ALBERT

Description: T-cell prolymphocytic leukemia (T-PLL) is a poor-prognostic neoplasm. Differentiation stage and immune-effector functions of the underlying tumor cell are insufficiently characterized. Constitutive activation of the T-cell-leukemia-1A (TCL1A) oncogene distinguishes the (pre)leukemic cell from regular post-thymic T-cells. We assessed here activation-response patterns of the T-PLL lymphocyte and interrogated the modulatory impact by TCL1A. Immunophenotypic and gene expression profiles revealed a unique spectrum of memory-type differentiation of T-PLL with predominant central-memory stages and frequent non-canonical patterns. Virtually all T-PLL expressed a T-cell receptor (TCR) and/or CD28-coreceptor without overrepresentation of specific TCR-clonotypes. The highly activated leukemic cells also revealed losses of negative-regulatory TCR-coreceptors (e.g. CTLA4). TCR-stimulation of T-PLL cells evoked higher-than-normal cell-cycle transition and profiles of cytokine release that resembled those of normal memory T-cells. More activated phenotypes and higher TCL1A correlated with inferior clinical outcomes. TCL1A was linked to T-PLL's marked resistance to activation- and FAS-induced cell death. Enforced TCL1A enhanced phosho-activation of TCR-kinases, second-messenger generation, and JAK/STAT or NFAT transcriptional responses. This reduced the input thresholds for IL-2 secretion in a sensitizer-like fashion. Mice of TCL1A-initiated protracted T-PLL development resembled such features. When equipped with epitope-defined TCRs or CARs, these Lckpr-hTCL1Atg T-cells gained a leukemogenic growth advantage in scenarios of receptor stimulation. Overall, we propose a model of T-PLL pathogenesis in which TCL1A enhances TCR-signals and drives accumulation of death-resistant memory-type cells that utilize amplified low-level stimulatory input and whose loss of negative coregulators additionally maintains their activated state. Treatment rationales are provided by combined interception in TCR- and survival signaling.

Description: Key Points Prognostic tool for CLL patients with high discriminatory power compared with conventional clinical staging systems. Prognostication on the individual patient level independent of clinical stage.

Description: [§ share last authorship] Background: In 2000-2010, the first large prospective trials in peripheral T-cell lymphoma (PTCL) showed outcomes burdened by high failure rates during induction. Concurrently, trials with the anti-CD52 monoclonal antibody alemtuzumab (ALZ) yielded promising responses in PTCL while demonstrating the feasibility of combining ALZ with CHOP. Hence, the Nordic Lymphoma Group initiated the randomized ACT-1 trial to test, in younger patients (pts) (18-65yrs), the addition of ALZ to CHOP + autologous stem cell transplant (ASCT). Primary endpoint was the 3 years event-free survival (EFS). Here, we present the final analysis of the ACT-1 trial (ClinicalTrials.gov: NCT00646854). Patients and Methods: Overall, 136 pts were randomized (43% of planned sample size due to slow accrual), five did not receive study treatment, and 131 were analyzed (ALZ-CHOP: 65; CHOP: 66). Due to lack of tumoral CD52 expression, anaplastic large cell lymphomas (ALCL) were not included in the ACT-1 trial. An amendment tapering ALZ dose from 360 mg (30 mg on days 1+2 of each CHOP course) to 120 mg (30 mg on day 1 of CHOP courses 1-4) was introduced early on due to systemic fungal infections in 2 pts. Of the 65 pts treated with ALZ-CHOP, 4 received the pre- and 61 (94%) the post-amendment dose. Monitoring for CMV- and EBV-DNA and antimicrobial prophylaxis were mandatory. Results: The median observation time for the Full Analysis Set was 66 months and the median age 51 yrs. The ALZ-CHOP and CHOP cohorts were well balanced with regard to classical prognostic factors and histological subtypes (PTCL-NOS 58% vs 54%, AILT 21% vs 25%, other 21% vs 21%). Feasibility: Neither CHOP nor ALZ-CHOP pts experienced substantial treatment delay. ALZ exposure did not affect stem cell harvest nor hematopoietic recovery. Grade 4 leucopenia was more frequent in ALZ-CHOP pts (73% vs 35%; p=0.001), whereas the occurrence of grade 3-4 anemia and thrombocytopenia did not differ significantly. After ALZ dose amendment, the frequency of bacterial and fungal infections of grade ≥3 was similar in both treatment arms. ALZ treated pts had more viral events (22/57=42% vs 4/23=17%), mainly due to asymptomatic CMV reactivations. The ratio of serious adverse events per ALZ-CHOP treated patient dropped markedly (from 3.25 to 0.86, comparable with 0.46 for CHOP) after dose amendment. Additional toxicity was mild and similar in both arms. Treatment related mortality was 4% (5% vs 3%). Efficacy: Complete remission (CR) was 52% in ALZ-CHOP vs 42% in CHOP. Primary refractory disease occurred for ALZ-CHOP and CHOP in 23% and 38% of pts, respectively. Overall, females had a significantly better outcome than males (p=0.004), also after adjustment for classical prognostic factors. Analyzing time-related endpoints without knowledge of CD52 expression, 3-years EFS, progression-free, and overall survival (PFS, OS) did not differ significantly between ALZ-CHOP and CHOP (EFS 35% vs 26%, PFS 37% vs 26%, OS 52% vs 50%). Fig.1A shows EFS by treatment arm, by gender, and by gender and treatment arm. Although not significantly different, EFS, PFS and OS values of ALZ-CHOP treated females in the ACT-1 trial were consistently higher than those of non-ALZ treated females or of males regardless of treatment group. RNA sequencing from evaluable pre-therapeutic tumor biopsies defined a signature of differentially expressed genes to be predictive of clinical outcome in ALZ-CHOP but not CHOP treated pts (n=33). Tumor microenvironment genes were prominent in determining response to ALZ. Tumors rich in B-cell milieu showed good responses, while the opposite was observed in tumors with signatures enriched with high endothelial cell genes (p

