ALBERT

Description: The 170 km long river course of the Guadalete River (western Andalucía) provides an excellent record of Late Pleistocene and Holocene fluvial sedimentation dynamics. Furthermore, its floodplain sediments are very well suited to describe geomorphic changes forced by climate fluctuations, sea-level changes, tectonic influences and human activity. Multiproxy investigations were based on field mapping and the study of 18 profile sections, mainly including sedimentological characterisation, soil-chemical analyses and radiocarbon dating of 34 samples. Findings were complemented by drillings and electrical resistivity tomography. The lowermost 50 km of the river section are divided into an upper and lower part (each 25 km long), based on different sediment preservation conditions. The boundary corresponds to the disappearance of the Late Pleistocene river terrace. Significant floodplain aggradation occurred at around 10 000 cal. years BP, while dynamics were strongly affected by sea-level fluctuations until the early Holocene. Furthermore, sedimentation starting at 8000, 6100, 4600, 2200, 900 and 400 cal. years BP is related to enhanced fluvial dynamics due to environmental stress that presumably was triggered by climate fluctuations, that is, aridification. However, the strongest intensity of sedimentation at 400 cal. years BP points to climate anomalies in the course of the Little Ice Age. In contrast, several periods of stability associated with alluvial soil formation took place during the Bølling and Allerød interstadials, prior to 8000, 6100 and 5100, and after 4300 and 2000 cal. years BP. The anthropogenic signal in floodplain evolution is not clearly distinguishable from that of climate. However, human land use had the potential to amplify geomorphic processes, especially during periods of climate deteriorations that caused increasing stress on the environment.

Description: Activation of phosphatidylinositol 3-kinase (PI3K)/Akt/mammalian target of rapamycin (mTOR) signaling plays a role in cell proliferation, survival, and drug resistance in solid tumors and hematologic malignancies including chronic myeloid leukemia (CML), B-cell precursor acute lymphoblastic leukemia (BCP-ALL), T-ALL and acute myeloid leukemia (AML). The investigational compound BEZ235 is a potent dual pan-class I PI3K and mTOR complex C1 and C2 inhibitor and an attractive agent for relapsed or refractory leukemias. Primary objectives of this phase I study were determination of the dose-limiting toxicity (DLT), maximum tolerated dose (MTD) and recommended phase 2 dose (RP2D) in pts. with advanced acute leukemia. Secondary objectives included assessment of pharmacokinetics (PK), pharmakodynamic (PD) parameters and preliminary evidence of anti-leukemic activity. Inclusion criteria included age 〉 18years, relapsed or refractory AML, ALL or CML-BP considered ineligible for intensive or established treatment. Pts. with a fasting blood glucose 〉160mg/dl or an HbA1c 〉8% were excluded. The starting dose of BEZ235 was 400 mg twice daily (BID), administered orally during 28d cycles. Dose escalation was based on a “rolling-six”design, followed by an expansion phase at the RP2D. PK analyses were performed on days 1 and 15 by HPLC and fluorescence detection, PD analysis included assessment of phosphorylation of AKT, S6 and 4EBP1 by Western blotting (WB) and flow cytometry. The presence of PI3KCA, AKT or PTEN mutations was evaluated by direct sequencing of exons with known mutation hotspots. All pts. gave informed written consent, the study was approved by the Ethics Committee of the University of Frankfurt. 22 pts. (13m, 9f), median age 62.5 years (range 29-82), were enrolled. Types of leukemia were AML (n=11), BCP-ALL (n=9), T-ALL (n=1) and CML in myeloid blast phase (CML-BP, n=1). 