ALBERT

Description: Backround: Arsenic trioxide (ATO) has been shown to be synergistic with melphalan both in vitro and in vivo. We conducted a phase I/II trial to determine the safety and efficacy of a combination of arsenic trioxide, melphalan and ascorbic acid (AA) as preparative regimen in patients undergoing high-dose therapy (HDT) and autologous hematopoietic progenitor cell transplantation for multiple myeloma (MM). We also assessed the impact ATO levels on melphalan pharmacokinetics (PK), engraftment and toxicity. Methods: Forty-eight patients with secretory myeloma (23 females, 25 males; median age: 54, range: 3570) were treated between 4/04 and 8/05. All patient received melphalan 100 mg/m2 IV on days -4 and -3 and AA 1000 mg/day IV on days -9 to -3. Patients were randomized to 3 arms; no ATO (arm 1), ATO 0.15 mg/kg IV on days -9 to -3 (arm 2) and ATO 0.25 mg/kg IV on days -9 to -3 (arm 3). Twelve patients had disease progression or relapse after a prior autograft. Median CD34 cells dose infused was 4.5 x 106/kg (range 2.3–10.9). Results: Patients in all 3 arms were evenly matched. With a median F/U of 14.0 months (range 6–25) post autograft, no dose-limiting toxicity or non-relapse mortality was seen. Toxicity was limited to grade I or II nausea, vomiting and diarrhea. Median ATO levels on day 0 in arms 1, 2 and 3 were 0.2, 26.3 and 46.2 ng/ml, respectively. Melphalan PK was not altered by ATO pretreatment. Median time to neutrophil engraftment (ANC 〉500/ dl) was 9 days. There were no engraftment failures or delays in the ATO arms. CR rate for the entire group was 23%, and total response rate (CR + PR) was 75%. 1-year Progression-free survival (PFS) and overall survival (OS) were 75% and 95%, respectively. There was no significant difference in CR, RR, PFS or OS between the 3 arms (p = 0.9, 0.9, 0.4 and 0.6, respectively). A prior autologous transplant (p = 0.02) and abnormal cytogenetics at transplant (p = 0.04) were associated with a significantly shorter remission. Conclusions: ATO + melphalan + ascorbic acid is a safe, effective and well tolerated preparative regimen for patients with multiple myeloma undergoing an autotransplant. A longer follow up is needed to assess the impact of ATO on progression-free and overall survival.

Description: DLBCL is a curable subtype of non-Hodgkin lymphoma, although a significant number of patients do not achieve a remission or they relapse with conventional chemotherapy. While clinical variables (e.g., IPI), tumor (somatic) genetic alterations, and gene expression profiling have all been shown to predict outcome, there remains a need for additional prognostic biomarkers. One understudied class of biomarkers is host genetic background. We evaluated the hypothesis that germline variability in 73 SNPs from 44 candidate immune genes was associated with overall survival in DLBCL. We addressed this hypothesis in 365 DLBCL patients aged 20–70 years who participated in a population-based case-control study conducted from 1998–2000 (prior to the use of R-CHOP) through the Surveillance, Epidemiology, and End Results (SEER) cancer registries in Detroit, Seattle, Iowa, and Los Angeles. Germline DNA was extracted from a venous blood sample or mouthwash buccal cell sample, which was collected a median of 4.8 months after diagnosis in this population-based study. All genotyping was conducted at the National Cancer Institute Core Genotyping Facility using the Taqman platform, and was successful in over 95% of the DNA samples for the SNPs evaluated. Histology, stage, presence of B-symptoms, first course of therapy, date of last follow-up, and vital status were derived from linkage to registry databases at each study site in the spring of 2005. Cox proportional hazards analysis was used to evaluate the association between individual SNPs, adjusted for age, demographic and clinical factors. Parallel modeling strategies were used to identify the best summary multi-SNP risk score to predict survival. At a median follow-up of 56 months (range, 27-78 months) for surviving patients, there were 96 deaths in 365 patients (26%). In multivariate modeling, SNPs in IL1A (rs1800587; HRCT/TT=1.90, 1.26–2.87), IL6 (rs1800795; HRGG=1.48, 0.99–2.23), IL-10 (rs1800896; HRAG/GG=1.48, 0.91–2.38), and IFNGR2 (rs2070385; HRAG/GG=1.35, 0.86–2.11) were the strongest and most robust predictors of overall survival. A summary score of the number of deleterious genotypes from these four genes in combination with clinical and demographic variables was strongly associated with survival (p=9.3 x 10−12); Kaplan-Meier 5-year survival estimates for low, intermediate, and high risk patients were 89%, 68%, and 47% respectively. In conclusion, host genetic background as measured by germline polymorphisms in immune genes including IL1A, IL6, IL10, and IFNGR2 were associated with overall survival in DLBCL after accounting for clinical and demographic factors. These promising results require confirmation and need further evaluation in patients treated with R-CHOP in conjunction with tumor and other prognostic biomarkers.

