ALBERT

Description: Background: Geriatric deficits in patients with malignancy are predictive of morbidity and mortality. Measuring geriatric deficits provides additional prognostic information not otherwise captured in routine oncology care. Currently, the gap in geriatric-care delivery is the paucity of data demonstrating effective interventions once geriatric deficits are identified. Older adults with hematologic malignancy are understudied and evaluating both the impact of geriatric factors and interventions to improve upon geriatric deficits are warranted. Here we demonstrate the impact of identifying functional impairment and an exercise program among older adults with hematologic malignancy. Methods: This was a single center prospective study of older patients (≥60 years) with hematologic malignancy. Patients actively receiving any therapeutic treatment (chemotherapy, immunotherapy, targeted agents) were enrolled in a six-month exercise program to attenuate functional decline. The Otago Exercise Program (OEP) has been found to be an effective exercise regimen to improve functional balance, muscle strength, and prevent fall-related injury and mortality.1 The OEP is a structured combination of physical therapist prescribed individualized exercise plans with home-based exercise targeted to improve balance and functional decline. Patients enrolled had mild or moderate impairments in physical function, as defined by a score ≤9 on the Short Physical Performance Battery (SPPB). Patients were evaluated at baseline for geriatric deficits (Visit 1), after four months of OEP training (Visit 2), and following two months of self-directed exercise (Visit 3 - end of study) using a standardized Geriatric Assessmpent (GA) tool (CARG GA). The relationship between geriatric deficits and mortality and hospital utilization were analyzed. The change in GA factors over 3 visits were evaluated through a linear mixed model. The proportional hazards model was built to assess the association between Visit 1 GA and overall survival (OS), where OS was defined as time from date of V1 to death, censoring patients who were still alive at time of last follow-up. The generalized linear models were used to link Visit 1 GA with other clinical outcomes such as hospital length of stay (LOS) and the probability of emergency room (ER) visit. Results: Older adults (median age: 75.5; range 62-83) actively receiving chemotherapy for hematologic malignancy were enrolled (n=30). Physical health scores as measured by the MOS-PFS increased significantly at the second visit. [Median MOS-PFS: V1=55 (0-100); V2=70 (30-100), p

Description: Introduction: Aggressive histologic subtypes of lymphoma such as mantle cell (MCL) and activated B cell (ABC) are considered incurable and affected patients often have a short median survival despite multimodal therapy. It is well established that altered expression of oncogenes and epigenetic dysregulation of tumor suppressor and regulatory genes promote cellular transformation of normal B cells into malignant lymphoma. Hypermethylation of histone proteins (H3R8 and H4R3) by the protein arginine methyltransferase 5 (PRMT5) enzyme has been documented in multiple cancer types and has been shown to promote tumor cell growth and survival. Importantly, PRMT5 over expression does not occur in normal B cells (resting or activated) and is only detected in malignant lymphoma cells. We have previously shown that PRMT5 regulates the Polycomb-repressive complex 2 (PRC2) complex including EZH2, a core histone-lysine N methyl transferase. EZH2 has tumor suppressor functions and has been shown to regulate WNT antagonist’s gene expression. WNT/β-CATENIN signaling pathway has been associated with increased cell proliferation and survival in various forms of cancers including lymphoma. Until recently, the role of PRMT5 in controlling WNT/β-CATENIN signaling has been unclear. We hypothesized that PRMT5, through its ability to repress EZH2 expression, would control WNT/β-CATENIN signaling and orchestrate downstream pathways that are relevant to lymphomagenesis. Methods: PRMT5 inhibition of patient-derived lymphoma cell lines, primary lymphoma tumor cells and mouse primary Eμ-BRD2 transgenic lymphoma cells by infecting with sh-PRMT5 lentivirus (or sh-GFP control) or a selective small molecule PRMT5 inhibitor (tool compound