ALBERT

Beschreibung: Abstract 3951 Poster Board III-887 Background An increased incidence of second cancers has been reported in some lymphoproliferative disorders. Whether the predisposition to other malignancies is due to disease-related immune-suppression rather than to the carcinogenic role of therapy given to treat the hematologic disease is still poorly understood. Purpose The aims of this study were to assess the frequency, characteristics and factors predicting second cancers in patients with WM and to evaluate whether WM patients are at increased risk of developing other malignancies as compared to an age- and sex-matched control population. Patients and methods The clinical records of 220 consecutive WM patients seen in two Hematologic centres of Northern Italy from 1980 to 2008 were reviewed. All cancers, with exception of non-melanoma skin cancers, were considered for this analysis. Standardized incidence ratios (SIRs), defined as the ratio between observed and expected cases, were used to compare the incidence of second cancers in WM with that of the general population. The number of expected cancers was obtained from age, sex and calendar-specific incidence rates reported by AIRTUM (Associazione Italiana Registri Tumori) for Northern Italy. A multivariate Cox proportional hazards regression model was used to examine risk factors for the development of second cancers. Therapy was analyzed as a time-dependent covariate. Results The median age of patients was 61 years (range: 26-86), 131 (60%) were males and 89 females (40%). The median follow-up was 4.8 years (range: 0.5-25). Overall, 136 patients (62%) with symptomatic WM received therapy, whereas a watch-and-wait policy was adopted in 84 patients (38%) with asymptomatic WM. Among treated patients, first-line therapy consisted of chlorambucil in 93 cases (68%), cyclophosphamide-based regimens in 15 (11%) and nucleoside analogs-containing regimens in 17 (13%). Rituximab was associated to chemotherapy in 19 patients (14%). Details on therapy were not available in 11 cases (8%). Overall, 52 second cancers were observed in 49 patients (22%). Forty-six patients (94%) had one malignancy and 3 (6%) developed two cancers. The types of cancer were: gastrointestinal (n=9, 17%), lung (n=8, 15%), breast (n=7, 13%), urinary tract (n=6, 11%), prostate (n=5, 10%), diffuse large B cell lymphoma (n=5, 10%), myelodysplastic syndrome/acute leukemia (n=3, 6%), brain (n=3, 6%), thyroid (n=2, 4%), mouth (n=2, 4%), other cancers (n=2, 4%). The diagnosis of cancer preceded that of WM in 13 cases (27%), was concomitant (within 3 months) in 6 (12%) and subsequent in 30 (61%). The median time from diagnosis of WM to the occurrence of a subsequent cancer was 4.3 years (range: 0.2-12.9). The cumulative probability of developing a second cancer after WM was respectively 11% at 5 years, 21% at 10 years and 33% at 15 years. As compared to the control population, the risk of second cancer in WM was 1.66 times higher than expected (95% CI: 1.16-2.37, p=0.005), without significant difference between males and females (p=0.7). In multivariate analysis, the risk of second cancer was not influenced by age (p=0.91), sex (p=0.45), reduction of IgG (p=0.91) or IgA (p=0.58) levels. In a time-dependent analysis, therapy given for WM did not increase the risk of developing a second malignancy (hazard ratio: 1.12, p=0.76). Conclusions This study shows that WM are at higher risk of developing second cancers as compared to the general population. We did not find an association between the occurrence of second cancers and treatment of WM. Disease-related immune-suppression may predispose WM patients to develop other malignancies. Disclosures: No relevant conflicts of interest to declare.

