ALBERT

Beschreibung: Introduction: DF, a polydisperse oligonucleotide, has anti-thrombotic, anti-ischemic and thrombolytic properties, especially on microvasculature. Studies have suggested that DF modulates endothelial injury in VOD. Methods: A phase II randomized study of two doses, 25 mg/kg/d [arm A] or 40 mg/kg/d [arm B], was carried out in pts with severe VOD. Correlation with markers of vascular injury was undertaken. Endpoints included CR rate, toxicity and mortality at d+100 post SCT. VOD diagnosis was by Baltimore criteria and severity by ≥30% risk on the Bearman model or MOF. Abdominal ultrasound (US) was required prior to enrollment, repeated during therapy and at completion of treatment.Pts with ≥ grade II GVHD were excluded. Treatment arms were stratified for age (

Beschreibung: Introduction/Methods: This international phase 3 study conducted at 93 sites is the largest randomized study to date in relapsed multiple myeloma (MM). Patients (pts) had to have received 1–3 prior therapies and those with dexamethasone (Dex) refractory disease were excluded. Pts were randomized to bortezomib (VELCADE®) 1.3 mg/m2 IV d 1, 4, 8, 11 q3wk for 8 cycles followed by 3 cycles on d 1, 8, 15, 22 q5wk, or Dex 40 mg PO d 1–4, 9–12, 17–20 q5wk for 4 cycles followed by 5 cycles on d 1–4 every 28 d. The 1° endpoint was time to progression (TTP); 2° endpoints included survival, response rate (CR+PR) using EBMT criteria, duration of response, time to response (TTR), time to skeletal events, infections ≥gr 3 and safety; exploratory endpoints included pharmacogenomics and quality of life. Pts with progressive disease on Dex were eligible to crossover to bortezomib in a companion study. Results: 669 pts were randomized and baseline characteristics were balanced in both arms. Based on a median follow-up of 8.3 mo, bortezomib demonstrated a 78% improvement in median TTP (hazard ratio 0.55, P

Beschreibung: The BM contains progenitor cells that give rise to hematopoietic tissue and also more primitive mesenchymal stem cells (MSC) which may differentiate into other tissues including endothelial cells. This potential of BM cells has already been employed in clinical studies suggesting that implantation of autologous BM cells may induce angiogenesis in ischemic tissues. In the present study 10 male pts with critical leg ischemia (41–64 yrs) suffering from pain at rest and/or foot ischemic ulceration (9/10 pts) with ABI (ankle/brachial index)

Beschreibung: BK virus is a highly ubiquitous polyoma virus with a peak seroprevalence in childhood ranging from 60–100%. After primary infection, which is often asymptomatic or occasionally associated with fever and upper respiratory symptoms, the virus remains latent in the kidneys. During heavy immunosuppression, as occurs following agents such as Alem or anti-thymocyte globulin (ATG), the virus reactivates and can cause significant uroepithelial cell lysis with resultant hemorrhagic cystitis (HC). Between April 2003 and June 2004, 25 patients (15 males, 10 females) undergoing allogeneic (13 MSD, 12 VUD) hematopoietic stem cell transplantation for a variety of indications (18 MDS/AML, 3 NHL, 1 CLL, 2 MM, 1 CML) were found to have BK viruria. Patients ranged in age from 20–67 years. 16 patients underwent ablative conditioning (12 busulfex [Bu]-fludarabine [Flu]-Alem, 1 Bu-Flu-ATG, 2 total body irradiation (TBI)-cyclophosphamide (Cy), 1 TBI-etoposide) whereas 9 patients underwent reduced-intensity (RI) conditioning (5 Blu-Flu-Alem, 2 Bu-Flu-ATG, 1 Flu-Cy, 1 Cy-ATG). Patients treated on ablative regimens containing Bu received a total dose of 12.8 mg/kg whereas those treated with RI conditioning received 6.4 mg/kg. Those who received Flu got 30 mg/m2/d for 5 doses. Alem-based regimens contained 30 mg/d for 3 days or 20 mg/d for 5 days. Graft-versus-host disease (GVHD) prophylaxis consisted of: tacrolimus (FK) alone (n=16), FK + methotrexate (MTX) (n=7), FK + steroids (n=1), cyclosporine-MTX (n=1). 23 patients had BK viral loads in urine measured by PCR with peak levels ranging from 1500 copies/ml to 〉 200,000,000 copies/ml. BK virus was first detected in the urine anywhere from day −7 to day +85 post-transplant. The time to peak level of BK viruria ranged from day −2 to day + 85 (median 17 days). 40 % (10/25) of these BK viruric patients developed symptomatic HC and 16 % (4/25) developed uretostenosis and/or hydronephrosis (2 required ureteral stent placement). Only 1 of 14 patients treated with multiple doses of Cidofovir (range 3–26 doses) either cleared their viruria by qualitative assay or had greater than a 3 log reduction by quantitative PCR within 4 weeks of starting antiviral therapy; 2 of the 13 patients did have a 2 log reduction in viral load within 4 weeks of initiation of antiviral therapy. It is interesting that 27% (3/11) of patients not treated with Cidofovir cleared their BK viruria between 21–54 days post-transplant. Of note, an additional 6 patients were identified who received Alem; overall 21/23 patients who received Alem developed BK viruria. In conclusion, we found an extremely high incidence of BK viruria (91%) in patients receiving Alem as conditioning therapy for allogeneic SCT. This was associated with ureteral stenosis or hydronephrosis in 4 patients. Therapy with cidofovir given at two different doses had no impact on the excretion of BK virus.

