ALBERT

Beschreibung: It has been shown in non-randomized studies that tandem transplant results in an increased CR rate. A randomized trial showed that tandem transplant resulted in a significantly longer EFS and OS in patients failing to achieve CR or near-CR with a single transplant. However, other studies failed to show a survival benefit from a second transplant. The aim of our study was to investigate the feasibility and efficacy in terms of response up-grading and survival from a second transplant intensification in patients with chemosensitive disease who failed to achieve CR or near-CR with a first transplant. Patients diagnosed with MM from Oct 1999 to Dec 2003 younger than 70 years received 6 courses of VBMCP/VBAD chemotherapy and responding patients were intensified with busulphan/melphalan or MEL-200 followed by stem cell support. Patients not achieving CR or near-CR were planned to undergo a second transplant (either a second auto with CVB - cyclophosphamide, etoposide and BCNU - intensification or a dose-reduced intensity “allo” with Fludarabine/MEL-140 conditioning, depending on sibling donor availability). It is of note that 99 (55%) did not receive the second HDT procedure because patient refusal -28 pts-, lack of CD34–17 pts-, progressive disease - 16 pts-, poor PS -15 pts-, physician decision -14 pts-, others -8 pts-. Patients who did not proceed with the second transplant were significantly older (58 vs. 55 yrs, p= 0.001) and had higher serum beta2-microglobulin levels (4.7 vs. 3.5, p=0.02). Fifty nine patients received a second autologous transplant while 23 underwent a “mini-allo”. Twenty-eight percent of the patients given a second autologous transplant achieved an up-graded response (CR or near-CR: 7%, PR: 10% and MR 12%) while 61% showed “no change”, progressive disease or early death. A response up-grade was observed in 43% of patients undergoing a “mini-allo” procedure (CR: 26%, PR: 4%, MR: 3%). The CR rate was significantly higher with the allogeneic procedure (26 vs. 5%, p=0.01). However, there was a trend towards a higher TRM with the “miniallo” procedure (5% vs. 17% (p=0.09). The survival from the second high-dose procedure was not significantly different between the two transplant modalities (2nd auto vs “mini-allo”). Conclusions. in about one-half of the patients in whom a tandem transplant is planned the second high-dose procedure is not performed, a dose-reduced intensity allogeneic transplant after an autologous procedure results in a significantly higher CR rate than a tandem autologous transplant, with the current follow-up we found no significant differences in survival between the two transplant modalities.

Beschreibung: Clinical management differs significantly for the various types of non-Hodgkin lymphoma (NHL), and the diagnosis of these lymphomas can be challenging in some cases. Further, existing NHL categories include subgroups that can differ substantially in gene expression, response to therapy and overall survival. We have created a custom oligonucleotide microarray, named LymphDx, which could prove clinically useful for molecular diagnosis and outcome prediction in NHL. Biopsy specimens were obtained from 559 patients with a variety of lymphomas and lymphoproliferative conditions. Gene expression profiles of these samples were obtained using Affymetrix U133 A and B microarrays. The 2653 genes on LymphDx were chosen to include:(1)Genes most differentially expressed among NHL types based on Affymetrix U133 or Lymphochip microarrays (2)Genes predicting length of survival in diffuse large B cell lymphoma(DLBCL), follicular lymphoma(FL) and mantle cell lymphoma(MCL) (3)Genes encoded in the EBV and HHV-8 viral genomes (4)Genes encoding all known surface markers, kinases, cytokines and their receptors, as well as oncogenes, tumor suppressors, and other genes relevant to lymphoma. The LymphDx microarray was used to profile gene expression in 434 biopsy samples. These data were used to create a diagnostic algorithm that can distinguish various NHL types and benign follicular hyperplasia(FH) based on gene expression. The algorithm classifies a sample into one of the following categories: Burkitt’s lymphoma(BL), DLBCL, FL, MCL, small lymphocytic lymphoma(SLL) or FH. The algorithm further distinguishes the 3 recognized DLBCL subgroups: germinal center B cell-like, activated B cell-like or primary mediastinal lymphoma. Using a leave one out, cross validation strategy, the algorithm was found to agree well with the pathology diagnosis (see Figure). Some samples were deemed unclassified when their gene expression did not adequately match with that of any of the NHL categories. For a few samples, the gene expression-based diagnosis and the pathology diagnosis were discordant. Pathology review showed that two NHL types coexisted (eg FL and DLBCL) in many of these cases, potentially explaining the results of the diagnostic algorithm. LymphDx could also reliably predict the overall survival of patients with DLBCL, FL and MCL. Prospective evaluation of the LymphDx microarray is warranted since it could be used to provide objective molecular diagnostic, and prognostic information for patients with NHL. Figure Figure

