without HZ. The other baseline variables had no impact on the occurrence of HZ. In the 77 pts who responded to bortezomib protocol therapy (complete/partial responses), the incidence of HZ was 14%, compared to an 8% incidence of HZ in the 159 non-responders (p=0.15). Conclusions: HZ may complicate the course of relapsed/refractory indolent or mantle cell NHL pts receiving bortezomib-based therapies, with an incidence similar to the myeloma population. Pts who are elderly, more heavily-pretreated, or have received prior purine analog therapy may be at greater risk of this complication, and should be strongly considered for antiviral prophylaxis during such therapy. Disclosures: Morrison: Merck: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Speakers Bureau; Amgen: Consultancy, Speakers Bureau; Genentech: Speakers Bureau; Pfizer: Speakers Bureau. Off Label Use: Discussion of Velcade in NHL subtypes other than mantle cell lymphoma is included. Fisher:Allos Therapeutics: Consultancy; CytoKinetics: Consultancy; GSK: Consultancy; MundiPharma: Consultancy; Seattle Genetics: Consultancy; Millennium Pharmaceuticals, Inc,: Consultancy. Goy:Millennium, Celgene, GSK and Genentech: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Bernstein:Millennium Pharmaceuticals, Inc: Consultancy, Honoraria, Speakers Bureau. Boral:Millennium Pharmaceuticals, Inc.: Employment; Takeda Pharmaceuticals: Equity Ownership. Neuwirth:Millennium Pharmaceuticals, Inc.: Employment.

Description: Background: Receptor activated tyrosine kinases like c-kit, c-fms and PDGFR are known targets of inhibition by imatinib mesylate (Gleevec) and are expressed on AML blasts. Marrow stromal cells and monocytes express the ligands KIT ligand, M-CSF and PDGF capable of activating survival pathways in these leukemic cells. Imatinib mesylate is a substrate of the multidrug resistance and ABC - transporters expressed in AML cells and displays a modest activity alone in AML in vitro and in vivo. Given the synergy in vitro between Ara-C and Gleevec on AML cell growth inhibtion, we initiated a Phase I study combining CLAG + Gleevec in AML patients. Method: Patients with relapsed, refractory AML or CML myeloid blast crisis were eligible to receive Cladribine 5 mg/m2 Days 3–7, Cytarabine 2 gm/m2 Days 3–7, G-CSF 300 mcg Days 2–7, and escalating doses of imatinib mesylate given on Days 1–15. The level 1 Gleevec dose was 400 mg, while level 2 was 600 mg and the level 3 dose 800 mg. Patients were allowed to receive a second course of treatment if a CR was not attained after the first course, and were eligible for allogeneic stem cell transplantation (ASCT) if a donor was available. Results: A total of 15 patients have been enrolled 14 AML and 1 CML blast crisis, 6 patients with relapse within 6 months following initial induction/consolidation, 5 patients relapsed within 6–12 months of therapy, 3 patients had refractory disease and 3 patients relapse following myeloablative ASCT. No dose limiting toxicity was reached. The dose escalation occured as planned and there was no clear evidence of added toxicity due to Gleevec. One patient with an extensive cardiac history died of cardiac causes on day 1 of therapy, no other deaths occured within 30 days of starting therapy. One patient had a grade 3 skin rash at level 2 and did not receive imatinib on the second induction therapy. None of the 15 patients treated have had a drug- related cause of death: the most common toxicities encountered during induction therapy were nausea, vomiting, ALT and AST increase, rash and diarrhea and were transient and/or reversible. There were two drug-nonrelated deaths one CNS bleed in a persistently thrombocytopenic patient after ANC recovery and ovelwhelming sepsis in another patient. Out of 14 evaluable patients 12 achieved a hypocellular marrow after initial induction with one additional patient achieving a hypocellular marrow following a second course of the same regimen. One patient had persistence of disease and was switched to another treatment. Out of the 12 evaluable patients 5 acheived a complete response (42%) with 4 of these patients achieving a complete cytogenetic response as well (33%). The relapse free interval ranged from 35 to 206 + days in evaluable patients. Imatinib mesylate (up to 800 mg) plus CLAG is a safe and well tolerated non anthracycline based salvage regimen in patients with relapsed/refractory AML.

Description: Background: AHSCT is standard therapy for recurrent or progressive, yet chemosensitive lymphoma, both non-Hodgkin’s (NHL) and Hodgkin’s (HL). However, relapse is frequent, and augmentation of existing conditioning regimens (e.g. BEAM) is one approach to reducing these relapses. Since BEAM has considerable regimen related toxicity (RRT), methods to allow safe dose augmentation are needed. Prior experience (BBMT2004;10(7): 473–83) indicates that AF may be useful in protecting vs RRT produced by high-dose MEL used alone; thus, we postulated a cytoprotective effect in this situation as well. Goals: Determine the maximum tolerated dose (MTD) of escalated dose MEL in BEAM, using AF and AHSCT, in a classical Phase I trial. Methods: We utilized AF 740mg/m2 daily before and during BEAM (i.e., −7 to −1) with MEL, starting at 140 mg/m2 (level A) and escalating by 20 mg/m2 per 4 - pt. cohorts. AHSCT and other supportive care measures were routine. (Thiotepa was used in patients with a history or at high risk of central nervous system (CNS) disease.) The Berman (JCO1989; 7(9): 1288–94) scale of grading RRT was used to determine the MTD in 4- pt. cohorts; those who died of non-RRT causes were deemed non-evaluable and replaced. Results: Between 07/30/2003 and 06/28/2006, we entered 18 patients (NHL13 /HL 5), med age 60 (range 23 to 72) years. All had progressed or relapsed; 12 were chemosensitive. To date, 6 patients at level A (140mg/m2), 4 patients at B (160mg/m2), 5 patients at C (180mg/m2) and 3 patients at D (200mg/m2) have been evaluated 〉D +30. Three patients (2 at level A and 1 at level C) were non-evaluable due to: Removal (pt’s request) during BEAM, Death due to CNS bleeding; and MI (with known pre-existing coronary artery disease), and were replaced. None of the remaining 15 had Bearman RRT 〉II; 2 had none and 10 had only grade I RRT. All (save one case of hepatic II RRT) were stomatitis and/or gastrointestinal. All had CD34+ 〉 2.0 x 10e6/kg and prompt hematopoietic reconstitution: ANC 〉0.5 and platelets 〉20K at median D+ 11 (range +9 to +12) and D+ 12 (range +9 to +24), respectively. No late (i.e., 〉D+ 30) hematologic or non-hematologic toxicities were noted. At present, 11 patients are alive, 7 in CR, one too early to evaluate at median D+ 469, range + 27 to 999. Conversely, 7 are dead, due to relapse (5), MI (one), and CNS bleeding (1). Responses occurred at all dose levels. In evaluable patients 〈 CR before AHSCT, 9/14 achieved CR (mostly confirmed by imaging studies, notably PET scans) by D +100; 6 remain in CR at median D +593, range +36 to +614, including one patient who had a “consolidation” allogeneic HSCT. Another patient in CR at AHSCT remains in CR at D +514. Conclusion: Although not strictly proven, we believe the use of AF allows the safe use of escalated doses of MEL in the BEAM regimen 〉/= 180mg/m2. Dose escalation will continue until a MTD is found.