bluuebunny/crossref_metadata_2025 huggingface dataset:
Imatinib 800 mg: Preliminary Results of a Phase II Trial of the GIMEMA CML Working Party in Intermediate Sokal Risk Patients and Status-of-the-Art of an Ongoing Multinational, Prospective Randomized Trial of Imatinib Standard Dose (400 mg Daily) vs High Dose (800 mg Daily) in High Sokal Risk Patients.
Authors: Rosti Gianantonio , Martinelli Giovanni , Castagnetti Fausto , Testoni Nicoletta , Specchia Giorgina , Bassan Renato , Stagno Fabio , Breccia Massimo , Abruzzese Elisabetta , Saglio Giuseppe , Pane Fabrizio , Simonsson Bengt , Nielsen Johan L. , Hjorth-Hansen Henrik , PorkKa Kimmo , Haznedaroglu Ibrahim , Nagler Arnon , Vignetti Marco , Russo Domenico , Amabile Marilina , Baccarani Michele
Published: April 2020

The conventional treatment of chronic myeloid leukemia (CML) in early chronic phase (ECP) is imatinib 400 mg daily. The estimated rates of major (MCgR) and complete cytogenetic response (CCgR) at 42 months are 91% and 84%, respectively (IRIS Trial - F Guilhot, ASH 2004), with a survival free from accelerated and blastic phase of 84%. The rates of CCgR are significantly different according to Sokal score, being 91%, 84% and 69% for low, intermediate and high risk categories. Phase I and II trials of imatinib have clearly shown a dose-response effect; more importantly, a single center phase II trial of imatinib 800 mg in ECP showed significantly better results vs standard dose, in terms of CCgR (90% vs 74%) and of complete molecular response (28% vs 7% at 18 months) [H. Kantarjian et al, Blood 103 (8), 2004]. The GIMEMA (Gruppo Italiano Malattie Ematologiche dell’Adulto) CML WP is conducting a phase II trial of imatinib 800 mg in intermediate Sokal risk in ECP (trial CML/021). Overall, 89 pts (mean age 53 yrs) have been enrolled. Fourty-four patients completed 6 months of treatment: the complete hematological response rate is 100%; the MCgR and CCgR are 90% and 81%, respectively. The 6 months CCgR rate of this trial parallels the IRIS trial one in intermediate risk cases (84%), with a much shorter treatment period. The major molecular response rate at 6 months (RTQ-PCR as ratio BCR-ABL/ABL) is 56% (cut-off ≤ 0.12%) or 41% (cut-off ≤0.05%). The compliance to the treatment improved time by time, being 47% the patients receiving ≥ 80% of the scheduled dose between months 1–3 and 60% between months 4 - 6. A second project, exploring imatinib high dose, is reserved to high risk cases: a multinational working group, within the frame of Leukemianet CML WP, is conducting a phase III randomized trial (1:1) of imatinib 400 mg vs 800 mg in high Sokal risk in ECP. By July 31, 2005, 80 patients have been enrolled: GIMEMA CML WP (44 pts), Nordic Countries - Sweden, Denmark, Norway and Finland (25 pts), Turkey (10 pts) and Israel (1 pt).
Imatinib Mesylate Determines a High Frequency of Major Molecular Responses in Newly Diagnosed Philadelphia Chromosome-Positive Chronic Phase Chronic Myeloid Leukemia (CML) on Behalf of the GIMEMA Working Party on Chronic Myeloid Leukemia (GIMEMA-CML).
Authors: Iacobucci Ilaria , Testoni Nicoletta , Rosti Gianantonio , Amabile Marilina , Poerio Angela , Soverini Simona , Colarossi Sabrina , Gnani Alessandra , Ottaviani Emanuela , Castagnetti Fausto , Terragna Carolina , Renzulli Matteo , Grafone Tiziana , Cilloni Daniela , Pane Fabrizio , Saglio Giuseppe , Baccarani Michele , Martinelli Giovanni
Published: April 2020

Imatinib has became the standard therapy for patients with CML. In order to determine the frequency of molecular response to imatinib and its long-term prognostic implications, we analyzed the results of molecular monitoring in 260 newly diagnosed CML Sokal low-risk patients, enrolled in a prospective clinical trial (protocol CML 023 of the GIMEMA Working Party on CML). Imatinib was given at the dose of 400 mg daily. Bone marrow samples were collected prior to therapy and every 12 months, peripheral blood samples were collected at the same check-points and at 3 months, 6 months and every 6 months thereafter. Relative BCR-ABL expression was measured by real-time quantitative PCR (TaqMan) normalized for ABL and the result was expressed as a ratio of BCR-ABL to ABL multiplied by 100. All experiments were performed in duplicate. The median follow-up time from the time treatment was started is 6 months (range, 1–18).

At the time of writing, are valuable for cytogenetic and molecular analysis at 12 months on imatinb 82 patients. At this time, complete cytogenetic remission (CCgR) was achieved in 90% of patients. Median BCR-ABL/ABL ratio before the start of imatinib was 16.1 (range, 112.6–0.004), it was 0.35 (range, 81.57–0.0006) at 3 months, 0.1 (range, 45.84–0.0002) at 6 months and 0.05 (range, 7.57–0.000001) at 12 months. Considering a major molecular response as reaching an absolute value of BCR-ABL/ABL ratio < 0.05%, we observed how after 12 months of treatment imatinib has determined a major molecular response in 52% of patients. If we were to use an absolute value of BCR-ABL/ABL ratio < 0.12 %, that has been demonstrated to be equivalent at a 3-log reduction (as referred by Hochhaus A), instead of an absolute value of 0.05%, a major molecular response would be achieved in about 70% of early chronic phase patients. BCR-ABL transcripts were undetectable at least one occasion (complete molecular response) in 4% of patient with a CCgR. Only 2 patients (2%) had no response to imatinib, in one of these we found the presence of the point mutation Y253H.