Description: Alemtuzumab is the standard therapy for treatment of patients with relapsed/refractory B-CLL, and significant responses have also been documented in the front-line CLL setting. We and others have demonstrated, in controlled studies and retrospective surveys, that heavily pretreated patients who achieve a complete response (CR) or partial response (PR), or even stable disease (SD), as defined by the National Cancer Institute (NCI) criteria, benefit in terms of quality of life and prolonged overall survival (OS). This is probably due to the fact that response is of long duration and that, in many cases, effective re-treatment is feasible. We analysed which treatments were used following a first course of alemtuzumab in CLL (Fiegl et al. Cancer2006;107:2408–16), and found that alemtuzumab, alone or in combination, was the most frequently used drug for re-treatment. Here we present updated data in 26 CLL patients re-treated with alemtuzumab. Seventeen patients were male (65%), had B-CLL (n=23), B-CLL with more than 15% prolymphocytes (n=2), or CLL with Richter’s transformation (n=1). The median number of previous therapies including the first course of alemtuzumab was 4 (range, 2–12), and 15 cases (58%) were fludarabine-refractory. At the start of re-treatment, the majority of patients had Rai stage 4 disease. Fluorescence in situ hybridization (FISH) cytogenetics according to Dohner’s classification were available in 13 patients, and 5 patients had a high risk anomaly (17p deletion). The median time interval between last dose of alemtuzumab and start of alemtuzumab re-treatment was 10.2 months (1.7–28.3 months). Response evaluation according to NCI criteria was available in 17 patients. Alemtuzumab re-treated patients had PR, SD, and progressive disease (PD) rates of 53%, 18%, and 18%, respectively. In 12% response could not be evaluated because of early death. Survival rates were available for all 26 patients. The median OS since start of alemtuzumab re-treatment was 16.7 months. This favourable survival time underscores the fact that patients receiving alemtuzumab re-treatment are selected because they benefited from the previous course of alemtuzumab. There was a dramatic difference in outcome depending on whether alemtuzumab re-treatment was necessary earlier or later: median OS was 8.4 months in patients who had to be re-treated within 10.3 months after last dose of initial course of alemtuzumab, whereas median OS was not reached in patients retreated after a longer interval (P=0.001). OS was inferior in cytogenetically poor risk patients (17.8 months in 17p-deleted patients vs. “not reached” in patients with 13q deletion, trisomy 12, or normal karyotype; P=0.01). There was no difference in OS in fludarabine-refractory patients. Re-treatment was well tolerated, with moderate toxicity. In conclusion, we hereby demonstrate that B-CLL patients who have been treated successfully with alemtuzumab may benefit profoundly from a second course of alemtuzumab, especially if there is a prolonged interval between the treatments, and a favourable cytogenetic profile is present.