Beschreibung: The role of an intensified program of autologous stem cell transplantation (ASCT) following a consolidation phase with alemtuzumab (A) in pts with chronic lymphocytic leukemia (B-CLL) who received a fludarabine-based regimen (Fbr) as debulking is still considered questionable. The reported evidence of a prolonged treatment free-survival and survival associated to the absence of minimal residual disease (MRD) in B-CLL pts treated with A doesn’t seem to justify an intensification with ASCT in case of MRD-. We have already reported our experience in B-CLL pts treated with Fbr who after a median period of discontinuation of 16 weeks, received A sc (10 mg x 3/w for six weeks) in order to obtain the maximum response of MRD negative remission. Pts obtaining a successful peripheral blood stem cell harvest (PBSC) were considered eligible for ASCT. After a longer follow-up period we analyze here the outcome of autografted pts. Furthermore results were compared with those of pts treated with the same regimen but excluded from transplant procedure. Overall 48 pts have been considered for the analysis. Twenty-nine pts underwent an ASCT. Mobilization regimen consisted in all but 1 pt of Ara-C (800 mg/ sqm/12h x 3 days) followed by granulocyte colony-stimulating factor (G-CSF) while the last patient received only G-CSF. Reason for exclusion from ASCT procedure in the 19 non transplanted pts was: 9 refusal, 4 progressive disease, 1 evolution to Richter syndrome, 2 priming failure, 3 physician decision. Initially, in the group of non-transplanted pts, 9 (47%) were in stage A, 9 (47%) B, 1 (6%) C; ZAP70 was positive in 4 (21%) cases. Response after consolidation with A was: 7 MRD- CR (37%), 7 MRD+ CR (37%), 1 PRn (5%), 4 PR (21%). As regards the transplanted pts: 9 (31%) were in stage Binet A, 16 (55%) B, 4 (14%) C; ZAP70 was positive in 10 (34%) cases. Disease status after A was as follows: 18 MRD- CR (62%), 6 MRD+ CR (21%), 5 PRn (17%). Median age at transplant was 55 years (range 44–64). In all pts a reassessment of response status was ruled out before transplant to exclude a disease progression. ASCT procedure was performed after a median of 12 mos from last A administration (range 6.5–16.8). One pt who reactivated a virus B hepatitis after consolidation was successfully transplanted after 16.8 mos interval from alemtuzumab. Conditioning regimen consisted of 12 Gy total body irradiation plus cyclophosphamide 120 mg/kg in 21 pts

Beschreibung: Fludarabine (F) in combination with cyclophosphamide (C) showed a relevant advantage over single-agent F in pts with relapsed CLL. Although minimal residual disease (MRD) remains detectable in many pts achieving CR, the combination of F and C seems to reduce MRD more efficiently. Still, pts in CR eventually relapse and require treatment, demonstrating the need for improved treatments able to further reduce or eliminate MRD and induce “better quality” and thus more durable responses. Alemtuzumab (CAM), anti-CD52 monoclonal antibody, acts synergistically with F in vitro and appears to have synergistic activity in vivo. Additionally, CAM is highly effective at clearing disease from bone marrow, the usual site of residual disease following purine analogue-based treatment. Therefore, we designed a phase II study to determine feasibility and efficacy, overall response rate (ORR)-duration of response-ability at clearing MRD, of a 4-weekly combination regimen consisting of F, C, and CAM (FCC). The study population is represented by pts with B-CLL with relapsed or refractory disease after at least one line of treatment. Subcutaneous route of administration of CAM has been adopted in this trial. MRD was measured by 4-color flow cytometry in the bone marrow. The FCC regimen consisted of F 40 mg/m2/d os (d 1–3), C 250 mg/m2/d os (d 1–3) and CAM 10 mg sc (d 1–3). This combination was repeated on d 29 for up to 6 cycles. The dose of CAM was increased after the first cohort of 10 treated pts from 10 mg to 20 mg sc. Currently, 25 pts have been enrolled in this trial. Median age was 57 years (range 42–79), 15/25 (60%) were male, 23/25 (92%) were in Binet stage B or C, median number of prior treatment regimens was 2 (range 1–4). In six (24%) pts 17p deletion was detected. IgVH unmutated was observed in 17 (68%) pts. At the moment of writing 19 pts are eligible for evaluation of toxicity and response. The ORR was 79%, with 7 (37%) pts achieving CR, 7 (37%) pts a PR, 1 (5%) pt a PRn. Three pts had SD, while 1 showed progression of the disease. MRD negativity was achieved in the bone marrow of 4/15 (27%) pts. Grade III-IV neutropenia episodes were observed in 43% of the administered courses while grade III-IV thrombocytopenia episodes were detected only in 8% of cycles. Four major infections were recorded: two sustained by Mycobacterium tuberculosis (1 cutis, 1 lung), one by Nocardia (lung) and one by E. coli (sepsis). The patient with pneumonia due to M. tuberculosis died because of respiratory failure. CMV reactivation occurred in 6 pts: no CMV disease was recorded. After a median follow up of 10 m (range 1–22) 73% of responding pts did not progressed. In conclusion, results from the interim analysis of this new, 4-weekly dosing FCC regimen suggest that combination therapy with F, C and CAM is feasible, safe, and effective in treating pts with relapsed and refractory CLL, even in those patients with inherent poor prognostic factors and who had received.