In conclusion, our results demonstrate that imatinib determines a high frequency of complete cytogenetic remission and major molecular remission in newly diagnosed CML patients. Achieving a major molecular response, particularly within the first year of therapy, could be predictive of a durable cytogenetic remission.
Conception and Pregnancy in Patients (pts) with Chronic Myeloid Leukemia (CML) Receiving Therapy with Imatinib Mesylate (IM).
Authors: Ault Pat , Kantarjian Hagop , O’Brien Susan , Koller Charles , Faderl Stefan , Freireich Emil J. , Rios Mary Beth , Cortes Jorge
Published: April 2020

Although pts with CML receiving IM therapy are required to practice contraception while on therapy, there are isolated case reports of conception and pregnancy while on therapy. Here we present our experience with 18 pts who conceived while on IM therapy: 10 females and 8 males. All 10 females received IM for chronic phase (CP) CML. At the time of conception 1 had a complete cytogenetic (CG) response (CG CR), 3 a partial CG response (CG PR), 2 a minor CG response (CG MR), 2 complete hematologic response (CHR), and 2 no response. All pts stopped therapy immediately when pregnancy was recognized. Pts were managed with hydroxyurea (n=3), leukapheresis (n=1), interferon (n=1) or observation. Two pts had a spontaneous and 1 an elective abortion; 7 pregnancies continued uneventfully until delivery (median duration of pregnancy 36 weeks). Eight babies have been born (1 pair of twins): one had hypospadias, 7 were normal. The median age of the children is now 14 months (mo) and all are developing normally. At the time of delivery/abortion, 5 pts were 100% Ph-positive, 3 had still a CG MR and 1 a CG PR [i.e. 5 of 7 evaluable had increased Ph off therapy (1 not tested yet, 2 results pending) (median off therapy 9 months, range 4 to 22 months).] Pts re-started therapy after delivery and again after a median of 18 months after delivery (range 5 to 48 months), 3 have a CG CR, 2 CG PR, 1 CG MR, 2 CHR and 1 unknown. Among 8 males (6 CP, 2 AP) who impregnated their partners while on IM, 9 pregnancies resulted in the birth of 8 healthy babies and 1 spontaneous abortion. One baby had a mild rotation of the small intestine that resolved surgically. There were no complications of the other 7 babies. With a median age of 37 mo (range, 5 to 50), there are no known growth or development problems for any of the babies. This small experience suggests that conception while receiving IM is most frequently associated with a normal pregnancy and healthy babies, provided IM is immediately discontinued. Still, the recommendation to practice effective contraception while on IM should be enforced.
Cardiac and Pulmonary Function Late Effects after Bone Marrow Transplantation in Childhood: Prospective Study on Behalf of EBMT LEWP Group.
Authors: Uderzo Cornelio , Corti Paola , Fedeli Sara , Tana Francesco , Messina Chiara , Pillon Marta , Tridello Gloria , Galambrun Claire , Zintl Felix , Dini Giorgio , Faraci Maura , Fagioli Franca , Nysom Karsten , Verdeguer Amparo , Urban Christian , Tichelli André , Socié Gerard
Published: April 2020

BACKGROUND

Patients (pts) undergoing bone marrow transplantation (BMT) for hematological childhood disorders might present long-term cardiac and pulmonary function (CPF) complications. The current study assessed incidence and risk factors of CPF late sequelae by a multicenter study.

METHODS

From March 1994 to December 1997 we enrolled 220 consecutive children (130 males, median age at BMT 9,5 yrs) who underwent BMT (162 allogeneic and 58 autologous) for malignant (193) and non malignant (27) diseases in 9 EBMT centers. Total body irradiation (TBI) based conditioning regimen was used in 120/220 pts. A total of 165/220 pts were alive at the end of the study with a reliable CPF assessment which consisted of pulmonary function tests (PFTs) and M-Mode echocardiography performed at pre-BMT phase, at 1st year post-BMT and yearly. Statistical analysis to evaluate the difference between pre-BMT and post-BMT CPF was performed by paired t-test, while the assessment of risk factors was based on univariate and multivariate analysis.

RESULTS

Median follow-up of evaluable pts was 5 yrs (range 4–8 yrs). Fifty-five of 220 patients deceased, none for late CPF abnormalities. The 5-year cumulative incidence of lung and cardiac impairment was 35% (hazard rate=0,07) and 23% (hazard rate =0,04) respectively. Patients presenting abnormal PFTs and shortening fraction (SF) at last follow-up were 15% and 12% respectively, even if asymptomatic. Chronic GVHD was a major risk factor in reducing lung function at both univariate (P=0.02) and multivariate analysis (P=0,006). Patients undergoing TBI based conditioning regimen showed a SF impairment at multivariate analysis (P=0,03). Gender, age, diagnosis, pre-BMT anthracyclines, BMT type, non-TBI based conditioning, malignant or non malignant diseases at BMT were not significantly related to pulmonary and cardiac late effects. No difference was ascertained in the cumulative incidence of non relapse mortality in a competing risk setting which suggests that BMT can also be successful for those children who experienced both abnormal PFTs and SF. At the end of the study all surviving pts had a median Lansky index >90.

CONCLUSIONS

Our study focused on low incidence of only asymptomatic CPF late effects in children transplanted for hematological disorders. TBI for cardiac function and C-GVHD for pulmonary function are the most important risk factors. Despite most of the alive pts remains in the normal range both for CPF complications from the beginning of BMT up to 5th year of median follow-up, a continue surveillance at least in adolescent age is recommended.
Prospective Study of Changes in Bone Mineral Density and Turnover in Children after Hematopoietic Cell Transplantation.
Authors: Petryk Anna , Bergemann Tracy L. , Polga Kristen M. , Ulrich Kami J. , Raatz Susan K. , Brown David M. , Robison Leslie L. , Baker Scott K.
Published: April 2020

