ALBERT

Description: Abstract 3156 T cell acute lymphoblastic leukemia (T-ALL) is one of the most common childhood cancers associated with mutations in NOTCH1. The Growth factor independent-1 (Gfi1) transcriptional repressor gene was originally discovered as a common target of Moloney murine leukemia virus (MMLV) proviral insertion in murine T-ALL. In fact, the Gfi1 locus is the most frequently activated gene in MMLV-induced T cell leukemia. Therefore, we investigated whether the most commonly activated gene in MMLV-induced murine T-ALL, Gfi1, could collaborate with the most commonly activated gene in human T-ALL, NOTCH1. Here, we show that GFI1 expression is associated with Notch signaling in human T-ALL (p'0.0003). Functionally, Gfi1 collaborates with Notch-induced murine T-ALL by accelerating an already rapid disease model (p=0.03) without altering the lymphoblastic nature of the disease. Furthermore, inducible deletion of Gfi1 is counter-selected in both Notch-driven retroviral and transgenic mouse models of T-ALL; whereas, constitutive absence of Gfi1 completely prevents transgenic Notch-induced T-ALL (p≤0.04). However, T-ALL tumors can form in Gfi1-/- animals using either ENU-mutagenesis or MMLV-infection, yet tumor formation is delayed (p≤0.02, p≤0.03 respectively). This suggests that Gfi1 deletion does not prevent the formation of the T-ALL initiating cell and that Gfi1 might be absolutely required for Notch-induced T-ALL. Most striking is that Gfi1 is required for T-ALL maintenance in vitro and in vivo. Using three separate Tal1-initiated murine T-ALL cell lines, the overexpression of the Gfi1 dominant-negative, Gfi1N382S, was quickly and completely counter-selected. As Gfi1 has previously been found to regulate pro-apoptotic genes in T cells, we attempted to rescue the above loss of function phenotype by overexpressing the anti-apoptotic factor Bcl2. Notably, counter-selection of Gfi1N382 is not observed or is significantly delayed in all three cell lines. In vivo, inducible deletion of Gfi1 leads to both mutagen- or Notch-induced tumor regression as measured by ultrasound. In fact, levels of Gfi1 expression directly correlate to tumor regression and disease free survival of T-ALL. Finally, targeting Gfi1 enhances the efficacy of radiation therapy and bone marrow transplantation. Deletion of Gfi1 sensitizes T-ALL tumors and T cells to p53-dependent apoptosis after exposure to DNA-damaging agents such as radiation, Etoposide or Daunorubicin by de-repression of the pro-apoptotic Gfi1 target gene Bax. These data extend the role of Gfi1 to human T-ALL and suggest that T-ALL is dependent upon Gfi1 to repress pro-apoptotic genes for tumor survival, ultimately highlighting a new therapeutic target in the fight against lymphoid malignancies. Disclosures: No relevant conflicts of interest to declare.

