ALBERT

Description: Bcl-2 is an anti-apoptotic protein closely linked to chemotherapy resistance and inferior survival in patients (pts) with CLL. Genasense (G) enhances apoptosis induced by fludarabine (F), dexamethasone, and rituximab (R) in vitro. Despite limited single-agent activity in heavily pre-treated CLL pts, G significantly increased the rate of durable complete responses (CR) in combination with fludarabine (F) and cyclophosphamide in relapsed or refractory CLL (Rai, ASH 2004). Down-regulation of Bcl-2 sensitizes CLL cells to apoptosis induced by F and R. In order to examine the impact of G on the FR combination, we initiated a phase II study of the combination of FRG in pts with either previously untreated (UT) or relapsed, previously treated (PT) CLL who require systemic treatment. Eligibility includes: plts ≥ 50,000/mm3; serum Cr ≤ 1.5 mg/dL; adequate organ function; negative Coombs; no history of autoimmune hemolytic anemia. In cycle 1, G is given by continuous intravenous infusion at 1.5 mg/kg/d days 1 to 7. R is given in a dose-escalating schema: 125 mg/m2 on day 4 and 250mg/m2 on day 6, with F (25 mg/m2/d) on days 6 to 8. In subsequent 28-day cycles (up to 6), the dose of G is escalated to 3 mg/kg/d days 1 to 7, with R 375 mg/m2 on day 5 and F days 5 to 7. Results: To date, 24 pts have been enrolled (19 PT and 5 UT). Characteristics included: median age, 56.5 yrs (range 25–82 yrs); Rai stage III, 6 pts (4 PT and 2 UT) and IV, 6 pts (6 PT and 0 UT). Median prior regimens (PT pts), 2; 13/19 (68%) had received F and R previously. Median # cycles administered: 6 (both UT and PT). Four PT pts discontinued treatment before completing 6 cycles, 2 due to disease progression, and 2 with prolonged (〉 4 week) Grade 3 thrombocytopenia/neutropenia. One PT pt completed only 3 cycles of R due to an R-related infusion reaction, but completed 6 cycles of G and F. Among the 5 UT pts, there was 1 case of grade 4 neutropenia. Among the 19 PT pts, there were 2 cases each of grade 4 thrombocytopenia and neutropenia. One of 5 UT pts had an SAE of reversible acute renal insufficiency. Seven of 19 PT pts (8 events total) experienced an SAE. These included R-related infusion reactions (2 pts), bacteremia (2 pts) and 1 pt each with fever, lymph node abscess, pneumonia, and thrombocytopenia/neutropenia. Responses have been observed in 5/5 UT pts (1 molecular CR (mCR), 1 nPR and 3 PR) and 10/19 PT pts (1 mCR, 2 nPR and 7 PR). Conclusions: 24 pts have been treated with the combination of FRG. Employing a three-day regimen of F, good tolerability and efficacy have been noted in relapsed/refractory patients. Based on these results, an additional cohort receiving a full 5-day regimen of F is ongoing with measurement of Genasense PK and bcl-2 intracellular levels (mRNA and protein).