6 pts. were in first and 9 pts. in second or later relapse, 7 refractory or in refractory relapse, 7 pts. had extramedullary leukemia, 14 pts. previously received an allogeneic stem cell transplant (SCT). Six pts. were evaluated at the starting dose of BEZ235 (400 mg BID). No DLTs were observed, but BEZ235-related AEs (stomatitis and GI toxicity grades 1-3) necessitated treatment interruptions in 3 of 6 pts. 400 mg BID was considered not tolerable for prolonged administration and 16 pts. were subsequently treated at dose level -1 (300 mg BID). The most frequent non-hematologic AEs were gastrointestinal primarily of grades 1 and 2 with diarrhea (n=20), nausea/vomiting (n=18/6), stomatitis/mucositis (n=20), decreased appetite (n=14), fatigue (n=10) and hyperglycemia (n=21). Grade 3/4 AEs included sepsis (n=6), pneumonia (n=4), diarrhea (n=3), hyperglycemia (n=2), mucositis and fatigue (2 each). No patient started at dose level -1 was dose-reduced and none discontinued BEZ235 because of toxicity, 300 mg BID was selected as the RP2D. Clinical responses were observed in 4 of 22 pts. (3/10 ALL): one pat. with pro-B ALL achieved a complete hematologic and molecular remission with full donor chimerism, ongoing after 11 cycles of BEZ235. Hematologic improvement was observed in two pts. with BCP-ALL (1 Ph+, 1 Ph neg) and stable disease of 4 mos. duration in an AML patient. Nineteen of 22 pts. discontinued because of disease progression, median time to progression was 28 days (5d-112d). PK analysis revealed substantial interpatient variability of peak and trough levels at steady state, with no clear dose-dependency. All three responders in whom PK data are already available had low steady state trough levels below 100 ng/ml. No activating mutations of PIK3CA, AKT or PTEN were identified in any of the 22 pts. Phospho-flow and WB analysis provided no evidence of PI3K pathway activation, even in responding pts. In conclusion, the RP2D for BEZ235 was determined to be 300 mg BID, without formal definition of DLTs and an MTD. Single-agent anti-leukemic efficacy was most pronounced in ALL, with an overall response rate of 30% and a sustained molecular remission in one patient. Results of PK analysis and assessment of PD markers associated with PI3K signaling did not correlate with response. The PI3K pathway appears to be a “driver pathway” in only a small minority of pts. with ALL or AML, but more comprehensive genomic analysis may identify a subset of patients likely to benefit from treatment with dual PI3K-mTOR inhibitors. Disclosures: Ottmann: Novartis: Consultancy, Membership on an entity’s Board of Directors or advisory committees, Research Funding, Speakers Bureau.

Description: Background: Leukemic relapse and graft-versus-host disease (GvHD) remain major obstacles after an allogeneic stem cell transplantation (HSCT). Panobinostat is a potent inhibitor of class I, II and IV deacetylases and has shown antileukemic as well as immunomodulatory activity. The hypothesis of our phase I/II PANOBEST trial was that panobinostat can effectively prevent relapse in patients (pts) with high-risk (HR) myeloid diseases while simultaneously reducing GvHD. We aimed to determine dose-limiting toxicity (DLT), maximum tolerated dose (MTD) and/or recommended phase 2 dose (RP2D) of panobinostat in adult pts with HR acute myeloid leukemia (AML) or myelodysplastic syndromes (MDS) in complete hematologic remission (CR) after a reduced-intensity HSCT. Secondary objectives were evaluation of safety and tolerability of panobinostat, and overall (OS) and disease-free survival (DFS) at 1 and 2 years after HSCT. Methods: In two sequential schedules, panobinostat was administered orally thrice weekly, (TIW), either every week (A) or every other week (B). In schedule A, panobinostat was started at a dose of 10 mg TIW and escalated to 30 mg TIW using a 3+3 design; in schedule B, panobinostat was given at doses of 20-40 mg TIW. Panobinostat was initiated between day +60 and +150 after HSCT and given for up to 1 year. Eligibility criteria included: ANC ≥ 1,000/μL, platelets ≥ 75,000/μL, adequate organ function and no severe GvHD. DLT was defined as prolonged G4 hematologic toxicity or any non-hematologic toxicity ≥ G3 unrelated to disease progression or intercurrent illness within 28 days of the first panobinostat dose. Results: 42 pts (37 AML, 5 MDS) were enrolled, with a median