ALBERT

Description: Background: Chronic lymphocytic leukemia (CLL) cells are weakly immunogenic, a property that may contribute to disease progression and inhibit the effectiveness of immunotherapies such as vaccines. Low surface expression of co-stimulatory molecules contributes to this poor immunogenicity. CLL cells express Toll-Like-Receptor-7 (TLR7), a powerful modulator of innate immunity. TLR7 agonists may be capable of enhancing the immunogenicity of CLL cells and thereby increasing T cell mediated killing of CLL. Methods: Circulating CLL cells were isolated directly from consenting patients by negative selection. TLR7 mRNA expression by CLL cells was demonstrated by RT-PCR. CLL cells were then incubated with S28690 (a TLR7 agonist), or with a negative control for 24–72h. Expression of the costimulatory molecules CD80, 83, 86, and 54 was determined by flow cytometry pre and post-incubation. Experiments were repeated in the presence of a NFkB inhibitor (dexamethasone), a p38 MAPK inhibitor, and a protein kinase C agonist (PDB). The effects of S28690 on phosphorylated-IkB and phosphorylated-STAT3 levels were measured by immunoblotting. The capacity of S28690-incubated CLL cells to stimulate T cell proliferation and killing was determined in mixed lymphocyte responses. Results: All tested CLL samples (n=20) expressed TLR7 mRNA, while Jurkat cells (T cell origin) did not. After incubation with S28690, CD80, 83, 86, and 54 surface expression increased on all CLL samples tested. The relative increase varied from 4 to 9-fold and was positively correlated with CD38 expression. NF-kB and p38 inhibitors decreased the effects of S28690 on co-stimulatory molecule expression while PDB amplified the effect. After incubation with S28690, IkB and STAT3 phosphorylation increased in CLL cells. S28690-incubated-CLL cells were able to stimulate moderate T cell proliferation, but did not increase T cell mediated killing of CLL cells. However, CLL cells incubated with both S28690 and PDB (a PKC agonist), exhibited much lower amounts of phosphorylated STAT3, triggered marked T cell proliferation, and stimulated T cell mediated killing of CLL cells. Conclusions: S28690 (a TLR7 agonist) causes increased expression of co-stimulatory molecules by CLL cells in vitro and transforms CLL cells into moderate stimulators of T cell proliferation. The effects of S28690 are synergistic with PKC agonists, potentially as a result of S28690-mediated NFkB activation and concurrent PKC-mediated inhibition of STAT3. These findings may find clinical application in immunotherapeutic approaches to CLL.

Description: Hodgkin lymphoma (HL) occurs in HIV-infected individuals more frequently than in the HIV-negative population and the incidence is rising. Patients (pts) with non-Hodgkin’s lymphoma in HIV appear to have improved outcomes if they receive HAART with chemotherapy (CT). ABVD is standard CT for HL and is frequently administered with HAART in pts with HIV-HL. However, some components of the ABVD regimen may interact with antiretroviral (ARV) medications to alter metabolism and increase toxicity. In particular, vinblastine (VBL) is metabolized by CYP3A4 and protease inhibitors, particularly ritonavir (RTV), appear to inhibit this cytochrome potentially leading to higher VBL exposure. Little definitive information is available regarding how interactions might affect clinical outcome. We conducted a retrospective review of 36 pts with HIV-related HL to identify the frequency of neurotoxicity (NT), hematologic toxicity (HT), and lung toxicity (LT), to identify risk factors for severe (grade III–IV) toxicity, and to determine its clinical significance. Clinical data were collected from the CFE database and by chart review from 3 centers. The median age at HL diagnosis (dx) was 41 (range 29–66) years and 34 (94%) were male. HL was advanced stage in 28 (78%). Hasenclever score could be calculated in 23 pts and was 0–4 and ≥5 in 15 and 8 pts respectively. ECOG PS was 0–1 in 13 and ≥2 in 8 (n=21). HIV risk factor was: sexual, n=21 and other, n=5 (n=26). Median CD4 count at HL dx was 210 (2–660) cells/ul (n=31). Median HIV viral load (VL) was undetectable (

