ALBERT

Description: Patients with aggressive T-cell non-Hodgkin’s lymphoma (NHL) treated with chemotherapy have a prognosis that is significantly inferior to that of B-cell NHL. Chemotherapy combined with CD20 monoclonal antibody therapy further improves the outcome for patients with B-cell NHL. The paradigm of combining monoclonal antibodies and chemotherapy has improved outcome for a variety of malignancies. Monoclonal antibodies directed against T cell antigens are available and it is important to evaluate their efficacy in combination with chemotherapy for the treatment of T-cell malignancies. We are conducting a single-center phase I dose escalation trial of Campath-1H with dose-adjusted EPOCH (DA-EPOCH) infusional chemotherapy to assess the maximum tolerated dose (MTD) and safety in patients (pts) with CD52-positive aggressive NHL. A single infusion of Campath-1H (30, 60, or 90 mg) is given over 12 hours before each cycle of chemotherapy; pts are premedicated with Prednisone 12 hrs before the Campath infusion is initiated. DA-EPOCH was initiated immediately following completion of the Campath infusion. Toxicity during the first cycle of treatment was used to determine Campath dose escalation. Pts were required to be chemotherapy naive and to express CD52 on the malignant T-cells. 17 pts were evaluated for eligibility and 14 pts treated; 3 were ineligible due to absence of expression of CD52 as assessed by flow cytometry on the malignant T-cells (2 with NK-T cell nasal lymphoma and 1 with CD30 positive peripheral T-cell lymphoma). 14 pts were entered (6 Peripheral T-cell lymphoma (NOS), 4 Adult T-cell leukemia/lymphoma, 2 Angioimmunoblastic T-cell lymphoma, 2 hepatosplenic T-cell lymphoma); 8 pts were treated at dose level 1 (30 mg), 3 at dose level 2 (60 mg), and 3 at dose level 3 (90 mg). The median age of treated pts was 35 years (range 17–77), median IPI 3 (range 0–5). A total of 56 cycles of treatment were administered. 2 of the 14 pts treated experienced grade 3 hypersensitivity reactions; most pts experienced grade 1–2 allergic and infusional reactions manifested as fever, chills, and urticaria. Although not originally incorporated into the definition of dose-limiting toxicity, bone marrow suppression with reversible bone marrow aplasia prevented the administration of further treatment in 2 pts at the 60 mg dose level (cycle 3 and 5) and 2 pts at the 90 mg dose level (cycle 4 and 5) of Campath. 3 of these 4 pts were CMV antigen positive and were treated with oral or intravenous gangciclovir. Grade 4 neutropenia was observed in all pts (12 during cycle 1) and grade 4 thrombocytopenia in 4 pts (3 in cycle 1). All but one pt developed grade 4 lymphopenia. Documented infections were observed in 11 pts and included bacterial, fungal and viral pathogens. 5 pts were CMV antigen positive during treatment; 2 pts developed hemorrhagic cystitis associated with BK virus infection that resolved despite continued treatment. Half of the pts entered have died due to progressive lymphoma, 5 are in complete remission (17, 10, 9, 7, 3 months) and two are too early to evaluate. Accrual at the 30 mg dose level of Campath is ongoing. Bone marrow suppression that prevented completion of therapy has not been observed in any patient treated at the 30 mg dose of Campath and appears safe for combination with DA-EPOCH for phase II evaluation.

