ALBERT

Description: The advent of imatinib has considerably changed treatment in chronic myeloid leukemia (CML). Although response rate and duration of response with imatinib monotherapy continue to be impressive, the majority of patients (pts) in complete cytogenetic remission (CCR) retain BCR-ABL transcripts as markers of residual disease and potential cause of relapse. In addition rapid evolvement of blast crises from CCR has been reported. Therefore, we designed an investigator-initiated phase IV prospective trial aiming to address the role of imatinib in combination with interferon alpha (IFN) or Ara-C and treatment intensification with high dose imatinib. In July 2002, the German CML-Study Group has activated the four-armed randomized controlled trial comparing imatinib 400 mg/d with imatinib+IFN, imatinib+Ara-C and imatinib after IFN failure in newly diagnosed pts with chronic phase CML. Randomization is stratified according to prognostic risk groups and not biased by consecutive allogeneic stem cell transplantation (SCT). High risk pts are randomly assigned to primary imatinib-based therapies including a 4th treatment arm with imatinib 800 mg/d. The treatment arm imatinib after IFN failure retains the chance of an IFN-induced CCR with 10 year-survival rates of 70–80%. In case of IFN failure pts are crossed over to imatinib. Allogeneic SCT is recommended for all pts with high risk, imatinib failure and EBMT-score 0–1. By August 2004, 429 pts were randomized: imatinib 400 mg/d (n=103), imatinib+IFN (n=130), imatinib+Ara-C (n=108), imatinib after IFN failure (n=84), and imatinib 800 mg/d (n=4). According to the New CML score, 34% of patients were low risk, 56% intermediate risk, and 10% high risk. At baseline, median WBC count was 63/nl (3.5–513), median platelet count was 385/nl (49–2,799) and median hemoglobin was 12.7 g/dl (6.1–16.6). We sought to evaluate results of the first cohort of pts (n=217) with a 〉12 months follow-up, recruited between 7/2002 and 5/2003 (imatinib 400 mg/d, n=52; imatinib+IFN, n=70; imatinib+Ara-C, n=49; imatinib after IFN failure, n=46). Median age was 56 yrs (16–82), 62% of pts were male. Cytogenetic data are available from 117 pts (68%) randomized to primary imatinib-based therapies. At 12 months, 104 pts (89%) achieved a major cytogenetic remission (Ph+

Description: Recently, it was shown that interferon consensus sequence binding protein (ICSBP), a member of the interferon regulatory factor (IRF) family, has a potential role in chronic myeloid leukemia (CML). Deletion of ICSBP gene in mice leads to a CML-like syndrome and samples from CML patients exhibited impaired ICSBP expression. The present study found that ICSBP expression correlated with risk features determined by Sokal score in untreated CML (P = .007 for high versus low risk). In addition, analyzing ICSBP expression during interferon-α (IFN-α) therapy in “good” (n = 27) versus “poor” (n = 15) cytogenetic responders, high ICSBP levels were only observed in “good” responders (P = .0002). Together, these data suggest that ICSBP levels are related to initial presentation of CML and the therapeutic response of CML to IFN-α, indicating an important role of ICSBP in CML.

Description: Chronic myeloid leukemia (CML) is a clonal disease of hematopoietic stem cells caused by a reciprocal translocation of the long arms of chromosomes 9 and 22. In human leukocyte antigen A*0201+ (HLA-A*0201+) individuals, response after interferon-α (IFN-α) was shown to be associated with the emergence of CML-specific cytotoxic T cells that recognize PR-1, a myeloblastin (MBN)–derived nonapeptide. In contrast, imatinib potently induces remissions from CML by specific inhibition of the ABL tyrosine kinase. Here, we explored molecular regulations associated with CML responses under different treatment forms using cDNA-array. Expression of MBN was found to be down-regulated in remission under imatinib therapy (0 of 7MBN+ patients). In contrast, MBNtranscription was readily detectable in the peripheral blood in 8 of 8 tested IFN-α patients in complete remission (P = .0002). IFN-α–dependent MBNtranscription was confirmed in vitro by stimulation of peripheral blood mononuclear cells (PBMCs) with IFN-α and by IFN-α–mediated activation of the MBN promoter in reporter gene assays. Finally, with the use of HLA-A*0201–restricted,MBN-specific tetrameric complexes, it was demonstrated that all of 4 IFN-α–treated patients (100%), but only 2 of 11 imatinib patients (19%), in complete hematological or cytogenetic remission developed MBN-specific cytotoxic T cells (P = .011). Together, the induction of MBNexpression by IFN-α, but not imatinib, may contribute to the specific ability of IFN-α to induce an MBN-specific T-cell response in CML patients. This also implies that the character of remissions achieved with either drug may not be equivalent and therefore a therapy modality combining IFN-α and imatinib may be most effective.