Beschreibung: Genetic analysis has an increasing role in the diagnosis, classification, and management of patients with CLL. Although translocations involving the IgH locus are well characterized in B-cell malignancies such as follicular cell lymphoma, their frequency and significance in CLL are less well defined. We studied a series of patients with a clinical diagnosis of CLL using a FISH probe set including IgH. Methods: FISH was performed on blood using a DNA probe set designed to detect common chromosome anomalies associated with CLL and translocations involving IgH. Patients with an IgH abnormality were further studied using FISH probes sets for IgH and cyclin D1, BCL-2, BCL-3, BCL-6, BCL-11a, c-MYC, MALT-1, c-MAF, FGFR-3 or PAX-5. The clinical presentation, pathology, and flow cytometric immunophenotype was reviewed in patients with various translocations involving IgH. Results: Between 1/1/03 and 6/15/04, samples from 1032 patients with a clinical diagnosis of CLL were analyzed by FISH. Of these, 76 patients (7%) had translocations involving the IgH locus. Sixty one patients had a single translocation partner gene (cyclin D1 45%, BCL-2 24%, BCL-3 8%, c-MYC 2.5%, or BCL-11a 1.3%). Two patients had two independent clones (cyclin D1 and BCL-2; BCL-3 and BCL-11a). In 13 pts (17%) we could not identify the translocation partner. Thirty five (46%) of the 76 patients with IgH translocations had been seen at Mayo Clinic Rochester and had clinical and laboratory data for detailed review. Among these 35 patients, 16 (45%) had fusion of IgH and cyclin D1 and were diagnosed with mantle cell lymphoma (MCL). The immunophenotype of the monoclonal B cells was typical of MCL (CD5+, CD23-) in 6 patients and typical of CLL (CD5+, CD23+) in 4 patients. Six MCL patients had non-diagnostic immunophenotypes: CD5-, CD 23+ (n = 3) and CD5-, CD23- (n = 3). Twelve (34%) of the 35 patients had the IGH/BCL-2 fusion gene. Of these, 3 patients had leukemic phase follicular lymphoma, one had both CLL and MCL, and 8 had the diagnostic immunophenotype of CLL. The remaining 7 patients (19%) had a variety of translocation partners: BCL-3 (n = 1), BCL-3 and BCL-11a (n = 1), c-MYC (n = 2), and unknown (n = 3). The patients with a translocation involving BCL-3 had a typical CLL immunophenotype. Discussion: The IgH FISH probe detected a molecular defect in 7% of patients with a circulating monoclonal B cell population. In patients with a CLL immunophenotype, use of the IgH probe identified the IgH/cyclin D1 translocation characteristic of MCL in 4 patients, a finding of major clinical significance. Interestingly, after exclusion of MCL patients, more than 4% patients with CLL had other translocations involving IgH, a proportion comparable with other better defined chromosomal abnormalities in CLL. Although IgH/BCL-2 translocation is usually associated with follicular lymphoma, we identified 8 patients with CLL and this translocation. Translocations involving BCL-3 had been described before in CLL with an “atypical” immunophenotype. In contrast both of our patients with BCL-3 had typical phenotypes. Translocations involving IgH and BCL-11a have not been previously described. We conclude that FISH studies using the IgH probe improve the precision of diagnosis in CLL and could also have prognostic value.