Description: p27 is a cyclin-dependent kinase inhibitor that plays a critical role in regulating G1/S progression, and whose activity is, in part, regulated through interactions with D-type cyclins. Mantle cell lymphoma (MCL) is characterized by the t(11;14) translocation resulting in deregulated cyclin D1. We previously showed that p27 expression in MCL, as assessed by immunohistochemistry (IHC), does not show the usual inverse relationship to proliferate seen in most other lymphomas that do not overexpress cyclin D1. This suggested that the normal expression or control of p27 activity on cell growth might be altered through potential interactions with cyclin D1. Using Western blot and coimmunoprecipitation studies, we assessed the interrelationship between cyclin D1 and p27 in several cyclin D1+ cell lines and primary MCL cases. Similar to our previous results by IHC, typical MCLs showed lower expression of p27 when compared to the more highly proliferative blastic cases or cell lines (mean arbitrary units: 58 versus 236 versus 120). Cyclin D1 was expressed at variable levels in both typical and blastic MCLs. p27 protein could be consistently coimmunoprecipitated with cyclin D1 from both cell lines and cases. Using techniques of exhaustive immunoprecipitation, we could demonstrate that most p27 protein was sequestered into complexes containing cyclin D1. We hypothesize that mantle cell lymphomagenesis results not only from direct consequences of inappropriate cyclin D1 expression, but also from the ability of overexpressed cyclin D1 to buffer physiologic changes in p27 levels, thereby rendering p27 ineffective as an inhibitor of cellular growth.

Description: Gene expression profiling has yielded a new molecular taxonomy of DLBCL in which 3 subtypes are distinguished; germinal center B-cell (GCB) subtype, derived from a germinal center B-cell; activated B-cell (ABC) subtype, derived from a post-germinal center B-cell; and primary mediastinal B-cell (PMBL) subtype, likely derived from a “thymic” B-cell. To define the effect of pathobiology on treatment outcome, immunophenotype has been used as an “approximate surrogate” biomarker for molecular taxonomy. Recent studies suggest that rituximab (R) benefit is primarily in BCL-6− (Winter et al Blood107:4207, 2006) and BCL-2+ (Mounier et al Blood101:4279, 2003) DLBCL, both more frequent in post-germinal center subtypes. Conversely, R-CHOP appears equivalent to CHOP in BCL-6+ DLBCL, which comprise up to 75% of all cases. We analyzed the outcome of DA-EPOCH-R using the immunophenotypic biomarkers BCL-6, BCL-2, MIB-1, CD10, MUM-1, and GCB vs ABC subtypes by the method of (Hans et al Blood 103:275, 2003). Patients had untreated de novo DLBCL excluding PMBL, stage II-IV, HIV-, and adequate organ function. No patients received radiation. Characteristics of 72 patients include median (range) age 50 (19–85); stage III/IV 69%; and High Intermediate/High International Prognostic Index (3–5) (IPI) 40%. Of 71 evaluable patients, response is CR/CRu 94%. At the median potential follow-up of 43 months, PFS is 82% and OS is 79% (Fig 1). PFS by Low/Low Intermediate (0–2) and High Intermediate/High (3–5) IPI is 93% and 64%, respectively, at 43 months. PFS by BCL-6 (Fig 1), and BCL-2 and GCB vs. ABC (Fig 2) is shown. PFS of DLBCL with MIB-1 〈 and 〉 80% was 92% and 81%, respectively. There was no significant difference in survival outcome by CD10 or MUM-1 expression (data not shown). Distribution by immunophenotype is shown below for patients with available tissue. Biomarker Distribution Biomarker Number Percent BCL-6 Neg 14 24 BCL-6 Pos 44 76 BCL-2 Neg 24 41 BCL-2 Pos 35 59 GCB 34 67 ABC 17 33 MIB-1 〈 80% 13 33 MIB-1 〉 80% 39 67 CD10 Neg 36 63 CD10 Pos 21 37 Mum-1 Neg 30 64 Mum-1 Pos 17 36 In conclusion, DA-EPOCH-R appears equally effective among all biomarker subgroups. Of note, DA-EPOCH-R is highly effective in BCL-6+ DLBCL, in which R does not appear to be very useful, suggesting the DA-EPOCH regimen itself may be highly effective in this group. The CALGB has initiated a Phase III randomized study of R-CHOP vr. DA-EPOCH-R to determine if DA-EPOCH-R represents a treatment advance. Gene expression profiling will be performed to assess the effect of the new molecular taxonomy and tumor biology on outcome. Figure Figure