Beschreibung: Rituximab (R) is an active and well tolerated agent in the treatment of Waldenstrom’s Macroglobulinemia (WM) whether used in untreated or in refractory/relapsed pts. Furthermore, there is evidence that the association of R with chemotherapy may improve the quality of responses. Fludarabine and Cyclophosphamide (FC) are synergistic with R in vitro in lymphoma cell lines, and the administration of the three drugs is associated with higher response rates in other lymphoprolipherative disorders. We updated our experience to define the efficacy and tolerability of FCR in symptomatic pts with WM. Patients: Nineteen pts, median age 57 y, received R 375 mg/sqm iv d 1, F 25 mg/sqm iv d 2–4, C 250 mg/sqm iv d 2–4 every 4 weeks. Anti-infective prophylaxis with cotrimoxazole and acyclovir was administered. Median time from diagnosis to FCR treatment was 46 m (range 1–156). Five pts received FCR as first line treatment while 14 pts, of whom 8 refractory, had been previously treated with a median of 2 lines of therapy (range 1–6), 5 having previous received monoclonal antibodies. Splenomegaly and lymphadenopathy were present in 32% and 36% of pts, respectively. In 42% of cases Hb was 4000 mg/dL in 53% of pts. Three pts were HCV-RNA positive and presented with cryoglobulinemia. Results: Pts received a median of 6 courses (range 3–6). Responses according to the IInd International Workshop on WM, updated in 2006, were categorized as follows: 15 PR (79%), 3 SD (16%), 1 PD (5%). Eight of the 15 PR pts could be considered as in “near CR”. In fact, the new response category could be justified by the achievement of complete resolution of symptoms, of adenopathy/organomegaly on CT scan, absence of malignant cells at BM immunophenotype and hystology, with only a persistence of a positive serum immunofixation (median serum MC protein of 0.3 g/dL). None of the variables considered (splenomegaly, lymphadenopathy, Hb level, serum albumin, β2M, IgM) was significantly associated with response. Ten pts showed a delayed response: 1 converted to CR after 4 m, in 9 a progressive reduction of MC is still detectable after a median follow-up of 10 m (range 4–31). Two pts underwent stem cell transplant (1 auto, 1 allo). Toxicity: Mild or moderate effects limited to the first and second R infusion, such as fever, hypotension, cutaneous rash, were seen in 5 pts (26%). None developed IgM “flare”. Neutropenia, observed in 82% of courses, was the main source of adverse effects. Two episodes of FUO and 1 clinically documented pneumonia were recorded. One pt died 3 m after the end of treatment while in PR for disseminated Aspegillosis. Conclusion: FCR regimen proved to be active and well tolerated even in previously heavily pre-treated WM pts; the response rate obtained is in line with clinical trials using R associated with other chemotherapeutic agents. A high percentage of near CRs and a progressive improvement of the quality of response has been observed even in pts with longer follow-up. The high incidence and long lasting episodes of neutropenia did not translate in major infectious episodes.