Description: Abstract 324 Introduction and classification: This is the largest adult T-ALL cohort treated according to immunologic subtypes. All patients were immunophenotyped in one central lab (Berlin). T-ALL (cyCD3+, CD7+) were subclassified into early T-ALL (sCD3-, CD1a-), thymic T-ALL (sCD3-/+, CD1a+) and mature T-ALL (sCD3+, CD1a-). T-ALL constitutes in 3 consecutive GMALL-studies 24% of ALL patients. Patients and methods: A total of 744 T-ALL pts (15 to 55 yrs) were accrued in 102 hospitals in the GMALL studies 05/93, 06/99 and 07/2003. In GMALL 05/93 239 adult T-ALL patients, were treated according to a multi-agent chemoprotocol. Stem cell transplantation (SCT) was not recommended in CR1. In GMALL studies 06/99 and 07/03 505 T-ALL pts received intensified chemotherapy; particularly with introduction of PEG-asparaginase in induction as well as HDMTX/PEG-Asp consolidation cycles. Based on study 05/93 results, SCT from sibling (Sib) as well as matched unrelated (MUD) donor in CR1 was recommended for all patients with early T-ALL, mature T-ALL and for high-risk (HR) pts with thymic T-ALL (defined as late CR, complex karyotype or MRD positivity (MRD+)). Results: T-ALL subtype distribution in the total cohort of 744 adult T-ALL was early-T 23% (N=170), thymic-T 56% (N=420), mature-T 21% (N=154), without any differences between the studies. GMALL Study 05/93: The overall CR rate was 86% (early-T 72%, thymic-T 93%, mature-T 84%. The lower CR rate in early T-ALL was mainly due to early death (19%). The overall CCR rate was 47% (early-T 45%, thymic-T 54%, mature-T 30%). The overall survival rate at 10 yrs for all pts was 47% (early-T 47%, thymic-T 55%, mature-T 25%). GMALL Study 06/99 and 07/03: Of the 505 patients, 87% achieved CR (early-T 84%, thymic-T 92%, mature-T 77%). PR/Failure was higher in early-T (13%) and mature-T (17%) compared to thymic-T (5%). Early death was 4% and equally distributed. 267 pts (64%) received chemotherapy only and the majority were 229 pts (86%) with thymic T-ALL, not considered for SCT in CR1. The CCR rate was 61%. The few early (n = 15) and mature (n = 23) T-ALL pts, which could not have a transplant in CR1, are a negative selection (e.g. early relapse, comorbidity, no donor) and their CCR rate was 33% and 22% respectively. This was due to a high relapse rate in early T-ALL (60%) and mature-T (74%) compared to 33% in thymic-T. Overall survival rate at 8 yrs for thymic T-ALL with chemotherapy was 68%, for the 77 adolescent pts (15 to 25 yrs) even 76%. Stem cell transplantation: 153 T-ALL pts in studies 06/99 and 07/03 received a SCT in first remission. SCT realisation rate in early T-ALL was 84%, in mature-T 68%. Overall CCR rate was 58% (early-T 47%, HR thymic-T 79%, mature-T 61%). Relapse rate after SCT was in early-T 33% and in mature-T 22%. The overall TRM rate was 18% despite more than half MUD SCT, without any TRM difference between the immunological subtypes. Overall survival rate after SCT in CR1 at 8 yrs was 53%, early-T 44%, thymic-T 67%, mature-T 59%. SCT modalit: 49% received alloSib, 55% alloMUD and 20% auto-SCT. Overall CCR rate after alloSib for the total cohort was 65% (early-T 60%, thymic-T 73% and mature-T 69%); for alloMUD total 55% (early-T 45%, thymic-T 77%, mature-T 61%) and for the small cohort of 20 pts with auto-SCT CCR was 35%. Conclusion: The strategy in three consecutive GMALL studies to stratify and treat adult T-ALL pts according to the immunologic T-subtypes was successful. Overall survival at 5 yrs could be improved to 56% from 44%. There was a particular improvement for mature T-ALL (49% vs. 30%) and early-T (40% vs. 33%). This was mainly due to a high realisation rate of SCT in early T-ALL and mature T-ALL and the substantial better results of SCT. Results of alloMUD SCT were comparable to alloSib SCT. The small cohort of HR thymic T-ALL pts also had a benefit from SCT. The excellent outcome of SR thymic T-ALL (∼ 50% of all T-ALL) with the OS of 68% and 76% in adolescents due to intensified chemo, partic. PEG-Asp, does not suggest SCT in CR1. Several molecular markers, such as ERG, BAALC, WT1, had in a retrospective analysis some prognostic relevance in this pt cohort. The new GMALL study generation will however focus in thymic T-ALL on early evaluation of MRD to decide for SCT (MRD+) or not (MRD-) whereas early/mature T-ALL remain allocated to high risk groups with SCT in CR1. Supported by Deutsche Krebshilfe 702657Ho2 and BMBF 01GI9971/8 Disclosures: No relevant conflicts of interest to declare.