Description: BACKGROUND: HIV-associated primary central nervous system lymphoma (HIV-PCNSL) is an AIDS-defining cancer. Tumors occur in patients with very low CD4+ counts, and tumors are almost always Epstein-Barr virus (EBV) infected. Overall survival (OS) has improved over time with antiretroviral therapy (ART)-associated immune reconstitution but is still generally less than 1 year. Treatment has traditionally included whole brain radiation, which can lead to devastating long-term neurotoxicity, including cognitive decline. ART has made it possible to treat patients with curative-intent, but radiation-sparing approaches have not been studied prospectively in HIV-PCNSL. METHODS: In a prospective phase II pilot study conducted in the HIV & AIDS Malignancy Branch at the National Cancer Institute, we evaluated curative-intent radiation-sparing immunochemotherapy in patients with untreated HIV-PCNSL (NCT00267865). Patients with HIV-PCNSL received ART, rituximab (375 mg/m2) and HD-MTX (6 g/m2) with leucovorin rescue (R-HD-MTX). Responses were evaluated by modified International Working Group Response Criteria for PCNSL after 6 cycles of induction R-HD-MTX and patients with a complete response (CR) received 2 consolidation cycles of R-HD-MTX. Patients with poor renal or cardiac function who were not eligible to receive HD-MTX at enrollment, received ART, rituximab and best-available radiation-sparing care. The primary objective of the study was to estimate the percentage of patients receiving ART and R-HD-MTX alive without recurrent lymphoma at two years. Response to treatment, immune reconstitution, and OS were evaluated using descriptive statistics and Kaplan-Meier methodology. RESULTS: Twelve patients were enrolled between September 2006 and June 2016. One enrolled patient was initially ineligible to receive HD-MTX due to renal dysfunction and received rituximab with temozolomide (TMZ) 150 mg/m2 for 5 days for one cycle followed by 6 cycles of R-HD-MTX + TMZ and 2 consolidation cycles of R-HD-MTX. Patient characteristics: 9 men, 3 women; median (med) age 33 years (range: 21-55); 8 African-American, 3 Hispanic, 1 white non-Hispanic; med Eastern Cooperative Oncology Group performance status 2 (1-3); med baseline Mini Mental State Examination (MMSE, maximum score = 30) was 22 (range: 5-29). Only 4 patients were on ART prior to diagnosis, and all but 1 had been on ART less than 4 months. Med time from HIV infection to PCNSL diagnosis was 30 weeks (range: 0-23 years). Med CD4+ T-cell count at PCNSL diagnosis was 16 cells/µL (0-409). Diagnosis of PCNSL was biopsy-confirmed (11) or made by 18fludeoxyglucose positron emission tomography/cerebral spinal fluid (CSF) EBV viral load criteria (1). 11/12 tumors were EBV positive. Flow cytometry showed leptomeningeal disease in 4 patients. Three had concurrent CNS infections, including Cryptococcus, histoplasmosis, and CMV retinitis. Ten were evaluable for response to R-HD-MTX induction. Two patients received only 1 cycle of therapy and were not evaluable due to treatment failure (TF). Responses after R-HD-MTX induction: CR (5), partial response (PR) (4) and progressive disease (PD) (1). Two patients with a PR received second-line TMZ at end of R-HD-MTX and obtained a subsequent CR. The patient with PD received second-line therapy with the Cancer and Leukemia Group B 50202 induction regimen and obtained a subsequent CR. There were 4 deaths on study: 1 pulmonary embolism, 1 CNS fungal infection in setting of PD, 2 TF. Eight patients (67%), including 3 patients who received second line therapy, obtained a durable CR. Med CD4+ T-cell increase following R-HD-MTX induction was +35 cells/uL (range: -54 - +369). In surviving patients, med MMSE after R-HD-MTX was 28 (27-30). For all patients, estimated 60-month OS was 66% (95% CI: 32-86%) with med potential follow-up of 82 months. Med OS was not reached. CONCLUSIONS:Treatment with ART and R-HD-MTX is associated with a high response rate, CD4+ immune reconstitution, preserved cognition, and improved OS, even in a high-risk patient population. Disclosures Uldrick: Celgene: Patents & Royalties: 10,001,483 B2; Celgene: Research Funding; Merck: Research Funding. Yarchoan:NIH: Patents & Royalties: Patents on IL-12 for KS and cereblon-binding drugs for KSHV diseases. Spouse has patent on KSHV IL-6. Patents assigned to DHHS/NIH.; Celgene Corp.: Research Funding.