Description: Introduction: Nearly one in five cancer survivors report limitations in ability to work following diagnosis, with poor work-related outcomes particularly noted in the hematologic cancers. Although much is known about the efficacy, toxicity and direct costs of treatment for follicular lymphoma, there is no data assessing the impact of this diagnosis on productivity of affected individuals. Methods: We conducted a consecutive cross-sectional study of patients attending a malignant hematology clinic at a large multi-disciplinary cancer centre. Patients with a diagnosis of FL or other indolent NHL were asked to complete questionnaires assessing demographics, health status (EQ-5D), and work productivity and activity impairment (WPAI questionnaire). Results: Eighty-four patients completed the survey study (〉95% response rate). Mean age was 58.7 (+/−13.8 SD) and 55% were male. Diagnoses included FL (55%), CLL (25%), and other indolent NHL (20%). The majority of patients presented in advanced stage (stage III–IV; 65%) and had received some therapy, although 29% were still being observed without having received therapy by the time of survey administration. The median disclosed income was $40,000–$59,000; 76% had pursued post-secondary education. Over 61% were working full-time prior to diagnosis while 14% were retired. Patients reported a minimal impact on their work productivity (1.9+/−3.2 on a scale of 0 to 10; 0=no effect and 10=complete impairment of activity) and on their daily activities (2.4+/−3.1) attributable to their cancer diagnosis. However, following diagnosis of NHL (and at the time of survey completion), only 33% were able to continue full-time work, 7% were working part-time, 10% required disability, and 37% were retired. Of those still working, a mean of 2.1 days (+/−6.9) were missed due to illness in the preceding 4 weeks, with a mean of 16 days (+/−8.7) worked in that period. Only 6% received paid assistance, while 17% required unpaid care from a partner/spouse, relative, or friend. Unpaid caregivers missed a mean of 11.3 days (+/−16.2) of work and provided a mean of 9.8 days (+/−13.4) of care. There was a significant inverse correlation between daily activity scores (high values=complete impairment) and health status ratings (high values=excellent health status/utilities) ascertained by the EQ-5D instrument (Spearman correlation coefficient −0.69; p5) was predicted by poor self-rated health status (OR 32.1; 95% CI 5.9–174.2; p

Description: Background: Patients with relapsed or refractory aggressive B-cell lymphoma, or transformed indolent lymphoma can achieve long-term survival with high dose therapy and autologous stem cell transplant (HDT/ASCT), provided their disease is sensitive to salvage chemotherapy. Unfortunately, approximately 50% of patients are insensitive to standard salvage regimens. Objectives: This trial investigated whether adding Rituximab to ESHAP (etoposide, solumedrol, cytosine arabinoside, cisplatin) induction improved chemosensitivity. The primary outcome was overall response rate (CR + CRu + PR) to R-ESHAP. Secondary outcomes were toxicity, ability to undergo ASCT, progression free survival (PFS) and overall survival (OS). Methods: The protocol was approved by the local ethics review board and all patients provided informed consent. Eligible patients received ESHAP every 28 days with GCSF support until 〈 15% bone marrow involvement was achieved (2–4 cycles). Rituximab was given weekly x 8 weeks concurrent with the first 2 cycles of ESHAP. GCSF mobilized stems cells were collected on day 10–11 of cycle 1 or 2. Results: The trial was stopped early after the complete response (CR) rate at a planned interim analysis exceeded 40% (a pre-specified criteria for stopping the trial). Final results of 26 patients are presented. Median age was 55.5 years (range 42–64). Twelve patients had relapsed aggressive lymphoma, 2 had refractory disease and 12 had transformed indolent lymphoma. Twenty-two of 26 patients were stage III/IV. The overall response rate to R-ESHAP was 92% (95% CI 82% to 100%). Twelve patients (46%; 95% CI 27% to 65%) had a CR or unconfirmed CR. Grade 3–4 thrombocytopenia, neutropenia, and anemia occurred in 57%, 40%, and 15% of R-ESHAP cycles respectively. Grade 3–4 infections complicated 7% of cycles. Median follow-up was 17 months (range 2.9 to 43.2) from enrollment. Twenty-three of 26 patients (88%) were transplanted. Notable post-transplant toxicity included 5 cases of herpes zoster, 2 cases of bacterial pneumonia, 1 case of pulmonary aspergillosis, and 1 fatal case of pneumocystis carnii pneumonia (PCP). Three patients did not proceed to HDT/ASCT; 2 were refractory to R-ESHAP and 1 died of a myocardial infarction after induction chemotherapy but prior to ASCT. Fifteen of 23 patients who received ASCT remain in remission, 6 have relapsed. Seven patients have died, 4 of progressive disease, 1 of myocardial infarction, 1 of PCP, and 1 of accelerated Parkinson’s Disease. Median PFS and median OS have not yet been reached. Conclusions: In this single-arm, phase II study of relapsed or refractory aggressive B-cell lymphoma and transformed indolent B-cell lymphoma, R-ESHAP induction therapy resulted in a very high ORR (92%) and enabled a large percentage of patients (88%) to proceed to HDT/ASCT. Toxicity of the R-ESHAP regimen was acceptable, and its efficacy compared favorably with other salvage regimens reported in the literature, including R-ICE.

