bluuebunny/crossref_metadata_2025 huggingface dataset:
Precise Prediction of Response to Therapy by Using the Chemosensitivity Index Ci in Patients with Chronic Lymphocytic Leukemia.
Authors: Staib Peter , Lube Rabea , Schinkothe Timo
Published: October 2019

There are quite a few number of prognostic factors known to determine the prognosis of patients with chronic lymphocytic leukemia (CLL). However, the individual response to therapy may still not be predicted by these factors. Therefore, we investigated prospectively the prediction of response to therapy and the prognostic relevance of the in-vitro chemosensitivity profile in patients with CLL within a randomized trial. For the evaluation of the chemosensitivity profile we applied the methodology of the chemosensitivity index Ci, which we described before in AML (Staib et al., Br J Haematol 2005). Peripheral blood samples from patients with the established diagnosis of B-CLL were taken with written informed consent before treatment was started. For in vitro chemosensitivity testing the Differential Staining Cytotoxicity (DiSC) Assay was used. The fresh leukemic cells were incubated with fludarabine, bendamustine and six other cytotoxic drugs. DiSC assay results were expressed as percent tumor cell survival (%TCS). The chemosensitivity index Ci was calculated according to dose-response curves for each clinically used drug and the area under the curve (AUC). The cut off point between resistance and sensitivity was adjusted at 0,5 for each drug by the AUC data of a subgroup of clinically resistant patients: Ci ≤0.5 indicates resistance, Ci >0.5 sensitivity to the drug.

Results: 53 patients were recruited to a two-arm randomized second line treatment trial from 2001 to 2005. The patients were treated with either fludarabine or bendamustine as a monotherapy. For all patients a chemosensitivity test was performed to predict the clinical outcome for the used treatment. 25 (47%) patients received fludarabine and 28 (53%) bendamustine. 41 pts. (77%) achieved a complete or a partial remission whereas 12 pts. had a stable or progressive disease (23%). All of the responding patients were predicted as sensitive (100%), and all 12 non-responding patients were predicted as resistant (100%). The over all accuracy was 100% (Pearson Chi-square p<0.001). The progression free survival time in patients who were tested to be resistant was 4 months compared to 22 months in patients who were tested to be sensitive (p<0.001).

Conclusion: The presented study demonstrates that the in-vitro chemosensitvity profile is able to predict the clinical treatment outcome in patients with CLL precisely. Therefore, the in-vitro chemosensitivity testing evaluated by the Ci may serve as a powerful tool for assay directed and individualized therapy strategies in B-CLL.
Chronic Lymphocytic Leukemia Cells Have Increased Expression of Cyclic Nucleotide Phosphodiesterase 7B, Which May Serve as Disease-Specific Therapeutic Target.
Authors: Zhang Lingzhi , Murray Fiona , Kanter Joan R. , Chou Daisy , Rassenti Laura , Kipps Thomas J. , Insel Paul A.
Published: October 2019

Non-specific inhibition of cyclic nucleotide phosphodiesterase (PDE) in chronic lymphocytic leukemia (CLL) cells leads to intracellular accumulation of cyclic nucleotides, which in turn can sensitize the CLL cells to spontaneous and/or drug-induced apoptosis. Recent studies have identified at least 11 isoforms of PDE, each of which catalyzes the hydrolysis of cAMP and/or cGMP and regulates the intracellular levels of cyclic nucleotides. The finding that various tissues differentially express selected PDE isoforms has prompted development of isoform-specific inhibitors that can selectively increase intracellular levels of cyclic nucleotides in target cells that over-express the inhibited PDE isoform. Accordingly, we examined for differential expression of PDE isoforms by CLL B cells by assessing the levels of mRNA encoding each of the 11 different PDE isoforms in CLL cells and normal blood lymphocytes using quantitative real-time RT-PCR. CLL cell samples (n = 24) and lymphocytes of healthy adults (n = 16) each expressed detectable levels of PDE isoforms 1A, 1B, 2A, 3A, 3B, 4A, 4B, 4C, 4D, 5A, 7A, 7B, 8A, 8B, and 9A. However, we discovered that CLL cells of each patient had significantly higher levels of PDE7B mRNA (2.8-fold to 368-fold) and significantly lower levels of PDE3B mRNA (5-fold to 138 fold) than did lymphocytes from healthy donors (n = 16). As such, the ratios of PDE7B/PDE3B in CLL cell samples were >3 (ranging from 3 to 1019), whereas normal lymphocytes had ratios of < 0.3 (ranging from 0.006 to 0.23). The mean PDE7B/PDE3B ratio for CLL cells (123.6 ± 45.0, S.D., n=24) was significantly higher than that for B-lymphocytes of normal donors (3.8 ± 1.1, n=10) (P<0.0001). Immunoblot analyses demonstrated that CLL cells uniformly expressed high levels of PDE7B and low levels of PDE3B relative to those of normal lymphocytes. Moreover, we found that PDE7B contributed predominantly to the total PDE activity in CLL cells but not in normal lymphocytes. We thus studied effect of a selective PDE7 inhibitor (BRL-50481) on CLL cells and normal lymphocytes in vitro and found that BRL-50481 dose-dependently promoted apoptosis of CLL cells, but not normal lymphocytes. Collectively these findings indicate that CLL B cells selectively over-express PDE7B and under-express PDE3B relative to normal lymphocytes or isolated blood B cells and suggest that selective inhibitors of PDE7B may be effective in the treatment of this disease.
Remarkable Differences in Cellular Activation State and Migratory and Proliferative Potential among Clonal Cells Derived from Different Tissues of Chronic Lymphocytic Leukemia Patients.
Authors: Damle Rajendra N. , Banapour Taraneh , Temburni Sonal , Wasil Tarun , Kolitz Jonathan E. , Allen Steven L. , Sherry Barbara , Rai Kanti R. , Chiorazzi Nicholas
Published: October 2019