Beschreibung: High dose (HD) chemotherapy followed by peripheral blood stem cell (PBSC) is widely used in the management of hematological malignancies and chemosensitive solid tumors. Different strategies of PBSC mobilization have been described, but currently the standard approach has not been established. Satisfactory results have been obtained by different chemotherapy schedules followed by haemopoietic growth factors: particularly HD Cyclophosphamyde or HDAra-C have a well known high mobilizing activity. With the intention to minimize hematological toxicity due to HD chemotherapy we performed this study to evaluate the mobilizing efficacy of intermediate dose Ara-C (IDAra-C). Methods: Pts with haematological malignancies received as mobilization treatment Ara-C 800 mg/m2 every 12 h for 6 doses followed by G-CSF 300 μg/d starting day +3 from the end of treatment until completion of leukapheresys (LP). CD34+ cells count was performed from day + 9. Failure of mobilization was defined as a persistent CD34+ cells count 10/μL CD34+ underwent LP. Pts not reaching the target of 2.5 x 106/kg CD34+ were considered as low mobilizer. Results: 98 pts, median age 56 y (range 27–70), underwent priming with IDAra-C. Disease characteristics are listed in table 1. All but 5 pts presented bone marrow involvement at diagnosis. Sixty-nine pts had previously received fludarabine, 56 anthracyclines and 30 alkilating agents. Thirty-three of the 98 pts had been considered low mobilizer or had failed a previous mobilization attempt, with HDAra-C in 20 cases A successful mobilization (threshold level 〉2.5 x 106/kg CD34+) was obtained in 73 pts (74,5%) (9/14 NHL, 42/43 CLL, 6/7 MM, 16/34 AML) with a median collection of 12,34 x 106/kg CD34+ (range 2,57–76,5). The peak value of CD34+ cells in the peripheral blood was achieved after a median of 13 d (range 10–19) from the end of therapy and a median of 1 LP (range 1–3) was required for a target collection. An adequate harvest was also observed among 17 of the 33 (51.5%) pts failing a previous mobilization attempt. After IDAra-C the median time to reach PMN 〉1000/μL and PLT 〉50000/μL was of 6 and 8 days respectively. There were no treatment-related deaths. During neutropenia we recorded 25 episodes of FUO, 9 infections microbiologically documented and 2 infections clinically documented. Median days temperature 〉 38°C was 2 (range 1–6). Extraematological toxicity consisted of: 1 gastrointestinal bleeding WHO III and 1 episode of atrial fibrillation. Overall 39 pts have been transplanted so far; median days for PMN 〉500/μL and PLT 〉50000/μL engraftment was of 9 and 12 d respectively. In conclusion IDAra-C and sequential G-CSF allowed predictable and efficient PBSC harvest in a limited number of leukapheresis session. Hematological recovery was rapid and toxicity manageable. These data confirm, in a larger series, the high mobilization activity of IDAra-C in CLL as previously reported. Moreover satisfactory efficacy has been observed in pts failing previous mobilization attempt with alternative regimen. This approach should be considered as an effective way to exploit a known mobilizing activity of Ara-C minimizing toxicity. Table 1 Disease characteristics AML NHL CLL MM ToT CR 32 3 35 3 73 CR 〉 1 2 3 − − 5 PR − 2 − 2 4 nPR − − 6 − 6 SD − 1 1 2 4 PD/RELAPSE − 5 1 − 6 Tot 34 14 43 7 98 median time from last treatment (months) 2,0 2,3 4,3 2,6 3,4