Osteoporosis is common in adults after hematopoietic cell transplantation (HCT). The data on bone mineral density (BMD) in children after HCT are limited. The goals of this prospective study were to determine the incidence, timing, magnitude and possible predictors of bone loss in children following HCT. The study population included 49 patients (age 5–18 years) who were eligible to receive HCT at the University of Minnesota. The patients were evaluated at baseline, 100 days, 6 months, and 1 year after HCT. Lumbar BMD (BMDL) was assessed by dual-energy x-ray absorptiometry. The number of patients with osteopenia increased from 18% at baseline to 33% one year after HCT, and with osteoporosis from 16% to 19%. Mean areal BMDL z-score decreased from −0.56 to −1.1 by 6 months and at 1 year was −0.94, which was significant compared to standard normal distribution (p=0.004 and p=0.022, respectively). The absolute loss of bone mineral corresponded to 5.3% reduction in areal BMDL and 4.8% reduction in volumetric BMDL. The level of bone-specific alkaline phosphatase decreased by 30% by day 100 (p=0.009), followed by recovery toward baseline by 6 months. The level of osteocalcin >6.5 ng/mL at day 100 predicted recovery from the initial bone loss by 1 year. A reduction in BMDL at 6 months correlated with a cumulative dose of glucocorticoids. In conclusion, this study demonstrates that bone loss is common in children after HCT and is primarily due to suppression of bone formation. Further studies are necessary to validate osteocalcin as a predictive biomarker.
Enhanced Anti-Myeloma Activity by Combination of Receptor Tyrosine Kinase (RTK) Inhibition, Proteasome Inhibition, and Dexamethasone: Therapeutic Implications for t(4;14) and t(14;16) Multiple Myeloma (MM) Subgroups.
Authors: Bisping Guido , Wenning Doris , Kropff Martin H. , Munzert Gerd , Hilberg Frank , Roth Gerald J. , Berdel Wolfgang E. , Kienast Joachim
Published: April 2020

Novel antineoplastic agents have opened perspectives to more selective treatment of multiple myeloma (MM). Targets include FGFR3 or c-maf and VEGFR1 expressed in MM subgroups carrying t(4;14)(p16.4;q32) or t(14;16)(q32;q23), respectively. The t(4;14) MM subgroup, overexpressing FGFR3, has been recently demonstrated to be sensitive to induction of apoptosis by receptor tyrosine kinase (RTK) inhibitors [Bisping, Blood102, 661, 2003; Podar, Blood103, 3474, 2004; Trudel, Blood105, 2941, 2005]. The present study aimed at investigating mechanisms of enhanced anti-myeloma effects of BIBF 1000, a highly selective RTK inhibitor, blocking VEGF and FGF dependent signaling, in combination with the proteasome inhibitor bortezomib and/or dexamethasone in cytogenetically defined MM subgroups. MM cells analyzed included a panel of five t(4;14) and six t(14;16) positive myeloma cell lines as well as fourteen CD138+ sorted primary MM cells with or without t(4;14) (3/11). We found a significant, dose-dependent inhibition of proliferation and induction of apoptosis in t(4;14)+ MM lines (4/5) as well as in primary t(4;14)+ CD138+ sorted marrow derived MM cells (3/3) by incubation with the RTK inhibitor BIBF 1000. Coincubation with the proteasome inhibitor bortezomib, or dexamethasone, or their combination revealed stepwise increased apoptosis in non RAS-mutated t(4;14)+ MM (4/4). Induction of apoptosis by BIBF 1000 in t(4;14)+ cells was associated with inhibition of the phosphorylation of mitogen-activated protein kinase (MAPK p44/42). In contrast, inhibition of MAPK-phosphorylation failed and induction of apoptosis did not appear in n-RAS-mutated t(4;14)+ NCI-H929 cells. In t(14;16)+ MM cells, variable proapoptotic effects of BIBF 1000 (in 5 of 6 lines tested) were significantly enhanced by dexamethasone and/or bortezomib. Interleukin-6 partially antagonized and the pan-caspase inhibitor z-VAD almost completely reverted induced apoptosis upon exposure to these combinations. In t(14;16)+ MM.1S cells, induction of apoptosis by BIBF 1000 was associated with inhibition of the phosphatidyl-inositol-3 kinase/AKT pathway. When combining BIBF 1000, bortezomib, and/or dexamethasone, we found a markedly higher proportion of cleaved caspase-3, caspase-8 and PARP in t(4;14) and t(14;16) MM, while caspase-9 was not activated. The data provide the rationale for clinical evaluation of a combination of this class of targeted tyrosine kinase inhibitors, proteasome inhibitors and dexamethasone in MM with focus on defined cytogenetic subgroups.
Treatment-Related MDS/AML after Autologous Stem Cell Transplantation for Chronic Lymphocytic Leukemia (CLL): An EBMT Survey.
Authors: Dreger Peter , van Biezen Anja , Brukx Kees , Boogaerts Marc , Michallet Mauricette , Milligan Donald , Niederwieser Dietger W.
Published: April 2020

Treatment-related myelodysplastic syndromes and acute myeloblastic leukemia (t-MDS/AML) have emerged as relevant complications of autologous stem cell transplantation (ASCT) for follicular lymphoma. Given the fact that also fludarabine-cyclophosphamide combination chemotherapy, which is increasingly used for primary treatment in CLL, has been implicated in induction of secondary stem cell disorders, t-MDS/AML might be a substantial problem after ASCT for CLL, too. Therefore the purpose of this study was to analyze the incidence and characteristics of t-MDS/AML among those patients who were autografted for CLL and registered in the EBMT database. For each case submitted between 1992 and 2004, centers received a questionaire asking for follow-up information with particular focus on t-MDS/AML.

Results: Of 1139 patients identified from the database, a reply was received for 457. After these 457 autotransplants, 18 cases of t-MDS/AML were observed, giving a crude rate of 3.9%. Median time from ASCT to t-MDS/AML was 28 (10–73) months. Patients with t-MDS/AML had received 2 (1–3) lines of conventional chemotherapy prior to ASCT, containing alkylating agents in 92% and fludarabine in 71% of the patients. Only a single patient had been pretreated with combined fludarabine-cyclophosphamide. High-dose regimens comprised total body irradiation in 71% of the t-MDS/AML cases; and mobilized peripheral blood was used as stem cell source in 92%, containing 2.9 (1.4–7.8) CD34+ cells/kg. Treatment of t-MDS/AML consisted of chemotherapy in 17%, ASCT in 6%, and allo-SCT in 17%, whereas the majority of the patients received supportive care only. Median survival from diagnosis of t-MDS/AML was 8 months with 2 of the 3 allografted patients being alive 10 and 13 months post diagnosis, respectively.