An antigen-independent process that takes place in the bone marrow (BM) leads to the birth of B cells from bone marrow precursors. Cross-talk between components of the microenvironment of BM or secondary lymphoid compartment(s), eg. spleen (SP), nurtures the subsequent evolution of B cells and governs in large part the natural history of normal B cells and B cell malignancies including chronic lymphocytic leukemia (B-CLL). Interaction of B cells with stromal elements confers upon them features enabling their transient sequestration, proliferation and extended survival. In this report we have compared the characteristics of clonal B-CLL cells obtained from paired specimens (peripheral blood, PB with corresponding BM or SP obtained within an interval of less than 1 month of each other) from 17 individual untreated B-CLL patients. These cells were tested by surface immunofluorescence and flow cytometry for their expression of a panel of chemokine receptors (CCR −1, −2, −4, and −7 and CXCR−1, −2, −3, and −4) and markers of cellular activation (CD23, CD62L, CD69, CD71 and HLA-DR). The relative age of the B cells (telomere length) and their ability to maintain telomere length (telomerase activity) were studied in paired BM/SP and PB samples from 15 of these cases. Although PB-, BM- and SP-derived B cells expressed activation markers, specifically, the percentages of cells expressing ZAP-70 and Ki-67 were significantly higher in BM- and SP-derived B cells than those expressed by corresponding PB-derived B cells (p<0.01). Increase in extent of CD38-positivity among members of the clone correlates with poor prognosis in B-CLL. Interestingly, in cases with low CD38 expression (<30% cells expressing CD38), the percentage of B-CLL cells expressing CXCR3 and CCR7 was significantly higher among PB-B cells, than BM/SP-derived B cells. No such differences existed in cases with high CD38 expression. This suggests a role for these receptors and their ligands in maintaining homeostasis of B-CLL cells in this subset of cases (that does not show remarkable progression of disease). In each of the 15 cases studied BM and SP-B cells had significantly higher telomerase activity (p<0.01) than those in PB, although telomere lengths of B cells from both sources were comparable. These findings highlight important differences in cellular kinetics among lymphoid compartments in B-CLL.
Fludarabine, Cyclophosphamide, Mitoxantrone Plus Rituximab (FCM-R) as Frontline Therapy for CLL: Results of a Phase 2 Study.
Authors: Faderl Stefan , Wierda William G. , O’Brien Susan , Ferrajoli Alessandra , Ravandi-Kashani Farhad , Detry Michelle , Kantarjian Hagop M. , O’Neal Brandi , Keating Michael J.
Published: October 2019