Description: A role for genetic susceptibility in non-Hodgkin lymphoma (NHL) is supported by the accumulating evidence of common genetic variations altering NHL risk. However, the pattern of NHL heritability remains poorly understood. We conducted a pooled analysis of 10 211 NHL cases and 11 905 controls from the International Lymphoma Epidemiology Consortium (InterLymph) to evaluate NHL risk among those with hematopoietic malignancies in first-degree relatives. Odds ratios (ORs) and 95% confidence intervals (CIs) of NHL and its subtypes were estimated from unconditional logistic regression models with adjustment for confounders. NHL risk was elevated for individuals who reported first-degree relatives with NHL (OR = 1.5; 95% CI = 1.2-1.9), Hodgkin lymphoma (OR = 1.6; 95% CI = 1.1-2.3), and leukemia (OR = 1.4; 95% CI = 1.2-2.7). Risk was highest among individuals who reported a brother with NHL (OR = 2.8; 95% CI = 1.6-4.8) and was consistent for all NHL subtypes evaluated. If a first-degree relative had Hodgkin lymphoma, NHL risk was highest if the relative was a parent (OR = 1.7; 95% CI = 1.0-2.9). If a first-degree relative had leukemia, NHL risk was highest among women who reported a sister with leukemia (OR = 3.0; 95% CI = 1.6-5.6). The pattern of NHL heritability appeared to be uniform across NHL subtypes, but risk patterns differed by specific hematopoietic malignancies and the sex of the relative, revealing critical clues to disease etiology.

Description: The LRF CLL4 trial randomised 777 previously untreated patients with Binet stage progressive A, B or C disease between January 1999 and October 2004 to receive either Chlorambucil, Fludarabine or Fludarabine and Cyclophosphamide. Interphase FISH for deletions of chromosome 6q, 11q, 13q, 17p and trisomy 12, IgVH gene mutational status (98% cut off), CD38 (7% cut off) and ZAP70 (10% cut off) expression were measured at randomisation on 579, 523, 535 and 478 patients respectively. Leukemic cells from 39 patients utilised the VH3-21 gene of whom 33 had homologous CDR3’s. Among the biological markers, log rank analysis showed that 〉20% p53 loss, del 11q, unmutated VH genes, high CD38 and high ZAP 70 correlated with disease progression or death (Table 1) but not deletion of chromosome 6q, 13q and trisomy 12 (p=0.7, 0.3 and 0.2 respectively). There was no difference in PFS or response duration between the 52 patients with 5–20% p53 loss and the 494 patients with no p53 loss. Multivariate Cox regression analysis showed that 〉20% p53 loss (p

