ALBERT

Description: Sustained complete remissions (CR) have been reached with allogeneic transplant in patients with poor prognosis B-CLL; however, mortality rates are high (20–50%); in order to reduced TRM, NM conditioning are widely used in haematological malignancies; however it is not clear if the use of NM regimens can maintain the efficacy reducing the toxicity. IN this report we performed a retrospective comparison between 30 patients (group A) who have received myeloablative conditioning consisted of TBI plus Cy in 23 pts (74%), TBI, Cy plus VP-16 in 6 pts (19%) and BuCy in 1 patient and 31 patients (Group B) who have received a NM transplant. Conditioning regimens in Group B included: Fludarabine plus Melphalan, 20 pts (64%), Fludarabine, Busulphan and ATG, 5 pts (16%), Fludarabine, TBI and ATG, 4 pts (13%) and Fludarabine plus TBI, 1 patient. All patients received peripheral blood stem cells from a HLA related identical donor. T-cell depletion was performed in 14 patients of the group A. Median age at transplant was significantly higher in the group B patients (53 versus 45, respectively) (p

Description: Background: Although clearly unsatisfactory, melphalan and prednisone remains the gold standard for elderly MM patients. Therefore new treatment strategies are needed for these patients. The proteasome inhibitor bortezomib (VELCADE) has shown significant activity in refractory/relapsed MM patients. Moreover, in vitro synergy has been reported when bortezomib is combined with cytotoxic agents such as melphalan. Aim: To define the appropriate dose of bortezomib in combination with MP and to analyse the toxicity and efficacy of V-MP (in terms of response) in untreated MM pts ≥ 65 years old. Methods: Treatment schedule consisting of four 6-week cycles followed by five 5-week cycles. First, two sequential dose levels of bortezomib (1.0 and 1.3 mg/m2) (6 pts each) were explored, administered on days 1,4,8,11,22,25,29 and 32 in combination with oral melphalan, 9 mg/m2 and prednisone, 60mg/m2 once daily on days 1 to 4. When maximum tolerated dose (MTD) of bortezomib in combination with MP was defined, the cohort of pts at the MTD was expanded to up to 60 patients to further refine estimates of efficacy and toxicity (PhaseII). Results: Median age of the 60 enrolled pts was 74(65–85) and the median number of cycles so far received is 3(1–9). During PhaseI, no dose limiting toxicity(DLT) was observed in the two cohorts of pts, and the recommended dose for phaseII was 1.3 mg/m2 of bortezomib in combination with MP. 53pts are evaluable for efficacy since they have already completed at least the first cycle. Analysis of response after cycle 1 revealed a Response Rate(RR) of 72%(6%CR with Immunofixation negative(CRIF-), 2%CRIF+ and 64%Partial Response(PR)). Analysis of best response after a median of 3 cycles revealed a RR of 85%(28%CRIF-, 11%CRIF+ and 45%PR); an additional pt(2%) achieved Minor Response(MR) and 7(13%) stable disease. The toxicity was manageable. Adverse events G3-4 reported for 60 pts included: Gastrointestinal toxicity, such as nauseas(2%), vomiting(2%), diarrhoea(15%) and constipation(8%); haematological toxicity, such as anemia(12%), neutropenia(G3 in 26% and G4 in 13%) and thrombocytopenia(G3 in 33% and G4 in 13%); infection(G3 en 12% and G4 in 2%) and peripheral neuropathy(G3 in 13% and G4 in 2%). Bortezomib and melphalan dose modification was required in 6 and 2 pts, respectively. Eight pts so far have been discontinued due to toxicity related to study medication: peripheral neuropathy in 5(G2 in 1, G3 in 2 and G4 in 2), diarrhoea in 1(G3), infection in 1(G3) and prolonged thrombocytopenia in 1(G4). With a median follow up of 7 months (range:3–15), two responding pts have progressed (months +9and+10), 54(90%) are alive and 6(10%) have died. Cause of death was lung cancer diagnosed 1 month after start of study treatment(1), progressive disease(1), septic shock(2), pulmonary thromboembolism (1) and pulmonary hypertension with right ventricular insufficiency and multiorganic failure(1). Conclusion: V-MP shows a high response rate(85% with 28%CRIF-) and manageable toxicities and could replace MP as the standard of care for elderly MM pts. An international phase 3 randomized trial is in progress to examine this.