Description: Follicular lymphoma (FL) grades 1 and 2 are regarded as a distinct disease entity, whereas data suggest that FL grade 3 might be an inhomogeneous tumor category. To define the biologic spectrum of FL, 89 follicular lymphomas were studied for their cytologic composition, antigen expression, mitotic and proliferation indices, cytogenetics, and clinical data. In contrast to the homogeneous appearance of FL grades 1 and 2 (29 and 33 cases, respectively), 2 types of FL grade 3 were recognized. Eleven cases of FL 3a displayed structural features similar to those of FL 1 and 2 and were composed of centroblasts and centrocytes, whereas 16 cases of FL 3b, with (n = 4) or without (n = 12) a diffuse large B-cell lymphoma component (DLBL) (FL 3b ± DLBL), consisted exclusively of blasts. In contrast to FL 3a, FL 3b ± DLBL were CD10+ in only 50% of cases and displayed plasmacytoid differentiation in 44% of cases.  Although FL3a was t(14;18)+ in 8 of 11 (73%) cases, only 2 of 16 (13%) FL3b ± DLBLs harbored this translocation. In contrast, chromosomal breaks at 3q27 were encountered in 7 of 16 (44%) FL 3b ± DLBL in contrast to only 2 of 11 (18%) FL 3a, and the spectrum of secondary aberrations in FL 3b ± DLBL was similar to that of diffuse large B-cell lymphoma. We conclude, therefore, that FL grade 3 is a heterogeneous disease group and that the distinction proposed in the new World Health Organization classification between FL 3a (with centrocytes) and FL3b (without centrocytes) is of biologic, and possibly clinical, importance.

Description: Introduction: Combination chemotherapy can cure patients (pts) with Non-Hodgkin’s lymphoma (NHL), but those with relapse still have a poor prognosis. High-dose chemotherapy (HDCT) with autologous stem cell support (ASCT) can improve the outcome of these pts. Rituximab demonstrated encouraging activity in aggressive NHL and showed low toxicity in the setting of combined immunochemotherapy. To investigate the influence of addition of rituximab to the intensified salvage program followed by a final myeloablative course with stem cell reinfusion we compared the group of patients treated with this program - immuntherapy group (IT) with the standard therapy group (ST) of patients treated with the same program without rituximab. Patients and methods: Eligibility criteria for both groups were as follows: age 18–67 years, eligibility for HDCT, histologically proven CD20+ relapsed or progressive NHL. Treatment program starts with two cycles DHAP (dexamethasone, cytarabine, cisplatin); pts with PR or CR receive cyclophosphamide (4g/m2) followed by PBSC harvest; methotrexate 8g/m2 and vincristine 1,4mg/m2; and etoposide 2g/m2. The final myeloablative course is BEAM followed by ASCT. Pts in IT received additionally rituximab (375mg/m²) to the each chemotherapy cycle. Results: In the immuntherapy and standard therapy group were enrolled 23 and 57 pts, respectively. There were 18 (78%) IT and 34 (60%) ST pts with relapsed and 5 (22%) IT and 23 (40%) ST pts with refractory disease. The majority of pts in both groups received CHOP-like regimens as first line treatment (91% IT vs. 79% ST). The response rate at the final evaluation for all patients was in IT 61% (52% CR and 9% PR) and in ST 43% (32% CR and 11% PR). The overall response rate (OR) for patients who responded to 2 cycles DHAP was in IT 83% (71% CR and 12% PR) and in ST 59% (44% CR and 15% PR). The therapy toxicity was tolerable and comparable in both groups. Conclusion: The preliminary results suggest better therapy outcome in patient with sequential high-dose chemotherapy with rituximab compared to pts treated with the same therapy regimen without additional antibody. The combination regimen allows effective mobilization of stem cells. The tolerability of the final myeloablative BEAM was in both groups not affected by rapid sequential administration of DHAP and high doses of cyclophosphamide, methotrexate, etoposide and rituximab. The toxicity was tolerable in both groups. The full results of match pair and multivariate analysis as well as OS and FF2F will be presented.

Description: A substantial minority of patients with chronic myelogenous leukemia (CML) achieve a complete response (CR) to treatment with interferon- (IFN), defined as the disappearance of Philadelphia chromosome-positive metaphases. Currently it is unclear how long IFN treatment should be continued for such patients. We used a competitive reverse transcriptase-polymerase chain reaction (RT-PCR) to quantify levels of BCR-ABL transcripts in 297 peripheral blood specimens collected from 54 patients who had achieved CR with IFN. The median duration of observation was 1.9 years (range, 0.3-11.0 years). Total ABL transcripts were quantified as internal control and results were expressed as the ratio BCR-ABL/ABL. All 54 patients had molecular evidence of residual disease, although 3 patients were intermittently PCR negative. The median BCR-ABL/ABL ratio at the time of maximal response for each patient was 0.045% (range, 0%-3.6%). During the period of observation 14 patients relapsed, 11 cytogenetically to chronic phase disease and 3 directly to blastic phase. The median ratio of BCR-ABL/ABL at maximal response was significantly higher in patients who relapsed than in those who remained in CR (0.49% versus 0.021%,P 

Description: Background: Polycythemia vera (PV) is a chronic myeloproliferative disorder derived from multipotent hematopoetic precursors. The pathogenesis of PV is still poorly understood; furthermore, it is not clear, why the bone marrow (BM) of patients with PV has an increased microvessel density. Aims: For these reasons, we aimed to investigate, if BM angiogenesis and pathogenesis in PV are associated, and if the increased angiogenesis can elucidate pathophysiologic mechanisms of PV. Methods: BM biopsies were taken from patients with PV before and during treatment. A total of 38 samples from 35 patients were analyzed. In three patients, we investigated biopsies in 12 months intervals. Also, eight patients with iron deficiency were studied. BM angiogenesis in thin sections was determined by immunostaining of endothelial cells (CD34, vWF) and counting the microvessels. The microvessel counts were correlated to hematologic features such as treatment modalities and iron metabolism parameters (zinc protoporphyrin (ZPP), ferritin). Iron deficiency was classified to be mild for ZPP ≤ 100 micromol/mol hem (normal value 〈 40) and for ferritin 7 to 35 microgramm/l (normal value 〉 35), and to be severe for ZPP 〉 100 micromol/mol hem and for ferritin 〈 7 microgramm/l. Results: When compared to healthy controls, the number of BM microvessels in patients with iron deficient anemia was indistinguishable from healthy individuals. As expected, the BM microvessel numbers of patients with PV at diagnosis (n= 6) or with only mild iron deficiency treated with various therapy schedules (n=20) showed no significant difference (p=n. s.). In contrast, in patients with severe iron deficiency, we detected a highly significant difference between two different treatment modalities: phlebotomy alone was associated with a normal microvessel density (n=7; mean 3.6/mm2, range 2.7 to 5.7/mm2), whereas other treatment modalites or a combination with phlebotomy were associated with a high microvessel density (n=10; mean 10.4/mm2; range 4.5 to 15.7/mm2; p=0.0004). The microvessel counts of the patients from who two sequential biopsies were investigated are in line with these results: the microvessel numbers in a patient who received an oral iron treatment increased from 9.3 to 15/mm2; the microvessels of another patient who was treated with hydroxy urea and phlebotomy showed almost unchanged microvessel counts, whereas, in a third patient, who was treated exclusively by phlebotomy, a clear decrease of BM microvessel density from 15.7 to normal value of 4.5/mm2 was observed. Conclusions: We conclude that i) iron deficiency per se does not induce increased microvessel density in the BM, ii) a severe iron deficiency induced by phlebotomy alone can reduce the BM microvessel density in patients with PV to normal. Provided that the increased BM angiogenesis is associated with pathogenesis in PV, which means that the multipotent hematologic precursors account for the increased angiogenesis, efficient iron depletion by phlebotomy represents the highly potent treatment for PV.

Description: Background: Treatment results in Hodgkin Disease (HD) have improved tremendously over the last two decades. Therefore long term sides effects of therapy as infertility are of growing importance. However, patients (pts) with HD have increased risk for inadequate semen quality even prior to treatment. To investigate the influence of disease and therapy on the fertility status in pts with HD we performed semen and hormone analysis before and after treatment. Patients and Methods: All analysis were evaluated in pts with first diagnosis of HD enrolled into trials of the GHSG between 1988 and 2002, in 40 centers in Europe. Pts had no history of chemotherapy or radiotherapy. All analysis were evaluated according to WHO-guidelines. Results: We included 243 male pts with a median age of 26,5 years (range 16–57,5 years). At first diagnosis 138 pts were in clinical stage (CS) I/II, 105 in CS III/IV, and systemic symptoms were present in 106 pts. 202 pts underwent fertility screening before therapy: normospermia was diagnosed in 40 (20%) pts and 162 (80%) had inadequate semen quality. Normal values of FSH, LH, and testosterone were found in 140/151 (93%), 99/125 (79%), and 84/101 (83%) of pts respectively. 112 pts underwent at last one fertility screening after therapy. Treatment consisted of chemotherapy alone in 10 pts, in 9 pts of radiotherapy alone and in 93 pts of combined modality. In 40 (36%) pts a recovery of spermatogenesis was observed. Normal values of FSH, LH, and testosterone after treatment were found in 32/63, 40/51, and 36/40 pts respectively. Table 1 shows time of onset of spermatogenesis and normal values of fertility hormones after the end of therapy. Table 1 1st year 2nd year 3rd year after 3rd year Spermatogenesis (40/112) 7 (18%) 9 (24%) 10 (26%) 14 (32%) Normal FSH (32/63) 8 (25%) 12 (38%) 6 (19%) 6 (19%) Normal LH (40/51) 13 (33%) 16 (40%) 6 (15%) 5 (13%) Normal testosterone (36/40) 17 (47%) 12 (33%) 1 (3%) 6 (17%) Recovery from azoospermia was observed in 8 (89%) pts treated with radiotherapy, in 1 (10%) pt treated with chemotherapy alone and in 31 (33%) pts treated with combined modality. Recovery rate from azoospermia was lower in pts treated with alkylating agents, BEACOPP chemotherapy, with systemic symptoms and elevated BSG. Conclusions: We confirmed that HD pts had inadequate semen quality even prior to treatment. The majority of pts had azoospermia after treatment, but recovery of spermatogenesis was observed, in general 2 years after the end of therapy. Hormone values usually recovered in the first two years. Patient treated with radiotherapy alone recovered in higher frequency. A detailed analysis (including multivariate analyses) will be presented at the annual meeting.

Description: Objectives PEG-Interferon alpha 2b (PEG-IFN) is a new formulation of Interferon with a prolonged half-life and can therefore be given once weekly. It has shown efficacy in patients refractory or intolerant to IFN. Within a German multicenter study (SHG CMLIIIA) PEG-IFN (PEG-Intron, Essex) was used in our centre for patients with CML in first chronic phase. Methods: 17 patients with newly diagnosed bcr-abl positive CML in chronic phase were included in our centre as part of the CML IIIA study. Median age was 42 yrs (range 24 – 78 yrs). After initial cytoreduction with hydroxyurea patients received 3–6 μg/kg PEG-IFN subcutaneously once a week. One patient received additional cytarabine at a dose of 20 mg/m2 10 days per month. Results: After 3 months 13/17 patients had a complete hematological response, 3 had a partial hematological response, 1 patient had a hereditary thrombocytopenia and therefor did not fulfill hematological CR criteria. Cytogenetics/FISH after 6 months were available in 12 patients and showed 1 complete cytogenetic response, 3 partial cytogenetic responses, 5 minor cytogenetic reponses and no response in 3 patients. 9 patients remained on PEG-IFN for at least 12 months and showed 2 complete, 1 partial and 2 minor cytogenetic responses and no response in 4 patients. Thus the rate of major cytogenetic responses was 33% at 6 months and at 12 months. PEG-IFN treatment was stopped in 14 patients due IFN-intolerance (n=6), patient decision (n=1), blast crisis (n=2), accelerated phase (n=1) or cytogenetic non-response (n=4). Relevant toxicities included acute pancreatitis in 1 patient, a grand mal seizure in a patient with a history of subdural hematoma, exacerbation of supraventricular tachycardia in 1 patient, transient elevation of GPT in 1 patient and a local abscess at the injection site in 1 patient. All patients experienced fever and flu-like symptoms in the first 4 weeks which gradually improved. Conclusion: PEG-IFN at a dose of 3–6 μg/kg was effective in producing complete hematological remissions after 3 months in the majority of patients and showed major cytogenetic responses in one third of patients. However there was a considerable toxicity. Still 53% of patients were able to continue treatment for at least 12 months and 4 of these (44%) are in continuous partial or complete cytogenetic response. This response rate is comparable to the results for conventional IFN in combination with Ara-C from the recent IRIS study. However in the IRIS study only 10.8% remained on IFN compared to 53% in our cohort. For patients able to tolerate this treatment PEG-IFN appears to be a valid alternative to IFN+Ara-C or imatinib in chronic phase CML.