Description: T-cell large granular lymphocyte (T-LGL) leukemia is a rare indolent lymphoproliferative disorder diagnosed by presence of 〉2,000/μL peripheral CD3+CD8+CD16+/−CD56 +/−CD57+ LGL and/or evidence of T-LGL clonality by T-cell receptor (TCR) gene rearrangement, accompanied by neutropenia and/or other cytopenias. We reported the efficacy of cyclosporin A (CsA) in the treatment of LGL-associated neutropenia [Blood1998;91:3372–8] and we report here long-term follow-up of our larger patient (pt) cohort. Between 1982 and 2006, 18 pts were diagnosed with T-LGL leukemia with the above strict criteria (M:F 11:7; median age, 67; range, 48–84 years). Mean follow-up from diagnosis is 59 (range, 2–303) months. Autoimmune phenomena were present in 6 (33%), including pure red cell aplasia in two, lymphocytic colitis and ascites in one, and erosive osteoarthritis and pulmonary granulomatous vasculitis in one other. Splenomegaly was present in 6 (33%). Median (range) hemoglobin (Hb), absolute neutrophil count (ANC) and platelet count were 10.4 (3.6–15.5) g/dL, 1,100 (0–5,900)/μL and 152,000 (69,000–583,000)/μL. Anemia, neutropenia (ANC

Description: Cancer cells, including B-cell lymphoproliferative disorders, sculpt their phenotype in an attempt to escape not only immune-surveillance but also evade the anti-tumor activity of biological agents and/or chemotherapy drugs including rituximab. In an attempt to study the mechanisms that regulate the emergence of rituximab resistance, we developed several rituximab-resistant cell lines and demonstrated that the emergence of a rituximab-resistant phenotype was associated with global down regulation of CD20 antigen and unexpectedly an increase in CD52 antigen. Validation of our findings in more clinically relevant settings is important to support alemtuzumab-based clinical studies in rituximab-resistant B-cell malignancies. To this end, we retrospectively studied changes in CD20 expression over time in alemtuzumab treated-patients with rituximab-fludarabine (RF) refractory CLL. Patients were identified using the institute tumor registry and pharmacy electronic database. Demographic characteristics, treatment history, outcome data were obtained for each patient. In addition, CD20 expression in CLL cells obtained from flow cytometry analysis performed on peripheral blood, bone marrow and tissue was reviewed. A total of 16 patients with RF refractory CLL treated with alemtuzumab were included in the analysis, 13 males and 3 females, the median age at the time of diagnosis was 55.5 yrs +/− 10.47stv, and most of the patients had a good PS (0) at the time of treatment with alemtuzumab (81%). The response rate to alemtuzumab was 56.3%, with 7 (43.5%) patients achieving a complete response (CR). After a median follow up period of 88.5 months, 7 patients are still alive, 3 are free of disease. Complete flow cytometry data was available only for 9 patients. A down regulation of CD20 antigen expression was observed among 5/9 patients in blood, bone marrow and/or tissue over time when compared to baseline CD20 levels. Following alemtuzumab therapy, CR was achieved in 3/5 patients with CD20 down-regulation versus 1/4 patients with steady levels of CD20. Alemtuzumab-treated CLL patients with CD20 down-regulation had a longer overall survival (141 months) than alemtuzumab treated CLL patients with steady levels of CD20 antigen overtime (116 months, Log Rank P = 0.026). Our data suggest, that emergence of rituximab-fludarabine resistance is associated with changes in the expression of CD20 antigen. A response to alemtuzumab in this setting appears to be higher than historical controls (2% CR). Refractory CLL patients with decreased levels of surface CD20 appears to respond better to alemtuzumab and have a longer overall survival than patients with steady CD20 levels. Similarly to what we have observed in our pre-clinical models, an increase in CD52 expression in rituximab-fludarabine refractory patients with CD20 down regulation could explain the higher response rate observed in this small group of highly selected patients. Detailed monitoring of CD20 and CD52 levels in CLL patients before, during and after treatment with rituximab-based regimens is warranted in an attempt to identify patients that can benefit from almetuzumab-based therapies.

Description: Smoking is associated with AML and lung cancer, suggesting a common carcinogenic origin and raising the question of how to treat patients with concomitant cancer presentations. The Roswell Park Cancer Institute Tumor Registry was searched for patients with both diagnoses, followed by medical record review. Among 775 AML cases and 5225 lung cancer cases presented to Roswell Park Cancer Institute between January 1992 and May 2008 we identified twelve patients with both AML and lung cancer (1.5% of AML cases; 0.2% of lung cancer cases). Of these, seven cases had metachronous and five cases had synchronous presentation. Eleven of the twelve (92%) patients had a known smoking history; five (42%) of them were males. The median age at the respective diagnoses was 65 (range 58–85) years for AML and 66 (range 53–79) years for lung cancer. Five of the twelve (42%) patients had a complex karyotype. Metachronous group: Lung cancer preceded AML in six patients by a median interval of eight (range five-14) years, while AML preceded the diagnosis of lung cancer in one patient by three years. For their lung cancer, five patients had surgical resection. Two had definitive chemoradiation, one patient had adjuvant chemotherapy and one patient had adjuvant radiation suggesting that their subsequent AML was secondary. Two patients had preceding MDS even though they underwent only surgical resection for their lung cancer. For their AML, five of the seven patients were treated with cytarabine and anthracycline-containing regimens; two achieved complete remission, two had primary refractory disease and one patient died during induction. One patient with primary refractory disease underwent sibling matched allogeneic transplantation and is still alive in remission. The median survival for lung cancer was 65 (range 22–120) months. The median survival since AML diagnosis was less than one (range

