ALBERT

Description: Cytotoxic lymphocytes (CTLs) which recognize distinct antigenic peptides on CML cells, contributed greatly to the cure after allografting. Previously, BCR-ABL specific peptides and the PR1 non-apeptide, were found to elicit a CML-specific CTL response (Molldrem, 1996/1997; Bocchia 1996, Clark 2001). PR1 is a peptide derived from myeloblastin (MBN), also known as proteinase 3. MBN is abundantly expressed in azurophil granules of normal myeloid cells and is substantially overexpressed in certain immature myeloid leukemia cells where it may be important for the maintenance of a leukemic phenotype. PR1-specific CTLs (PR1-CTLs) lyses and inhibits the proliferation of CML cells but not of normal myeloid precursors. The association between the emergence of PR1-CTLs and the response to IFN-a in vivo strongly implied that IFN-a can induce remissions via induction of a CML-specific PR1-CTLs response (Molldrem et al, 2000). Recent data demonstrating a failure of IM to kill cell cycle-arrested CML precursors advice us to be attentive to arising escape mechanisms of even chronic phase CML; therefore the sequential combination therapy of IFN-a given alone to CML patient with undetectable disease achieved with IM, might be more effective than any current monotherapy. We have treated until now 4 CML patients who had undetectable residual disease for at least one year after IM therapy. The patients discontinued IM and started IFN-a at the dose of 3 M/U/m2 weekly. The median duration of IM therapy was 58 (range, 31–68) months before IM interruption. At a median follow-up of 5 months (range, 3–12 months) after IFN-a, all patients still have an undetectable level of BCR-ABL transcript. The details of patients characteristics will be discussed during the presentation. These preliminary results demonstrate that treatment with low dose IFN-a in CML patients with undetectable disease is feasible and did not lead to a molecular relapse. We are starting a large prospective randomized study to evaluate the role of IFN-a employed alone after 1 year of complete molecular remission achieved with IM (Arm A) vs contination of IM alone (Arm B). The main objective of this study is to verify the real effect of the immune modulation following IFN-a in CML patients with undetectable disease.

Description: Background: Imatinib, a selective inhibitor of the bcr-abl tyrosine kinase, induces CCR in the majority of patients with CML in first chronic phase (CP). In the present study we addressed the question if such achievement of CCR can occur also in patients relapsed after autografting and IFN-α therapy. Methods: from 1991 to 2001, 50 patients with early chronic phase were treated with hydroxyurea; subsequently, when WBC count was less than 10x109/L, the patients were treated with idarubicin containing regimen (ICE/mini-ICE protocols), mobilization of diploid or prevalently diploid peripheral blood stem cells (PBSC) with G-CSF during the early phase of recovery after chemotherapy and high-dose therapy followed by autologous diploid PBSC previously collected and cryopreserved. After engraftment, the patients received maintenance therapy with IFN-α (3MU/three times weekly). From september 2000, Imatinib became available for CML patients relapsed after IFN-α treatment. From that time all patients who relapsed after autografting and IFN-α received rescue therapy with Imatinib at 400 mg/daily for CP (Novartis protocol CSTI-106) and 600 mg/daily for accelerated phase (AP) (Novartis protocol-Italian Cooperative Study Group CSTI-003). Imatinib was given to 22 patients cytogenetically relapsed in CP and to 1 patient evoluted in AP. Results: At the time of analysis (July 31, 2004), the median treatment duration with Imatinib was 32 months (range, 1 to 47). Four patients stopped Imatinib between 9 and 12 months for no response/progression. The patient in AP died of heart failure one month after starting Imatinib; since this patient have had previous history of cardiac failure, it is not clear if this event should be correlated with Imatinib therapy; two other patients died for progression. Imatinib induced major cytogenetic responses in 16/23 patients (70%) of whom 14/23 achieving CCR (61%). At a median follow up of 36 months the PFS and OS were 78% and 87%, respectively. Grade ≥III hematological toxicity occurred in 5 patients; this toxicity resolved with temporary discontinuation of the treatment. Conclusion: Imatinib is an effective therapy for CP-CML patients who relapsed after autografting and IFN-α. The high rate of sustained haematological and cytogenetic responses achieved with Imatinib were associated to a favourable and manageable toxicity profile.