Beschreibung: Clinical use of tyrosine kinase inhibitors (TKIs) for chronic myeloid leukemia (CML) has highlighted uncommon side effects of this group of novel anti-cancer agents. One of these peculiar side effects observed with imatinib (IM) is the occurrence of a bone marrow (BM) polyclonal lymphoid (Ly) infiltrate, usually accounting for 15–30% of total BM cellularity, sometimes taking the form of mature lymphoid follicles. No such effect has so far been described with nilotinib (NIL). We report on 2 CP-CML pts, one on IM and the second one on NIL, who developed transient massive BM Ly infiltrate without any clinical modification and with stable disease. Case1 A 40 yr old male pt was started on IM 400 mg/day as first line therapy in July 2003. Complete Cytogenetic Response (CCyR) and complete molecular response (CMoR) were obtained at 3 and 12 mos respectively. Routine BM monitoring showed progressive increase of the Ly infiltrate coincident with CCyR, up to 30%. In March 2007, BM examination disclosed massive infiltration with mature lymphocytes accounting for 60% of total BM cellularity; cytogenetic and molecular monitoring for CML were negative and peripheral blood count (PBC) was normal. The BM examination repeated a month later showed a spontaneous regression of Ly infiltrate to 25%; the remaining lymphocytes were prevalently B, polyclonal by molecular biology; cariotype was normal; FISH showed non specific abnormality (18% of 45 nuclei positive for del 17p13). Subsequent follow up disclosed normal BM with stable lymphocyte infiltrate and persistent CCyR and CMoR. Case2 A 60 yr old female pt resistant to IM was switched to NIL on November 2005. CCyR were obtained at 12 mos. BM monitoring showed progressive increase of the Ly infiltrate coincident with CCyR, up to 25%. The pt was mildly leucopenic throughout treatment. In March 2007, BM examination disclosed a 50% infiltration of mature lymphocytes; cytogenetic, molecular analysis and PBC were invariate. BM examination was repeated and the Ly infiltrate had spontaneously regressed to 20%. Considering the paucity of residual lymphoid cells, no further analysis was performed. Subsequent follow up showed normal BM with stable Ly infiltrate and persistent CCyR. Discussion. Data from the literature support the correlation between clinical efficacy of IM and increased BM Ly infiltration. Such correlation has also been found in our pts receiving IM and NIL. What has not yet been described is the massive transient polyclonal Ly infiltrate observed in our pts with both IM and NIL. This finding are of uncertain clinical relevance: PBCs were unaffected and molecular studies did not disclose presence of other hematological disorders. However, the known possibility of chronic lymphoproliferative disorders developing during CML needs to be kept in mind. An environmental factor - e.g. a subclinical viral infection - can not be excluded considering that both pts developed the same BM changes concomitantly. The role of TKIs is still unclear, in this case, and the clinical relevance of this event is uncertain. However, the similar mechanism of action of IM and NIL may suggest that a similar mechanism underlies the development of the BM massive Ly infiltrate observed in our pts.

Beschreibung: Background: In Waldenstrom’s Macroglobulinemia (WM) the combination of Fludarabine (F) + Cyclophosphamide (C) induces response rates of 85% and 55–89% in previously untreated and relapsed/refractory pts, respectively. Rituximab (R) monotherapy is active and well tolerated in WM and there is evidence that R in association with chemotherapy may improve the quality of responses. Few studies with a small number of pts demonstrated the feasibility of FCR regimen in WM with responses ranging from 79% to 90%. Methods: in February 2005 we started a multicenter, two-stage design, phase II study on the effectiveness, tolerability and safety of FCR in symptomatic WM pts previously untreated or relapsed/refractory to one line of chemotherapy. Pts previously treated with FC