Conclusions: The incidence of t-MDS/AML after ASCT for CLL does not seem to exceed the range reported for follicular lymphoma. t-MDS/AML generally occurs within the first 6 years post transplant and has a very poor prognosis. A particular impact of fludarabine-cyclophosphamide pretreatment could not be detected.
Allogeneic Peripheral Blood Stem Cell Transplants (PBSCT) May Have a Benefit in Acute Lymphoblastic Leukemia (ALL) Outcome.
Authors: Vigorito Afonso C. , Aranha Francisco J.P. , Oliveira Gislaine B. , Eid Kátia A.B. , Statistic Roberto Zulli , Colturato Vergilio , De Souza Mair P. , Lodi Fernanda M. , Bittencourt Henrique , Castro Nelson , Barros José Carlos , Pontes Érica R. , Brandalise Silvia R. , Pereira R. DÁlmeida , Ribeiro A. A. F. , Novis Y. , Hamerschlak Nelson , Ferreira E. , Azevedo Alexandre M. , De Magalhães K. G. , Bouzas Luiz Fernando , Ruiz Milton A. , Maiolino Angelo , Nucci Marcio , Ruiz Jeferson , Pasquini Ricardo , De Souza Cármino A.
Published: April 2020

Hematopoietic stem cell transplantation is a valid alternative as post-remission therapy in ALL. Our aim was analyzed retrospectively the clinical outcomes of 97 ALL patients with HLA identical sibling donors who underwent an allo PBSCT. Median age was 24 ys (2–45), advanced disease was present in 74%, conditioning without irradiation was 56%; GVHD prophylaxis with MTX/CsA was 91%; CD34+ median was 4.6X106/kg (1.2–24); the median follow-up for surviving patients was 22 months (1.6–93). Median day for neutrophils and platelets engraftment was 15 and 13, respectively; no TBI conditioning, no MTX/CsA, were associated significantly with faster neutrophils engraftment; no MTX/CsA with platelets. Cumulative incidence (CI) for ≥ 2 aGVHD was 45%, extensive cGVHD 50%; aGVHD in patients who received TBI conditioning was 34% (P=0.04). The estimates of OS and DFS at 92 months was 21% and 31%, respectively; OS for patients >36ys was 16% (P=0.04), for patients with aGVHD 11% (P=0.03); there was a trend towards better OS and DFS in patients with cGVHD (54%, 63%; P=0.07, P=0.06). CI for relapses was 60%; relapses for cGVHD patients were 36% (P= 0.05), and there was a trend towards higher relapses in advanced disease (66%, P=0.06). TRM was 64%; in those patients with aGVHD, 73% (P=0.008). In multivariate analyses no MTX/CsA was related with the speed of platelets engraftment (P=0.007); TBI conditioning was associated with less aGVHD and TRM (P=0.05, P=0.01); aGVHD had a negative impact on OS with higher TRM (P=0.02, P=0.02). Although not confirmed in the multivariate analyses, fewer relapses, and a trend towards better OS, and DFS were found in patients with extensive cGVHD. However, further follow up will be necessary to confirm these results.
Rituximab Added to an Intensified Salvage Chemotherapy Program Followed by Autologous Stem Cell Transplantation Improve in Relapsed and Refractory Aggressive Non-Hodgkin-Lymphoma.
Authors: Sieniawski Michal , Glossmann Jan-Peter , Reineke Thorsten , Diehl Volker , Engert Andreas , Josting Andreas
Published: April 2020

Background

We investigated the addition of rituximab to an intensified salvage program followed by a myeloablative course with autologous stem cell transplantation (ASCT) in patients with relapsed or refractory aggressive NHL.

Methods

Patients with relapsed or progressive aggressive NHL were treated with two cycles of conventional salvage chemotherapy followed by high-dose sequential chemotherapy and a final myeloablative course with ASCT. Rituximab (375mg/m2) was administered at each treatment cycle. This cohort was compared with a historical control group of patients treated with the same chemotherapy but without rituximab. Patients from both treatment groups were matched according to age, duration of first remission, lactate dehydrogenase (LDH) serum level and B symptoms at relapse/progress.

Results

22 patients were treated with immunochemotherapy and 57 patients with chemotherapy. The overall response rates (ORR) at the final evaluation were 71% (65% CR and 6% PR) for the immunochemotherapy group compared to 65% (59% CR and 6% PR) for the chemotherapy group. In the historical controlled analysis freedom from second failure (FF2F) at two years in the immunochemotherapy group was 64% and overall survival 77%. Within the chemotherapy group FF2F was 25% (p=0,0185) and OS 44% (p=0,0159). In the matched-pair analysis FF2F was 64% in the immunochemotherapy group, compared to 47% in the chemotherapy group (p=0,7274). OS was 82% vs. 70% respectively (p=0,4854). The toxicity was tolerable and comparable in both groups.

Conclusions

The addition of rituximab to an intensified salvage chemotherapy regimen seems to improve the prognosis. However, only prospective randomized trial can offer sufficient data of the value of rituximab in relapsed and refractory aggressive NHL.
Total Therapy 2 (No Thalidomide Arm, TT2-) Is Superior to Total Therapy 1 (TT1) for Newly Diagnosed Multiple Myeloma (MM): Doubling 4-Yr Survival among Patients with Cytogenetic Abnormalities (CA) Due to Consolidation Chemotherapy (CCT) and DEX Maintenance.
Authors: Barlogie Bart , Tricot Guido , Rasmussen Erik , Anaissie Elias , van Rhee Frits , Zangari Maurizio , Hollmig Klaus , Milner Teresa , Epstein Joshua , Shaughnessy John , Crowley John
Published: April 2020

Background: TT2 introduced T into the frontline therapy for MM in a randomized phase III trial design (ASCO 2005). In comparison to TT1, TT2 applied: (1) more intensive chemotherapy for induction prior to and introduced CCT after melphalan 200mg/sqm-based tandem autotransplants, designed to improve survival in high-risk patients with CA; (2) DEX pulsing was added during the 1st year of interferon (IFN) maintenance therapy. We now report on the outcome of patients treated on the “no thalidomide” arm of TT2 (TT2-) in comparison to TT1, in order to evaluate the effect of dose-intensification during induction and post-transplant therapy.