Description: The clinical studies have demonstrated the efficacy of Imatinib in the induction of hematological remission, cytogenetic remission (CCR) and molecular reduction of the bcl-abl transcript as shown by RT-qPCR. Unfortunately, the optimal long-term management of patients who achieve CCR after Imatinib is unknown. It is unclear that Imatinib alone will prove to be curative and initial responders may eventually lose Imatinib responsiveness. Therefore it may be prudent to collect autologous PBSC in CCR patients treated with Imatinib with low levels of detectable leukemia analyzed by molecular tests. We evaluated G-CSF mobilisation of PBSC in 18 patients who have achieved CCR with Imatinib. Our data demonstrated that the target CD34+ cell yields of ≥ 2.0x106/kg was attained with G-CSF at the dose of 10 mg/kg/day in 4/8 (50%) patients during uninterrupted Imatinib therapy and in 8/10 (80%) when Imatinib was temporarily interrupted. Three patients (37%) in the first group and 7 patients (70%) in the second group achieved 〉1x106/kg CD34+ cell yield per apheresis. Twelve patients were evaluated on PBSC for bcr-abl by RT-qPCR. Three patients were negative and in the other 9 patients, a median of 0.20 (range, 0.02–8.6) remained detectable. These data compared favourably with a median of 0.04 (range, 0.02 – 0.86) of all measurements taken before mobilisation. There was no impact of G-CSF mobilisation on the CML as measured by cytogenetic and serial blood bcr-abl levels. In conclusion, PBSC mobilisation with Imatinib and G-CSF in CCR patients is feasible, CD34+ cell yield is significantly better with temporary withheld of Imatinib, G-CSF did not preferentially mobilize leukemic progenitors and leukemic burden did not show significant change in the months following G-CSF mobilisation.

Description: The development of reduced intensity conditioning regimens (RICT) has renewed interest in allografting for patients with multiple myeloma (MM). Taking advantage of this new approach, we firstly postulated that combining maximal tumor reduction achieved with autografting and the benefits of RICT, we could achieve more cures of multiple myeloma (MM) with acceptable toxicity. Sixteen patients, 51 years of age (range, 36–63) with previously treated stage III MM were given melphalan 140 mg/m2 and autologous peripheral blood progenitor cells (PBPC) reinfusion. The regimen-related toxicities were moderate with a median of 8 and 11 days of neutropenia and thrombocitopenia, respectively. Forty-six to 156 days later (median, 79 days), the patients received fludarabine 30 mg/m2/d x 3 days plus 2 Gy TBI and HLA-identical donor mobilized PBPC. Postgrafting immunosuppression consisted of cyclosporine and mycophenolate mofetil. Donor lymphocyte infusions were given to eight patients with stable mixed chimerism or progressive disease who did not show signs of aGVHD. Engraftment occurred in 14 patients (87%). Ten patients (62%) are alive with 9 of them in continuous complete remission 11–36 months (median, 30 months) after transplants. All remitters patients achieved full chimerism and developed GVHD. Grade II–III acute GVHD occurred in 7 patients (43%) but no patient died of aGVHD. Three patients (18%) developed extensive chronic GVHD requiring intensive therapy. Six patients died; five of them of progressive disease and one of progressive disease combined with extensive cGVHD and interstitial pneumonitis. In conclusion, this 2-step approach is feasible and demonstrated to have a strong antimyeloma activity with reduced deaths due to acute toxicities.