Description: Background: Patients with relapsed or refractory aggressive B-cell lymphoma have a poor prognosis. If sensitive to salvage chemotherapy, high dose therapy followed by autologous stem cell transplant (ASCT) can result in long-term survival for some. Unfortunately, 50% of patients are insensitive to standard salvage regimens and thus are ineligible for ASCT. Hypothesis: Combining Rituximab with ESHAP may improve chemosensitivity and ASCT eligibility, of patients with CD20+, relapsed or refractory aggressive lymphoma, or CD20+ transformed indolent lymphoma. Objectives: The primary outcome was response rate (CR + CRu + PR) to R-ESHAP. Secondary outcomes were toxicity, ability to undergo ASCT, presence of minimal resdidual disease in the stem cell harvest, and progression free and overall survival. Methods: Eligible patients were 16–65 years old, had ECOG performance status 0–2, and had pathologically confirmed CD20+, relapsed/refractory aggressive lymphoma or transformed indolent lymphoma. Patients with refractory disease had a PR with initial anthracycline-based therapy. ESHAP (etoposide 40mg/m2 day 1–4, solumderol 500mg day 1–5, cytosine arabinoside 2g/m2 day 5, cisplatin 25mg/m2 day 1–4) was given every 28 days with GCSF support until 〈 15% bone marrow involvement was achieved (2–4 cycles). Eight infusions of Rituximab (375mg/m2) were administered weekly concurrent with the first 2 cycles of ESHAP. GCSF mobilized stems cells were collected on day 10 or 11 when 〈 15% bone marrow involvement was achieved (mainly in cycles 1 or 2). Results: Preliminary results of 14 of 44 planned patients are presented. Median age was 54 years (range 42–64). All pts had CD20+ aggressive lymphoma, 6 had relapsed aggressive lymphoma, 2 had refractory aggressive lymphoma (with PR after initial therapy) and 6 had transformed indolent lymphoma. Twelve of 14 patients were stage III/IV. The response rate to R-ESHAP was 93% (2 CR, 2 CRu, 9 PR, 1 PD). Thirteen of 14 patients proceeded to ASCT. Data on minimal residual disease in the stem cell harvest is pending. Grade 3–4 thrombocytopenia, neutropenia and anemia occurred with 53%, 31%, and 20% of R-ESHAP cycles respectively. Two of 14 patients had febrile neutropenia, one with bacteremia. Two patients had non-neutropenic bacteremia (1 with septic shock). There were no toxic deaths. Median follow-up post-ASCT is 5 months (range 1–18). Two patients progressed 4 and 5 months post-ASCT respectively. There were 3 deaths, 2 lymphoma related and 1 due to accelerated Parkinson’s Disease. Median PFS has not yet been reached. Conclusions: This trial is still accruing patients. However, preliminary results are promising. R-ESHAP appears to be well tolerated with a high response rate. This regimen may enable more patients with relapsed/refractory aggressive lymphoma or transformed indolent lymphoma to proceed to ASCT.