Patients and Methods: 231 patients were enrolled in TT1 (median follow-up, 11yr) and 345 in TT2- (median follow-up, 3.5yr). Completion rates of 1st/2nd transplants were 195/165 (84%/71%) with TT1 and 292/235 (85%/68%) with TT2-. In TT2-, 64% started CCT and 36% received DEX consolidation (when platelets failed to recover or no benefit was documented from induction DCEP). TT2- and TT1 were compared in terms of pre-transplant-1 and final CR rates (intent-to treat), EFS/OS from treatment start, 1st transplant and from last (2nd or 1st) transplant. EFS and OS were examined in the context of baseline prognostic variables including CA.

Results: Compared to TT1, TT2- induced similar pre-Tx1 CR rates (11% vs 12%, p=0.8) and final CR rates (41.3% vs 40.7%, p=0.9). The median onset of CR was 8.9mo for TT2 vs 8.4mo for TT1 (p=0.4). 5-year EFS/OS were 45%/63% with TT2- vs 28%/57% with TT1 (p<0.001/p=0.06). 4-yr post-transplant-1 EFS/OS were 48%/65% with TT2- vs 28%/56% with TT1 (p<0.001/p=0.02); 4-yr post-transplant-2 EFS/OS were 46%/64% with TT2- and 31%/50% with TT1 (both p=0.01). Pre-study CA, high LDH (>=190U/L), and low Hb (<10g/dL) were independently, significantly associated with poorer post-transplant-2 EFS and OS (p<0.05); independent of these factors, TT2- improved post-transplant-2 EFS and OS compared to TT1 (p<0.001/p=0.033). In the presence of CA, TT2- with CCT vs TT2- with DEX improved 4-yr OS (measured from a 6-mo landmark post-transplant-2) from 37% (similar to 39% with TT1 [no DEX or CCT]) to 78%, which is comparable to the 65% for TT1 without CA.

Conclusion: In this historical comparison of TT1 with TT2-, the more intensive induction chemotherapy with TT2- did not improve CR. However, post-transplant CCT benefited the 1/3 of patients with CA, doubling 4-yr post-transplant OS in comparison with TT1 in this high-risk subgroup. A phase 3 randomized trial addressing the CCT concept is warranted.

Figure Figure
Arsenic Trioxide with Ascorbic Acid and High-Dose Melphalan: A New Preparative Regimen for Autologous Hematopoietic Stem Cell Transplantation for Multiple Myeloma.
Authors: Qazilbash Muzaffar H. , Davis Marilyn S. , Ana Aleman , Roden Linda , Libunao Floralyn , Thall Peter F. , Wang Xuemei , Couriel Daniel , De Lima Marcos , Hosing Chitra , Kebriaei Partow , Weber Donna , Wang Michael , Jones Roy B. , Matthes Steven G. , Champlin Richard E. , Giralt Sergio A.
Published: April 2020

Backround: Arsenic trioxide (ATO), an active agent against multiple myeloma, has been shown to be synergistic with melphalan both in vitro and in vivo. We conducted a phase I/II trial to determine the safety and efficacy of a combination of arsenic trioxide, melphalan and ascorbic acid (AA) as prepaprative regimen in patients undergoing high-dose therapy (HDT) and autologous hematopoietic progenitor cell transplantation (AHPCT) for multiple myeloma (MM). We also assessed the impact ATO levels on melphalan pharmacokinetics (PK), engraftment and toxicity.

Methods: Twenty-five patients with secretory myeloma (11 females, 14 males median age: 53, range: 49 – 69) were treated b/w 4/04 and 1/05. All patient received melphalan 100 mg/m2 IV on days -4 and -3 and AA 1000 mg/day IV on days −9 to −3. Patients were randomized to 3 arms; no ATO (arm 1), ATO 0.15 mg/kg IV on days −9 to −3 (arm 2) and ATO 0.25 mg/kg IV on days −9 to −3 (arm 3). Seven patients had a prior autograft. Median CD34 cells dose infused was 4.4 x 106/kg (range 2.3–10.9). Results: Patients were evenly matched except for a high median β2m level (3.6 vs. 2.4 in arms 1 and 2, p=0.04) in arm 3. With a median F/U of 7.1 months post autograft, no dose-limiting toxicity or non-relapse mortality was seen. Median ATO level on day 0 in arms 1, 2 and 3 were 0.2, 26.3 and 46.2 ng/ml, respectively. Toxicity was limited grade I or II nausea, vomitting and diarrhea. Median time to neutrophil engraftment (ANC >500/dl) was 9 days. There were no engraftment failures or delays in the ATO arms. Response rates (RR) are shown in Table 1. With a median F/U of 7.1 months (range, 6.4 – 8.9 months), the progression-free survival (PFS) and overall survival (OS) are as shown in Figure 1. There was no significant difference in RR, PFS or OS between the 3 arms. Melphalan PK was not altered by ATO pretreatment.

Conclusions: Arsenic trioxide, given in combination with melphalan and ascorbic acid as preparative regimen, is safe and well tolerated. A longer follow up is needed to determine the impact of this combination on survival.