Description: We postulated that it is possible to safely extend the benefits of allografting to metastatic breast cancer by combining cytoreduction achieved with high-dose therapy and autologous stem cell transplant (HDT/ASCT) and graft versus tumor effect mediated through transplanted donor immune cells with nonmyeloablative allografting (RICT). Seventeen patients, 41 years of age (range, 31–57), with heavily pretreated disease were given HDT/ASCT. No patient died after HDT/ASCT. Thirty-one to 92 days (median, 51 days) after HDT/ASCT the patients received fludarabine 30 mg/m2/day x 3 days and cyclophosphamide 300 mg/m2/day x 3 days and donor PBPC from HLA-identical siblings. Postgrafting immunosuppression consisted of cyclosporine and methotrexate. Donor lymphocyte infusions were given to 11 patients with stable mixed chimerism and/or progressive disease, who did not show signs of GVHD. Thirteen patients (76%) achieved sustained donor engraftment. Three patients achieved partial remission (PR) after HDT/ASCT and complete remission (CR) after RICT; another no-responsive patient achieved PR for an overall response rate of 4/17 (22%). The first signs of responsiveness in CR patients began at day +80, +90 and +110 and the maximal response was achieved on day +240, +300 and +390. The 3 remitters patients achieved full chimerism and developed GVHD before regression of the disease. Grade ≥II aGVHD occurred in 5 patients (29%) and extensive cGVHD in 5 patients (29%). No transplant-related deaths (TRD) were observed during the first 100 days. Three patients died of extensive cGVHD in the first year. At April 2004, 5/17 patients (29%) are alive 90–2160 days (median, 1320) from RICT. In conclusion, this 2-step approach is a feasible procedure in metastatic breast cancer patients; the exploitation of graft versus tumor effect is a promising finding.

Description: Multiple Myeloma (MM) is the most frequent indication for autolografting and allografting. Autografting (AutoSCT) represents the most effective palliation for these patients. Even the double AutoSCT where there is demonstrated good long-term control in a minority of patients do not appear to result in cure of disease. Myeloablative AlloSCT is penalized by excessive transplant-related mortality (TRM) and toxicity.The introduction of reduced-intensity conditioning for allografting (RICT) has renewed interest in the use of AlloSCT for MM. Recent studies have reported encouraging results with tandem AutoSCT followed shortly thereafter by RICT in MM patients as compared to AutoSCT or myeloablative AlloSCT alone. Here we present the results achieved in our Unit in patients receiving AutoSCT (single or double) compared to patients receiving tandem AutoSCT/RICT. The major results are summarized in the table. In the AutoSCT/RICT group the risk of disease progression was reduced for those patients who achieved full chimerism, acute and/or chronic GVHD. This finding confirms the existence of a graft-versus-myeloma effects. Since the first clinical signs of response of remitters patients were noted between 70 and 120 days and maximum response between 160 and 200 days after RICT (and after DLI in 2 patients) these responses should be considered immunological responses. In conclusion, these data suggest that AutoSCT/RICT significantly reduces the incidence of disease progression but did not impact on overall survival with respect to single or double AutoSCT. Single Double AutoSCT AutoSCT AutoSCT + RICT (n=15) (n=35) (n=24) Age, median 64 (range 48–73) 62 (range 35–73) 50 (range 34–63) No. prior cycle chemoth., median 5 (range 3–8) 4 (range 3–6) 4 (range 3–6) Conditioning regimen for AutoSCT Melph. 200 mg/m2 Melph. 200 mg/m2 Melph. 200 mg/m2 Conditioning regimen for RICT ==== ==== TBI-Flu (19 pts) Flu-Melph. (5 pts) Days from Dx to AutoSCT, median 210 (range 120–390) 320 (range 120–840) Days from AutoSCT to RICT ==== ==== 80 Overall Survival 73,3% (11/15) 60% (21/35) 66% (16/24) Median Overall Survival 37 (range 10–132) 51 (range 13–147) 28 (range 6–87) Pts alive in CR 1 (6,6%) 4 (26,6%) 10 (41,6%) CR duration, median 20 mo. 56 mo. (range 28–70) 67 mo. (range 8–78) TRM 1 ==== 3