Beschreibung: It is assumed that patients with primary refractory myeloma are the most likely to benefit from early HDT. In four series the CR rate was between 8 and 40% and the overall survival ranged from 4 to 6 years. However‚ the number of patients with progressive disease vs those with “stable disease” was not given in published series. The aim of our study was to investigate the efficacy in terms of response up-grading and survival of early HDT in patients with primary refractory myeloma. From October 1999 to December 2003 patients with MM younger than 70 years were given 6 courses of VBMCP/VBAD chemotherapy. Patients with refractory disease were scheduled to receive a tandem transplant‚ the first procedure intensified with busulphan-12 mg/kg-/melphalan-140 or melphalan-200 and the second with the CVB -cyclophosphamide‚ etoposide and BCNU- or with a dose-reduced intensity “allo” conditioned with fludarabine/melphalan-140‚ depending on sibling donor availability. Response and progression were defined according to the EBMT criteria. Forty-nine patients with primary refractory disease were identified. Twenty patients showed progression after their initial chemotherapy while 29 patients had “non-responding‚ non-progressive disease”. Eighty percent of the patients achieved some degree of response after the first autologous transplant (CR or near-CR: 8%‚ PR: 56%‚ MR: 16%) while 10% did not respond and 10% died from the procedure. Twenty-four patients were given a second transplant (autologous: 17‚ allogeneic: 7). Forty-six percent of the 17 patients who received a second autologous transplant upgraded their response (CR: 6%‚ PR: 17%‚ MR: 23%) while 41% had progressive disease or “no-change” and 13% died from the procedure. Three of the seven patients who underwent a dose-reduced intensity “allo” responded (2 CR‚ 1 PR) while two had progressive disease and two died from transplant-related complications. The median survival of the whole series of 49 patients was 32 months. Patients who had progressive disease after the initial chemotherapy had a significantly shorter survival than those who showed “non-responsive‚ non-progressive disease” (median 21 months vs. not reached‚ p=0.003). Finally‚ patients with “non-responding‚ non-progressive disease” had similar survival than those with chemosensitive disease intensified with HDT in the GEM trial. Conclusions. A high-dose therapy approach in patients with primary refractory myeloma results in a high overall response‚ but the CR rate is low‚ patients with progressive disease to the initial chemotherapy have short survival despite intensive therapy‚ and patients with “non-responding‚ non-progressive disease” have similar survival than chemosensitive patients. Whether the good outcome of the latter patients is mainly due the effect of HDT or to the natural history of a more indolent disease remains to be determined.

Beschreibung: Introduction: Justification and Objectives There are little epidemiologic data about Myeloma Multiple in Spain. The heterogeneity and complexity of this pathology, and the several sociodemographic factors, justify the interest of this type of studies. On the other hand, this disease needs a high assignement of welfare and therapeutic resources, and besides new strategies have arisen for its treatment. The Spanish Leukaemia and Lymphoma Foundation (FLL)has analyzed the actual situation of Myeloma Multiple in Spain, compiling several epidemiologic and welfare parameters about the disease in a Multiple Myeloma “White Book” for Spain. Patients and Methods The period of analysis was 10 years, from 1.991 to 2.001. The information was compiled from a Hospital Based Survey about MM and the following official sources: International Agency for Research on Cancer (IARC): “Cancer incidence in Five continents” and “Incidence and Mortaliity for Cancer In Spain, Patterns and Tendences” Data Base of EUCAN and GLOBOCAN (Cancer Incidence, Mortality and Prevalence Worldwide) EUROCARE III study, (IARC Cancer Base Number 5, Lyon, IARCPress). “Natural Changes of Population and Demography. Spanish National Statistic Institute (INE) and National Spanish Center for Epidemiology (CNE.) Official Records for Mortality Rates by MM in Spain in Spanish Regions (CCAA) (death records Demograhy Records of INE). INE Hospital Case Rate Inquest. CMBD Data Base of Department of Health (Inmunoproliferative Neoplasm and Multiple Myeloma, CIE-9 Diagnosis Code: 203.0)The indicators used were: Deaths number, median of age, proportional mortality, mortality rates, mortality rates adjusted by age, gender and potential years of life lost due to multiple myeloma, (item 203 of ICD-10, OMS) during the last ten years in Spain. Results The incidence rates of MM, adjusted to the European population were: 3,54 cases by 100.000/year for men and 2,54 cases by 100.000/year for women. The global incidence rate were 4,44 cases by 100.000/year for men and 4,22 cases by 100.000/year for women. These rates were similar in all geographic regions. Performed predictions show a prevalence increase during the following five years, which means more than 2.400 cases in men and more than 2.100 in women MM cases per year. Regarding mortality, rates, myeloma is a very slightly frequent cause of death: 3.23 cases by 100.000/years of men and 2.3 cases of women. A whole an increase of mortality of 45.2 per cent was observed for the period of time between 1992 and 2001. Comments and Conclusions The MM incidence and mortality rates in Spain for this period were lower than expected in comparison with other European epidemiology studies. Nevertheless we observed that the MM mortality and prevalence rates present a continuous and uniform increment in the last years. Part of these increases can be due to the incorporation of new technologies, more sensitive for diagnosis, and to the increase of aging of the population. Furthermore certain occupational and chemical exposures and other environmental changes could explain these trends.

