ALBERT

Description: Background: Id/KLH vaccine (FavId) administered as a single agent has been associated with tumor regressions in patients with relapsed/refractory (RR) FL. B-cell depletion has been demonstrated to augment the T-cell immune response to subsequent vaccine administration in mice (Qin 1998 Nat Med 4:627). Objective: To evaluate the efficacy and safety of Id-KLH administered during the period of rituximab induced B-cell depletion. Eligibility: FL pts who were: treatment naïve (TN); RR following chemotherapy; or relapsed following rituximab. Treatment: Following rituximab (375mg/m2 i.v. weekly x 4) pts received Id-KLH (1 mg s.q. monthly x 6) starting on week 12. GM-CSF, 250 mcg, was administered s.q. at the Id-KLH injection site on days 1–4. Pts could continue Id-KLH until progression. Results: 103 pts received rituximab. Response to rituximab at month 3 was 35% (3-CR; 33-PR). Eleven (11) pts were PD following rituximab (11%). Id/KLH could not be made for 4 pts (4%). Eighty-eight (88) pts were begun on Id-KLH. Among the 45 RR pts, 32 (72%) have not progressed at a median follow-up of 12 months compared with 40% of historical control pts treated with rituximab alone (Witzig 2002 JCO 20:2453). Among the 43 TN pts, 82% have not progressed after a median follow-up of 9 months. RRI (SD to PR, PR to CR after month 3) was observed in 21 pts (12-SD to PR; 9-PR to CR). Robust T-cell responses to both Id and KLH were observed (3 of 3 pts tested). Anti-KLH antibody responses were generally not seen until B-cell recovery. The most frequent adverse event was an injection site reaction. A flu-like syndrome was also observed consistent with GM-CSF administration. Conclusion: Id/KLH vaccine (FavId), administered to pts with FL during a period of B-cell depletion induced by rituximab, can result in an anti-Id T-cell response, and appears to result in an RRI and an increased TTP compared to historical controls. A randomized, double-blind, placebo-controlled, Phase 3 trial of rituximab + FavId has been initiated.

Description: Over the last four years we have undertaken a development program in collaboration with the UK National External Quality Assessment Scheme for Haematology NEQAS(H) to use internet-based teaching and digital photography to improve consensus opinion on haematological cellular morphology. We began with providing participants with a series of individual images of haematological blood cells to most recently, multiple ‘stitched’ images with tutorial based feedback on cell type and diagnosis. We present the results from a fourth internet-based blood cell morphology exercise. Participants were invited to visit the Central Manchester Laboratory website (www.manlab.co.uk) or the UKNEQAS (H) website to review a series of digital photographic images of blood cells. Volunteers to the exercise were able to call up images from a previously reported haematology case with complex morphology and report on their findings. Digital images were presented in three formats. The first provided twelve static images with expert morphological comment and participant’s consensus comments from the original national survey. The second part provided four static images with an interactive tutorial clearly identifying specific cell types and morphology of interest. The third component was a composite of nine individual images ‘Stitched’ together that allowed movement across the image and a zoom facility. Of 426 participants 128 (30%) returned results to UK NEQAS (H). Part 1: Over 90% of responders gave positive opinion regarding image quality, access to the website, presentation of expert opinion and agreed that the single images appropriately represented the morphological features of the case. Part 2: Over 95% responded positively to the educational value of the tutorial. Part 3: Of 128 responders, 34 were unable to download the software necessary to view the ‘Stitched’ image due their Trust’s internet policy. Of the remaining 94 responders, 90% found the image quality adequate and representative. A high proportion (71%) thought the ease of navigation and magnification offered by the Stitched image offered advantages over single static images and provided a better overview of morphology. The positive feedback from this exercise supports our intention to place digital images of the six annual UK NEQAS(H) blood film surveys on the internet. The problems of downloading stitched imaging software are to be addressed and there is ongoing development of stitching 40–100 single images into a virtual slide. A key role for external quality assessment schemes is to provide an educational service. The digital imaging procedure offers the opportunity to provide tutorial based learning to highlight interesting morphology and build up consensus opinion. The educational aspect of this is creating much interest and will provide a mechanism for continuing professional development of scientific and medical staff.