Description: Introduction Intensification therapy in MM with autologous PBSCT is widely indicated for younger patients with favourable results regarding response, OS and PFS. However, there is no clear plateau in the survival curve. To improve these results and to prolong remission duration, various maintenance treatments have been proposed. Interpheron alpha2b s.c, at low dose, steroids on alternate days and most recently, low dose oral thalidomide, have demonstrated improvements in EFS and OS times but these results needs confirmation. Recently a new formulation of interpheron alpha2b (Pegintron®) is available conjugated with polietilenglicol with the advantage of being administered on a unique weekly dose. This new formulation of Interpheron alpha has been tested scarcely in MM. We present the preliminary results of a spanish, phase II, non comparative, multicentric study (PI-MM-01) with Pegintron® (Schering-Plough) as maintenance treatment after autologous PBSCT. Patients y Methods From May 2003 to March 2007, 30 patients were included in this study, 64% female and 36% male, with a median 56 years, received Pegintron® once a week subcutaneously as maintenance treatment after favourable response post-HDT with autologous PBSCT when the engraftement was stable and complete. The initial dose was 15 mg/week × 2 week and this dose was escalated to 25 mg/week and then 35 mg/week. The final dose was adopted according clinical and hematological tolerance. The maintenance treatment was continued at least 5 years postransplant or until toxicity, relapse or progressión. Results 30 patients were evaluable for this preliminary analysis. The median time from transplant to IFN treatment was 3.8m. The median dose of Pegintron was 15 mg/week. 9 patients have suspended the treatment (30%). 5 cases (16%) due to progression, 2 (4%) for toxicity and 2(4%) for other reason. The remainder 21 patients (76%) continue the treatment with clinical response, with median duration of 16 months (2–42). At present all patients are alive. Astenia, “pseudo-flu” symptoms and thrombopenia and neutropenia were the most common adverse effects observed, that limited the dose escalation, being 15 mg/week the best tolerated and mos frequent dose (70%). One patient suspended the treatment due to dermatological reaction with pruritus. Conclusions and Comments Although these results need completion and further analysis, maintenance treatment with a weekly dose of Interpheron-a2b conjugated with Polietilenglicol (Pegintron®) is well tolerated after autologous PBSCT in MM. No major adverse effects were observed and no relevant negative impact was observed on the autologous graft. Pegintron® sc could be an alternative to standard interpheron sc with the main advantage of therapy simplification with only one dose weekly. More experiences and longer follow up are needed to evaluate the role of this strategy in the global treatment of MM and new approaches for maintenance have to be investigated, including association and comparison with steroids or new drugs as thalidomide, bortezomib or lenalidomide.

Description: Introduction Plasma Cell Leukemia (PCL) is characterized by a high number of plasma cells in peripheral blood (〉2 × 109/L) and more than 20% of circulating plasmocytes on differential count. Primary PCL or secondary form, after previous multiple myeloma (MM), represent the most aggressive forms of clonal gammapathy with very poor outcome from both conventional chemotherapy and autologous or allogeneic transplant. For this reasons new effective treatment approaches are required. The proteasome inhibitor Bortezomib has been shown to be effective in advanced MM with a rapid response but few reports have been published regarding its potential role on PCL. We report here the clinical results of a serie of PCL patients that received proteasome inhibitor, Bortezomib (Velcade®), as induction therapy. Patients and Clinical Results We describe 10 patients with PCL treated with Bortezomib. Median age was 58 y (30–70). 4 cases were primary, de novoPCL and 6 cases were secondary forms of relapsed or progressive MM. Patients with secondary PCL had received a median of 3 previous lines of therapy including autologous transplantation (5 cases). Bortezomib at standard dose iv: 1.3 mg/m2 days 1,4, 8,11 every 21 days were used alone in 2 patients and in combination with high dose of Dexamethasone +/− Adryamicin in the rest. 3 cases recived the BDD scheme (Bortezomib iv, Pegylated Doxorrubicin iv and oral Dexamethasone). 9 patients were evaluable for drug efficacy with 7 cases showing some grade of favourable response with the first cycle, including 3 cases of CR. 4 patients have died: 1 during first weeks and 3 for progression, 2–3 months after initial response. 3 cases received allogeneic transplant with related donor and reduced conditioning and are alive 12, 14 and 30 months postransplant. The median follow up since PCL diagnosis of 6 alive patients is 14 months (3–39 months). 3 patients received maintenance therapy that included low dose thalidomide. Grade 2 thrombopenia, neutropenia and gastrointestinal symptoms were the main secondary toxicity. No complicated tumoral lysis syndrome were observed. Conclusions and Comments Bortezomib has been shown to be effective by several mechanisms in patients with MM resistant to multiple previous treatments and as induction therapy alone or in combination with other drugs. The favourable responses observed in these cases of PCL; including de novo patients, and the biological ex vivo results in PCL cell lines, suggest the potential efficacy of this agent combined with dexamethasone and doxorubicin. Although more experience is necessary these data support future trials with Bortezomib combined with other drugs for example BDD scheme in the induction treatment of PCL. The role of allogeneic intensification therapy has also to be investigated in young patients after control of PCL with this approach. For maintenance of response, the role of this drug or other new drugs as thalidomide or lenalidomide has to be investigated.