Description: Background: B cells express toll-like-receptor-7 (TLR7), a powerful modulator of inate immunity. We hypothesized that the immunogenicity of indolent B cell lymphomas and leukemias could be increased through activation of the TLR7 pathway. This might lead to increased immune clearance of malignant cells. Imiquimod 5% (an imidazoquinolone) has recently been identified as a TLR 7/8 agonist. It is available as a topical formulation and has demonstrated activity against condylomata as well as skin carcinomas. A small number of case reports also suggest activity against cutaneous T cell lymphoma. Case: A 71 year old Caucasian man presented with Rai Stage 0 CLL. For approximately 8 years prior to presentation, he suffered recurrent, erythematous, nodular lesions on his hands, arms and torso. The lesions were removed with liquid nitrogen but recurred. At the time of diagnosis with CLL, several lesions were present. Biopsy demonstrated a diffuse infiltrate of small round lymphocytes without epidermotropism. CD20 staining was positive. Molecular analysis confirmed a monoclonal B cell population consistent with B cell lymphoma. The patient was otherwise asymptomatic and did not warrant conventional therapy for CLL. Based on the safety and efficacy of imidazoquinoline in other skin cancers, he was offered and consented to a trial of this therapy. The drug was applied to the affected area 3x per week as recommended for treatment of genital warts. After 8 weeks, an area of hypopigmentation had formed, however the size of the lesion had not decreased. The frequency of application was increased to 1x per day. Over a 6 week period the lesion gradually disappeared. Six months after stopping the drug, the lesion has not recurred. No side effects were noted. Untreated lymphomatous lesions and peripheral blood lymphocyte counts did not change over the course of treatment. In vitro Data: We hypothesized that Imiquimod might increase the immunogenicity of CLL cells by increasing their surface expression of costimulatory molecules. To investigate this hypothesis, the above patient’s CLL cells were isolated (with his consent) directly through negative selection and then incubated for 48h with an active soluble imidazoquinalone or with a control. Expression of co-stimulatory molecules was determined by flow cytometry pre and post-incubation. CD80, 83, 86 and 54 surface expression were found to be increased significantly by TLR-7 agonists in vitro. Conclusion: We report the first case of Imiquimod activity against a cutaneous B cell lymphoma. We propose that the drug increases co-stimulatory molecule expression by malignant B cells, thereby facilitating cytotoxic T cell activation and killing of CLL cells. We believe that further study of TLR7 agonists is warranted in B cell malignancies.

Description: Background: We previously reported that 20 patients with newly diagnosed, stage III/IV mantle cell lymphoma (MCL) treated prospectively with an in vivo rituximab purge, autologous stem-cell transplantation (ASCT) and rituximab maintenance experienced superior progression free survival (PFS) compared to 40 matched, historical controls treated with conventional chemotherapy. We now report extended follow-up from this trial. Methods: Eligible patients were treated with 4–6 cycles of CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) followed by high dose therapy (cyclophosphamide, carmustine and etoposide) and ASCT. Rituximab (375 mg/m2) was given once 5 days prior to stem cell collection (as an in vivo purge), and as two, 4-week maintenance courses 8 and 24 weeks after ASCT. Historical control patients matched for age, stage and gender were randomly selected from a lymphoma database maintained by the British Columbia Cancer Agency. Two control-patients were selected for every trial patient. All control patients were treated with either an anthracycline based-regimen, or a regimen containing fludarabine and cyclophosphamide. Results: Median follow-up is 5.3 years for the experimental cohort and 10.1 years for the control cohort. In the ASCT cohort, 8 patients have relapsed and 4 patients have died, 2 of progressive disease, 1 of a presumed cardiac event 7 months post-ASCT, and one of hepatitis B reactivation 11 months post-ASCT. Five-year OS and 5-year PFS were superior in MCL patients treated with ASCT+ rituximab compared to matched, historical MCL patients treated with conventional chemotherapy (5y OS 80% vs. 38%, P=0.0017; 5y PFS 72% vs. 19%, P=0.0001). One patient developed myelodysplastic syndrome 5.5 years after ASCT, and one patient was diagnosed with breast cancer 4.8 years after ASCT. Conclusions: With more than 5 years of follow-up MCL patients treated with ASCT plus rituximab continue to experience significantly improved OS and PFS compared to matched, historical controls. Overall Survival Overall Survival

Description: Abstract 4671 TTP results from deficiency of ADAMTS13 that leads to accumulation of high molecular weight multimers (HMWM) of von Willebrand factor (VWF) and thrombosis in the microvasculature. Previous studies have shown that HMWM VWF purified from blood group O individuals were cleaved faster by ADAMTS13 compared to HMWM VWF from non-O blood group individuals. We hypothesized that blood group O patients have lower prevalence of TTP and/or less severe form of TTP. We conducted a retrospective chart review of all TTP patients treated at our institution from 1993 to 2010. The patients were identified from the review of plasmapheresis treatment records. Any patients with missing charts were excluded. The diagnosis of TTP was made on the basis of laboratory evidence of microangiopathic hemolytic anemia and thrombocytopenia and neurologic and/or renal abnormalities, following exclusion of alternative diagnoses. ADAMTS13 levels were determined by collagen binding assay in select patients. 94 patients were included in the study. The patient characteristics were as follows: 32 males versus 62 females, mean age 45.4 years. 37/94 (39%) patients had ADAMTS13 analyzed with the following results: low ADAMTS13 (21 patients), normal ADAMTS13 (15 patients), equivocal 1. Presentation laboratory investigations were available for 91 patients and were as follows: median platelet count 16×109/L (min 3, max 274) and median hemoglobin 89 g/L (min 48, max 152). At presentation, 19/91 (20.9%) patients had fever (〉38C) and 43/91 (47%) had neurological abnormalities (ranging in severity from headache to seizures and decreased level of consciousness). The blood group distribution in the TTP cohort was blood group O 41 patients, non-O 48 patients, data not available 5 patients. All patients received plasmapheresis with cryosupernatant plasma (CSP) or FFP, with some also receiving steroids and other therapies. The patients received a median of 12 (min 1, max 67) plasmapheresis treatments. Overall mortality rate was 22%. The other outcomes were as follows: death at 6 months follow-up 19%; death at 6 months or relapse 20%, death during treatment or permanent dialysis or permanent neurological disability 21%. The prevalence of blood group O versus non-O in our TTP cohort (n=89) was not significantly different from the prevalence of blood group O versus non-O in the general patient population of our institution over 2000–2010 (n=24,852; p=0.71). As illustrated below, in univariate analysis, TTP patients with blood group O did not have significantly different outcomes compared to TTP patients with non-O group blood. Outcomes Group O patients Non-group O patients p-values Death at 6 months 6/41 11/48 0.32 Death at 6 months or relapse 13/41 20/48 0.16 Death during treatment/permanent disability/permanent dialysis dependence 7/41 10/48 0.38 Conclusion: The prevalence of blood group O vs. non-O was not significantly different between the TTP cohort and our general patient population. Although there appeared to be a trend towards worse outcomes in patients with non-O blood group, there were no statistically significant differences in the outcomes in the patients with blood group O vs. non-O. The outcomes assessed in our study included death at 6 months, death at 6 months or relapse, and death during treatment/permanent neurological disability/permanent dialysis dependence. Disclosures: No relevant conflicts of interest to declare.