CMP5). Gene expression was monitored by immunoblotting and reverse transcription (RT) real time PCR. Recruitment of target proteins to promoter regions was examined by ChIP assays. To evaluate PRMT5 and WNT antagonist expression in NHL patient samples, primary tumor samples were collected from 4 patients with MCL. Cellular growth and apoptosis was assessed by proliferation assay and FACS analysis. Results: PRMT5 supports WNT/β-CATENIN activity by direct transcriptional repression of AXIN2 and WIF1 via a PRMT5-EZH2 repressor complex. PRMT5 indirectly supports EZH2 expression via inactivation of the RB-E2F pathway. AXIN2 and WIF1 are two proteins that negatively regulate WNT/bCATENIN. Additionally, PRMT5 inhibition with shRNA or CMP5 leads to repression of the WNT/β-CATENIN signaling pathway by allowing de-repression of AXIN2 and WIF1, leading to decreased nuclear phospho-b-CATENIN and decreased transcription of the target genes CYCLIN D1, c-MYC and SURVIVIN. Reduced nuclear localization of phospho-β-catenin (S675) led to differential enhanced recruitment of co-repressors LSD and HDAC2 (and loss of epigenetic marks H3K4Me3 and H3K9Me3) and loss of activating epigenetic marks H3K9Ac and H3K14Ac on CYCLIN D1, c-MYC and SURVIVIN promoters. We also found that PRMT5 regulates target gene repression in primary blastic variant MCL patient samples and mouse primary lymphoma tumor cells. Significance: Our observations show that PRMT5 is an important epigenetic regulator that governs the expression of its own target genes, the PRC2 program as well as regulating the WNT/β-CATENIN-driven pro-growth and survival genes c-MYC, CYCLIND D1 and SURVIVIN. These results, together with the prevalence of PRMT5 and EZH2 over expression and activation of WNT targets in multiple lymphoma histologic subtypes, suggests that inhibiting PRMT5 is likely to result in removal of repressive histone arginine and lysine marks and promote restoration of normal growth and survival checkpoints in malignant lymphomas. Disclosures No relevant conflicts of interest to declare.

Description: Abstract 3113 Background: Pre-transplantation FDG-PET/CT (PET/CT) has been associated with progression-free survival (PFS) and overall survival (OS) in patients (pts) with relapsed Hodgkin's and diffuse large B-cell lymphoma (Spaepan, Blood.102 :53-59, 2003). However, no data exist regarding the role of PET/CT pre-transplant in pts with mantle cell lymphoma (MCL). We performed a retrospective analysis of pts with MCL and available pre-transplant PET/CT to evaluate the association of pre-transplant PET/CT findings with PFS and OS. Methods: PET/CT was reviewed by a single radiologist according to International Harmonization Committee (IHC) criteria with mediastinal blood pool as the referenced background activity and also utilizing liver blood pool. Bone marrow (BM) uptake was not utilized in the PET/CT response assessment. Associations between PET/CT positivity and clinical characteristics were performed using Fisher's Exact and Wilcoxon rank sum tests. PFS curves were constructed from date of transplant until date of relapse or death by the Kaplan-Meier method and evaluated by the log-rank test. Univariable proportional hazards models described the relationship between clinical variables and PFS. Results: Twenty-nine pts with PET/CT prior to autologous stem cell transplant were included. Median age was 60 (range 37–73), and 86% were male. Median MIPI was 5.9 (range 4.9–7.0), with 36%, 40%, and 24% of pts classified as low (〈 5.7), intermediate (5.7–6.2), or high risk (〉 6.2), respectively. At diagnosis, 93% of pts had BM involvement, 56% had splenomegaly, and 27% had bulky adenopathy ≥ 5cm. Sixty-nine percent of pts were induced with RCHOP and methotrexate (RCHOP+M, Damon, JCO 27 :6101–6108); other therapies included RCHOP (n=4), RHyperCVAD (n=2), bortezomib (n=2), and REPOCH (n=1). Sixty-six percent, 21%, and 14% of pts received 2, 3–5, or 6 induction cycles prior to transplant, respectively. Conditioning regimens were BEAM (59%) and BEC (41%) and 90% of pts underwent transplant in first remission. Median time to transplant from diagnosis was 5.4 months (range 3.4–82). With a median follow up of 18 months (range 0.7–43), estimated median PFS is 42 months (95% CI 15–45). There have been 7 relapses (4 RCHOP, 1 RCHOP+M, 1 bortezomib, 1 REPOCH) and 5 deaths (disease progression, n=3, and pneumonia, n=2). Seventeen pts (59%) had a negative PET/CT prior to transplant, with identical results using mediastinal or liver blood pool. In 19, 6, and 4 pts respectively receiving 2, 3–5, and 6 cycles of induction therapy, 58%, 50%, and 75% were PET/CT negative prior to transplant. PET/CT positive pts received RCHOP+M (n=10), RCHOP (n=1), and bortezomib (n=1), Compared to PET/CT negative pts, PET/CT positive pts were younger (median age 55 v. 62, p=0.04) with lower MIPI (p=0.05). There was no significant association of bulky adenopathy (p=0.09), induction with RCHOP+M (p=0.23), or number of induction cycles (p=0.87) with PET/CT findings. 5 pts had a positive pre-transplant BM biopsy, of which 2 were BM negative by PET/CT. BM positivity on pre-transplant PET/CT was observed in 14 pts with only 3 also positive by BM biopsy. Median PFS was 45 months (95% CI 13–45) for PET/CT negative pts and 33 months (95% CI 3–33) in PET/CT positive pts (Figure 1; p=0.03). At this time, 4 of 17 PET/CT negative pts have progressed or died compared to 5 of 12 PET/CT positive pts. Of the 5 deaths experienced thus far, 4 have occurred in PET/CT positive pts. Presence of bulky adenopathy ≥ 5cm was also associated with a worse PFS (p=0.01), but MIPI (p=0.31) and age (p=0.61) were not. Conclusions: PET/CT associates with PFS after autologous stem cell transplantation in MCL (p=0.03). However, additional follow-up is needed to see if this association between PET/CT positivity and early relapse in MCL persists. In addition, as the majority of pts had 2 cycles of induction therapy with RCHOP+M, the impact of treatment regimen and number of cycles is difficult to assess in this series. Interestingly, neither age nor MIPI were associated with PFS from transplant, perhaps indicating that clinical characteristics at diagnosis are less important in pts that achieve a complete response by IHC criteria prior to transplant. Prospective investigation with centrally reviewed PET/CT scans compared with standard CT is required to determine the predictive role of pre-transplant PET/CT in MCL. Disclosures: No relevant conflicts of interest to declare.

Description: Introduction: EPOCH-based chemotherapy is considered a preferred first-line treatment for HIV-associated diffuse large B-cell lymphoma (DLBCL) and primary effusion lymphoma in the 2019 NCCN guidelines. We previously reported that adding the HDAC inhibitor vorinostat (VOR) to EPOCH had no impact on complete response (CR) rate, the primary trial endpoint, and similar 1-year survival rates (ASCO 2018, abstract 7573). Here, we report updated results from AMC075 and evaluate the impact of a DTI ≥15 days on clinical outcomes. A DTI ≥15 days has been shown to be associated with a better prognosis in an HIV-negative population treated with R-CHOP (Maurer et al. J Clin Oncol 2018; 36:1603-1610). We also look at the impact of allowing 1 cycle of systemic therapy given prior to study enrollment in order to circumvent logistical challenges in recruiting otherwise eligible trial subjects. Methods: Between 2012 and 2017 we conducted a randomized phase II study of EPOCH (with rituximab in CD20+ tumors) ± VOR 300 mg administered on days 1-5 of each cycle with HIV antiretroviral therapy in 90 participants with aggressive HIV-NHLs. Eligible patients had at least one of the following high-risk features or tumor characteristics: Age-adjusted International Prognostic Index (aa-IPI) of 2-3, Ki-67 ≥ 80%; activated B-cell (ABC) diffuse large B-cell lymphoma(DLBCL); or any other aggressive non-germinal center (non-GCB), non-Burkitt B-cell NHL. Patients who received 1 prior cycle of chemotherapy (CHOP-like or EPOCH) +/- rituximab were allowed to register. The primary endpoint was CR rate. Secondary objectives included determining adverse events, survival rates, and the effect of EPOCH +/- VOR on HIV viral reservoirs. We performed a post-hoc analysis evaluating the impact of time from DTI ≥15 days vs. 200 cells/mm3(Table 1). The 3-year overall survival rates for VOR-EPOCH was 70% and for EPOCH 77% (log-rank P=0.39), and 3-year event-free survival rates were 63% vs. 69%, respectively (log-rank P=0.32) [Figure 1]. Thirty-six patients (86% of n=42) with long DTI (≥15 days) had CR, compared to only 25 (57% of n=44) with short (