Description: In the present study we have evaluated the outcome of reduced intensity conditioning allogeneic transplant (RIC) in 31 patients with symptomatic B-CLL. 74% of the patients were older than 50 years, and 70% had previously received purine analogues, with 38% of them relapsing or progressing after treatment. At transplant, 83% had active disease. Data from VH homology, FISH analysis, CD38 expression and ZAP 70 expression was available in 21, 27,12 and 2 patients, respectively. 21 out of 31 were conditioned with melphalan plus fludarabine according to our GETH 99–051 protocol; the other patients received other fludarabine-containing regimens. All patients engrafted. Early complete donor chimerism (CDC) (days +28) in Bone Marrow (BM) was observed in 67% of patients; all except two relapsing patients remained CDC after day +180. With a median follow up of 36 months (1–63), 9 patients have died, two of them due to disease progression and seven (22%) due to TRM. In the univariate analysis age older than 55 years, aGVHD and more than two lines of previous chemotherapy significantly influenced TRM (p

Description: Myeloablative transplant has been investigated in poor prognosis indolent lymphoma; although recurrence rate is low it is associated with high mortality; the use of non-myeloablative conditioning regimens could reduce TRM maintaining the GVH effect. Up to February 2004, 40 patients with indolent NHL(87% Folicular lymphoma(FL) 5% a lymphocytic well differenciate lymphoma (WDLL) 5% Waldenström Macroglobulinemia(WM) and 3% a Marginal Lymphoma(MZL) have been registered in two prospective multicenter trials;Conditioning regimen consisted of Fludarabine 150 mg and Melphalan 70–140 mg. GVHD prophylaxis consisted of CSA plus short-course MTX. All patients received filgrastim-stimulated peripheral blood stem cells from a HLA related identical donor.Median age at transplant was 50 years (34–67) and 15(40%) had received a previous autologous transplant. At transplant, 5 patients (13%) were in CR1 (after several lines of chemotherapy), 9 (22%) in 〉CR1, 16 (40%) in PR, 1(2%) had stable disease (after 3 chemotherapy lines) and 9(23%) progressive disease. All patients engrafted. Acute GVHD developed in 22 patients (55%) (18 patients grade II–IV). Chronic GVHD developed in 22 out of 27 patients at risk (81%), being extensive in 13; Disease was evaluated at day +100 and at that moment 22 patients(58%) were in CR, 3 (8%) in PR, two (5%) had stable disease and 11 patients (27%) have died. With a median follow up of 30 months (range: 10–56 months), 24 patients (60%) are alive disease free, 16 (39%) have died, 14 of them (35%) due to transplant toxicity and 2 patients (5%) due to progression. Overall Survival (OS) and Event Free Survival (EFS) are 60 and 58 % respectively. Analysing variables which influence on OS and EFS, patients ≥55 years have a OS significantly shorter than patients 〈 55 years old (22% vs 66%; p:0,01). Moreover, patients who develop chronic GVHD have an OS and EFS significantly better than those which do not develop it (OS: 89,7 vs 57%; p=0,02 (HR: 9,3-IC95% (2,08–41,5); EFS: 89 vs 42%; p=0,002 (HR: 11,08-IC95% (2,49–49,28)). In conclusion, our results demonstrates the efficacy of non-myeloablative transplant in indolent NHL with a very low relapse rate, indicating the important role of chronic GVHD in the control of the disease; however, mortality rate is still high, mainly in patients ≥55 years