Description: Abstract 880 On behalf of the German Low-Grade Lymphoma Study Group (GLSG) and the European MCL Network Background: In younger patients with mantle cell lymphoma (MCL), autologous stem cell transplantation (ASCT) significantly prolonged response duration with a trend towards improved overall survival in a randomized trial of the European MCL Network (Dreyling et al., ASH 2008). A recently updated clinical trial of the German Low-Grade Lymphoma Study Group (GLSG) also reported a significantly prolonged response duration by the addition of Rituximab to first-line CHOP (Hoster et al., ASH 2008). By pooled analysis of these trials we investigated whether Rituximab and ASCT independently prolong response duration. Methods: The analysis included all advanced stage MCL patients of the trials “CHOP vs. MCP” (Nickenig et al., Cancer 2006), “CHOP vs. R-CHOP” (Lenz et al., JCO 2005) and European MCL trial 1 (Dreyling et al., Blood 2005) with complete or partial remission to either CHOP or R-CHOP first-line induction and randomization between ASCT and Interferon-α maintenance. Response duration was defined as time from the end of successful induction chemotherapy to relapse or death from any cause, overall survival from the end of successful induction chemotherapy to death from any cause. Stratified Kaplan-Meier curves for response duration and overall survival were calculated for the four treatment groups (CHOP without ASCT, CHOP with ASCT, R-CHOP without ASCT and R-CHOP with ASCT). By multiple Cox regression we tested whether the impact of Rituximab (R) and ASCT was independent and additive. Results: One-hundred and eighty patients with MCL were evaluable, 80 treated with R-CHOP, 78 with ASCT (CHOP without ASCT: 56, CHOP with ASCT: 46, R-CHOP without ASCT: 44 and R-CHOP with ASCT: 34). Median age was 55 years (range 34-65), the MIPI classified 71% as low risk, 22% as intermediate risk, and 6% as high risk, and baseline characteristics were comparable between treatment groups. With a median follow-up of 63 months, median response duration was 16 months after CHOP without ASCT, 26 months after R-CHOP without ASCT, 39 months after CHOP with ASCT, and 41 months after R-CHOP with ASCT. In multiple Cox regression including R and ASCT, the hazard ratios of R (0.60, 95% CI 0.42-0.86, p = 0.0056) and ASCT (0.50, 95% CI 0.35-0.70, p = 0.0001) were independently significant. There was no interaction between R and ASCT (p=0.43). Median overall survival was 54 months after CHOP without ASCT, 66 months after R-CHOP without ASCT, 90 months after CHOP with ASCT, and not reached after R-CHOP with ASCT. The hazard ratios for OS were 0.70 (95% CI 0.44-1.12, p = 0.14) for R and 0.63 (95% CI 0.41-0.97, p = 0.0379) for ASCT. Conclusions: Our results indicate an additive effect of ASCT and Rituximab in combination with CHOP on response duration in advanced stage MCL patients and support strategies of several study groups to combine Rituximab-containing induction therapies with ASCT in younger MCL patients. However, even after combined treatment approaches, delayed relapses have been observed, supporting the use of maintenance therapy and the introduction of molecular targeted therapeutical strategies. Disclosures: Hoster: Roche: Travel Support. Off Label Use: Rituximab in Mantle Cell Lymphoma. Pfreundschuh:Roche: Membership on an entity's Board of Directors or advisory committees. Dührsen:Roche: Honoraria, Research Funding; Amgen: Honoraria, Research Funding. Gisselbrecht:Roche: Research Funding, Speakers Bureau. Unterhalt:Roche: Travel Support. Dreyling:Roche: Honoraria, Research Funding.