Beschreibung: XIAP is a potent inhibitor of caspases 3, 7, and 9 and its over-expression renders malignant cells resistant to chemotherapy. Through an enzymatic derepression assay, we identified chemical XIAP antagonists, including 1396-12, based on a polyphenylurea pharmacophore (Cancer Cell, 1:25–35;2004). This compound binds and inhibits the caspase 3/7 inhibitory BIR2 domain of XIAP. Given the potential therapeutic utility of IAP inhibitors, we tested this XIAP antagonist in leukemia cell lines and primary patient samples. The XIAP antagonist 1396-12, but not the structurally related control compound, directly induced apoptosis in leukemia cell lines at low micromolar concentrations and sensitized leukemia cells to cytarabine. 1396-12 activated downstream caspases 3/7 prior to the activation of upstream caspases 8 and 9, and independent of Bcl-2 or caspase-8, consistent with the inhibition of the BIR2 domain of XIAP. To evaluate this XIAP antagonist as a potential novel therapy for acute myeloid leukemia (AML), primary AML blasts (n= 27), normal bone marrow mononuclear cells (n =1), or normal mobilized peripheral blood stem cells (PBSC) (n =6) were treated with increasing concentrations of 1396-12. Apoptosis was measured 24 hours after treatment by Annexin V staining. Median LD50 among the AML patient samples tested was 6 μM (range: 2μM to 〉40μM). The XIAP antagonist 1396-12 induced apoptosis of primary AML samples with a LD50 ≥ 10μM in 16 of 27 (60%) samples and with a LD50 〉40μM in 7 of 27 (26%) samples. In contrast, 1396-12 was less toxic to the normal PBSC or marrow with a LD50〉40μM in all normal samples tested. As a comparison, the inactive control compound was not toxic to any of the AML or normal samples at concentrations up to 40μM. In addition to the short-term cytotoxicity assays, the effects of 1396-12 on AML and normal samples were evaluated in colony formation assays. The XIAP antagonist inhibited clonogenic survival in 4 AML samples tested with a mean LD50 of 4 ± 0.8μM. Treatment with 1396-12 also reduced colony formation by 2 normal PBSC samples with LD50’s of 8.5 ± 0.3μM and 5.6 ± 0.4μM. In the normal PBSC samples, both BFU-E and CFU-GM lineages were equally reduced after treatment with the XIAP antagonist. Treatment with the control compound did not reduce colony growth in the AML or normal samples. Among the primary AML samples, response to the XIAP inhibitors correlated with XIAP protein levels. Low to absent levels of XIAP were associated with a higher probability of resistance to treatment with XIAP inhibitors (p =0.04, by logistic regression analysis). In conclusion, polyphenylurea-based XIAP antagonists directly induce apoptosis in leukemia cells and patient samples at low micromolar concentrations through a mechanism of action distinct from conventional chemotherapeutic agents. These antagonists can be used as biological tools to understand the role of IAPs in normal and malignant hematopoietic cells. They may also serve as lead compounds for the development of useful therapies for the treatment of leukemia and other malignancies, but their potential hematologic toxicity will have to be carefully evaluated in phase I clinical trials.