Description: Epstein-Barr virus (EBV) is a human herpesvirus that infects over 90% of the world's population and is associated with a wide-range of diseases. EBV has evolved to manipulate host cellular networks in the absence of proper immune function and is linked to malignant lymphoproliferative disorders (LPD) such as Hodgkin's lymphoma and diffuse large B-cell lymphomas. The lack of standard or effective therapeutic approaches for individuals with these aggressive and clinically complicated diseases represents an important unmet need. We have recently demonstrated EBV-induced B cell transformation to be dependent upon the dysregulation of protein arginine methyltransferase 5 (PRMT5), an epigenetic writer that functions as a global transcriptional repressor. We hypothesize that epigenetic readers, writers and erasers are similarly dysregulated following EBV infection of B cells and that these enzymes represent novel therapeutic candidates. The bromodomain and extra-terminal (BET) protein bromodomain 4 (BRD4) is an epigenetic reader that binds acetylated lysine residues and promotes transcription of genes that drive cell growth and survival. Here, we evaluate the relevance of BRD4 to EBV-driven B cell transformation and identify it as a potential therapeutic target for EBV-LPD. We used the highly selective and potent BRD4 inhibitor (BRD4i), JQ1, as a model to examine the relevance of BRD4 in EBV-driven lymphoproliferative disease (LPD). JQ1 treatment of, EBV-transformed lymphoblastoid cell lines (LCLs) led to reduced proliferation, but not direct cytotoxicity. However, similar concentrations of JQ1 in a more physiologically-relevant co-culture setting of EBV-LCLs cultured with autologous peripheral blood lymphocytes (PBMC), resulted in a robust depletion of LCLs, loss of suppressive myeloid populations (TAM/M2 phenotype) and expansion of anti-tumor adaptive, memory CD3/CD8 immune effector cells. Using a single dose of JQ1 (500nM) in a co-culture of LCLs and autologous PBMCs, there was a marked expansion of activated, effector memory (CD3+, CD8+, CD45RO+, CD62L-) cytotoxic T-cell population as compared to vehicle-treated co-cultures. Furthermore, a dramatic reduction in both CD19+ LCLs and suppressive myeloid populations (CD33+, CD11b, HLADR+, CD206+, PD-L1+) was observed after 10 days. Despite the depletion of myeloid cell subsets by CD33 depletion, we still saw the outgrowth of cytotoxic T cell population in the presence of JQ1. In order to delve into the causes of this heightened immune response, we looked at the changes in the expression of highly immunogenic EBV specific proteins. BRD4 inhibition led to upregulation of the EBV oncoprotein, latent membrane protein 1(LMP1), as well as MHC class I antigen presentation machinery in LCLs. The enhanced expression of LMP1 in LCLs with BRD4i, led to modulation of downstream signaling networks driven by this oncogene including PI3K/pAKT (decreased), NF-ĸB (canonical down/non canonical up) and pSTAT3 (decreased). Because LMP1 oncogenic activity is vital for EBV-driven B cell immortalization and transformation, we next conducted in-vitro assays where primary, naïve B cells were infected with EBV in the presence and absence of JQ1 (50, 500nM) treatment. Selective BRD4i was introduced in separate transformation cultures in seven-day intervals following EBV infection and absolute cell counts were monitored. At all timepoints BRD4i prevented EBV-driven transformation of purified naïve B-lymphocytes. Our findings highlight the utility of BRD4i as an experimental therapeutic strategy for EBV-driven lymphomas as it functions to target pathways initiating and sustaining transformed B cell outgrowth and survival while supporting anti-tumor host memory, immune networks. Collectively, these experiments identify BRD4 as a key driver of cell cycle progression, oncogene activation, and a potential immune checkpoint modulator in transformed B lymphoblasts. Furthermore, BRD4i enhances host immunity by eliminating suppressive myeloid cell populations permitting the activation and expansion of memory CD3+/CD8+ cytotoxic T cells. This work demonstrates BRD4i is an attractive therapeutic strategy as it sensitizes malignant cells while enhancing the responsiveness of the host immune system, making it an ideal candidate to be used in future trials with T cell immune therapies. Disclosures Baiocchi: Essanex: Research Funding.