Description: Background: Leukemia is the most common pediatric malignancy, accounting for nearly 40% of all new childhood cancer. The cure rates for pediatric ALL have increased to more than 80% and the cure rates for pediatric AML now approach 50%. Much of this progress can be attributed to cytogenetic and molecular risk stratification with subsequent randomized control trials. Genomic instability events may also serve as relevant prognostic biomarkers. A novel high-throughput genomic technology called Molecular Inversion Probes (MIPs) quantifies genomic instability, gene copy number and allelic imbalances at the highest genomic resolution. MIPs can analyze genetic target sequences in parallel with high specificity and sensitivity. Further classifying leukemic blasts using more precise molecular techniques could prove useful in further risk stratifying and developing new treatment strategies. Objective: To adapt MIPs to characterize and define unique molecular subtypes of childhood leukemia. Methods: DNA was extracted from AML and ALL clinical samples obtained at diagnosis. 400 ng of leukemic DNA was mixed with a previously synthesized MIP cancer probe set (667 probes representing all human chromosomes from exon sequences of 298 cancer genes); each probe contains two unique recognition sequences to targeted genomic DNA and a unique barcode (tag) sequence. A thermostable polymerase and ligase were added, and the mixture was denatured. Probe homology sequences were then annealed to complementary genome sites. Standard PCR reagants were added including one fluorescent-labeled primer and unlabeled primer. The reaction was thermocycled and probes circularized in the nucleotide specific “gap fill” reaction were amplified. The PCR mixture was hybridized to a barcode microarray overnight. The chip was stained and washed, and then interrogated by an Affymetrix scanner via argon laser excitation at 488-nm. ‘Cluster along Chromosomes’ analysis was performed to detect significant amplifications or deletions. Results: Childhood ALL and AML samples had unique patterns of multiple gene deletions. Additionally, overlap was found in several of these deleted genes. Significantly deleted genes in common between ALL and AML samples included: RAP1GA1, HYAL1, HSPA9B, CSF1R, TNF, NOTCH4, FANCE, CCND3, BAG2, PLAGL1, MAD1L1, POLM, POLD2, IGFBP3, PSD, SUFU, CYP17A1, MXI1, HRAS, IGF2, RRM1, BRCA2, TP53, ERBB2, ERCC2, and POLD1. Conclusions: MIPs represent a novel technology for highly sensitive and specific gene copy analysis of childhood leukemia. Unique and distinguishing signatures of allelic imbalance can be determined between ALL and AML clinical samples using MIP technology. The unexpected overlap of deleted genes in both ALL and AML may represent a common molecular mechanism that requires further investigation. We currently are adapting MIPs for an expanded cancer probe set and are exploring new techniques to determine loss of heterozygosity (LOH) in pediatric leukemia.

Description: Background: Many hospitalized patients with PE die. A large registry study described a mortality rate of 17.4% in patients with PE and suggested 45% of these deaths were due to the PE. Data on death and PE is usually derived retrospectively from hospital databases without chart confirmation and to our knowledge no study has attempted to determine the accuracy of coding for PE deaths. Furthermore, it is unclear how often deaths caused by PE could have been prevented. Methods: A retrospective chart review of PE cases hospitalized at a tertiary care center. Charts over an 8 year period ending in 2004 were reviewed if the hospital database record identified PE as a diagnosis by the ICD-10 coding system. Charts of those who died were independently reviewed by two thrombosis experts with discrepancies resolved by consensus or a third reviewer. Prior to chart review definitions were agreed upon. The coding as PE was considered correct (confirmed PE) if there was supportive imaging, an autopsy, or in the case of death without imaging or autopsy, the clinical scenario was such that PE could have occurred. The degree of certainty that PE contributed to the death was classified as certain (unexplained hypotension, hypoxia, cardiac arrest with no other explanation other than PE and autopsy confirmation or radiographic confirmation), highly probable (same as certain but no autopsy confirmation), probable (criteria for highly probable but another disease could have caused the death). We considered these cases to be death due to PE. Deaths were also classified as possible (other cause suspected based on clinical evidence but 100% certainty not available), or unlikely due to PE (all other cases). In cases defined as death due to PE we determined whether any further intervention could have prevented death. Results: 612 cases were identified of whom 68 had radiographic or autopsy data that ruled out the diagnosis and in 46 the coding was clearly an error. 498 cases of PE were identified, 111 of whom died during hospitalization; the mortality rate in those the hospital coded as PE was 18% vs 22% of those with confirmed PE. Death due to PE was diagnosed in 70 patients (14% of patients with confirmed PE and 11% of all patients coded as PE). In the remaining 41 deaths, PE was possible in 24 and unlikely in 17. Disagreement was uncommon. There was no difference between the likelihood of death from PE in the group diagnosed by imaging and autopsy compared with the group where PE death was confirmed by an appropriate clinical scenario. 38 deaths due to PE may have been prevented with an additional intervention: prophylaxis (55%), earlier diagnosis (45%), inferior vena cava filter (IVCF) (32%), anticoagulation (18%), embolectomy 5%, thrombolytics (3%). The remaining deaths due to PE were not preventable since 15 patients were palliative and did not receive active treatment, 9 died before a diagnosis was made and in 8 another disease prevented treatment. Conclusions: Using hospital database records is a reasonable means to evaluate PE mortality and our death due to PE rates are similar to those in registry publications. Surprisingly imaging and autopsy results do not increase the probability of reaching the conclusion that death is due to PE. Over half of preventable PE deaths may have been prevented by prophylaxis and one third with an IVCF.