Description: Life-threatening thromboembolism (TE) is the most feared complication in patients with paroxysmal nocturnal hemoglobinuria (PNH). Thrombophilia in PNH likely involves a hypercoagulable state, possibly due to intravascular hemolysis with scavenging of the coagulation regulator nitric oxide, and platelet activation. Approximately 45% of PNH deaths result from TE. Thrombosis is more frequent in patients with larger PNH clones, but can occur in patients with smaller clones. Primary prophylactic anti-coagulation may reduce the thrombotic risk in PNH patients, although controlled studies have not been performed and there is a known serious hemorrhage risk. A randomized, placebo-controlled, 26-week phase 3 study of the terminal complement inhibitor eculizumab in 87 PNH patients (TRIUMPH) recently demonstrated dramatic reductions in intravascular hemolysis and RBC transfusions; 1 TE was reported with placebo and 0 with eculizumab. This single study was not powered to examine the effect of eculizumab on TE, and we prospectively examined the aggregate TE event rate in eculizumab-treated patients from TRIUMPH, the two other PNH trials, and the subsequent phase 3 extension study as compared to each patient’s pre-treatment event rate. Before receiving eculizumab, examination of patient records identified 126 TE events in 195 patients, and 103 were on anticoagulants. While pre-treatment TE event rates were variable in the 3 individual PNH studies, eculizumab reduced TE in each study. The TE event rate with eculizumab treatment was 1.22 per 100 patient years, compared to 7.49 (p

Description: Background: The addition of rituximab to chemotherapy (R-CHOP) has been shown to improve response rates in mantle cell lymphoma (MCL), but prolongation of response duration or overall survival was not observed (Lenz et al., JCO 2005). In a similar randomized comparison of 90 patients, again the addition of rituximab to MCP showed a tendency towards higher CR rates, but no improvement of overall response rate, progression free, or overall survival (Herold et al., ICML-10, 2008). Methods: We present an update of a previously published trial randomly comparing efficacy and safety of R-CHOP to CHOP induction in previously untreated patients with advanced stage MCL. Results: Of the 123 evaluable patients, 63 patients were randomized to R-CHOP. Median age was 62 years, and risk profiles of the two treatment arms were comparable. Overall response rates were 92% vs. 75% for R-CHOP vs. CHOP (p = 0.0139) and complete remission rates 33% vs. 8% (p = 0.0008). After a median follow-up of 65 months, median time to treatment failure was prolonged from 14 months for CHOP to 28 months for R-CHOP (p = 0.0003). Similarly, median response duration was prolonged from 18 (CHOP) to 29 months (R-CHOP, p = 0.0052). So far, no significant improvement of overall survival has been observed with median not reached vs. 59 months and 5-years OS rates of 59% and 46% (p = 0.27) after R-CHOP and CHOP, respectively. Toxicity was not significantly higher for R-CHOP treated patients. Conclusions: After longer follow-up, superior remission rates, time to treatment failure, and response duration of combined immuno-chemotherapy were confirmed. However, in contrast to other lymphoma entities, improvement of overall survival has not yet been proven in MCL patients. Therefore new therapeutic options are urgently warranted to further improve the long term outcome in this otherwise dismal disease.