Description: Abstract 4917 Introduction: Systemic sclerosis (SSc) is presumed to result from aberrant activation of autoreactive T cells. However, the exact pathogenesis of SSc is not known. Patients and Methods: To contribute to the understanding of the immunopathology of systemic sclerosis (SSc), we compared blood counts of multiple lymphocyte subsets between 20 adult SSc patients not treated with immunomodulatory drugs and healthy controls. The patients had to fit entry criteria for SCOT trial (Scleroderma – Cyclophosphamide or Transplantation?, www.sclerodermatrial.org), i.e, 1. symptoms for no longer than 5 years (except for Raynaud's phenomenon), 2. diffuse scleroderma, and 3. either moderate lung involvement (forced vital capacity (FVC) or diffusion of carbon monoxide (DLCO) between 45 and 70% predicted) or moderate kidney involvement (history of hypertensive renal crisis, but normal renal function at study entry). Multiparameter flow cytometry was used for the determination of the lymphocyte subset counts. Results: Counts of the following subsets were significantly lower in the patients compared to the controls: total T cells (median 1316 vs 2088/ul, p=0.015), total CD8 T cells (273 vs 580/ul, p

Description: Introduction: Pts with Chronic Lymphocytic Leukemia (CLL) are reported to have quantitative and qualitative T and NK cell dysfunction. While NK cells act through non-specific killing, T-cells are more specific. The 2 types of T-lymphocytes, CD4+ (Th; helper) and CD8+ (Ts; cytotolytic/suppressor) are subcategorized based on cytokine secretion profile upon activation. Release of different cytokines from these immune cells modulates the host response. T1 cells (Th1, Ts1) secrete IL-2 and interferon-g which initiate the Th1 response- mainly CD4+ activation along with B and T cells, leading to proliferation and differentiation of these cells. T2 (Th2, Ts2) cells initiate the Th2 response (release of TNF-a, IL-10) resulting in direct lysis of the target cell by production of cytokines such as IL-4, IL-5 and IL-10. Hypothesis: To decipher this antitumor mechanism of L in CLL pts we investigated its effect on the efferent arm of immune response by evaluating the T cell population and the afferent response by change in expression of co-stimulatory molecules on B-CLL cells and cytokine profile in these pts treated on a phase II clinical study. Methods: CLL pts treated with L were evaluated for absolute number of T (CD4+, CD8+) and NK (CD56+) cells by flow cytometry on day before (day0) start and on Day 8 of treatment with L. Peripheral blood was collected and ficolled to obtain enriched mononuclear cells. The serum was used to study the cytokines. Activation status was determined by co-expression of CD45+. Serum cytokine profile was measured by Flow cytometry using the Luminex system. B-CLL surface co-stimulatory molecules were detected by flow cytometry and analyzed by FACS. These responses were correlated with the tumor flare (TF) reaction that the patients developed during the first week of treatment with L. Results: Eighteen out of 45 pts have so far been evaluated for immunomodulatory activity of L. There were 2 complete responders (CRs) and 6 partial responders (PRs); while 4 had stable disease (SD), 4 were clinically unevaluable and 2 were too early for response in this group. Mean baseline (bl) NK cell count pretreatment was 251 (range 31–1510) vs. post treatment was 193 (range 6–13,482). Six out of 18 patients showed an increase, ranging from 20 −199% in the absolute NK (CD16+/CD56+/CD45+). While there was no appreciable change in CD4+ numbers there was a general trend in increase of CD8+ cells. No change in monocyte population was noted. Concurrent increase in the expression of co-stimulatory molecules such as CD95 and CD80 was noted. This response in co-stimulation was confirmed by in vitro experiments done on isolated B-CLL cells (n=4)treated with L. An increase in Th-2 cytokines such as IL-4, IL-5, IL-6 and IL-10 was noted in all eight responders, while VEGF levels were decreased in 6/18 patients. 99% of patients had a TF and the grade of TF correlated with the changes in T cells and cytokine profile. Conclusion: It appears that in vivo L is able to orchestrate an anti-tumor response in CLL by modulating the NK cells, changing the cytokine profile and up-regulating co-stimulatory molecules. This change in the immune effector cell repertoire and the Th2 skewing may explain the initial flare reaction noted in these L treated pts. Data from these correlative studies is being evaluated in the context of the phase II clinical trial to be reported at the 48th ASH annual meeting.