Description: 80% of patients with CLL present with a lymphocytosis detected on a routine blood count. Many studies have identified risk factors for disease progression but there remains uncertainty about the magnitude of risk and which factors are most useful in determining this risk. To address this we have studied a cohort of 122 stage A0 patients who presented with a lymphocytosis and typical CLL immunophenotype before 1996 and whose CLL has either progressed or remained stable over a 10 year period. All patients were reviewed at least annually. Disease progression was defined as the need for anti-leukemic therapy, an increase in stage or a downward trend in haemoglobin or platelet count, progressive lymphadenopathy or splenomegaly or constitutional symptoms. Karyotypic data, from analysis of G banded metaphases derived fromTPA stimulated lymphocyte cultures, were available on all cases at diagnosis. CD38 and ZAP 70 expression were measured on DMSO frozen cells. VH gene usage and mutational status, and telomere length were assessed on frozen DNA samples, while interphase FISH for del 13q14, del 11q and 17p (ATM and p53 loss) and trisomy 12, was undertaken on fixed cell suspensions. All samples had been collected and stored at, or close to the time of diagnosis. 50 patients had progressive disease. Of the 72 patients with stable disease, the lymphocyte count remained below 20x109/l in 53 and rose with a lymphocyte doubling time of 〉 1 year in the remainding 19 (termed slowly progressive). In univariate analysis, a lymphocyte count of 〉 20x109/l, unmutated VH genes, high expression of CD38 (cut off 30%) and ZAP70, del 11q, abnormal presenting karyotype and short telomere length all predicted for disease progression. There was no difference in VH gene usage between the progressive and stable groups. Among the 107 patients for whom lymphocyte count, VH gene mutational status, CD38 and ZAP 70 expression are all currently available, the number of poor risk factors in the progressive and stable groups is shown in Table 1. There was no difference in the number of risk factors between the stable and slowly progressive groups. Del 11q was found in 9 progressive cases all of whom had 2 or more risk factors. P53 loss was found in a single patient with stable disease and no risk factors. 20/122 patients presented with a lymphocyte count 〈 5.0x109/l, below which patients have been considered to have monoclonal B cell lymphocytosis. Interestingly, 5 of these developed progressive disease. Using only the lymphocyte count, CD38 and ZAP 70 expression, Table 2 shows the risk of disease progression according to the risk factors present. In summary, once ZAP 70 measurement by flow cytometry is standardized, readily available prognostic tests can provide a quantitative estimate of the risk of disease progression. Performing interphase FISH for 11q and p53 loss in poorer risk cases only may provide additional prognostic information. Table 1 No. of adverse factors at presentation. (%) 0 1 2 3 4 Group Progressive 11(25) 10(23) 11(25) 9(20) 3(7) Stable/Slowly progressive 44(70) 16(25) 3(5) 0 0 Table 2 Odds of Progression % of Patients Progressing No risk factors 0.2 16.9 ZAP70 only 0.74 42.7 Lymphs〉20 0.89 47.0 CD38 only 1.57 61.1 ZAP70+lymphs 3.24 76.4 ZAP70+CD38 5.75 85.2 CD38+lymphs 6.85 87.3 All 25.1 96.2

Description: Cardiac events, including heart failure and arrhythmias, are the major cause of death in patients with b-thalassemia. Although cardiac arrhythmias in humans are believed to result from iron overload, excluding confounding factors in the human population is difficult. The purpose of these studies was to evaluate the development of cardiac arrhythmias using the guinea pig model of secondary iron overload. Electrocardiograms were recorded via surgically implanted telemetry devices in guinea pigs loaded intraperitoneally with iron dextran and controls. Cardiac and liver iron concentrations were significantly elevated in the iron loaded animals when compared to control, and were in the range of those reported for humans with thalassemia. Arrhythmias were noted infrequently in both iron loaded and control guinea pigs. No life threatening arrhythmias were detected in either group. These data suggest that iron alone may be insufficient to cause cardiac arrhythmias, and that arrhythmias detected in individuals with iron overload may be the result of a complex interplay of factors.