Description: B-cell chronic lymphocytic leukemia (CLL) with 17p deletion responds poorly to chemotherapeutic agents. This retrospective study evaluated the benefit of alemtuzumab monotherapy in unselected patients with advanced CLL, categorized by cytogenetic profile. Methods: This is the largest data base with efficacy analysis of alemtuzumab in CLL stratified according to cytogenetics. Detailed data analysis was done in 138 CLL patients, in whom cytogenetic analysis was performed by FISH using the standard CLL analysis categorized according to Doehner et al. (N Engl J Med343, 1910; 2000). Responses were evaluated according to the NCI criteria; progression-free survival (PFS) and overall survival (OS) were also assessed. Results: 73% of the patients were male. At start of alemtuzumab therapy, the median age was 64 years (range, 46–92); 12% were in Rai stage I, 18% in stage II, 20% in stage III, and 50% in stage IV. The median number of two prior therapies was 2 (range, 0–10); of the patients who received prior fludarabine (F) (n=113), 70% were F-refratory, 25% sensitive, and in 5% this was unknown. 30% and 17% of patients had bulky lymphadenopathy (〉5 cm) and giant splenomegaly (〉20 cm), respectively. Cytogenetic abnormalities were as follows: 13q deletion 14%; trisomy 12, 12%, 11q deletion 20%; 17p deletion, 33%, none of these, 22%. The overall response rate (ORR) was 38% in the total cohort. ORR was 53%, 56%, 21%, and 44% in the subgroup of 13q deletion, trisomy 12, 11q deletion, and 17p deletion, respectively; patients without any of these abnormalities had an ORR of 27%. From start of alemtuzumab, median PFS and OS for the whole cohort was 6.9 months and 30 months, respectively. Notably, PFS and OS in 17p deletion patients was 7.1 months and 19.1 months, respectively, an encouraging outcome when considering the unfavourable risk profile in these patients. In 17p deletion patients, response was remarkable also in disease involved lymph nodes (78%). Patients with F-resistant disease and 17p deletion, an extraordinarily poor prognostic group (n=25), had encouraging ORR, PFS, and OS rates (28%; 7.2 months; and 19.1 months, respectively), which did not differ from those in F-resistant patients with good risk cytogenetics. In a multivariate Cox regression analysis, independent risk factors for shorter OS were anemia (hazard ratio [HR] = 2.48; 95% CI, 1.50–4.11; P

Description: Introduction: T-cell prolymphocytic leukemia (T-PLL) is an aggressive disease with a poor median overall survival of

Description: Background: The course of chronic lymphocytic leukemia (CLL) is highly variable. Therefore, there is a need for prognostic factors that are readily performed and have a high predictive power. Methods: The occurrence of translocations, a recently identified prognostic factor in CLL (Blood2006;107:742–751), was studied in 148 previously untreated, mostly early-stage patients and compared with respect to treatment-free survival (TFS) to several prognostic factors (Binet stage, mutational status of immunoglobulin genes, CD38, thymidine kinase serum concentration and cytogenetic aberrations detected by interphase FISH). To investigate chromosomal translocations, we applied a new method, CpG oligodeoxynucleotide stimulation that allows efficient preparation of metaphase spreads from CLL cells. Results: The occurrence of translocations classified the majority of patients with poor prognosis. If translocations were investigated in addition to the currently used prognostic factors they identified those patients who were classified to be in a low-risk group based on traditionally used criteria, who had in fact a high risk for progression. Vice versa, patients in the high-risk groups for progression who did not have translocations had a long TFS. There was a substantial overlap of patients who had translocations and additional risk factors. But when we omitted patients who had translocations in addition to a given risk factor, we found that the respective risk factor lost its prognostic significance for the remaining patients. The two factors that retained their prognostic power in these patients were translocations and the Binet stage. This could suggest that the prognostic significance of the currently used factors derives from their frequent co-occurrence with translocations. Finally, multivariate analyses demonstrated that Binet stage (p=0.02) and translocations (p=0.0005) are the factors with the highest impact on TFS in our study cohort. Conclusion: We present a method for efficient preparation of metaphase spreads in CLL cells in order to investigate chromosomal translocations. The occurrence of translocations is an independent prognostic marker in CLL. Finally, translocations occur not as a late event in the course of the disease and may define a new biological subgroup in this disease entity.