age of 52 years (range, 21-71). Cytogenetics were classified as low (n=6), intermediate-1/2 (n=20) or adverse risk (n=16) according to ELN criteria. Panobinostat was started a median of 98 days (range, 60-147) after HSCT from a matched related (n=9), matched unrelated (n=24), mismatched unrelated (n=6) or haploidentical donor (n=3). The majority of patients (n=28, 67%) were transplanted with active disease (bone marrow blasts 0-80%, median 21%, 1 pt. with extramedullary AML), 9 in CR1 (21%) and 5 in CR2 (12%). Patient and transplant characteristics were equally distributed between schedules A and B. Of 42 pts, 22 (54%) have completed one year of panobinostat, 1 remains on treatment and 19 (46%) discontinued prematurely after a median of 70 days (range, 12-342) due to adverse events (AEs) (n=10), relapse (n=6), patient decision (n=2) or prohibited comedication (n=1). To date, 24 out of 42 patients experienced panobinostat-related grade 3/4 AEs (schedule A: n=14, 67%; schedule B: n=10, 48%). The most common AEs were hematologic toxicity (G3: 14 pts, 33%; G4: 2 pts, 5%), constitutional (G3: 7 pts, 17%) and gastrointestinal symptoms (G3: 5 pts, 12%). Neurological AE and pain (G3, 2 pts each, 5%) as well as metabolic/laboratory alterations (G3: 3 pts., 7%) and renal toxicity (G3, 1 pt, 5%) were also reported. AEs were fully and rapidly reversible after interrupting panobinostat (n=24); 14 patients needed dose adjustment and no study-related deaths occurred. The RP2D was 20 mg TIW in arm A and 30 mg TIW every other week in arm B based on 5 DLTs: fatigue G3 at 20 mg, colitis and nausea/emesis G3 each at 30 mg (arm A), diarrhea and headache G3 at 40 mg each (arm B). Prophylactic or preemptive donor lymphocyte infusions (median 2, range, 1-6) were administered to 10 pts (42%, median 1.5x106 CD3+ cells/kg) in arm A and 8 pts (33%, median 0.5x106 CD3+ cells/kg) in arm B. Cumulative incidence (CI) of moderate (n=8) or severe (n=2) chronic GvHD was 24±0.4% at one year after HSCT and did not differ between both arms. There was no evidence of impaired immune reconstitution. To date, median OS and DFS have not been reached after a median follow up of 22 months (range, 6-57). At two years after HSCT, 5 patients have died from relapse (n=3), sepsis (n=1) or sudden death (n=1 at 3.5 months after study discontinuation) and CI of relapse was 21±0.5%, resulting in probabilities for 2-year OS and DFS of 88±5% and 74±7%, resp. Discussion: Panobinostat maintenance following HSCT for high-risk AML or MDS is feasible with a RP2D dose of 20 mg TIW weekly or 30 mg TIW every other week and associated with a low relapse rate. This provides a rationale for a prospective randomized trial of panobinostat as post-transplant intervention. Disclosures Bug: NordMedica: Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Other: Travel grants, Research Funding; Novartis Oncology: Honoraria, Other: Travel grants, Research Funding; Boehringer Ingelheim: Membership on an entity's Board of Directors or advisory committees; Astellas: Other: Travel grant; TEVA Oncology: Other: Travel grant; Gilead: Honoraria. Off Label Use: Panobinostat has not been approved for maintenance therapy after an allogeneic stem cell transplantation in ANL and MDS patients . Burchert:Bristol Myers Squibb: Honoraria. Bader:Neovii: Other: Institutional grants; Medac: Other: Institutional grants; Amgen: Consultancy; Novartis: Consultancy; Jazz Pharmaceuticals: Consultancy; Riemser: Other: Institutional grants. Ottmann:Ariad: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Astra Zeneca: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Description: LBL is a rare subtype of NHL and mostly displays a T-cell phenotype. The WHO classification combines acute lymphoblastic leukemia (ALL) and LBL; pts with ≥ 25% bone marrow (BM) infiltration are considered as ALL. LBL pts are usually treated according to ALL protocols and sometimes reported within ALL trials. There are however specific clinical and management questions, such as role of mediastinal irradiation (MedRad), optimal remission evaluation or risk stratification