combination or monoclonal antibodies were excluded. Treatment consisted of: R 375 mg/sqm d1, F 25 mg/sqm and C 250 mg/sqm iv d 2–4 every 4 weeks. Accrual of the planned 43 pts ended on March 2008. The first assessment of the disease, including bone marrow (BM) evaluation, was performed after the third FCR course. Pts with progressive disease (PD) were considered as failure, responding pts or those with SD went on to receive up to 3 further courses. Results: 18 females and 25 males, median age 65 yrs, were enrolled. Median time from diagnosis to FCR was 25.5 mos; 65% of pts were in first line treatment, 7% and 28% in relapsed and refractory disease, respectively. According to the International Scoring System for WM (ISSWM) 39.5% of pts were low risk, 51.2% intermediate and 9.3% high risk. As of August 10, 2008 analysis has been performed on 40 pts; final evaluation will be available in October 2008, since 3 pts completed treatment but response data are pending. A median of 6 courses (range 2–6) have been administered; 65% of pts received the planned 6 cycles. Reasons for not completing the 6 courses were: 1 PD, 1 hemolytic anemia, 1 hypersensitivity reaction to R, 8 severe neutropenia, 3 pneumonia. Thirty-six pts (90%) received ≥ 4 courses of therapy and have been considered valuable for response. As the protocol was designed before 2006, response criteria did not include MR and were categorized as follows: 14% CR, 69% PR, 14% SD, 3% PD (according to the updated criteria: 14% CR, 69% PR, 6% MR, 8% SD, 3% PD). Nine of the 25 patients in PR could be considered as in “near CR” as they fulfilled criteria for CR except for the persistence of a positive immunofixation. None of the patient and disease variables (age, sex, light chain, disease status, Hb, PLT and Ig level, % BM infiltration, b2m, albumin, creatinine, ISSWM) was significant for the achievement of a response. A comparison was performed between responses achieved after the third course and after the end of treatment. We observed that there was a significant improvement of responses (p=0.015) at last response assessment (5 CR+ 25 PR+ 5 SD+ 1 PD vs 2 CR+ 20 PR + 13 SD + 1 non evaluated after the third FCR course). Extrahematological toxicity was manageable and mostly limited to grade 1 and 2. An episode of grade 3 asthenia was reported. Twenty-one pts developed Rituximab-related reactions, grade 2 maximum, limited to the first or second infusion. In one case FCR treatment was interrupted because of grade 3 cutaneous hypersensitivity. Neutropenia occurring in 60% of courses was the main haematological toxicity, which caused the interruption of planned treatment in 20% of pts. Thirty-five percent of pts developed long lasting episodes of neutropenia (median duration 5 mos, range 3–15) mostly after 6 FCR courses (range 3–6). None of the clinical and disease characteristics analysed were statistically predictive of neutropenia development. Three episodes of pneumonia and 2 of FUO requiring hospitalization were observed during neutropenia. During follow-up we observed a late improvement of responses, as 3 further PR converted to CR (after a median of 10 mos), and 1 SD to PR (after 10 mos). Median DFS and OS have not been reached after a median follow-up of 15.1 and 20.4 mos, respectively. Conclusion: FCR produced a high ORR with good quality of responses, which improved over time. We registered, however, high incidence of neutropenia with long lasting neutropenic episodes limiting the administration of the planned therapeutic program. According to the analysis of our population it seems reasonable to reduce to four the number of planned FCR courses, administering, if required, Rituximab as consolidation/maintenance to avoid myelotoxicity.