Description: Background: Minimal residual disease (MRD) status is an independent prognostic marker for response duration in patients with mantle cell lymphoma (MCL). Rituximab-based therapy led to a molecular remission (MR) in 48% young MCL patients treated with intense chemo-immunotherapy. More recently, 4 courses of R-DHAP were reported to yield a 66% MRD negativity rate prior to high dose chemotherapy and autologous stem cell transplant (HDC-ASCT). Ofatumumab is a humanized type 1 anti-CD20 mAb that binds to a unique, more membrane-proximal epitope on the CD20 antigen. Pre-clinical studies have demonstrated that ofatumumab (O) is more active than rituximab in eliciting complement-mediated cytotoxicity (CMC) in MCL cell lines, primary tumor cells and murine lymphoma xenograft models. Hence, we evaluated the safety and efficacy of combining ofatumumab with HyperCVAD/MA (O-HyperCVAD) in newly diagnosed MCL (NCT01527149). Study design: This was a single-arm, open-label, multi-center (2 centers), prospective, phase 2 clinical trial. Thirty-seven transplant-eligible patients with newly diagnosed MCL were enrolled. Ofatumumab (1000mg) was given every 3 weeks on day 1, followed by standard doses of alternating HyperCVAD and MA starting on day 3. A total of 6 cycles were given at 3-week intervals followed by HDC-ASCT. Maintenance rituximab 375 mg/m2 every 2 months for 3 years post-ASCT was added after protocol amendment following publication of the LyMa study. Primary objectives were to determine the overall response rate (ORR) and CR rate (CRR) at the end of therapy. Secondary objectives included MRD negativity, progression free survival (PFS), overall survival (OS), feasibility of successful mobilization of autologous stem cells and safety assessment. MRD assessment was performed in peripheral blood (PB) and bone marrow (BM) using high sensitivity multiparametric flowcytometry at baseline, after 2 cycles, after 4 cycles, pre-ASCT, post-ASCT and 6 months post-ASCT. Exploratory endpoints included correlation of MRD with survival, correlation of surface CD20 levels with response and to compare differences in ORR according to Cheson and modified Cheson (MC) criteria. Results: Median age was 60yrs; 73% of patients were male, 92% had an ECOG PS 0-1, majority (81%) had stage 4 disease with 86% having bone marrow involvement; 22% had low risk, 43% had intermediate risk and 35% had high risk MIPI score; 11% had blastoid and 11% had pleiomorphic variants of MCL; 25% harbored p53 deletion. MRD was assessed in 28 of 37 patients; 9 patients from partner site were excluded due to time lag in sample delivery for flowcytometry. MRD positivity was noted in 75% patients in PB and 71.4% patients in BM at baseline. Subsequent samples showed an MRD negativity rate of 82.1% and 64.3% after 2 cycles and 76% and 96% pre-ASCT in PB and BM respectively. Post-ASCT, MRD in BM and PB was found negative in 58% and 90%, respectively. Attainment of early MRD negativity (after 2 cycles) was associated with improved PFS (p=0.04) and OS (p=0.03). Since majority of patients were MRD negative pre-ASCT, we could not demonstrate correlation between pre-ASCT MRD and survival outcomes. The ORR and CRR were 95% and 62% by Cheson and 97% and 84% respectively by modified Cheson criteria. At the end of induction therapy, ORR was 86% and CRR was 62% by Cheson criteria. 73% pts underwent HDC-ASCT. Only one patient failed stem cell collection. The median PFS and OS were 45.5 months and 56 months respectively. There were 3 deaths while on therapy- 2 from sepsis and one from acute myeloid leukemia. Grade 3 and 4 adverse events (AEs) were observed in 22% and 68% of the patients, most of them were hematological AEs related to the chemotherapy regimen. Correlation of surface CD20 expression using mean fluorescent intensity (MFI) and response rates is currently under analysis and will be reported at the meeting. Conclusion: The addition of ofatumumab to HyperCVAD/MA led to high rates of MRD negativity by flowcytometry in patients with newly diagnosed MCL. Early MRD negativity (after 2 cycles) was associated with better PFS and OS. Despite higher ORR, CR and MRD negativity rates, survival outcomes were similar to historical cohorts using rituximab-HypeCVAD/MA. This may be in part due to increased number of patients with high-risk disease in our study. Disclosures Reddy: KITE Pharma: Consultancy; Abbvie: Consultancy; Genentech: Research Funding; Celgene: Consultancy; BMS: Consultancy, Research Funding. Sait:Celgene: Consultancy. OffLabel Disclosure: Ofatumumab was investigated in combination with chemotherapy in newly diagnosed mantle cell lymphoma in this clinical trial.