and there is a lack of prospective trials in LBL. The German Multicenter Study Group for Adult (GMALL) has reported results on 45 T-LBL pts (Hoelzer et al, Blood 2002). Based on this experience a prospective T-LBL trial was activated (cohort I) followed by a prospective registry with documentation of pts treated according to an GMALL expert recommendation (cohort II). Therapy was based on the GMALL trial for ALL (07/2003) with a prephase (Dexa, Cyclo), induction I (Dexa, VCR, Dauno, PEG-Asparaginase) and induction II (Cyclo, ARAC, Mercaptopurine) together with CNS irradiation and i.th. prophylaxis. MedRad (36 Gy) was scheduled after induction and followed by consolidation (cons) I (VCR, Dexa, VP16, HDMTX, HDARAC), cons II, III, VI (HDMTX/PEG-ASP), reinduction, cons IV (HDARAC) and V (CYCLO/ARAC). Salvage therapy was recommended in pts without CR/CRu after cons I. Essential time-points (TP) for remission evaluation were after induction II (TP1), after MedRad (TP2 in cohort I only) and after cons I (TP3). For cohort II MedRad was omitted and PET analysis was recommended in CRu or PR at TP3. 149 pts (cohort I:101; cohort II: 48) from 64 hospitals were included between 9/04 and 1/13. The median age was 31 (17-62) yrs. 73% were male. 93% had mediastinal involvement, 61% pleural and 34% pericardial effusion, 18% BM and 2% CNS involvement. 59% had stage III-IV disease. 63% had a thymic subtype (N=66) and 37% had an early or mature T phenotype (N=39). Results of response evaluation according to standard procedures (excluding PET) are given in table 1. CR/CRu rates increased from 34% to 59% and 76% through TP1-3. 96% had CR,CRu or PR as best response at TP1-3. Positive PET results at TP3 were detected in 0/21 pts with CRu and 10/22 (45%) pts with PR (p=0.001). Overall survival (OS) was 65% at 5 yrs. 3 yr OS appeared superior in cohort II vs cohort I (76% vs 67%; p〉0.05), due to a lower relapse rate (15% vs 31%;p=0.07) but at shorter median follow-up (1.9 vs 5.6 yrs). 2% died in CR. No difference was observed in terms of 5y OS for pts with CR, CRu or PR, 71%, 82% and 75% resp (p〉0.05). In the majority of PR pts therapy was continued per protocol. 5y OS was slightly superior for pts with thymic (N=66; 78%) vs early/mature (N=39; 58%) subtype (p〉0.05). Pts 25 yrs had 5 yr OS rates of 75% vs 60% resp. (p=.09); stage , BM involvement and aaIPI had no significant impact on OS. Pts with early achievement of CR/CRu (TP1) had a slightly better OS (N=49; 69%) compared to those with PR/Failure (N=95; 65%) (p=.09). Overall 26% of the pts relapsed (42% BM±other, 11% CNS+other, 8% CNS only, 40% lymph node or extramedullary only). The proportion of mediastinal relapses did not increase in cohort II vs cohort I (24% vs 17%). This is the largest so far reported cohort of prospectively treated adult patients with T-LBL. The response rate including PR was high (96%). Response evaluation was challenging since many patients showed persistent residual mediastinal tumors (CRu/PR) and responses formally evolved slowly. Conventional remission evaluation had limited clinical relevance as indicated by similar OS of CR, CRu and PR pts. PET evaluation yielded positive results in 45% of the PR pts and may be helpful for decision making on salvage therapies. The omission of MedRad did not impact relapse risk and may have contributed to better feasibility of dose intense chemotherapy. Whereas pts with early/mature phenotype and older pts had a trend towards poorer OS other factors did not significantly influence outcome. In the future additional prognostic factors like minimal residual disease evaluation may help to identify patients with potential benefit from salvage therapy and/or stem cell transplantation (supported by the Jose Carreras Foundation; Grant: Ho9/01f) Table 1: Results of Remission Induction TP1 (after induction) TP2*(after irradiation) TP3 (after consolidation) Best response Evaluable 148 86 138 149 CR 22% 33% 63% 60% CRu 12% 26% 13% 13% PR 62% 35% 15% 23% Failure 3% 2% 6% 1% Early death 3% 5% 3% 3% * Cohort 1 only Disclosures No relevant conflicts of interest to declare.