Description: Abstract 3903 Abnormalities of the κ:λ free light chain (FLC) ratio can detect monoclonal FLC elevations and are a valuable tool in the diagnosis and follow-up of plasma cell dyscrasias. However, due to their generation in active cells of the immune system and their renal metabolism, polyclonal FLC elevations might also provide valuable hints to other pathologic conditions. Recent reports suggest e.g. a role in predicting outcome in chronic viral infectious diseases. In a previous study, we screened the cohort of the German Heinz Nixdorf Recall Study for monoclonal gammopathies by combined serum protein electrophoresis and screening immunofixation (Eisele et al. EHA 2010, Abstract #0949) and also measured FLC concentration by nephelometric immunoassays (FREELITE, The Binding Site, UK) in all available samples. We here report our first preliminary results of the analysis of polyclonal FLC elevation with regard to all-cause mortality in the Heinz Nixdorf Recall cohort. The Heinz Nixdorf Recall Study cohort comprises 4814 men and women from 3 large adjacent cities in Germany. Subjects were randomly selected from statutory lists of residence and gave informed consent. We screened serum samples from the baseline examination which took place from 2000 until 2003. After exclusion of samples with monoclonal FLC elevation, laboratory results together with clinical information of 4350 study subjects (2180 male, 2170 female) were available for analysis. We used summated FLC (total FLC, tFLC) as a measure for polyclonal elevation. tFLC ranged from 2.7 to 275 mg/l with a median of 30.2 mg/l. High levels of tFLC were associated with high-sensitive CRP (hsCRP) and chronic kidney disease (CKD). Both quintiles of tFLC and CKD stage were associated with shorter survival in univariate analysis. Using the median as cutoff, tFLC still separated groups with different survival within CKD stages 0 and 1. tFLC remained an independent predictor of survival in multivariable cox regression analysis adjusted for sex, age, hsCRP and CKD stage (HR 1.13 (95%CI 1.03 – 1.24 per quintile, p=0.0068). For the 274 deaths that occurred during a median observational time of 5 years we had information available from death certificates. Causes of death were categorized into cardiopulmonary, infectious, cancer, and other. The number of deaths increased from the lowest to the highest tFLC quintile (34 vs. 98), however we found no associations of tFLC with categorized causes of death. Polyclonal FLC measurements are affected by a variety of health conditions and may thus be subject to fluctuations over time. We are currently measuring FLC in the 5-year follow-up samples of the Heinz Nixdorf Recall study. This will provide us with a more precise estimate of polyclonal FLC elevation and will help us to further define their role in predicting mortality. These results will also be reported at the conference. Disclosures: Eisele: Celgene: Research Funding. Dürig:Celgene: Research Funding.

Description: Paroxysmal nocturnal hemoglobinuria (PNH) is a potentially life-threatening acquired hemolytic anemia in which red blood cells (RBCs) lacking complement inhibitory proteins are sensitive to complement-mediated destruction or hemolysis. Intravascular hemolysis in these patients often results in the need for clinical support with packed RBCs (PRBCs) in order to maintain tolerable hemoglobin levels. Eculizumab, a terminal complement inhibitor, has recently been shown in a placebo-controlled randomized phase III clinical trial (TRIUMPH) to reduce intravascular hemolysis and transfusion requirements in patients with PNH. Reported here is a detailed analysis of the effect of eculizumab on various parameters of anemia in these study patients. Eculizumab-treated patients, as compared to placebo, showed an 85.8% decrease in intravascular hemolysis (as measured by LDH area under the curve, p

Description: Bcl-2 plays a key role in the regulation of apoptosis. We investigated the role of a novel regulatory single-nucleotide polymorphism (−938C〉A) in the inhibitory P2 BCL2 promoter in B-cell chronic lymphocytic leukemia (B-CLL). The −938C allele displayed significantly increased BCL2 promoter activity and binding of nuclear proteins compared with the A allele. Concomitantly, Bcl-2 protein expression in B cells from CLL patients carrying the −938 AA genotype was significantly increased compared with CC genotypes. Genotype distribution between 123 CLL patients (42 AA, 55 AC, 26 CC) and 120 genotyped healthy controls (36 AA, 63 AC, 21 CC) was not significantly different, suggesting that genotypes of this polymorphism do not increase the susceptibility for B-CLL. However, median time from first diagnosis to initiation of chemotherapy and median overall survival were significantly shorter in patients with −938AA genotype (38 and 199 months, respectively) compared with AC/CC genotypes (120 and 321 months, respectively; P = .008 and P = .003, respectively). Multivariable Cox regression identified the BCL2−938AA genotype as an independent prognostic factor for the time to first treatment (hazard ratio [HR] 1.9; P = .034) together with disease stage at diagnosis (HR 2.5; P = .004) and ZAP-70 status (HR 3.0; P = .001). The BCL2−938AA genotype is associated with increased Bcl-2 expression and a novel unfavorable genetic marker in patients with B-CLL.