Description: Abstract 2835 Background: Diffuse large B cell lymphoma (DLBCL) is associated with the human immunodeficiency virus (HIV). The optimal treatment for DLBCL in persons with HIV is uncertain. Anthracycline-based chemotherapy plus rituximab is frequently administered because this therapy has an established survival benefit in non-HIV DLBCL. However, there is controversy regarding the risks and benefits of rituximab in the setting of HIV, and practice remains varied. Due to concerns about tolerance and drug interactions, controversy also exists regarding whether highly active antiretroviral therapy (HAART) should be administered concurrent with chemotherapy. Methods: We completed a retrospective cohort study of all patients with HIV-DLBCL treated with curative-intent, at St. Paul's Hospital in British Columbia, Canada, and at St. Michael's and Sunnybrook Hospitals in Ontario, Canada. Univariate and multivariate analyses were completed to identify factors associated with improved overall survival (OS). Due to differences in provincial funding, we were able to compare patients treated with and without rituximab during the same time period. Results: Seventy-four patients were identified; 21 were treated between 1992 and 2000 (prior to the introduction of rituximab); 53 were treated between 2001 and 2009. Mean age was 45 years, 93% were male, 80% had stage 3–4 disease, 53% had an IPI (International Prognostic Index) 〉 2, 63% had a CD4 count 〈 200 and 18% had a CD4 count 〈 50. Median follow-up was 8.8 months (range 0.7 to 79.1). One-year OS was 53% and 32 of 35 deaths occurred in the first year. Seven deaths were due to infectious complications of chemotherapy, only one of these patients received rituximab, six had CD4 counts greater than 100, and four were receiving HAART. Because none of the patients prior to 2001 received rituximab, and because the pre-2001 cohort was very different from the post-2001 cohort with respect to CD4 counts, HAART usage and primary chemotherapy, comparative survival analyses were restricted to the post-2001 cohort (N=53). In univariate analyses, the only factor associated with improved OS in this cohort was concurrent administration of HAART (p=0.002). A Cox proportional hazards model incorporating use of rituximab, age, IPI 〉 2, CD4 count 〈 200, and concurrent HAART was constructed. As illustrated in table 1, IPI 〉 2, CD4 count 〈 200, and concurrent HAART were significantly and independently associated with overall survival. Conclusions: In this retrospective analysis, rituximab did not appear to be associated with a high toxic death rate in patients with HIV-DLBCL. However, rituximab was also not associated with significantly improved OS. Concurrent administration of HAART, higher CD4 count and lower IPI were independently associated with improved OS in patients with HIV-DLBCL. It is possible that this study was under-powered to detect a benefit of rituximab, however, we also hypothesize that previous studies reporting a benefit of rituximab in this population may have been biased by the use of historical controls. Disclosures: Leitch: Roche Canada: Honoraria.

Description: Background: Multiple myeloma disproportionately affects the elderly and is currently an incurable malignancy. New therapies for myeloma, particularly oral therapies, are urgently needed. Objectives: To determine if thalidomide with or without other agents, improves response rate (≥ 50% reduction in monoclonal protein), survival, and/or progression in patients with previously untreated myeloma. To determine the frequency and significance of major adverse events associated with thalidomide in this setting. Methods: A literature search of Medline (1966–June 2006), Embase (1980–June 2006), the Cochrane Library, abstracts from the annual meetings of the American Society of Hematology (1999–2005) and the American Society of Oncology (1999–2006) was completed with a pre-specified search strategy. No language restrictions were applied. Randomized controlled trials of induction thalidomide (any dose, any duration) for adults with previously untreated multiple myeloma were included. Trials of exclusively maintenance therapy were excluded. Two reviewers independently extracted data. The methodological quality of selected trials was assessed and summarized. Weighted data was expressed as relative risk, risk difference, number needed to treat (NNT), and number needed to harm (NNH). A random-effects model was used. Results: Six eligible studies involving almost two thousand patients (N=1875) were identified and meta-analyzed. Two studies were published and four were reported in abstract form only. Five studies reported overall response rate (ORR); the four largest trials reported statistically significant improvements in ORR with the addition of thalidomide to standard therapy. The weighted relative risk of responding to a thalidomide-containing regimen versus control was 1.50 (95% CI 1.21 to 1.86). The NNT to achieve one additional response with thalidomide was 4 (95% CI 2.9 to 8.3). Two trials reported improvements in EFS/PFS. One trial reported an improvement in OS. The risk of VTE, peripheral neuropathy, and constipation was consistently elevated with thalidomide such that for every 50 patients treated with a thalidomide-containing-regimen, one could expect 12 to 13 additional patients to respond, 4 additional patients to develop VTE (NNH 12.5; 95% CI 8.3 to 20), 2 additional patients to develop peripheral neuropathy (NNH 25; 95% CI 16.7 to 50), and 4 additional patients to develop constipation (NNH14; 95% CI 10 to 25). In our analyses, prophylactic anticoagulation appeared to decrease, but not abolish, the risk of VTE with thalidomide. Conclusions: Thalidomide improves response rate and possibly progression free and overall survival in patients with previously untreated myeloma. It also increases the incidence of VTE, neuropathy, constipation and other adverse events. Further studies are required to confirm the survival advantage seen in one study, and to determine the optimum strategy for VTE prophylaxis.