Description: The critical importance of specific proteins including Bcl-2, Mcl-1, XIAP, Bax, Caspase-3, Traf-1, and ZAP70 in predicting disease progression, prognosis, and response to therapy in CLL have been extensively studied through in vitro experiments. We now report molecular data obtained from a large prospective clinical trial involving 278 previously untreated patients with CLL. This ECOG-led intergroup trial involved participation from CALGB and SWOG, and currently provides quantitative information regarding protein levels on 217 cases assessed immediately prior to treatment. NCI criteria for therapy in CLL were met before patients were randomized to receive either Fludarabine or Fludarabine plus Cytoxan. On-study analyses included: interphase cytogenetics by Fluorescence In Situ Hybridization (FISH), p53 mutational analysis, immunoglobulin variable heavy chain (IgVH) gene rearrangement, and quantitative analysis of the aforementioned specific proteins. Peripheral blood mononuclear cells were obtained from each patient at registration before starting therapy. Lysates were prepared from the patient cells and separated by SDS-PAGE. Proteins were detected by immunoblot analysis using the multiple antigen detection method previously developed by our group. Detection was performed by an enhanced chemiluminescence method and quantified by densitometry. Expression levels were calculated relative to expression in the Jurkat T cell line (for ZAP70) or the RS11846 lymphoblastoid cell line (for apoptosis-related proteins). Using a two-sided Wilcoxon rank sum test, molecular data were compared with FISH and IgVH mutational status. Patients with either p53 mutations or del(17p) had significantly lower levels of XIAP (p=0.022). Patients with del(11q) had significantly higher Bcl-2/Bax ratios (p=0.052). Patients with trisomy 12 had lower levels of Bcl-2 (p=0.066); higher Mcl-1 (p=0.026); higher Bax (p=0.09); and higher Caspase-3 (p=0.019) levels. Interestingly, these specimens also had lower ratios of Bcl-2/Bax (p=0.0016). Patients with del(13q) had significantly higher levels of Bcl-2 (p=0.0059) lower levels of Caspase-3 (p=0.047), and higher Bcl-2/Bax ratios (p=0.0569). IgVH mutated patients had significantly lower levels of Caspase-3 using either a 98% cut-off (p=0.0008) or the 97% cut-off (p

Description: Inflammation may play an essential role in vaso-occlusion in sickle cell disease. Sickle patients have high white counts and elevated levels of serum C-reactive protein (CRP), cytokines, and adhesion molecules. In addition, circulating endothelial cells, leukocytes, and platelets are activated. We examined 4 transgenic mouse models expressing human α- and sickle β-globin genes to determine if they mimic the inflammatory response seen in patients. These mouse models are designated NY-S, Berk-SAntilles, NY-S/SAntilles (NY-S × Berk-SAntilles), and Berk-S. The mean white counts were elevated 1.4- to 2.1-fold (P ≤ .01) in the Berk-SAntilles, NY-S/SAntilles, and Berk-S mice, but not in the NY-S mice compared with controls. Serum amyloid P-component (SAP), an acute-phase response protein with 60% to 70% sequence homology to CRP, was elevated 8.5- to 12.1-fold (P ≤ .001) in transgenic sickle mice. Similarly, serum interleukin-6 (IL-6) was elevated 1.6- to 1.9-fold (P ≤ .05). Western blots, confirming immunohistochemical staining, showed vascular cell adhesion molecule (VCAM), intercellular adhesion molecule (ICAM), and platelet-endothelial cell adhesion molecule (PECAM) were up-regulated 3- to 5-fold (P ≤ .05) in the lungs of sickle mice. Ribonuclease protection assays (RPAs) demonstrated VCAM mRNA also was elevated in sickle mice 1.2- to 1.4-fold (P ≤ .01). Nuclear factor κB (NF-κB), a transcription factor critical for the inflammatory response, was elevated 1.9-fold (P ≤ .006) in NY-S sickle mouse lungs. We conclude that transgenic sickle mice are good models to study vascular inflammation and the potential benefit of anti-inflammatory therapies to prevent vaso-occlusion in sickle cell disease.