Description: Imatinib mesylate (IM) is a powerful and selective p210 Bcr-Abl tyrosine kinase inhibitor that has been demonstrated to be effective for the treatment of CML. An Italian multicenter study was performed to investigate the safety, efficacy, tolerance and compliance of IM in newly diagnosed CML patients. From February 2000 through February 2007, we collected 339 CML patients in different phases of disease and previously treated with Interferon-alpha and/or other therapies. One hundred fifty-two untreated Ph+ CML patients received Imatinib at diagnosis at a dose of 400 mg orally per day; 88 were male and 64 female with a median age of 50 (range, 17–80) years. Complete hematological remission was achieved in 94% of patients. The estimated rate of complete cytogenetic remission (CCR) was 69% after 12 months; with a median follow up of 38 months the rate of CCR raised to 86,8%. Levels of Bcr-Abl transcripts had fallen by at least 3 log in 59% of cytogenetic remitters patients at 12 months; after a median follow up of 38 months, 26% of these patients achieved complete molecular remission (CMR). The most commonly reported adverse events after IM were edema (including peripheral and periorbital edema) (50%), muscle cramps (37,7%), diarrhea (40,7%), fatigue (38,8%); moreover in 8 (5,2%) patients grade 3–4 events were observed consisting of pancitopenia and/or elevated liver enzymes. Eight (5,2%) patients died: 2 patients for progressive disease after allografting, 2 patients of cardiac infarction, 1 patient of severe necrotic fascitis, 1 patient of metastatic colon cancer and 2 patients of blastic crisis. In summary, at 84 months 144/152 (94,7%) patients are alive and 125 (86,8%) of them are still receiving IM. Nineteen (13%) patients discontinued Imatinib: 7 patients for adverse events grade 3–4 and 12 patients for progressive disease. These data are comparable to those of IRIS study and confirm the safety and efficacy of IM in newly diagnosed patients.

Description: Nonmyeloablative (NM) regimens extended the application of allogeneic transplantation (AT) to older and/or medically unfit patients ineligible for high-dose conditionings. Moreover, several patients are offered AT after failure of prior lines of therapy. We retrospectively evaluated 108 patients, median age 51 (16–67), with advanced or heavily pre-treated hematological cancers [19 acute myeloblastic (AML) and 1 lymphoblastic leukemia (ALL); 8 myelodysplastic syndrome (MDS); 9 chronic myeloid (CML) and 9 chronic lymphocitic leukemia; 3 myelofibrosis (MF); 48 myeloma beyond first line treatment; 8 Hodgkin’s and 8 non-Hodgkin’s lymphoma) who underwent NM-AT at 12 Italian transplant Centres. Median time between diagnosis and transplant was 20 months. Sixty-one% of patients had failed at least one prior line of therapy, including 36 refractory or relapsed patients after 1 or more autologous transplants. At allografting, 15 patients had disease at lower risk of relapse (AML and ALL in first complete remission (CR), MDS without blast excess, CML in first chronic phase, untreated MF). Forty-two patients had active disease. The comorbidity score was evaluated with an AT-specific comorbidity index (CI) as described by Sorror et al: 51 patients had CI=0, 42 CI=1–2 and 15 CI≥3. Patients were conditioned with fludarabine 90 mg/m2 and 2 Gy total body irradiation. GVHD prophylaxis consisted of cyclosporine and mycophenolate mophetile. Graft failure was observed in 1 patient and rejection after disease recurrence in 4. After a median follow-up of 28 months post-allografting, 58 (54%) had refractory/progressive disease and 36 (33%) were in CR, including 23 who were not in CR at transplant (p