Description: Inhibitors of class I/II histone deacetylases (HDACi) possess anti-leukemic activity and have been reported to modulate the function of immune effector cells. Thus, they could provide specific clinical benefit in the allogeneic hematopoietic stem cell transplantation (HSCT) setting. Panobinostat (PAN) is a potent, orally available pan-HDACi reported to either suppress or stimulate regulatory T cells (T reg), depending on the administered dose (Shen L & Pili R, OncoImmunology 1;7:948, 2012). The feasibility and efficacy of PAN treatment following HSCT for patients (pts) with high risk acute myeloid leukemia (AML) has not been established. We report clinical and translational results of the dose-escalation phase of the PANOBEST study with PAN as post-HSCT maintenance. Primary objectives were, based on dose-limiting toxicity (DLT), determining the maximum tolerated dose (MTD) and/or the recommended phase 2 dose (RP2D) of PAN in patients with high risk AML or myelodysplastic syndromes (MDS) in complete remission (CR) after reduced-intensity conditioning HSCT. Secondary objectives were the evaluation of safety, tolerability and immunoregulatory properties of PAN, and overall (OS) and disease-free survival (DFS) of treated patients. PAN was started at 10 mg p.o. three times a week (TIW) and escalated to 20 and 30 mg TIW using a 3+3 design. Treatment was initiated 60-150 days after HSCT and continued for up to one year. Eligibility criteria included: recovery of peripheral blood counts, adequate organ function and no severe graft versus host disease (GvHD). All pts gave written informed consent. DLT was defined as prolonged grade 4 hematologic or grade 3/4 non-hematologic toxicity within 28 days of the first PAN dose. Immunophenoytyping of lymphocyte subsets was performed pre-treatment and on days 3, 8, 30, 90, 180 and 360. 12 pts (11 AML, 1 MDS), median age of 52 years (21-62) were enrolled. PAN was started within a median of 73 days (60-126) after HSCT, which was performed with active disease (n=11) or in CR2 (n=1). The RP2D was determined to be 20 mg TIW based on one DLT (fatigue grade 3) at 20 mg and two DLTs (nausea/emesis and colitis grade 3 each) at 30 mg. Grade 2-4 adverse events (AEs) were reported in 10 out of the 12 pts (83%). Grade 3/4 AEs included hematologic toxicity (50% of pts), laboratory alterations (33%), gastrointestinal symptoms (25%), fatigue, pulmonary infection (17% each), sepsis, herpes stomatitis, diabetes, syncope, deep vein thrombosis and pulmonary embolism (8% each). Toxicity was reversible and required at least one PAN dose reduction in 3 pts. Acute GvHD grade 2 (1 pt) and 3 (2 pts) was responsive to steroids in 2 pts or salvage therapy in 1 pt. Four pts developed mild (n=3) or moderate (n=1) chronic GvHD. To date, 5 pts have completed one year of PAN and 2 pts remain on treatment (days 238, 290). Five pts discontinued treatment prematurely after 10-217 days due to grade 3 toxicities (n=4) or AML relapse (n=1). With a median follow up of 579 days (129-911), 11/12 pts are alive and 10/12 in continuous CR after HSCT. Seven pts received prophylactic donor lymphocyte infusions (DLIs, 1-5 doses of 0.1-20x106 CD3+ cells/kg). Immunophenotyping revealed no impact of PAN on absolute T reg numbers (9 pts), but a significantly reduced proportion of CD4+CD25++CD127dim/- T reg to CD3+CD4+ T helper (Th) cells by day 8 after 3 doses of PAN (mean±SEM: 14.6±2.6 vs. 9.6±1.2%, p value of t test =0.03). While Treg/Th proportion continuously decreased in pts with ongoing CR, it again increased after PAN discontinuation or remained stable under PAN treatment in both relapsing patients. Outcome of the study population was compared with a historical cohort of 29 consecutive pts with active AML transplanted in Frankfurt in 2000-2009. Both cohorts were similar in age, gender, disease stage or BM blasts at time of HSCT, donor type and use of DLIs. In a landmark analysis including all pts who were in CR and without severe GvHD on day 73 after HSCT, probabilities for DFS and OS at 18 months after HSCT were 83±11% vs. 55±9% (p=0.145, log-rank test) and 92±8% vs.66±9% (p=0.085) in the PANOBEST vs. historical cohort (Fig 1). PAN is well tolerated after HSCT at a RP2D of 20 mg TIW. Comparison with a historical control cohort of pts transplanted with active AML shows a low relapse rate, which appears to be associated with a PAN-induced modulation of the T reg/Th proportion. Disclosures: Bug: Novartis: Honoraria, Travel grants, support for the clinical study Other. Ottmann:Novartis: Consultancy, Membership on an entity’s Board of Directors or advisory committees, Research Funding, Speakers Bureau.