Description: Background: Acute myeloid leukemia (AML) is an aggressive malignancy associated with poor long-term outcomes. This malignancy arises in the context of an immunosuppressive milieu, which fosters immune escape and tumor growth. Myeloid-derived suppressor cells (MDSCs) represent a heterogeneous group of immature myeloid cells with immunosuppressive activity, the most potent of which are the monocytic MDSCs (mMDSCs). The presence of mMDSCs within the bone marrow microenvironment of patients with AML, along with their impact on disease relapse and overall survival has yet to be fully characterized. Therefore, we sought to address this unanswered question through a retrospective analysis of a cohort of AML patients (pts) at Roswell Park Comprehensive Cancer Center. Methods: Medical records were retrospectively reviewed under an IRB approved protocol in order to identify pts aged 18-70 years old with normal karyotype (NK) AML treated with standard cytarabine and anthracycline based chemotherapy with refractory or subsequent relapsed disease. Demographics, disease-specific variables, baseline clinical characteristics, treatment response, and adverse events were analyzed using descriptive statistics. Overall survival and relapse-free survival were estimated utilizing Kaplan-Meier (KM) analysis. Detailed analysis of previously collected clinical multiparameter flow cytometric data was performed utilizing WinList software to identify mMDSCs at serial clinical time points (diagnosis, after induction chemotherapy, and relapse). A mononuclear gate was created utilizing CD45 vs. SSC (blasts excluded), followed by FSC vs. SSC to eliminate dead cells and aggregates. Based on the scientific literature, mMDSCs were defined as the subset of marrow cells co-expressing CD14+ and HLA-DR dim, and was reported as the percentage of total monocytes in the marrow aspirate sample. Results: Six pts with NK-AML who received induction chemotherapy with cytarabine, daunorubicin, and etoposide (ADE) were identified. Mean age was 56 years (range 35 - 67), with 3/6 male pts (50%) (Table 1). NPM1 was mutated in 2/6 pts at diagnosis, with no FLT3-ITD mutations identified. In addition, 2 pts had an elevated WBC at presentation. Following induction therapy, 2 pts had primary refractory disease with four achieving complete remission (CR). Furthermore, each of the 6 pts relapsed. All 6 pts had marrow aspirate samples containing detectable mMDSCs by flow cytometry at multiple time points. Of note, 5 of 6 pts had elevated mMDSCs (average 76.2%; range 72.8% - 82.6% of total marrow monocytes) detected at time of response assessment following induction. Median relapse-free survival was 48 months (Figure 1). Overall survival not yet been reached. Mean duration of follow up was 85 months (range 61 - 119 months). Conclusions: This retrospective analysis suggests that high numbers of marrow mMDSCs (〉72%) are associated with relapsed/refractory AML in a small patient cohort. Of note, other risk factors for refractory/relapsed disease (i.e. elevated WBC at presentation and FLT3 mutation) were not consistently present in our cohort, thus supporting a potential role of mMDSCs in promoting disease recurrence. Additional studies to further quantify and delineate the biological role of mMDSCs in a larger pt cohort are needed to corroborate these findings and determine the potential role of these immune cells in therapy resistant AML. Disclosures Wang: Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Speakers Bureau; Jazz: Speakers Bureau; Amgen: Consultancy; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy; Novartis: Speakers Bureau; Jazz: Speakers Bureau; Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees.