ALBERT

Beschreibung: Background: Monoclonal antibodies directed towards specific cell surface antigens on neoplastic cells have been increasingly used in lymphoid malignancies in the last few years. Alemtuzumab is a humanized monoclonal antibody which binds the CD52 antigen highly expressed on B-CLL cells. Alemtuzumab significantly depletes both B and T lymphocytes increasing the risk of opportunistic infections. Cytomegalovirus (CMV) infection causes significant morbidity and mortality in the setting of immunodeficiency. CMV reactivation has been described in most of the reported series in which alemtuzumab has been administered. Aim: We investigated the incidence and management of CMV reactivation in a population of B-CLL patients treated with FAMP including regimens, followed by Alemtuzumab as consolidation. Methods: 35 B-CLL patients, 22 males and 13 females, median age 55 (range 39–64), responding to FAMP including regimens (32 FAMP alone, 3 FAMP+cyclophosphamide) received subcutaneous Campath-1H three times a week for six weeks in escalating doses up to 10 mg in order to treat residual disease. Monitoring of CMV reactivation by CMV pp65 antigenemia test was weekly performed, starting from the first week of alemtuzumab treatment until 4 weeks after discontinuation. Results: CMV pp65 antigenemia positive test was detected in 20 patients (57%). The median time for reactivation was 43 days (range 23–61) from the beginning of therapy. Among those twenty pts, 11 showed less than 10 positive cells. All the 9 pts (25.7%) showing positive test with more than 10 cells [median positive cells 44.5 (range 12–751) ] received pre-emptive treatment with oral Gancyclovir 1g thrice daily (oGCV). Only three of this group of 9 pts presented mild symptoms (fever and/or epigastric pain). Among the 11 pts presenting with positive antigenemia in less than 10 cells, seven received oGCV as pre-emptive therapy while the remaining four were not treated. Only one of the seven pts given pre-emptive therapy was symptomatic, presenting fever. The four pts not receiving treatment with oGCV showed a negativity at the subsequent test within a week from the first positive detection. Negativity of antigenemia test was obtained in all the pts receiving pre-emptive oGCV treatment. After short-time of discontinuation, alemtuzumab was restarted in all 20 cases tested positive for pp65 antigenemia. Organ involvement was never seen. Conclusion: Our survey shows that pp65 antigenemia is a sensitive test for monitoring CMV reactivation in pts treated with alemtuzumab. We suggest that the combination of FAMP and alemtuzumab is permissive to a higher risk of CMV reactivation in B-CLL pts. Pre-emptive treatment with oGCV is able to prevent the severe manifestations of CMV such as pneumonia and colitis and to permit the completion of the therapeutic program. To improve the cost-effectiveness of this strategy we propose: antigenemia monitoring not before the 4th week of treatment; closely repeating the test in case of positivity less than 10 cells; treating only in case of increase of the number of positive cells.

Beschreibung: In the GIMEMA LAL 0496 trial, which has been conducted in Italy between 1996 and 2000, patients with adult ALL received an induction therapy with VCR, DNR and ASP until they reached complete remission (CR). Consolidation therapy with Ara-C and CTX was then administered and, if still in CR, patients received a 3-year maintenance therapy. Ph+ ALL patients were considered at high risk and after the induction phase a stem cell transplant (SCT) was planned, allogeneic for patients with an HLA identical sibling or autologous. A total of 498 patients have been enrolled by 50 GIMEMA Centers. Of these, 29 patients (5.8%) with either t(4;11) or t(1;19), who received the standard post-remissional approach, showed a statistically significant worse prognosis after CR: the projected probabilities of DFS and OS at 2 years were 19% (C.I. 95%: 4.1–34.4) and 31% (C.I. 95%: 14.2–47.9), respectively. Thus, in the new protocol - GIMEMA LAL 2000 - these patients received an intensive post-remissional treatment including SCT. Between 2000 and 2003, a total of 383 patients have been enrolled in this new protocol. Of these, 23 (6.0%) were positive either for t(4;11) or for t(1;19). The clinical characteristics of these patients are comparable to those of the patients enrolled in the previous study and the overall CR rate is also super imposable. GIMEMA LAL 0496 vs GIMEMA LAL 2000 Fig. 1 shows the comparison in DFS at 2 years between LAL 0496 and LAL 2000; though not statistically significant, a trend towards a better prognosis is clearly seen. The DFS probability projected at 2 years is 52% (95% C.I. 26–78) compared to 19% (95% C.I. 4–35). The OS, projected at 2 years, is 42% (95% C.I. 14–70) compared to 31% (C.I. 95%: 14.2–47.9). Despite the relatively limited case series, these results suggest that for t(4;11)+ and t(1;19)+ adult ALL intensification of the post-remissional treatment with SCT is a feasible approach that may improve the outcome in this subset of patients at high risk of relapse with standard post-remissional therapies. Figure Figure GIMEMA LAL 0496 GIMEMA LAL 2000 p Patients t(4;11) or t(1;19) 29 23 0.7626 Sex (M/F) 14/15 8/15 0.3280 Age yrs, median (min-max) 37.8 (14.9–59.4) 39.4 (19.6–59.2) 0.1481 WBC x 109/L median (min-max) 41.2 (2.2–663.0) 50.3 (2.4–300.0) 0.9193 Phenotype (B/T) 29/0 23/0 - CR rate 92.8% 85.7% 0.6392