Description: Background: We postulated that it is possibile to safely extend the benefit of allografting to relapsed or resistant Hodgkin’s Lymphoma (HL) by combining cytoreduction with high-dose therapy/autologous stem cell transplant (HDT/ASCT) and graft versus HL effect mediated through transplanted donor immune cells with nonmyeloablative allografting (RICT). Methods: Twenty-two patients, 32 years of age (range, 16–39) with heavily pretreated disease were given HDT/ASCT. At a median of 92 days after HDT/ASCT the patients received fludarabine 30 mg/m2/day x 3 days and cyclophosphamide 300 mg/m2/day x 3 days and non-T depleted donor peripheral blood stem cells from HLA-identical siblings. Postgrafting immunosuppression consisted of methotrexate and cyclosporine. Cyclosporine was withdrawn early in patients with mixed chimerism or disease progression. Donor lymphocyte infusions were given to 12 patients with stable mixed chimerism and/or progressive disease. Results: Seventeen patients (77%) achieved full chimerism and 5 patients mixed chimerism. Twelve patients (55%) achieved CR after tandem transplant. The first signs of responsiveness in CR patients began at day ≥60 and the maximal response was achieved on day ≥80. The remitters patients achieved full chimerism and developed acute/chronic GVHD before regression of the disease; moreover, 5 patients achieved CR after DLI. At last follow-up (July 31, 2004), 9 out of 12 CR patients are alive at a median of 1844 days (range, 1092 to 2045). Subsequently, 5 patients relapsed and are now alive on therapy and four patients maintain CR after a median follow-up of 1874 days (range, 1092–2045). Acute GVHD grade ≥ II occurred in 9 patients (40%); chronic GVHD developed in 5 patients (23%), four of them with extensive chronic GVHD requiring further immunosuppressive therapy. Two patients died of GVHD/infections, 1 patient died of extensive chronic GVHD and 7 patients of progressive disease. Conclusions: This tandem auto-allotransplant protocol demonstrated to be highly effective also in advanced resistant Hodgkin’s Lymphoma patients. The exploitation of graft-versus-lymphoma effect is a promising finding

Description: Residual diploid hematopoietic progenitor cells (HPC) represent a quantitatively useful reservoir from a therapeutic standpoint, particularly early in the course of the disease. Clinical evidence for the persistence of diploid HPC in CML has been provided by the fact that Ph-negative cells are mobilized into the blood of patients treated with chemotherapy/G-CSF, IFN-a and, more recently, with Imatinib. In this report, we update our experience in 50 patients with early chronic phase not previously treated with IFN-a. All patients completed the mobilization protocol (ICE/mini-ICE) and diploid or prevalently diplod HPC were mobilized in peripheral blood after G-CSF. High-dose therapy consisted of Busulfan (4 mg/kg/d x 4 days) (44 patients) or TBI-containing regimen (6 patients). No patient died of the procedure. After engraftment, all patients were treated with IFN-a (3–5 MU/d three times weekly). The median follow-up of 50 patients is 77 months (range, 8 to 142 months). At present (July 31, 2004), 39 patients (78%) are alive at a median follow-up of 89 months (range, 43 –142) from autografting: 15/39 patients maintain major cytogenetic remission (MCyR) under IFN-a (1 patient received MUD in MCyR;) 23 patients (22 in CP and 1 in AP), who relapsed cytogenetically received Imatinib. Sixteen out of 23 pts on Imatinib achieved MCyR (2 patients) or complete cytogenetic remission (CCyR) (14 patients). Eleven out of 50 patients died at a median of 35 months (range, 8 to 106 months): 9 patients of blastic transformation (2 in the Imatinib group), 1 patient of fulminant hepatitis and 1 of cardiac arrest under Imatinib treatment. In conclusion, intensive treatment with autografting/IFN-a ± Imatinib was able to control the disease in 39/50 patients of whom 31 patients are still in major/complete cytogenetic remission.