Response Rate at 3-Month Evaluation Response at 3 months CR PR MR SD PD p = 0.55 CR = complete response, PR = partial response, MR = minimal response, SD = stable disease, PD = progressive disease Arm 1 (no ATO) 1 5 0 1 1 Arm 2 (ATO 0.15) 1 5 2 0 1 Arm 3 (ATO 0.25) 0 7 0 0 0 Figure 1. The Kaplan-Meier estimates for progression-free survival probability (N=25). Figure 1. The Kaplan-Meier estimates for progression-free survival probability (N=25). Figure 2. The Kaplan-Meier estimates for overall survival probability (N=25). Figure 2. The Kaplan-Meier estimates for overall survival probability (N=25).
X-Linked Clonality Analysis and Quantitative JAK2V617F Assessment Reveals a Strong Association between Clonality and JAK2V617F in PV but Not in ET/MMM, and Identifies a Subset of JAK2V617F Negative ET and MMM Patients with Clonal Hematopoiesis.
Authors: Levine Ross L. , Belisle Claude , Wadleigh Martha , Lee Stephanie J. , Chagnon Pierre , Gilliland D. Gary , Busque Lambert
Published: April 2020

Polycythemia vera (PV), essential thrombocythemia (ET), and myeloid metaplasia with myelofibrosis (MMM) are categorized as a set of phenotypically related myeloproliferative disorders (MPD). Recent work has identified a somatic mutation in the JAK2 tyrosine kinase (JAK2V617F) in the majority of PV and in a subset of ET and MMM. As most, but not all, patients with MPD have clonal granulocytes, we sought to determine if there was a relationship between granulocyte clonality and JAK2V617F mutational status using a quantitative clonality assay for the human androgen receptor gene (HUMARA) and a quantitative real-time PCR assay for JAK2V617F. 168 of 190 female MPD patients were informative for the HUMARA polymorphism, and 121 patients (72%) had allele skewing consistent with clonal granulopoiesis including 80% of MMM, 75% of PV, and 67% of ET. The quantitative real-time PCR assay for JAK2V617F detected the JAK2V617F allele in 98.8% of PV, 69% of ET, and 33% of MMM, and was more sensitive than direct sequencing. A significant correlation between the degree of allele skewing and quantitative JAK2V617F allelic ratio was observed in PV (p<0.0001) but not in ET (p= 0.2) or MMM (p=0.771). In addition, a subset of patients with ET and MMM with clonal granulocytes had JAK2V617F present in some, but not all, clonal granulocytes. These data suggest acquisition of the JAK2V617F mutation may be sufficient for the development of PV, but additional genetic events are necessary to cooperate with JAK2V617F in ET and MMM. Most importantly, we identified a subset of patients with ET (23%) and MMM (17%), but not PV, with clonal granulocytes who were JAK2V617F negative. A high-throughput screen for novel activating mutations in signal transduction pathways in JAK2V617F negative ET and MMM is warranted.
Complete Response (CR) with Total Therapy 2 (TT2) for Multiple Myeloma (MM): Low Frequency in Case of Prior MGUS without Adverse Consequences for Survival - Yet Critical for Disease Control in Presumed “De Novo” MM.
Authors: Fassas Athanasios , Rasmussen Erik , Shaughnessy John , Tricot Guido , Zangari Maurizio , van Rhee Frits , Anaissie Elias , Hollmig Klaus , Fox Michele , Epstein Joshua , Crowley John , Barlogie Bart
Published: April 2020

Background: It is now widely accepted that stringently defined CR is a prerequisite for durable EFS and OS also in MM.

Patients and Methods: The results of TT2 (4 cycles of intensive induction prior to and consolidation chemotherapy after tandem autotransplant) have recently been reported (ASCO 2005), demonstrating a significantly higher CR rate and longer EFS but not OS among those randomized to thalidomide. Baseline laboratory variables and the clinical history off 668 patients enrolled in TT2 were examined for their potential impact on CR and, in turn CR’s impact on EFS and OS. The Kaplan-Meier method was used to estimate EFS and OS. Cox regression was used to evaluate multivariate factors of CR, EFS, and OS; the prognostic value of CR and 1st and 2nd transplants were modeled as time-dependent covariates in order to adjust for the guarantee time associated with reaching these treatment markers.

Results: Of 668 patients enrolled, 45 had a documented history of prior MGUS (n=22) or smoldering MM (SMM) (n=23); 20 had a prior solitary plasmacytoma (SPC) of bone. 2-yr estimates of CR (negative immunofixation, normal bone marrow) were 47% for the 588 without history of preceding SPC/MGUS/SMM, 55% for SPC and 22% for the MGUS/SMM groups. EFS and OS at 4 yrs were 57% and 71%, independent of a preceding disorder. Multivariate analysis revealed faster onset and higher frequency of CR with only light chain MM (HR, 2.6; p<.001), in the absence of MGUS/SMM (HR, 1.8; p=.049), and with thalidomide (HR, 1.7: p<0.001). Cytogenetic abnormalities (CA), del13q14 and amp1q21, while adversely affecting EFS/OS, did not influence CR. On multivariate analysis for EFS and OS accounting, in addition to baseline variables, also for T, CR, 1st and 2nd transplant, and pre-MM history of MGUS/SMM, we observed that patients attaining a CR had significantly improved EFS and OS independent of key baseline variables (amp1q21, del13q14, CA, LDH, albumin) and treatment markers (T, 1st and 2nd transplants).

Conclusion: We confirm that documented MGUS/SMM pre-MM is associated with lower CR rate without impacting survival negatively, probably implying the re-establishment of the precursor condition. For the remainder, CR was critical for prolonged survival. Gene expression analysis is applied to recognize, in the absence of prior history, those patients likely having evolved from MGUS and thus contribute fundamentally to a distinction of “de novo” MM from “MGUS-evolved MM”. Those results will be presented at the meeting.
Short Telomeres Are Associated with Genetic Instability and the Occurrence of High Risk Genomic Aberrations in Chronic Lymphocytic Leukemia.
Authors: Kröber Alexander , Grabowski Pawel , Bühler Andreas , Seiler Till , Döhner Hartmut , Rosenquist Richard , Roos Göran , Stilgenbauer Stephan
Published: April 2020