Description: Abstract 1613 Background: Elderly patients with aggressive B-cell lymphoma are underrepresented in almost all clinical trials and treatment related toxicity mainly due to anthracycline treatment is a major concern. Individual pharmacogenetic settings may influence the prognosis due to altered efficacy and treatment related toxicity. Several single nucleotide polymorphisms (SNPs) involved in metabolization of chemotherapeutic agents have been proposed to influence the clinical course of disease in younger patients. However, no data are available in elderly patients. Methods: We retrospectively analyzed and characterized 83 consecutively diagnosed patients ≥75 years with aggressive B-cell lymphoma (78 cases of diffuse large B-cell lymphoma and 5 cases of follicular lymphoma grade 3) from January 2004 until December 2011 treated at our tertiary cancer center by chart-based review. DNA was extracted from diagnostic tissue samples and analysis for 10 SNPs with previously reported effect on pharmacodynamics of components of the CHOP regimen were performed with commercially available primers (rs1883112 NCF4, rs3957357 GSTA1, rs4673 CYBA, rs1799977 MLH1, rs1045642 ABCB1, rs9024 CBR1, rs1695 GSTP1, rs17222723 ABCC2, rs7853758 SLC28A3, rs1056892 CBR3). Results: The entire cohort of 83 patients had a median age of 80 years (range 75–97 years) and 43 of 83 patients were male. Based on clinical judgment of fitness 82% of all patients received a combination of anthracycline and rituximab based therapy. The median overall survival (OS) in all patients was 43 months. Unsurprisingly, patients deemed eligible for a treatment with an anthracycline and rituximab had a better median OS than patients not eligible for this approach (54 vs 6 months p〈 0.0001). Patients not treated with this combination therapy were significantly older (p

Description: Introduction Chronic lymphocytic leukemia (CLL) is typically diagnosed at an early stage and a watch & wait (W&W) strategy is applied. Only when the disease progresses to a more active, symptomatic form, treatment is indicated. The prospective CLL1 trial was designed to evaluate the benefit of early risk-adapted therapy with fludarabine (F) monotherapy, and to document the natural course of the disease from diagnosis. Here we present follow-up data to assess overall survival from the time point of treatment indication. Methods At enrolment, risk stratification was performed based on bone marrow (BM) infiltration pattern, lymphocyte doubling time (LDT), serum beta2-microglobulin (ß2-MG), and serum thymidine kinase (TK). Pts were “high-risk” (HR) if they had diffuse BM infiltration pattern and/or LDT7.0 U/L and/or ß2-MG 〉3.5 mg/L at enrolment. HR pts were randomized in a 1:1 ratio to early F (HR-F), or to W&W until classical treatment indication (HR-W&W), which was also applied to all low-risk (LR) pts. Results Between 1997 and 2004, 710 pts with Binet A stage CLL were enrolled and underwent risk stratification (RS) per protocol. Median time from diagnosis to enrolment was 3.2 mo (range 0-33.7) and median follow-up time was 8.5 years (yrs) (range 0-13.9). 521 pts (73%) were stratified to LR and 189 pts (27%) to HR, of whom 93 pts (49%) were randomized to HR-F and 96 pts (51%) to HR-W&W. Median age was 60 (range 32-75) yrs, 61% were male, 34% had unmutated IGHV status; high-risk cytogenetic features (17p- and 11q-) had 3% and 8% of pts, respectively. Early intervention with F among HR pts significantly prolonged progression-free survival (PFS) (30 vs. 13 mo; p3.5 mg/L, and age 〉60 yrs as independent prognostic factors for OS for patients with progressive, active disease and treatment indication. Conclusions Monotherapy with fludarabine is not superior to the W&W approach for the management of early stage CLL pts, since early F did not improve OS or outcome following subsequent therapies. Disclosures: No relevant conflicts of interest to declare.