Beschreibung: Rituximab in combination with CHOP-like chemotherapy has demonstrated to improve the results in young and elderly patients with DLBCL compared to chemotherapy alone. Re-treatment with rituximab is feasible in patients with indolent lymphoma, but there is few data on the effect of rituximab in combination with chemotherapy in the re-treatment of relapsed patients with DLBCL who have respond previously to rituximab + chemotherapy. In order to investigate the effect of rituximab in this setting, we have performed a multicenter retrospective study in 50 patients with DLBCL re-treated with rituximab in combination with chemotherapy. We have included in this study 46 patients (31 males, 15 females), median age 60 (range, 20 to 81 years), who achieved CR with the previous rituximab-containing regimen. At initial diagnosis, 32 patients had Ann-Arbor stage III or IV and 20 patients had IPI 3 or 4. The median interval between courses was 14.7 months. The most frequent regimens administered as up-front therapy in combination with rituximab were CHOP-like regimens (30 patients) and the commonest chemotherapy regimens used as salvage therapy were R-ESHAP (20 patients), R-ICE (7 patients), rituximab in combination with gemcitabine-based regimens (4 patients) and TTR (3 patients). The overall response rate in the assessable population was 81% (46% CR, 35% PR). In 25 assessable patients who have received rituximab in combination with chemotherapy as second-line therapy, the overall response rate was 92% (56% CR, 36% PR). The overall response rate was slightly lower in those patients re-treated with rituximab as third-line therapy (78% with 33% CR and 45% PR). The follow-up is too shorter (median 6 months) to assess the impact of re-treatment on duration of remission. The adverse events were not different to those usually observed with these regimens. In conclusion, the re-treatment with rituximab in relapsed patients with DLBCL who had respond previously to rituximab in combination with chemotherapy seems not to compromise the results in terms of response. Logically, larger prospective studies are necessary to confirm these encouraging results.

Beschreibung: Introduction: Mantle cell lymphoma (MCL) is a CD20+ malignancy comprising up 5% of non-Hodgkin’s lymphomas, and has a poor prognosis under standard chemotherapy. The HyperCVAD-M/A regimen (fractionated high-dose cyclophosphamide, vincristine, doxorubicin and prednisolone alternated with methotraxate and cytarabine) has yielded encouraging results when combined with autologous stem cell transplantation (ASCT) in MCL, with 5-year failure-free survival of 54% and overall survival 72%. In an effort to improve these results further, we have combined rituximab in vivo purging and post-transplant consolidation with HyperCVAD-M/A plus ASCT. Methods: Patients aged