Telomere length has been associated with the mutation status of the immunoglobulin variable heavy chain (VH) gene and the clinical course in chronic lymphocytic leukemia (CLL). In an unicentric CLL cohort of 108 patients, we have analyzed the telomere length by quantitative real time PCR, genomic aberrations by FISH with a comprehensive set of DNA probes (11q, 12q, 13q, 14q, 17p), the VH mutation status by DNA sequencing, ZAP-70 expression (clone 2F3.2, Upstate, according to Crespo et al., NEJM 2003) and CD38 expression by flow cytometry, to further study the prognostic impact and associations among these factors. A relative telomere-single-copy-gene ratio (T/S) was calculated for each sample, where low and high T/S values correspond to short and long telomere lengths, respectively. The median T/S value was 0.33 (range 0.06–1.18). There was an inverse correlation between telomere length and the following parameters: 1. VH homology (r=−0.56, p<0.001), 2. CD38 expression (r=−0.44, p<0.001) and 3. ZAP-70 expression (r=−0.25, p=0.01). Cases with T/S values below the median of 0.33 (short telomeres) and cases with T/S values above the median (long telomeres) had similar incidences of genomic aberrations (76 vs. 67%), 13q- (54 vs. 52%) and +12q (9 vs. 9%). In contrast, 13q- as a single aberration was significantly more frequently observed in cases with long telomeres (43 vs. 17%, p=0.006), whereas 11q- (30 vs. 9%, p=0.014), 17p- (24 vs. 0%, p<0.001) and cases with two or more genomic aberrations (26 vs. 6%, p<0.001) were significantly more frequent in cases with short telomeres. Compared to cases with long telomeres the treatment free survival from diagnosis (TFS) and overall survival (OS) in the group with short telomeres were significantly shorter (TFS: 29 vs. 67 months, p=0.002; OS: last observed death at 100 months, survival probability 57% vs. last observed death at 141 months, survival probability 77%, p=0.02). In conclusion, telomere length was inversely correlated with the VH mutation status, CD38 expression and ZAP-70 expression. Short telomeres were associated with genomic instability indicated by a high number of aberrations and the occurrence of 11q- and 17p- in CLL. These observations have biological and prognostic implications in CLL.
Nurselike Cells in Chronic Lymphocytic Leukemia Have Gene Expression Profiles and Functional Characteristics That Are Distinct from Those of Monocytes or Dendritic Cells.
Authors: Messmer Davorka , Endo Tomoyuki , Messmer Bradley T. , James Danelle , Zvaifler Nathan J. , Schmidt-Wolf Ingo G.H. , Tom Kipps J.
Published: April 2020

When CD14+ blood mononuclear cells are cultured with chronic lymphocytic leukemia (CLL) B cells they can differentiate into “nurselike” cells (NLCs), which in turn can support the survival of CLL B cells in vitro and possibly in vivo. While factors that contribute to NLC-mediated support of CLL B cell survival have been identified, it is not clear how this cell type relates to other cell types that also can differentiate from CD14+ blood cells, such as monocyte-derived dendritic cells (DCs). Prior studies have identified some phenotypic differences between NLCs, DCs, and other CD14+ blood mononuclear cells. Thus we hypothesized that these cell types may have different gene expression patterns that may relate to distinctive functional properties. To resolve this we examined the genes expressed by monocytes, NLCs, and immature DCs using Affymetrix U133 microarray analyses. Gene expression profiles were generated from the CD14+ monocyte progenitors, NLC, and DC from three different individuals. The expression profiles of DCs and NLCs differed from the CD14+ progenitors by the expression of many thousands of genes and NLC were distinguished from DCs by the expression of several hundred genes. Some of the genes expressed at higher levels in DCs relative to NLCs encode accessory molecules involved in antigen presentation. Consistent with this, we found that immature DCs were 10 times more effective than NLCs in presenting antigen to allogeneic T cells.

DCs express toll like receptors (TLR) on their cell surface that recognize pathogen components and upon exposure to TLR ligands DCs undergo a maturation process, whereby they upregulate surface molecules and gain increased T cell stimulatory capacity. The expression of TLR2, 4, and 9 was analyzed in DCs and NLCs by RT PCR. Both DCs and NLCs were found to express mRNA for TLR2 and 4, but only NLCs expressed TLR9. In concordance with this, NLCs but not DCs unregulated MHC-II after exposure to nonmethylated CpG oligodeoxinucleotides (ODN), a TLR9 agonist, whereas both cell types upregulated MHC-II after exposure to lipopolysaccharide.

Given the propensity of CD14+ cells to differentiate down a NLC pathway when co-cultured with leukemic B cells in vitro, we speculate that differentiation of CD14+ cells into NLCs may be favored in patients with CLL over differentiation into DCs. Given the relative differences in APC function of these two cell types, this may account in part for the acquired immune deficiency often observed in patients with this disease. On the other hand a stimulus like CpG ODN, might increase the ability of NLCs to activate T cells and decrease their ability to support CLL B cells survival.
Characterization of Distinct Molecular Signatures in Myeloproliferative Diseases with the JAK2V617F Mutation and Wild Type JAK2.
Authors: Ebert Benjamin L. , Levine Ross L. , Wadleigh Martha , Brunet Jean-Philippe , Pretz Jennifer L. , Buque Lambert , Lee Stephanie J. , Gilliland D. Gary , Golub Todd R.
Published: April 2020