Description: Introduction: T-cell prolymphocytic leukemia (T-PLL) is a very rare & aggressive disease. Therapeutic advances during recent years have been very limited. Even after initial response, the vast majority of T-PLL patients (pts) relapse quickly and the median overall survival remains below 2 years (ys). This also holds true for induction therapies with the anti-CD52 antibody Alemtuzumab (A). Furthermore, life-threatening viral infections are a severe problem in pts treated with this antibody. In a precursor trial (Hopfinger et al, Cancer 2013), we evaluated a consolidation therapy with A after polychemotherapy induction. In the T-PLL2 trial, we evaluated feasibility, safety and efficacy of the addition of A s.c. to an induction treatment with Fludarabine, Mitoxantrone & Cyclophosphamide (A-FMC), followed by an A s.c. maintenance therapy. Patients and Methods: 16 pts (12 untreated and 4 with pretreatments) with T-PLL were enrolled between 06/2010-09/2013. Pts received an induction treatment with A 10mg s.c. on day (d) 1-3 combined with 20mg/m2 Fludarabine i.v. d 1-3, 6mg/m2 Mitoxantrone i.v. d1 & 200mg/m2 Cyclophosphamide d1-3. After 2 cycles the A dose was increased to 30 mg s.c., if a stable disease (SD) or a partial remission (PR) was achieved. A-FMC treatment was administered every 28 days for up to 4 cycles, followed by a maintenance treatment with 30mg A s.c. starting 1 month (mo) after final staging. During the first 6 mo, A s.c. was administered monthly and in addition once in mo 10 and 13. For younger and fit pts, the option of allogeneic transplantation (tx) was explicitly recommended after induction therapy. Peripheral blood (PB) samples were taken at diagnosis & at the time of relapse/progression. Valganciclovir was recommended for prophylaxis. Results: 16 pts with a median age of 68 ys (range 32-78) and a median score on the cumulative illness rating scale of 3 (range 0-6) were enrolled. The diagnosis of T-PLL was established based on clinico-pathologic characteristics, with the lead finding of a monoclonal mature T-cell population in PB. All leukaemias (100%) were CD52 positive, 15/16 cases (93.75%) expressed TCL1 & the most frequent abnormalities by FISH/classical karyotyping were aberrations involving 14q32.1 in 14/14 cases (100%), gains of chromosome 8q in 10/14 cases (71%), & deletion 11q23 in 8/14 cases (57%). A median number of 4 courses (range 2-4) were administered for induction treatment. Six pts (37.5%) proceeded with maintenance treatment with a median of 4 (range 1-6) A applications. In total, 94 non-infectious CTC grade 3-4 adverse events (AE) & 28 episodes of CTC grade 1-4 infections were documented. Non-infectious grade 3/4 AEs were most frequently due to myelosuppression: neutropenia/leukopenia occurred in 14/16 pts (87.5%), anaemia in 7/16 pts (43.75%) & thrombocytopenia in 10/16 pts (62.5%). Two cases of cytomegalovirus (CMV) & 1 case of varicella zoster infection were documented. Most AEs could be successfully managed, however 2 (12.6%), possibly treatment related deaths occurred, both from fatal bleeding in thrombocytopenia. In all pts response data after induction treatment was available. The overall response rate was 68.75% (11/16pts) with complete remissions (CR) in 4 pts (25%), CR with insufficient bone marrow recovery in 1 pt (6.25%) & a PR in 6 pts (37.5%). Progressive disease (PD) was documented in 4 pts (25%), a SD in 1 pt (6.25%). The trial was terminated in May 2014. Until today, 11 deaths (68.75%) were reported & 1 pt (6.25%) was lost to follow-up. Prophylaxis with Valgancyclovir was administered in 12/16 pts (75%), 2 pts (12.5%) received prophylactic Valaciclovir & 2 pts (12.5%) received no viral prophylaxis at all. Seven pts (43.75%) received an allogeneic tx after the study treatment: 3 pts after the induction phase, 1 pt after 5 maintenance applications & 3 pts after bridging/salvage therapy. Tx outcomes were documented with 5 CRs & 2 PDs. Conclusion: A s.c. combined with FMC & A maintenance therapy is a relatively safe and feasible regimen in pts with T-PLL. However, safety seems to come at the cost of response quality. Therefore, the authors currently recommend using A i.v. as part of the initial therapy for T-PLL pts. Prophylaxis with Valganciclovir was effective in preventing CMV infection, one of the major threats to pts treated with A. Most importantly, the study emphasizes the need for new therapies and intensified clinical research for pts with T-PLL. Disclosures Off Label Use: Therapeutic off-label use of Alemtuzumab, Fludarabine, Cyclophophamide and Mitoxantron in T-PLL. Hopfinger:Genzyme: Research Funding. Weit:Beckman Coulter GmbH, Krefeld, Germany: Employment. Stilgenbauer:Genzyme : Consultancy, Honoraria, Research Funding. Eichhorst:Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding, Travel grant Other; Mundipharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Travel grant, Travel grant Other; GSK: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Gilead: Consultancy. Hallek:Genzyme, Bayer: Research Funding.