Description: Active disease (ActDis), poor-risk cytogenetics, and older age have historically been considered the most important adverse risk factors for survival after BMT for AML. We performed a multivariable analysis of these and other potential risk factors for overall and progression-free survival. From August 1992 to July 2005, we treated 87 patients with AML, who also had informative cytogenetic studies, with high-dose busulfan-containing preparative regimens and an HLA-matched sibling BMT. The median age was 43 years (range 19 to 62). The median LDH level at the time of BMT was 204 U/L (range 93–1555 U/L; normal 100–220 U/L). Forty-one patients were in either first (n= 30) or second complete remission (n=11; CR). 46 patients with ActDis were treated. The 87 patients were then classified according to the SWOG/ECOG (Blood96:4075, 2000), MRC (Blood92:2322, 1998), and CALGB (Blood100:4325, 2002) cytogenetic classification systems. With a median follow-up of 56.0 months (range 4.5–107.8 months), the median relapse-free survival is 13.5 months for patients in CR1 and 4.1 months for patients in CR2. The relapse-free survival of patients with ActDis was 5.5 months. A Cox proportional hazards analysis that included gender, age, LDH, disease status, cytogenetic risk group, preparative regimen, source of stem cells, and CMV status was performed for overall and relapse-free survival. Significant risk factors for shorter survival in univariate analysis included male gender, LDH 〉330 U/L (but not LDH 〉220 U/L or per 100 U/L increase), and peripheral stem cells as a source of hematopoietic reconstitution (n = 7). Surprisingly, a male donor to a male recipient was also an adverse risk factor (p330 U/L (p=0.002), source of stem cells (p=0.019), and male donor to male recipient (p 330 U/L had significantly worse survival as shown below. We conclude that high LDH (〉1.5X upper limit of normal) is a significant adverse risk factor for survival after BMT for AML and predicts outcome better than more traditional risk factors such as age, disease status, and cytogenetic risk profile. Figure Figure

Description: Inhibitors of histone deacetylase (HDAC) have generated major interest for the treatment of multiple cancers including B-cell Chronic Lymphocytic Leukemia (CLL). To date, HDAC inhibitors introduced for clinical development in CLL have been associated either with suboptimal activity relative to concentrations required to mediate cytotoxicity in vitro (Valproic Acid, MS-275, SAHA), or demonstrate unacceptable acute or long-term toxicities (depsipeptide) that limit their clinical potential. Fortunately, several alternative HDAC inhibitors are in pre-clinical or early clinical development. One such agent currently undergoing pre-clinical testing by the National Cancer Institute-sponsored RAID program is OSU-HDAC42 (s-HDAC-42), a novel, orally bioavailable phenylbutyrate-derived HDAC inhibitor with both in vitro and in vivo efficacy against prostate cancer cells. We therefore tested OSU-HDAC42 against CD19-positive cells obtained from patients with CLL to determine its potential in this disease. The LC50 of OSU-HDAC42 in CLL cells was 0.46 uM at 48 hours of continuous incubation by MTT assay, which was corroborated by annexin V-FITC/propidium iodide flow cytometry. To determine the minimum amount of time that OSU-HDAC42 must be present to induce cell death, cells were incubated for various times, washed, resuspended in fresh media without drug, then assessed by MTT at a total of 48 hours incubation. The effects of OSU-HDAC42 were eliminated in CLL cells when drug was removed after 4 or 6 hours. However, there was a gradual increase in effect over time, and by 16 hours, approximately 60% of the cytotoxicity achieved with continuous incubation was retained. OSU-HDAC42 induced acetylation of histone proteins H3 and H4 as early as 4 hours that was dose and time dependent. LC/MS interrogation of OSU-HDAC42-treated CLL cells is currently underway to determine specific post-translational modification changes of all histone proteins and variants. OSU-HDAC42 also was able to sensitize CLL cells to TNF-Related Apoptosis Inducing Ligand (TRAIL) at 24 hours in a dose-dependent manner, supporting its class I HDAC inhibitory activity as recently reported by Inoue and colleagues (Cancer Res.2006; 66:6785). Evidence of class II HDAC inhibitory activity was also observed with OSU-HDAC42 at 12 hours with acetylation of tubulin. Unlike depsipeptide, OSU-HDAC42 activated both caspase-8 and -9 followed by PARP processing. Cell death induced by OSU-HDAC42 was completely inhibited with pre-treatment by the pan-caspase inhibitor Z-VAD-FMK. In vivo experiments are underway to examine the efficacy of OSU-HDAC42 in several murine models of leukemia to confirm in vivo efficacy as well as influence on murine effector cells. Our data strongly support continued investigation of OSU-HDAC42 in CLL and related B-cell malignancies.