Beschreibung: Despite impressive primary response rates relatively few patients with multiply relapsed or refractory Hodgkin lymphoma (HL) are ultimately cured with conventional chemotherapy. The application of allogeneic stem cell transplantation has historically been limited in this group by high transplant related mortality (TRM) rates, and evidence for a clinically relevant graft-versus-lymphoma (GvL) effect has been limited. Reduced intensity transplantation (RIT) approaches enable durable engraftment of allogeneic stem cells with a low spectrum of toxicity, but graft-versus-host disease (GvHD) remains a significant cause of morbidity and mortality. In vivo T-cell depletion (TCD), using alemtuzumab, has been shown to reduce the incidence of GvHD. However, this approach potentially adversely impacts on disease response by abrogating GvL activity. To explore the impact of TCD in HL we have compared the results in 89 recipients of a RIT enrolled in 2 prospective studies based on conditioning with the same combination of fludarabine (30mg/m2 x 5) and melphalan (140 mg/m2). The studies differed in GvHD prophylaxis. The United Kingdom regimen (MF-A, n=49) used cyclosporin A plus alemtuzumab, whereas the Spanish regimen (MF, n=40) used cyclosporin A plus methotrexate. There were no significant differences in age (median 32 versus 35 years), sex or histological subtype (nodular sclerosis in 86% versus 88%). Median follow-up in surviving patients is 826 (MF-A) versus 376 (MF) days. In those with matched sibling donors use of alemtuzumab resulted in a trend towards a lower incidence of acute GvHD (29% versus 46% at day 180, P=0.09) and significantly less chronic GvHD (10% versus 57%, P=0.0003). This was associated with a trend towards lower TRM in the MF-A group (actuarial 2 year TRM 17% versus 33% for MF, P=0.06), but no apparent excess of relapse/progression (actuarial 2 year relapse risk 49% for MF-A versus 68% for MF, P=0.16). In this sibling transplant cohort both overall and event-free survival were superior in the MF-A group (actuarial 2 year OS 72% versus 48%, P=0.04; EFS 47% versus 19%, P=0.009). Sixteen patients in the MF-A group and 10 in the MF group received donor lymphocyte infusions (DLIs) to achieve disease control. Nine (8CR, 1PR) of the former, and 6 (3CR, 3PR) of the latter achieved a response. On univariate analysis of the entire cohort chemo-sensitivity significantly influenced relapse risk (p=0.01), OS (P=0.01) and EFS (P=0.003). TCD significantly improved EFS (P=0.01) despite an excess of unrelated/mismatched donors (18 versus 3, P=0.001) and patients who had failed a prior autograft in the MF-A cohort (44 versus 29, P=0.03). Prior autograft or donor source had no significant influence on TRM, relapse, OS or EFS. More patients were chemo-sensitive prior to RIT in the MF-A group (36 versus 20, P=0.03) but TCD retained independent positive prognostic significance for EFS in multivariate analysis (P=0.02; Hazard ratio 0.69(0.51–0.93)), as did chemo-sensitivity (P=0.01). In conclusion, alemtuzumab significantly reduced GvHD without resulting in an apparent impact on disease relapse. Both groups often required DLIs to achieve tumor control and the response rates support a significant GvL activity.

Beschreibung: From 06/1982 to 12/2003, 281 patients (163 male) received autologous (AuSCt) and/or allogeneic (AlloSCT) transplantations as part of first line treatment (61%) second line treatment(21%) or salvage therapy (17%). There were 140 multiple myelomas (including 3 amyloidosis), 62 lymphomas, 51 acute myeloid leukemias, 24 solid tumors and 4 chronic myeloid leukemias.Two hundred and sixty nine patients-median age: 64 y(60–77) - received Au SCT (28/261 received a second Au SCT in med of 2–7 months), 1patient (71 y) received a double syngeneic transplant,12 patients -median age: 62(60–68) received AlloSCT. Conditionning regimen (Cond reg) for the first Au SCT included Melphalan 140 mg/m² n=168; BEAM n=41; Melphalan 200mg/m² n=29; Mel Busulfan (8 to 16 mg/kg) or Mel TBI 8 grays n=18; Cytoxan 200mg/kg Melphalan1 40 n=9: TBI 8 Grays n=7; BCNU 600mg/m² n=3. Cond reg for the second Au SCT included Mel 200 n=20; Mel 140 n=4; BCU 600 n=4. Cond reg for the double syngeneic transplant were Mel 140 and Bu 8 Mel 140.Cond reg for the AlloSCT were Fludarabin/Busulfan/ATG (FBS) based reduced intensity regimen (RIC) in 11 cases. Ninety percent of the patients received peripheral blood stem cells-med 5,3.10*6CD34/kg (2–40)- 10% of the patients transplanted before 1994 received bone marrow cells. Tolerance was good with only 9/281 transplant related deaths: 5 sepsis/MOF in aplasia (D11–D21) 2 ARDS (D30–D80) 1 AGVH (D 60) 1 CGVH (3 years). Theses deaths occured in 4 ref MM( 2 renal instability,1 cardiac amyloidosis), 2 CR2 NHL, 1 OR1 MM, 1 stable MDS after FBS in 2 pts, BEAM in 2 pts, Mel 140 in 4 pts, Mel 200 (second transplant) in 1 pt. With a median follow up of 20 months from transplant,7/281 second cancers had occured: 1AML, 1ALL, 2 NSC pulmonary carcinoma, 1 colon cancer, 1uterin carcinoma, 1 melanoma; 2 of these 7 patients had died. One hundred and fifty eight patients had relapsed in a median of 11 months (1–92). Median survival for the 281 patients is 37 months without diference between pts older or younger than 65. Median survival for MM, NHL/HL, AML or ST are 40 months, 45 months, 18 months and 23 months respectively