Beschreibung: Patients who failed fludarabine (FLU) or showing a relapse after several lines of chemo or immuno therapy have poor chance to obtain further response to treatment. Oxaliplatin (OX) is a third generation platinum compound with a 1,2 diaminocyclohexamine carrier ligand, it has a different activity and side effect profile from cisplatin. In order to test the activity of OX in CLL we administered first this agent as monotherapy in relapsed patients. OX covalently binds DNA, inducing DNA intra and inter-strand cross-links. FLU has been shown to have a biochemical modulating effect on others antineoplastic agents. Moreover, FLU and Ara-C act synergistically to inhibit excision repair of DNA cross-links. This evidence provides a rationale to test the combination of OX, FLU and Ara-C in patients with advanced CLL. The first cohort of patients received OX 140 mg/m2, as single agent. The second cohort of patients received OX, at increasing dose 17.5 (1st course), 25 (2nd course), 35 mg/m2 (from 3rd course up to the 6th course), days 1–4; Fludarabine 25 mg/m2, days 2 and 3; Ara-C 1 g/m2, days 2 and 3. Courses were given every 4 weeks for a total of 6 courses; all patients received G-CSF 5μcg/m2. Prophylaxis against tumor lysis syndrome, PCP and DNA virus were provided. Seven patients (M=4;F=3; Median age = 62 years; Binet stage B =3, Binet stage C= 4) who received a median of 3 previous (range 2–5) lines of treatment, two of them resistant to FLU, have been treated with OX as single agent. Patients receiving at least 1 course were evaluable for toxicity. Four patients completed the entire program of treatment, 2 patients received 4 courses of OX and they didn’t continued treatment because of persistant neutropenia from the previous course. The last patient stopped OX after the second course because of disease progression. The major toxicity was hematologic. Grade 3–4 neutropenia and thrombocytopenia were experienced in 5 and 6 patients respectively. There were no treatment related deaths. One patient showed a disease progression, 2 patients showed PR while 4 remained with stable disease. No response was observed in patients who had failed FLU. In the second cohort 4 patients (M=3: F=1; Median age=61 years) have been treated with the combination of FLU, OX and Ara-C. Three patients presented abdominal bulky disease resistant to the last treatment. Three patients were FLU resistant. Three patients received the entire program while the fourth patient stopped treatment after three courses because of a hepatic toxicity while on partial response. The major toxicity was hematologic and appeared OX-dose dependent. Grade 3/4 neutropenia was experienced by 1/4, 2/4 and 4/4 patients treated at 17.5, 25 and 35 mg/m2 OX levels respectively. Grade 3–4 thrombocytopenia was experienced by 2/4, 3/4 and 4/4 patients treated at 17.5, 25 and 35 mg/m2 OX levels respectively. No treatment related deaths were observed. One patient reached CR, and 3 patients a PR. Considering the three patients with bulky disease, disappearance of the abdominal involvement in one patient and reduction 〉 50% in the other two patients were recorded. The usefulness of OX given as single agent is limited in patients with advanced CLL, at the contrary these preliminary results of the combination OX, FLU and Ara-C appeared very promising. Further accrual of patients to be treated with the combination using OX at 35 mg/m2, days 1–4, is warranted.

Beschreibung: Contamination of reinfused stem cells with leukemic cells is a major concern affecting outcomes after ASCT in patients with CLL. In fact, outcomes after ASCT strongly correlate with disease status before transplantation. Persistence of minimal residual disease (MRD), as detected by consensus primer PCR, or the switch from a negative to a positive MRD status during follow-up, are both highly predictive of clinical relapse after ASCT. In order to minimize the risk of contaminating the collection with leukemic cells, in our institution patients who undergo an ASCT receive alemtuzumab before peripheral blood stem cell (PBSC) mobilization, to purge in vivo any residual disease. We evaluated the outcome of ASCT in 20 CLL patients who were pretreated with fludarabine (FAMP) containing regimens and subsequently received alemtuzumab SC (10 mg x 3/w for 6 weeks) to purge MRD. A FAMP containing regimen had been administered as first-line treatment in 18 cases and as second-line in 2 cases; median number of FAMP cycles administered was 6 (range, 4–8). All but 1 PBSC patient was mobilized with Ara-C (800mg/m2/12h x 3 d) followed