Description: Abstract 2716 Background Btk is a tyrosine kinase involved in B cell receptor (BCR) signal transduction. Recent studies indicate that chronic active BCR signaling is a pathogenic mechanism in ABC DLBCL that engages the classical NF-κB pathway. Mutations in the BCR pathway (CD79A/B and CARD11) and toll like receptor (TLR) pathway (MYD88) lead to constitutive NF-κB activation in ABC DLBCL. PCI-32765 kills ABC DLBCL cell lines with constitutive BCR signaling but has no effect on ABC and GBC DLBCL cell lines that do not rely on constitutive BCR signaling. PCI-32765 is an oral, well-tolerated and irreversible inhibitor of Btk. Study Design Patients with relapsed/refractory ABC DLBCL received PCI-32765 at a fixed dose of 560 mg po once daily × 35 days (1 cycle). Patients underwent CT and FDG-PET scanning pre-treatment and every 2 cycles. Where possible, pre-treatment and 48-hour post-treatment tumor biopsies were performed for gene expression profiling (GEP) and mutational analysis of CD79A/B, CARD11 and MYD88. Results Eight of 15 planned patients are enrolled. Characteristics include median (range) age 54 (40–79); LDH 〉 normal limits (63%); any extranodal site (75%) and stage 4 disease (63%). IPI distribution was 0–2 (25%) and 3–5 (75%). Patients received a median (range) of 3 (1–6) prior chemotherapy regimens. Best response by IWG criteria include CR: 2 (25%) for 11+ and 5 months; SD (stable disease) 3 (37%) for 4, 2 and 2 months; and PD (progressive disease) 3 (38%). One patient who was primary refractory achieved SD with PCI-32765, associated with a 25% tumor reduction, and is currently in CR following allogeneic BMT. PCI-32765 was well-tolerated without significant side effects. No patients discontinued PCI-32765 due to AE. Grade 〉3 AEs were reported in 4 patients, none were considered related to PCI-32765. One death has occurred on study, in a patient who received subsequent therapy following progression on PCI-32765. Toxicities that are possibly related to PCI-32765 include diarrhea (grade 1) in 2 patients, nausea (grade 1) in 2 patients and fatigue (grades 1–2) in 4 patients. CD79B mutations were uncovered in two patients, the patient with SD who achieved a 25% tumor response and one patient who achieved CR. Of note, the other patient who achieved CR did not have the CD79B mutation, suggesting that chronic active BCR signaling may occur in the absence of this mutation. None of the patients had MYD88 or CARD11 mutations. Comparison of the pre-treatment and on-treatment biopsy samples by gene expression profiling was completed on 5 patients (1 CR, 4 SD/PD). Gene expression signatures reflecting tumor infiltrating immune cells, including CD8+ T cells and macrophages, were diminished by PCI-32765 treatment in the one patient in CR and the one patient in SD who achieved a 25% tumor reduction, but not in the others. In these same two cases, a gene expression signature of interferon signaling was reduced upon PCI-32765 treatment, associated with a concomitant decrease in interferon gamma mRNA levels, again suggesting the loss of activated T cells in the responding tumors. One hypothesis to explain this observation would be cytokine modulation since chronic active BCR signaling promotes synthesis and secretion of IL-10 and multiple chemokines, including CXCL13, CXCL9 and CCL3, which were all down-modulated in the responding tumors. Conclusions The Btk inhibitor PCI-32765 has clinical activity in relapsed/refractory ABC DLBCL and modulates chronic active BCR signaling in responders. Thus, chronic active BCR signaling is a tractable therapeutic target in ABC DLBCL. Disclosures: Buggy: Pharmacyclics, Inc.: Employment. Hedrick:Pharmacyclics: Employment, Equity Ownership.