Description: The marrow repopulating potential (MRP) of different sources of human hematopoietic stem cells (HSCs) was directly compared using an in vivo assay in which severe combined immunodeficient disease (SCID) mice were implanted with human fetal bones. HSCs from 2 human lymphocyte antigen (HLA)-mismatched donors were injected individually or simultaneously into the fetal bones of a 3rd distinct HLA type and donor and recipient myeloid and lymphoid cells were identified after 8 to 10 weeks. The study compared the MRP of umbilical cord blood (CB) and adult bone marrow (ABM) CD34+ cells as well as grafts of each type expanded ex vivo. Equal numbers of CB and ABM CD34+ cells injected individually demonstrated similar abilities to establish multilineage hematopoiesis. However, when CB and ABM cells were transplanted simultaneously, the engraftment of CB cells was markedly superior to ABM. CB and ABM CD34+ cells were expanded ex vivo using either a porcine microvascular endothelial cell (PMVEC)-based coculture system or a stroma-free expansion system. Primary CB CD34+ cells or CD34+ cells expanded in either culture system demonstrated a similar ability to engraft. However, the MRP of expanded grafts simultaneously injected with primary CB cells was uniformly inferior to primary CB cells. CD34+ cell grafts expanded in the stroma-free system, furthermore, outcompeted CD34+ cells expanded using the PMVEC coculture system. The triple HLA-mismatched SCID-hu model represents a novel in vivo stem cell assay system that permits the direct demonstration of the functional consequences of ex vivo HSC expansion and ontogeny-related differences in HSCs.

Description: Tumor-related immunoglobulin heavy-chain (IgH) rearrangements are markers for polymerase chain reaction (PCR) detection of minimal residual disease (MRD) in B-cell malignancies. Nested PCR with patient IgH allele-specific oligonucleotide primers can detect 1 tumor cell in 104 to 106 normal cells. In childhood acute lymphoblastic leukemia (ALL), persistence of PCR-detectable disease is associated with increased risk of relapse. The clinical significance of qualitative PCR data can be limited, however, because patients can harbor detectable MRD for prolonged periods without relapse. Recent studies indicate that a quantitative rise in tumor burden identifies patients who are at high risk for relapse. Therefore, an efficient and reliable PCR method for MRD quantification is needed for ALL patients. We have developed a real-time PCR method to quantify MRD with IgH VH gene family consensus fluorogenically labeled probes. With this method, a small number of probes can be used to quantify MRD in a large number of different patients. The assay was found to be both accurate and reproducible over a wide range and capable of detecting approximately 1 tumor cell in 5 × 104 normal cells. We demonstrate that this methodology can discriminate between patients with persistence of MRD who relapse and those who do not. This technique is generally applicable to B-cell malignancies and is currently being used to quantify MRD in a number of prospective clinical studies at our institution.

Description: Bortezomib (formerly PS-341, VELCADE®) is a selective inhibitor of the ubiquitin-proteasome pathway, which plays an important role in degrading regulatory proteins that control cell cycle functions, neoplastic growth and tumor spread. It has been approved by the FDA for the treatment of relapsed and refractory myeloma patients (pts). Phase I and II trials have suggested activity in B-cell indolent and aggressive lymphomas including mantle cell lymphoma. Preclinical studies have also shown that B-CLL cells undergo apoptotic cell death following inhibition of the proteasome pathway. We therefore conducted a multicenter phase II study to assess the safety and efficacy of 3 doses of bortezomib in pts with B cell CLL who were refractory to or intolerant to fludarabine. Pts with an ANC ≥ 1 x 109/L and platelets ≥ 30 x 109/L were eligible. Bortezomib was given as i.v. push on days 1, 4, 8, and 11 of a 21 day course for a maximum of 9 courses. Pts were initially randomized to 1.0 (n=5) versus 1.3mg/m2/dose (n=9) and later, after review of preliminary data, to 1.3 versus 1.5mg/m2/dose (n=8). Twenty-two pts were enrolled. Median age 62 yrs (range 46-83). Median number of prior therapies 4 (2–11). Median number of yrs from diagnosis to therapy 5.5 (0.8–14.2). b2-microglobulin 〉 5.5 mg/L in 10 pts (45%). Fifteen pts (68%) had ≥ Rai stage 3. Of 19 evaluable pts no responses according to NCIWG criteria were demonstrated [stable disease 8 pts (42%), progressive disease 11 pts (58%)] based on investigator assessment. When analyzed by specific sites of disease, five pts (23%) experienced ≥ 50% decrease in ALC and 6 pts (27%) showed ≥ 50% decrease in lymphadenopathy. Bortezomib was well tolerated throughout all 3 dosing groups. Most common toxicities were ≤ grade 2 and included nausea (n=9;42%), headache (6;27%), diarrhea (5;23%), vomiting (5;23%), dyspnea (5;23%), anorexia (5;23%), and peripheral neuropathy (3;14%/ grade 3 in 1 pt). Pharmacodynamic evaluation of 20S proteasome inhibition at 1 hour postdose was similar to that reported for these doses in other studies, and was highest in the 1.5mg/m2 dosing group. We conclude that bortezomib as single agent is not effective in pts with fludarabine-refractory B-cell CLL at these doses. However, in view of the evidence of clinical activity, further exploration of bortezomib in combination with other agents might be the appropriate next step to define the optimal role of this new agent in the management of advanced CLL.