by G-CSF, while the last patient received only G-CSF. Median age at transplant was 56 y (range, 45–65); all patients (pts)were in CR based on the NCI-WG criteria. Of 20 pts who underwent PBSC harvest, polyclonal IgH rearrangement was evident in 13 pts (65%), as assessed by PCR. The conditioning regimen consisted of 12 Gy TBI plus cyclophosphamide 120 mg/kg in 14 pts 〈 60 yrs, and Melphalan 180 mg/sqm in 6 pts 〉60 years. Median number of CD34+ cells reinfused was 17.4 x106/kg (range, 3.1–30.4), and in 13 cases the reinfused product was polyclonal for IgH. The median time for PMN (〉500/ml) and PLT (〉20000/ml) recovery was 9 (range, 8–11) and 11 (range, 9–13) days respectively. During marrow aplasia 13 patients experienced an episode of fever 〉38°C with a median duration of 2 days (1–8); in 3 pts the fever was of unknown origin, in 8 cases sepsis was due to Staphilococcus epidermidis, and in 1 case it was due to P. aeruginosa. Intravenous antibiotics were administered in 11 cases, and only 1 patient required intravenous antifungal therapy. One patient died due to a pulmonary fungal infection sustained by Aspergillus Terreus. No incidence of grade 3–4 nonhematologic toxicity was observed. During the 3 months post-transplant 2 pts required hospitalization: 1 for a fever, and the other for acute polyneuropathy. No pathogens were isolated in either case. At 11 months post-transplant 1 patient developed thrombocytopenia. None of the pts developed CMV reactivation, even in the 9 cases, which became CMV positive during alemtuzumab treatment. Herpes Zoster was observed in 2 patients at 5 and 10 months after transplant. At a median of 28 months after receiving alemtuzumab (range, 15–48 months), and a median 17 months after PBSC transplantation (range, 1–41 months), 19 pts are in CR. At the 9- and 12-month post-transplant evaluation, performed on 16 and 12 pts respectively, all but 1 patient showed polyclonal IgH rearrangement. ASCT after sequential treatment with FAMP and Campath-1H is feasible with no significant increase in major infections; a substantial number of patients achieved a sustained polyclonal IgH rearrangement after transplant.

Beschreibung: Persistence of minimal residual disease (MRD) after therapy has been shown to be a powerful prognostic factor for relapse among patients with chronic lymphocytic leukemia (CLL). Treatment with the anti-CD52 monoclonal antibody alemtuzumab (Campath®), either as a single agent or in combination with fludarabine, has been shown to induce MRD-negative responses, even among patients who are not responsive to traditional therapeutic interventions. Dramatically improved responses and MRD negativity have also been achieved using alemtuzumab as consolidation therapy, to purge MRD after initial therapy with a fludarabine-based regimen. The pharmacokinetics (PK) of alemtuzumab administered subcutaneously to achieve MRD negativity after induction therapy with fludarabine are reported here. Of 41 patients (median age, 54 years) who received consolidation therapy with alemtuzumab, all 16 patients participating in the PK analysis were MRD-positive after receiving induction therapy as measured by PCR consensus primer. At least 8 weeks following the completion of induction therapy, dose escalated alemtuzumab 10 mg was administered for 6 weeks, 3 times a week. Plasma samples were collected from 16 patients on Days 1, 3, 5, 15, 17, 22 and 31, and ELISA was used to assess the PK of alemtuzumab. On Day 15, blood samples were drawn at 1, 2, 3, 4, 6, 8 and 12 hours after alemtuzumab administration. Alemtuzumab plasma concentrations gradually increased during the first 2 weeks, and reached concentrations 25.5-fold higher on Week 3. The median pre-dose concentrations (Cpre-dose) were: 0.01 μg/mL (range, 0–0.07 μg/mL) on Day 3, 0.58 μg/mL (range, 0–1.2 μg/mL) on Day 15, 0.51 μg/mL (range, 0–2.61 μg/mL) on Day 17, and 1.09 μg/mL (range, 0.19–3.08 μg/mL) on Day 31. The median Cmax plasma concentration was 1.05 μg/mL (range, 0.097–1.75 μg/mL) and the median Cpre-dose was 0.58 μg/mL (range, 0–1.2 μg/mL). An analysis was performed to correlate quantitative response as represented by polyclonal complete remission and AUC0–12 values. Preliminary data indicate that the systemic exposure associated with effective therapy corresponds with an AUC0–12 value higher than 5 μg•h/mL on Day 15 of the administration schedule. Therefore, complete response (CR) rates, expressed as percentage of patients with AUC0–12 values correlating with effective treatment, increased with higher levels of systemic exposure to alemtuzumab.