Description: Solid tumors are dependent on preexisting vasculature and neovascularization for their growth. Successful cancer therapies targeting the tumor vasculature would be expected to block the existing tumor blood supply and to prevent tumor neovascularization. We tested the antitumor activity of experimental therapy with 2 distinct antiangiogenic drugs. Vasostatin inhibits endothelial cell growth and neovascularization, and interleukin-12 (IL-12) targets the tumor vasculature acting through interferon-γ (IFN-γ) and the downstream chemokines interferon-inducible protein-10 (IP-10) and monokine induced by IFN-γ. Individually, vasostatin and IL-12 produced distinct efficacy profiles in trials aimed at reducing tumor growth in athymic mice. In combination, these inhibitors halted the growth of human Burkitt lymphoma, colon carcinoma, and ovarian carcinoma. Thus, cancer therapy that combines distinct inhibitors of angiogenesis is a novel, effective strategy for the experimental treatment of cancer.

Description: Key Points A subset of lymphomas with gene expression and pathological characteristics of Burkitt lymphomas but absence of MYC translocation does exist. These lymphomas carry chr 11q proximal gains and telomeric losses, suggesting co-deregulation of oncogenes and tumor suppressor genes.

Description: Abstract 2707 Background: We hypothesized that immunotherapy with autologous tumor-derived idiotype (Id)-vaccine may improve the outcome of mantle cell lymphoma (MCL). Some murine lymphoma models have shown that Id-vaccine can induce an anti-tumor humoral response but others indicate that eradication of tumor requires a CD4+ and/or a CD8+ T-cell response. Antitumor T-cells may produce one or many cytokines. The Th1/Tc1 cytokines (IFNγ, IL-2, TNFα, GM-CSF) are commonly believed to mediate antitumor effects. However, a recent paper (Codarri et al. Nat Immunol 2011) proposes that production of GM-CSF by helper T-cells relies on activation of RORγt and that GM-CSF secretion is required for induction of autoimmune inflammation irrespective of helper T-cell polarization. We reported the results of Id-vaccine following DA-EPOCH-R in 26 untreated MCL patients (Neelapu et al Nat Med 2005) and found no association between PFS (19%) or OS (89%) and immune responses at the median of 46 months potential follow-up. We now present an 11-year follow-up and association between OS and antitumor immune responses. Study Design: DA-EPOCH-R was administered q3 weeks × 6, followed by 5 cycles of Id-vaccine beginning at least 12 weeks later to untreated MCL patients. Id protein was produced using hybridoma technology, conjugated to keyhole limpet hemocyanin (KLH), and administered together with GM-CSF × 5 over 6 months. Pre- and post-vaccine samples were tested in parallel to assess humoral and cellular immune responses. Anti-Id and anti-KLH antibody responses were determined by ELISA. KLH-specific cellular responses were determined by intracellular cytokine assay and cellular responses against autologous tumor cells were determined by cytokine induction and IFNγ ELISPOT assays. For cytokine induction assay, PBMCs were cultured with and without autologous tumor cells. After 6 days TNFα, IFNγ and GM-CSF were assessed in culture supernatants by ELISA. Normalized post-vaccine responses were calculated for each patient. Results: Characteristics of all 26 patients: median age 57 (r 22–73), PS 1 (0–2), male sex 73%, blastoid variant 15%, and MIPI (low-65%; intermediate-16%; high-19%). Responses to DA-EPOCH-R: CR-92%, PR-8%. Immune analyses were performed in 24 patients; vaccine could not be made in one patient and one patient progressed