Description: Fludarabine-refractory CLL has a poor prognosis with a median overall survival time of less than 12 months despite salvage chemotherapy and intravenous alemtuzumab (Campath-1H) is the approved treatment based on a remission rate of 33% and a median survival time of 16 months (Keating et al., Blood 2002). The CLL2H trial of the GCLLSG was initiated to evaluate the subcutaneous application of 3 × 30 mg alemtuzumab weekly in fludarabine refractory CLL. The current analysis is based on 109 consecutive patients enrolled until completion of the trial in April 2006. Median age was 63 (36–81) years, 71% were male. A median number of 3 (1–9) prior lines of therapy had been given. Subcutaneous treatment was performed on an outpatient basis in all cases and had to be temporarily interrupted in 68 patients due to neutropenia (43%), anemia (6%), thrombocytopenia (3%), infections (40%, CMV reactivations 30%), and was stopped early in 63 cases due to insufficient response (44%), hematotoxicity (16%), infection (17%), and CMV reactivation (13%). The median alemtuzumab dose given was 722 (3–2203) mg. Toxicity was mostly grade I/II apart from hematotoxicity (grade III/IV anemia: 42%, thrombocytopenia: 52%, neutropenia: 54%) and grade III/IV infections (25%). After a median follow up time of 21.4 months, 56 deaths have occurred (due to progression 52%, infections 39%, not CLL related 9%). The overall response rate was 33% (CR 4%, PR 27%), the median progression free survival time was 7.7 months, and median overall survival time was 19.1 months. Genetic high-risk factors were present in the vast majority of cases (unmutated VH 66%, 17p–29%, 11q–19%, TP53 mutation 39%). Responses (CR or PR) were observed in 22% of VH unmutated, 24% of 11q-, 39% of 17p-, and 33% of TP53 mutated cases. Progression free survival and overall survival were not significantly different when comparing the genetic subgroups, particularly TP53 mutated, 11q-, and 17p- (see figure). In conclusion, subcutaneous alemtuzumab is feasible in an outpatient setting in a high-risk population of fludarabine-refractory CLL and appears to be of similar efficacy as by intravenous administration. Most importantly, genetic high risk subgroups with unmutated VH, 11q- or 17p- appear to respond to alemtuzumab. Figure Figure

Description: Abstract 4037 Background: We utilized the biobank of the ongoing population-based, prospective Heinz Nixdorf Recall Study to determine the prevalence of monoclonal gammopathy of undetermined significance (MGUS) and a recently defined entity – light-chain MGUS (LCMGUS) – in the densely populated Ruhr area in Germany. Methods: The Heinz Nixdorf Recall study cohort comprises 4814 men and women from 3 large adjacent cities in Germany. Subjects were randomly selected from statutory lists of residence and gave informed consent. We screened serum samples from the baseline examination which took place from 2000 until 2003. Standard serum electrophoresis (SPE) was combined with parallel screening immunofixation electrophoresis (scIFE) using pentavalent antisera (Hydragel 12 IF, Penta-Kit, Sebia, Fulda, Germany). Where a monoclonal band was visible or suspected, confirmatory IFE followed. Free light-chain (FLC) κ and λ measurements were performed on a Dade Behring BNII automated nephelometer (Siemens, Germany) utilizing a commercially available kit (FREELITE, The Binding Site Ltd, Birmingham, UK). Definition of MGUS cases was based on common criteria including monoclonal protein concentration, laboratory results, and disease history. LCMGUS cases were defined as an abnormal FLC ratio, an increase in the FLC that caused the abnormal ratio and no detectable intact immunoglobulin (Dispenzieri et al. Lancet 2010: 1721-8). Age-standardization of prevalences was performed by direct standardization to the U.S. population 2000. Results: 165 MGUS cases were identified in a total of 4708 screened samples, translating into a prevalence of 3.5% (95% CI, 3.0 – 4.1). The median age of MGUS cases was 63 years (range 47 – 75), 103 (62%) were of male gender, and prevalence increased with age. The age-standardized prevalence was 3.9% (95% CI 3.2 – 4.5) which was significantly higher (p