Description: Although autologous transplant is the election in poor prognosis patients with Non Hodgkin agressive histologies, some patients relapse, for others collection of progenitor cells is not possible and in some categories as Mantle Cell Lymphoma results after autologous transplant are dismal. From 1999, three prospective multicenter trials with non-myeloablative allogeneic transplant in hematological malignancies have been performed in Spain. Up to now, 36 patients have been registered in these trials. From them,28 (58%)had aDBLCL,1 (3%) a transformed MZL,1 (3%) a BL and 14 (37%) a MCL. The conditioning regimen consisted of fludarabine 30 mg /m2 intravenously (IV) on days −8 to −4 followed by melphalan 70–140 mg/m2 IV on days −3 and−2. The last 25 patients enrolled in the latest trial received rituximab 375mg/ m2;on days −8, −1,+8 and +15 as part of conditioning; filgrastim stimulated peripheral blood stem cells were infused on day 0. GVHD prophylaxis consisted of cyclosporine A (CsA) from day −7 plus short-course methotrexate (MTX) (10mg/m2, days +1, +3, +6), followed by folinic acid rescue. Median age was 51 years (range 27–68);at transplant 5 (13%) of the patients were in CR1, 4 (11%) in a later CR and 29 (76%) had active disease 18 (47%) had sensitive disease and 11 (29%) resistant disease. Days to reach more than 500x 109 granulocytes and more than 20000x109 platelets were +14 (range 10–93) and +12(range 8–18). At a median time of 25 days (range 19–97), 19 patients (50%) developed acute GVHD (13 patients (34%) grade II–IV). At a median time of 107 days(80–267), 68% out of 19 patients at risk developed cGVH being extensive in 11 (39%)Disease was evaluated at day +100 and at that moment 23 patients(65%) were in CR (including 4 / 8 patients transplanted on PGR), 4% in PR and 23% have died due to NRM(Non relapse mortality). With a median follow up of 31 months (range: 6–67 months), 19 patients (50%) are alive, 17 disease free and 19(50%) have died, 10(26%) due to NRM and 8 (21%) due to progression with a proyected NRM at 1 year of 22%. OS and EFS at 5 years of of 43 and 36% respectively. None of the variables analysed influenced on NRM. Regarding efficacy of transplant in different histologies, OS and DFS for MCL were 71% and for BDLCL, 31% and 20% respectively. In this preliminary analysis results in MCL are quite good however for patients with DLBCL should be improved. severe toxicity is still present and to date it should be performed only in the setting of well designed clinical trials.

Description: For more than 25 years, melphalan and prednisone has remained as the gold standard treatment for elderly multiple myeloma (MM) patients. Bortezomib has shown significant activity with manageable toxicity in refractory/relapse MM patients. Moreover, in vitro synergy has been reported when bortezomib is combined with cytotoxic agents such as melphalan. Aim: To define the appropriate dose of bortezomib in combination with MP and to analyse the efficacy of V-MP in untreated MM patients ≥ 65 years old. Methods: This is a dose escalation study with two sequential dose levels (Ph 1) and expansion of the cohort at the MTD by 60 patients to further refine estimates of efficacy (Ph 2). In the first cohort, bortezomib (1mg/m2) was administered as a iv bolus to 6 consecutive patients on days 1,4,8,11,22,25,29 and 32 followed by a 10 day rest period in combination with oral melphalan, 9 mg/m2, and prednisone, 60mg/m2, once daily on days 1 to 4. In the 2nd cohort, bortezomib was administered at 1.3mg/m2. MTD was defined as that dose level below which 2/6 patients had a DLT. Patients: 12 patients have been enrolled to date - 6 in cohort 1 and 6 in cohort 2. Results: Toxicity has been manageable. The first cohort at 1 mg/m2 has completed at least two 6-week treatment cycles. There was no DLT in the first cycle. The 2nd cohort has enrolled 6-patients at a dose of 1.3 mg/m2 but none has completed the first cycle yet. In the first cohort, there was one patient with grade 3 neutropenia (ANC = 0,668) observed at Cycle 1 Day 25. During the second cycle, there were no patients with grade 4 therapy-related toxicity and only one grade 3 adverse event (neutropenia) was observed. The most common grade1 or 2 toxicities were nausea, vomiting, rash, constipation, diarrhea, fever, herpes zoster infection, anorexia, neutropenia, anemia and thrombocytopenia. Ocular neuropathic pain (grade 2) developed de novo in 1 patient during the first cycle; one dose of bortezomib was held and the adverse event resolved with analgesic treatment in 4 days. Treatment was continued at a dose of 0,5 mg/m2 at D11 and D22. After this date, bortezomib at 1.0 mg/m2 was restarted. The second cohort is in the first 6-week cycle at present, so observations are limited. One serious adverse event (pulmonary embolism and probably septic shock with death) was observed in this cohort in a patient at day +11. He had normal WBC. Two grade 3 adverse events (leucopenia and neutropenia) were observed in one patient. Other grade 1 or 2 toxicities are similar to those observed in the first cohort. Regarding response, after two cycles of treatment, in the first cohort, 3 out of the 6 patients have experienced 〉50% reduction in M-protein (two with 〉 75% reduction) and the others three have experienced either a minor response (1) or stable disease (2). In the second cohort, response data are not available at this time. Conclusion:The combination of V-MP is well tolerated at standard doses of MP with bortezomib 1 mg/m2 with no DLTs in 6-patients. Bortezomib (1.3 mg/m2) is being explored in the second 6-patient cohort in order to define the MTD. So far, no patient has developed DLT. Rapid M-protein responses have been seen. Results will be updated and presented for the 2nd cohort.