Description: Abstract 2693 Background: Aggressive B-cell NHL harboring a c-MYC rearrangement (myc+) with or without t(14;18) is associated with shortened PFS and overall survival (OS) (Savage, Blood 2009; Johnson, Blood 2009). Clinical presentation, risk-assessment, and therapies vary among pts and institutions. We reviewed pts with myc+ and double hit NHL treated at the Ohio State University (OSU) from Aug 2008-Jan 2012 to determine factors associated with prolonged PFS and OS. Methods: Pts with de-novo B-cell NHL who were myc+ by FISH break-apart probe were included. Pts with Burkitt's, follicular, and transformed NHL were excluded. Most pts were also evaluated for presence of t(14;18) by FISH, and those myc+ pts with t(14;18) were classified as double hit NHL. Response was determined by PET/CT at the completion of first-line therapy. Associations between myc+ and clinical characteristics were described. PFS and OS were defined from date of diagnosis to date of relapse or death. Univariable and multivariable Cox regression models were performed to assess relationships of selected clinical variables with PFS and OS. Results: Of 49 myc+ pts, 55% were male, and median age at diagnosis was 62 (range: 23–83). Morphologically, 30 pts had diffuse large B-cell lymphoma (DLBCL), 10 pts had B cell lymphoma unclassifiable with features intermediate between diffuse large B cell and Burkitt lymphoma (BCLU), and 9 pts had high grade NHL not otherwise specified. Twenty-eight pts had ECOG performance status ≤1, and 40 pts had stage III-IV disease. Twelve pts had bone marrow involvement, and 26 pts had bulky disease ≥5cm. IPI was ≥3 in 24 pts, and median Ki-67 was 90% (range: 45–100). Twenty-nine of 43 assessed pts (67%) were positive for t(14;18). Therapies included R-CHOP (N=17), R-EPOCH (N=17), Burkitt's-like (ie, R-HyperCVAD, R-CODOXM/IVAC, or R-CHOP with high dose methotrexate; N=11), or other (N=4). No pts underwent autologous transplant in first remission. Twenty-nine pts (59%) achieved a complete response (CR), 2 pts had a partial response, 1 pt had stable disease, 8 pts had progressive disease (PD), and 9 pts died before response assessment (5 pts after cycle 1, 3 pts after cycle 2, and 1 pt after cycle 3). With a median follow-up of 26.2 months (mos; range: 4.8–45.0), the median PFS for all pts was 16.6 mos (95%CI: 9.6 - not reached=NR), and median OS was 37.7 mos (95%CI: 15.7–NR). Median PFS was 3.9 mos for pts without CR vs. not yet reached in pts with CR (p

Description: Mantle cell lymphoma (MCL) is an aggressive B-cell malignancy with a median survival of 3 years despite chemoimmunotherapy. Rituximab, a chimeric anti–CD20 monoclonal antibody (mAb), has shown only modest activity as single agent in MCL. The humanized mAb milatuzumab targets CD74, an integral membrane protein linked with promotion of B-cell growth and survival, and has shown preclinical activity against B-cell malignancies. Because rituximab and milatuzumab target distinct antigens and potentially signal through different pathways, we explored a preclinical combination strategy in MCL. Treatment of MCL cell lines and primary tumor cells with immobilized milatuzumab and rituximab resulted in rapid cell death, radical oxygen species generation, and loss of mitochondrial membrane potential. Cytoskeletal distrupting agents significantly reduced formation of CD20/CD74 aggregates, cell adhesion, and cell death, highlighting the importance of actin microfilaments in rituximab/milatuzumab–mediated cell death. Cell death was independent of caspase activation, Bcl-2 family proteins or modulation of autophagy. Maximal inhibition of p65 nuclear translocation was observed with combination treatment, indicating disruption of the NF-κB pathway. Significant in vivo therapeutic activity of combination rituximab and milatuzumab was demonstrated in a preclinical model of MCL. These data support clinical evaluation of combination milatuzumab and rituximab therapy in MCL.