Beschreibung: Clinical management differs significantly for the various types of non-Hodgkin lymphoma (NHL), and the diagnosis of these lymphomas can be challenging in some cases. Further, existing NHL categories include subgroups that can differ substantially in gene expression, response to therapy and overall survival. We have created a custom oligonucleotide microarray, named LymphDx, which could prove clinically useful for molecular diagnosis and outcome prediction in NHL. Biopsy specimens were obtained from 559 patients with a variety of lymphomas and lymphoproliferative conditions. Gene expression profiles of these samples were obtained using Affymetrix U133 A and B microarrays. The 2653 genes on LymphDx were chosen to include:(1)Genes most differentially expressed among NHL types based on Affymetrix U133 or Lymphochip microarrays (2)Genes predicting length of survival in diffuse large B cell lymphoma(DLBCL), follicular lymphoma(FL) and mantle cell lymphoma(MCL) (3)Genes encoded in the EBV and HHV-8 viral genomes (4)Genes encoding all known surface markers, kinases, cytokines and their receptors, as well as oncogenes, tumor suppressors, and other genes relevant to lymphoma. The LymphDx microarray was used to profile gene expression in 434 biopsy samples. These data were used to create a diagnostic algorithm that can distinguish various NHL types and benign follicular hyperplasia(FH) based on gene expression. The algorithm classifies a sample into one of the following categories: Burkitt’s lymphoma(BL), DLBCL, FL, MCL, small lymphocytic lymphoma(SLL) or FH. The algorithm further distinguishes the 3 recognized DLBCL subgroups: germinal center B cell-like, activated B cell-like or primary mediastinal lymphoma. Using a leave one out, cross validation strategy, the algorithm was found to agree well with the pathology diagnosis (see Figure). Some samples were deemed unclassified when their gene expression did not adequately match with that of any of the NHL categories. For a few samples, the gene expression-based diagnosis and the pathology diagnosis were discordant. Pathology review showed that two NHL types coexisted (eg FL and DLBCL) in many of these cases, potentially explaining the results of the diagnostic algorithm. LymphDx could also reliably predict the overall survival of patients with DLBCL, FL and MCL. Prospective evaluation of the LymphDx microarray is warranted since it could be used to provide objective molecular diagnostic, and prognostic information for patients with NHL. Figure Figure

Beschreibung: Background: Relapsed aggressive histology non-Hodgkin’s lymphoma (NHL) has a poor prognosis, and new treatments are needed. Angiogenesis is increased in aggressive NHL and may be a target in these diseases. Low-dose chronic chemotherapy (metronomic chemotherapy, MC) inhibits angiogenesis in vitro and in vivo. Since COX-2 may promote neoplasia and tumor angiogenesis, selective COX-2 inhibitors may have antitumor effects in NHL. We assessed response and toxicity to MC and COX-2 inhibition in patients (pts.) with relapsed aggressive NHL following anthracycline-based chemotherapy. Methods: Pts. with measurable disease and normal renal function received cyclophosphamide 50 mg po qd + celecoxib 400 mg po bid. Pts. were assessed clinically and radiologically in serial fashion. We measured serial plasma VEGF and TSP-1 levels and pharmacokinetics (PK) were performed in selected pts. Serial circulating endothelial cells (CEC) and their precursors (CEP) were measured by flow cytometry as of October 2003. Results: To date, 29 of a planned 32 pts. have been enrolled; 3 are ineligible and 25 are evaluable for response. Median age: 62 y (range 22–83). Histology: 17 DLBCL, 1 MCL, 3 transformed (CLL+FL), 2 T cell, 3 anaplastic large cell. Median 2.7 yrs from diagnosis (range 0.5–9.5); Median # of previous chemotherapy regimens: 3 (range 1–6); 31% were chemoresistant to preceding regimen; 8 had undergone prior ASCT. Median time to death or last follow-up: 4 mos (range 0.9–22). Response:10/25 pts. responded (2 CR/CRu, 8 PR, ORR 40%) at a median time of 4.6 mos, and at last f/up, 6/10 remained in PR at 22, 21, 16, 11, 8 and 7 mos. respectively. Three pts. achieved stable disease (SD) but 2 later progressed at a median time of 6 mos (range 4–14 mos) and 12/25 progressed primarily (PD) at a median time of 1.9 mos (range