Description: There were 26 patients enrolled in a pilot study of high-dose immunosuppressive therapy (HDIT) for severe multiple sclerosis (MS). Median baseline expanded disability status scale (EDSS) was 7.0 (range, 5.0-8.0). HDIT consisted of total body irradiation, cyclophosphamide, and antithymocyte globulin (ATG) and was followed by transplantation of autologous, granulocyte colony-stimulating factor (G-CSF)-mobilized CD34-selected stem cells. Regimen-related toxicities were mild. Because of bladder dysfunction, there were 8 infectious events of the lower urinary tract. One patient died from Epstein-Barr virus (EBV)-related posttransplantation lymphoproliferative disorder (PTLD) associated with a change from horse-derived to rabbit-derived ATG in the HDIT regimen. An engraftment syndrome characterized by noninfectious fever with or without rash developed in 13 of the first 18 patients and was associated in some cases with transient worsening of neurologic symptoms. There were 2 significant adverse neurologic events that occurred, including a flare of MS during mobilization and an episode of irreversible neurologic deterioration after HDIT associated with fever. With a median follow-up of 24 (range, 3-36) months, the Kaplan-Meier estimate of progression (≥ 1.0 point EDSS) at 3 years was 27%. Of 12 patients who had oligoclonal bands in the cerebrospinal fluid at baseline, 9 had persistence after HDIT. After HDIT, 4 patients developed new enhancing lesions on magnetic resonance imaging of the brain. The estimate of survival at 3 years was 91%. Important clinical issues in the use of HDIT and stem cell transplantation for MS were identified; however, modifications of the initial approaches appear to reduce treatment risks. This was a heterogeneous high-risk group, and a phase 3 study is planned to fully assess efficacy. (Blood. 2003;102:2364-2372)

Description: Previous studies indicated that aspirin (acetylsalicylic acid [ASA]) can have profound immunomodulatory effects by regulating cytokine gene expression in several types of cells. This study is the first in which concentrations of ASA in the therapeutic range were found to significantly reduce interleukin (IL)-4 secretion and RNA expression in freshly isolated and mitogen-primed human CD4+ T cells. In contrast, ASA did not affect IL-13, interferon-γ, and IL-2 expression. ASA inhibited IL-4, but not IL-2, promoter-driven chloramphenicol acetyltransferase expression in transiently transfected Jurkat T cells. The structurally unrelated nonsteroidal anti-inflammatory drugs indomethacin and flurbiprofen did not affect cytokine gene expression in T cells, whereas the weak cyclo-oxygenase inhibitor salicylic acid was at least as effective as ASA in inhibiting IL-4 expression and promoter activity. The inhibitory effect of ASA on IL-4 transcription was not mediated by decreased nuclear expression of the known salicylate target nuclear factor (NF)–κB and was accompanied by reduced binding of an inducible factor to an IL-4 promoter region upstream of, but not overlapping, the NF of activated T cells– and NF-κB–binding P1 element. It is concluded that anti-inflammatory salicylates, by means of a previously unrecognized mechanism of action, can influence the nature of adaptive immune responses by selectively inhibiting the expression of IL-4, a critical effector of these responses, in CD4+ T cells.

Description: We performed immunophenotypic and IgVH mutation analyses on the chronic lymphocytic leukemia (CLL) cells of 307 patients for expression of CD38, ZAP-70, and IgVH mutation status to determine the relative strength of each in predicting the need for early treatment. For this we assessed the time from diagnosis to initial therapy for progressive and/or symptomatic disease. Patients confirmed to have remained untreated were censored for this endpoint. Expression of CD38 was defined as the proportion of CD38-stained CLL cells that had fluorescence intensity above a defined threshold. Similarly, cases were defined as ZAP-70+ when 20% or more of the ZAP-70-stained CLL cells had fluorescence intensity above a defined threshold, as described (NEJM351:893, 2004). CLL cells were classified as expressing mutated IgVH genes if they expressed IgVH with