Beschreibung: The efficacy of ASCT in pts with CLL may be compromised by the reinfusion of neoplastic cells with the autograft leading to relapse. For this reason in our Institution pts eligible for an ASCT receive Campath-1H before peripheral blood stem cell (PBSC) mobilization to perform a purging in vivo in order to minimise the contamination of the collection. We evaluate the safety and feasibility of APBSCT in fourteen CLL patients pretreated with Fludarabine (FAMP) containing regimens and subsequent Campath-1H subcutaneusly (10 mg x 3/w for 6 weeks). A FAMP containing regimen had been administered as first line treatment in 12 cases and as second line in 2 cases; median number of FAMP cycles administered was 6 (range 4–8). In all but one pts PBSC were mobilized with Ara-C (800mg/m2/12h x 3 d) followed by G-CSF while the last pt received only G-CSF. Median age at transplant was 57.5 y (range 45–63); all pts were in CR, 9 pts showing a polyclonal rearrangement of the IgH at PCR by consensus primer. Conditioning regimen consisted of 12 Gy TBI plus cyclophosphamide 120 mg/kg in 9 pts aged 〈 60 y, Melphalan 180 mg/sqm in the 5 pts aged 〉 than 60 y. Median number of CD34+ cells reinfused was 17.1 x106/kg (range3.4–30.4), the reinfused product was polyclonal for the IgH in 9 cases. The median time for PMN (〉 500/μl) and PLT (〉 20000/μl) recovery was 9 (range 8–10) and 11 (range 9–13) days respectively. During marrow aplasia nine pts experienced an episode of fever 〉 38°C with a median duration of 2 days (1–8); in three pts the cause of fever remained of unknown origin while in the remaining 6 cases a sepsis due to Staphilococcus Aureus was recorded. Intravenous antibiotics were administered in 7 cases; none of the pts required intravenous antifungal therapy. No grade 3–4 extrahematological toxicity and no treatment related deaths were observed. During the 3 months post transplant period two pts required hospitalisation for fever in one case and for acute polineuropathy in the other case; in both cases no pathogens have been isolated. In none of the pts a CMV reactivation was recorded even in the 6 cases showing a reactivation during Campath-1H treatment. An Herpes Zooster infection was observed in 2 pts after 5 and 10 months from transplant. The recovery of CD4+ and CD8+ cells is illustrated in the followig table. CD4 and CD8 reconstitution after ASCT pre ASCT month +3 month +6 month +12 * * 6 pts CD4/ μl 57 91 86 174 CD8/ μl 171 310 377 540 After a median follow-up of 10 months (3–30) from transplant all pts are in CR. At the three months post-transplant evaluation, performed in 13 cases, all but one pts showed polyclonal IgH rearrangement. ASCT after sequential treatment with FAMP and Campath-1H is feasible with any evidence of increased number of major infections; a substantial number of pts achieved after transplant a polyclonal IgH rearrangement.

Beschreibung: Although an increasing number of patients with chronic lymphocytic leukemia (CLL) may achieve complete remission (CR) relapse is almost inevitable, due to re-emergence of the malignant clone. The eradication of minimal residual disease (MRD) is associated with improved remission durability and has great potential in offering the possibility of cure in many lymphoid malignancies. The monoclonal antibody alemtuzumab is the foundation of many eradication-based treatment approaches because of its ability to achieve clinical remissions and to successfully purge MRD. We investigate the use of subcutaneous (sc) alemtuzumab for the eradication of residual disease in the bone marrow of patients in clinical response after fludarabine treatment, as determined by NCI criteria. At least 8 weeks after fludarabine treatment, 35 B-CLL patients (13 female, 22 male; median age 55 [range 39–64] years) received sc alemtuzumab, three times weekly for 6 weeks, at escalating doses up to 10 mg. Residual disease was assessed using a consensus polymerase chain reaction methodology to detect the clonality of IgH sequences. Patients obtaining a successfull peripheral blood stem cell (PBSC) harvest (CD34+ 2.5 x 109/l) after either granulocyte colony-stimulating factor (G-CSF) or intermediate-dose Ara-C (800 mg/m2, every 12 h, for six doses) plus (G-CSF) were considered eligible for autologous PBSC transplant. Pharmacokinetic parameters were estimated in seven patients. Serum samples of alemtuzumab were assayed by indirect immunofluorescence with target cells (HUT-78, a human T cells line) and antibody concentration was calculated by comparison with a standard curve. Post fludarabine responses were: 10 CRs, 11 nodular partial responses (PRn) and 14 partial responses (PR). Post alemtuzumab responses were: 29 CRs, 4 PRn, 2 PR. Overall, 51% of patients converted to polyclonal IgH pattern (MR). Of the patients in CR before alemtuzumab, 7 achieved MR; nine of the patients in PRn before immunotherapy, improved to CR, five achieving MR. Of the fourteen patients in PR before alemtuzumab, twelve improved (two PRn, ten CR) and six achieved MR. Twenty-three out of 25 patients successfully mobilized PBSC. Fourteen patients have been transplanted so far. Subcutaneous alemtuzumab was generally well tolerated; fifteen patients (57%) developed cytomegalovirus (CMV) reactivation, but CMV disease was prevented by prompt treatment with oral ganciclovir. Alemtuzumab serum concentrations measured at second week after the start of therapy, just before the next dose (Ctrough), were relatively stable: Ctrough = 0.79±0.6 mg/ml. Sequential treatment with fludarabine and alemtuzumab is feasible, effective and safe. Overall 83% of patients reached CR according to NCI criteria. Eighty-four percent of patients improved to CR or PRn after alemtuzumab. Residual disease was not detected in 51% of patients. Sequential treatment did not compromise PBSC mobilization, allowing patients to proceed to autologous transplantation.