and did not have immune analyses. The associations between OS and MIPI scores and normalized immune responses (KLH and anti-Id antibody responses, frequency of KLH-specific CD4+ T-cell responses in PBMC (intracellular IL-2 and TNFα), antitumor cytokine responses and IFNγ ELISPOT) were determined. With 122 mos median potential follow-up (r 111–132), the median PFS is 24 mos and OS is 104 mos. MIPI was significantly associated with OS (Fig 1; p=0.01); median OS: low (not reached), intermediate (84 mos) and high (44 mos). There was no association between OS and KLH humoral response or KLH-specific CD4+ T cells. There was also no association between OS and Id-specific humoral response, IFNγ ELISPOT, or antitumor TNFα, or IFNγ cytokine responses. However, there was a significant association between antitumor GM-CSF production and OS (Fig 2). The median OS at the median GM-CSF normalized value (4.3) was 79 mos versus not reached, respectively (p=0.015 (unadjusted) and p=0.045 (bonferroni adjusted)). MIPI and GM-CSF were jointly assessed in a Cox model and showed a trend toward improved OS for higher GM-CSF (p=0.10) after adjusting for MIPI (p=0.20). Conclusions: With 10-year median potential follow-up, GM-CSF cytokine response mediated by antitumor T-cells was significantly associated with OS. Recent studies support the hypothesis that antitumor T-cells that produce significant amounts of GM-CSF are uniquely polarized and that non-GM-CSF producing T-cells do not induce antitumor effects even if they produce TNFα or IFNγ. This may explain why we did not observe an association between OS and TNFα or IFNγ cytokine responses or an anti-Id-antibody response. These results provide the first evidence that Id-vaccines may improve the survival of MCL following induction with immuno-chemotherapy and need to be confirmed in future trials. Disclosures: Neelapu: Biovest International, Inc.: Research Funding. Kwak:Biovest International, Antigenics: Consultancy, Membership on an entity's Board of Directors or advisory committees; Biovest International: Other remuneration; Antigenics, Xeme Biopharma: Equity Ownership.

Description: Key Points A 20-gene gene expression-based assay accurately and robustly assigns COO subtypes of DLBCL using formalin-fixed paraffin-embedded tissue.

Description: The new recently described provisional lymphoma category Burkitt-like lymphoma with 11q aberration comprises cases similar to Burkitt lymphoma (BL) on morphological, immunophenotypic and gene-expression levels but lacking the IG-MYC translocation. They are characterized by a peculiar imbalance pattern on chromosome 11, but the landscape of mutations is not yet described. Thus, we investigated 15 MYC-negative Burkitt-like lymphoma with 11q aberration (mnBLL,11q,) cases by copy-number analysis and whole-exome sequencing. We refined the regions of 11q imbalance and identified the INO80 complex-associated gene NFRKB as a positional candidate in 11q24.3. Next to recurrent gains in 12q13.11-q24.32 and 7q34-qter as well as losses in 13q32.3-q34, we identified 47 genes recurrently affected by protein-changing mutations (each ≥3 of 15 cases). Strikingly, we did not detect recurrent mutations in genes of the ID3-TCF3 axis or the SWI/SNF complex that are frequently altered in BL, or in genes frequently mutated in germinal center–derived B-cell lymphomas like KMT2D or CREBBP. An exception is GNA13, which was mutated in 7 of 15 cases. We conclude that the genomic landscape of mnBLL,11q, differs from that of BL both at the chromosomal and mutational levels. Our findings implicate that mnBLL,11q, is a lymphoma category distinct from BL at the molecular level.