The recently discovered JAK2V617F mutation provides a critical insight into the molecular pathogenesis of polycythemia vera and other myeloproliferative diseases (MPD). However, the mutations present in patients with wild type JAK2 have not been discovered, and the precise molecular consequences of JAK2 mutation have not been elucidated. We employed gene expression profiling to characterize the molecular phenotype of cells with the JAK2V617F mutation, to identify a distinct signature in cells without JAK2 mutations, and to refine a molecular taxonomy of MPDs. Using purified neutrophils from 70 patients with myeloproliferative diseases and 11 unaffected individuals, we performed gene expression profiling using oligonucleotide microarrays, sequencing of the JAK2 gene, quantitative genotyping by mass spectrometry and allele-specific quantitative PCR, and X-inactivation clonality assays. To reduce the confounding influence of normal neutrophils that are admixed with cells bearing disease-causing mutations, we examined the gene expression profiles of samples in which greater than 80% of JAK2 alleles bear the V617F mutation. PRV1, a previously identified marker of polycythemia vera, was powerfully overexpressed in neutrophils with a homozygous JAK2 mutation. In addition, cells with the JAK2 mutation had increased expression of a set of kinases, including JAK2, and decreased expression of a set of phosphatases. Cells that rely on JAK2 activation for clonal dominance may therefore derive a selective advantage from increased expression of the JAK2 gene. We next examined samples that have high clonality, and therefore relatively few normal neutrophils, but do not have a mutation in the JAK2 gene. These samples have a markedly different gene expression profile and overexpress a distinct set of kinases. The kinases overexpressed in cells with wild type JAK2 are candidates for further mutational analysis and are potential therapeutic targets. Utilizing these signatures and unsupervised analytical algorithms, the samples cluster according to their mutational status and the percentage of normal neutrophils in the sample. Our data demonstrate that the gene expression profiles of MPD samples are not uniform regardless of JAK2 genotype, implying that samples with and without JAK2 mutations have not activated the same pathway via alternative mechanisms. Moreover, we have identified a common signature in samples without JAK2 mutations that meets significance, indicating that one or a small number of mutations may play a critical role in these cells. Genotype and gene expression analyses are defining a molecular classification of myeloproliferative diseases with subtypes that have distinct therapeutic targets.
Chronic Lymphocytic Leukemia Patients with a V1-69 Gene Rearrangement Do Not Have Inferior Survival with Respect to Patients That Express Other Unmutated VH Genes.
Authors: Panovska Irina , Ivanovski Martin , Pavkovic Marica , Siljanovski Nikola , Hadzi-Pecova Liljana , Stojanovic Aleksandar , Cevreska Lidija , Efremov Dimitar G.
Published: April 2020

The mutational status of the immunoglobulin variable heavy chain genes (VH) is a major prognostic indicator in patients with CLL. More recently, additional prognostic categories have been identified by recognizing disease subsets which utilize unique VH genes. Examples include the V3-21 and V3-72 genes which are invariably associated with progressive and stable disease, respectively. The V1–69 gene is the most frequently rearranged VH gene in CLL and is almost always unmutated. We therefore investigated whether CLL patients that express this VH gene differ in clinical course and outcome with respect to CLL patients expressing other unmutated VH genes. The study group consisted of 106 consecutive CLLs that had been diagnosed at our institution prior to 2000. The 25 V1–69 cases (23.6%) were identified by allele-specific VH gene fingerprinting and all were found to be unmutated by nucleotide sequencing. Forty of the remaining cases were randomly selected for VH gene nucleotide sequence analysis; 19 cases expressed another unmutated VH gene, 14 cases expressed a mutated VH gene and the VH gene sequence could not be determined in 7 cases. The V1–69 cases did not differ significantly from cases with other unmutated VH genes with respect to age (median age 60 years for both subgroups), gender (male: female=21:4 for V1–69 cases and 13:6 for other VH unmutated cases, P=n.s.) and median follow-up (V1–69 cases: median 56 months, range 6 to 109; other VH unmutated cases: median 59 months, range 20 to 97, P=n.s.). The percentage of cases presenting at an advanced stage was higher in the V1–69 subgroup (36% of cases in Rai high risk category) than in the subgroup with other unmutated VH genes (5% of cases in Rai high risk category, P=0.027), whereas no significant difference was observed with respect to Ly counts and total tumor burden at diagnosis. Interestingly, 80% of the V1–69 cases compared to 42% of cases with other unmutated VH genes had received treatment immediately following diagnosis, but median time to treatment was not significantly different between the two subgroups (1 month vs. 9 months, respectively, P=0.085). To date 24 V1–69 cases (96%) and 15 cases with other unmutated VH genes (79%) have died, with median survival times of 56 and 60 months, respectively (P=0.9). For comparison, median survival of the 14 VH mutated cases from this series was 125 months (P<0.0001 with respect to both subgroups with unmutated VH genes). We therefore conclude that chronic lymphocytic leukemia patients with a V1–69 gene rearrangement constitute a uniform group with unfavorable prognosis, but their survival does not differ significantly from patients with other unmutated VH genes.

Figure Figure
Possible Role of the Activation Loop Tyrosine Residue (Y842) in FLT3/ITD Signaling May Be Mediated by SHP-2.
Authors: Chen Peili , Williams Allen , Molina Henrik , Pandey Akhilesh , Small Donald
Published: April 2020

Internal tandem duplication (ITD) mutations in the FLT3 juxtamembrane domain lead to constitutive activation of FLT3 tyrosine kinase activity and cooperate in the oncogenic transformation of hematopoietic cells. Although numerous signaling molecules are known to be involved in FLT3/ITD signaling, the sites of interaction and mechanisms are not fully understood. In this study, FLT3/ITD protein was immunoprecipitated from TF-1/ITD cells and subjected to nanoLC-MS/MS analysis for determination of tyrosine phosphorylation sites. We found that tyrosine residue 842 (Y842) in the FLT3/ITD activation loop is constitutively phosphorylated. Mutation of this tyrosine residue to phenylalanine (FLT3/ITDY842F) reduces FLT3/ITD phosphorylation and activation of FLT3 downstream targets, including STAT5, AKT and ERK/MAPK. CEP-701, a selective FLT3 inhibitor, inhibits the proliferation of BaF3 cells expressing FLT3/ITD or FLT3/ITDY842F mutant with a similar potency. This implies CEP-701 targets FLT3/ITDY842F as effectively as FLT3/ITD. To identify the signaling pathway(s) initiated by FLT3/ITD Y842, SHP-2 and other molecules downstream of FLT3 were investigated. SHP-2 is known to be activated by FLT3 signaling and its interaction with Gab2 regulates the ERK/MAPK pathway. Previous studies also suggested that SHP-2 is possibly involved in STAT5 activation. Co-immunoprecipitation experiments revealed that SHP-2 association with the FLT3/ITDY842F mutant was considerably diminished as compared to the FLT3/ITD receptor. In addition, the interaction of SHP-2 with Gab2 adaptor protein was greatly compromised in FLT3/ITDY842F expressing BaF3 cells. Taken together, our data suggests that SHP-2 binds FLT3/ITD, either directly or indirectly, and contributes to the signaling pathways activated by mutant FLT3.