Beschreibung: To test if small deletions or amplifications (ie. below the resolution of cytogenetics) exist in bone marrow-derived tumor DNA from acute myeloid leukemia (AML) patients (pts), we used a dense tiling path array comparative genomic hybridization (aCGH) platform consisting of 386,165 unique oligomers spaced evenly at ∼6Kb intervals across the genome. We analyzed 144 adult de novo AML pts; 64 had normal karyotypes, and 80 had 1 or 2 clonal aberrations. Similar numbers of FAB M0/1, M2, M3, and M4 pts were included, and all samples had 〉30% blasts (median=72%). To generate a cancer-free control set of data, we also analyzed 23 DNA samples from normal individuals matched for age and ethnicity, and with no history of cancer. Both the tumor and cancer-free control DNA samples were co-hybridized with a pool of control DNAs from blood of 4 healthy young males. To define the sensitivity and specificity of the aCGH platform, we examined its ability to detect cytogenetically defined chromosome gains and losses. Of the 33 gains and losses present in 〉20% of metaphases, 29 (88%) were detected by aCGH. Of the 20 gains and losses present in ≤20% of metaphases, aCGH detected only 5 (25%). Three of 63 (4.8%) balanced translocations [t(15;17), t(8;21), t(9;11)] were detected using aCGH, indicating that breakpoints of some translocations contained small deletions. Further, we identified many previously described germline copy number variants (CNVs) in both the AML pts and cancer-free controls. To improve our ability to define even smaller somatic microdeletions and amplifications, we tested 20 AML pts using CGH arrays containing 1.5 million probes per genome (average probe spacing 1.5 Kb). To preclude detection of germline CNVs, the higher resolution CGH experiments were performed comparing tumor and skin-derived DNA from the same patient. These same sample pairs were also analyzed individually with the Affymetrix 500K SNP arrays. Using stringent criteria to define abnormal segments, we identified 64 altered loci in the 20 AML pts that were not apparent cytogenetically, and that contained ≥1 gene. SNP arrays confirmed aCGH findings in 7/9 loci 〉100 Kb, and in 1/55 loci

Beschreibung: Deletions and gains of chromosomal segments detectable cytogenetically have long been recognized as valuable tools for AML classification and prognostication. Segmental amplifications and deletions can be reliably detected at the whole genome level using array-based CGH. In this study, we utilized a novel dense tiling path array consisting of 386,165 unique isothermal (Tm=76°C) oligomers (average length 51 nt) spaced evenly at ~6Kb intervals across the genome. We analyzed 144 adult de novo AML samples: 64 had normal karyotypes, and 80 had 1 or 2 clonal, balanced or unbalanced abnormalities (samples with ≥3 clonal chromosome aberrations were excluded). Similar numbers of FAB M0/1, M2, M3, and M4 cases were included, and all samples had 〉30% blasts. Bone marrow-derived tumor DNA or control DNA derived from the blood of 23 normal individuals (matched for age and ethnicity, and with no history of cancer) was co-hybridized with a control pool of DNAs derived from the blood of 4 healthy young males. Of the 23 gains and losses detected cytogenetically in 〉20% of metaphases, 22 (96%) were also detected by CGH. Of the 20 copy number changes present in ≤20% of metaphases, CGH detected only 7 (35%). CGH identified X chromosome number correctly in all samples. Further, a number of previously described segmental copy number polymorphisms (CNPs; Sebat et al, Science2004;305:525) were identified in both the AML samples and the normal control population. Using very stringent criteria to define abnormal segments (≥8 consecutive oligomers with log2 values of at least +/− 0.5), we identified 47 independent loci in the AML samples that had abnormal segments that were not apparent cytogenetically (mostly due to small size). Thirteen of these were present in multiple AML samples (range 2–22), but were also present in at least one cancer-free control sample, or were previously identified in normal individuals. These clearcut CNPs tended to be small (

Beschreibung: Absence of shear stress due to disturbed blood flow at arterial bifurcations and curvatures leads to endothelial dysfunction and proinflammatory gene expression, ultimately resulting in atherogenesis. KLF2 has recently been implicated as a transcription factor involved in mediating the anti-inflammatory effects of flow. We investigated the effect of shear on basal and TNF-α–induced genomewide expression profiles of human umbilical vein endothelial cells (HUVECs). Cluster analysis confirmed that shear stress induces expression of protective genes including KLF2, eNOS, and thrombomodulin, whereas basal expression of TNF-α–responsive genes was moderately decreased. Promoter analysis of these genes showed enrichment of binding sites for ATF transcription factors, whereas TNF-α–induced gene expression was mostly NF-κB dependent. Furthermore, human endothelial cells overlying atherosclerotic plaques had increased amounts of phosphorylated nuclear ATF2 compared with endothelium at unaffected sites. In HUVECs, a dramatic reduction of nuclear binding activity of ATF2 was observed under shear and appeared to be KLF2 dependent. Reduction of ATF2 with siRNA potently suppressed basal proinflammatory gene expression under no-flow conditions. In conclusion, we demonstrate that shear stress and KLF2 inhibit nuclear activity of ATF2, providing a potential mechanism by which endothelial cells exposed to laminar flow are protected from basal proinflammatory, atherogenic gene expression.

Beschreibung: 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.