Combinations of monoclonal antibodies (moabs) with chemotherapy have produced higher rates of complete remission (CR) and better quality of responses (minimal residual disease [MRD]-negative) than have been achieved with chemotherapy or moabs alone. We have previously shown an overall response (OR) rate of 95% with a CR rate of 73% when combining fludarabine, cyclophosphamide, and rituximab (FCR) as first-line treatment for symptomatic patients with CLL (Keating et al. J Clin Oncol23:4079; 2005). Recent reports of FC plus mitoxantrone (FCM) have demonstrated response rates of 60% and up to 88% in pts with relapsed and untreated CLL, respectively. Here we report preliminary results of a pilot study exploring FCM plus rituximab and pegfilgrastim as frontline therapy for pts with untreated and symptomatic CLL and b2M < 4 mg/L. Treatment consisted of F 25 mg/m2 i.v. d2–4, C 250 mg/m2 i.v. d2–4, M 6 mg/m2 i.v. d2, and R 375 mg/m2 i.v. d1. Pegfilgrastim was 6 mg s.c. d4. For courses 2–6, FCM started day 1 together with R 500 mg/m2, and pegfilgrastim on d3. Courses were repeated q4–6 wks. The primary objectives included efficacy [clinical response by NCI-WG criteria and based on 2-color flow (CD5/CD19) response rate at 3 and 6 mos] and toxicity (especially myelosuppression). Thirty-one pts were enrolled of whom 29 pts are evaluable for response at 3 mos, and 21 pts at 6 mos (1 pt was taken off for insurance reasons after one course, and 1 did not receive any therapy). The median age was 57 yrs (range 38–69). Fourteen pts (48%) were male. Four pts (14%) had Rai stage ≥ 3. Median b2M was 2.6 mg/dL (1.4–4) and the median WBC 59.9 x 109/L (5.6–355). Two pts had 11q23 and 17p− abnormalities by cytogenetics/FISH. Unmutated IgVH occurred in 12/17 (71%) pts; ZAP-70 immunohistochemistry was positive in 11/19 (58%) pts. Twenty-eight pts (97%) responded at 3 mos (41% CR, 17% nPR, 39% PR); 10 pts (34%) had <1% CD5/CD19+ cells in the marrow. Response rates at 6 mos: 33% CR, 10% nPR, 57% PR for an OR rate of 100%. Nine pts had PR because of persistent cytopenias without marrow involvement or residual lymphadenopathy. Eleven pts (55%) had < 1% CD5/CD19+ cells in the marrow at 6 mos. Grade >/= 3 neutropenia occurred in 77% of the pts, thrombocytopenia in 7%, and anemia in 13%. Infectious episodes were seen in 13 pts (45%). Of 21 pts who completed therapy, 3 have received less than 6 courses because of ongoing cytopenias. In conclusion, FCM-R is an active induction regimen for symptomatic patients with CLL. However, clinical response rates and frequency of pts with flow cytometry response < 1% CD5/CD19+ cells does not appear to be different from the FCR experience. Neutropenia occurs in most patients and continued use of hematopoietic growth factors throughout therapy is recommended.
Subcutaneous Alemtuzumab in Patients with Refractory/Relapsed B-Cell CLL after a Fludarabine-Based Regimen. An Interim Analysis.
Authors: Bezares R. Fernando , Stemmelin German , Argentieri Daniel , Lanari Emilio , Guy-Garay Efrain , Campestri Reinaldo , Bartomioli Miguel , Garcia Juan Jose , Giralt Sergio , Milone Gustav ,   on Behalf of the Latin American Cooperative Onco-Hematology Group (LACOHG)
Published: October 2019

Background: Alemtuzumab is the only single agent immunotherapy to demonstrate a survival benefit in patients with B-cell chronic lymphocytic leukemia (B-CLL), who have relapsed from or are refractory to Fludarabine therapy. The optimized schedule for alemtuzumab that achieves maximal efficacy with manageable toxicity is still being explored. Here, we report the second interim analysis of a new, less intensive schedule of alemtuzumab administered subcutaneously (SC) to patients with refractory/relapsed B-CLL.

Methods: Alemtuzumab was dose escalated from 10 to 20 mg during the first week, 30 mg twice week during the second and third weeks, and 30 mg once weekly during Weeks 4, 6, 8, 10, 12, 16, 20, 24, 28, 34, and 40. Antiviral prophylaxis included TMP/SMX bid 3 times a week and acyclovir 200 mg three-times daily.

Results: Of the 38 patients who were recruited to participate in the trial, 12 (31.6%)were refractory and 26 (68.4%) had relapsed from prior therapy. Patients had a median age of 66.5 years (range, 43–86 years), 30 were male (79%), 45%/53% had Binet stage B/C disease. The median number of prior therapies was 1 (range: 1–4). The median duration of therapy was 7 weeks (range, 2–24 weeks), with a median cumulative alemtuzumab dose of 457 mg (range, 120–1,080 mg). Among the 35 patients who were evaluable for response, the overall response rate was 88.6%: 45.8%complete response (CR), 2.9% unconfirmed CR, 42.8% partial response (PR). Four patients ( 11.5%) did not respond to therapy. Of the 9 patients with refractory disease, 1 achieved a CR, 6 a PR and 2 did not respond. Median follow up was 13 months and median overall survival was not achieved. Minimal residual disease (MRD) was measured by flow cytometry in 6 patients who achieved a CR: 4 patients had <0.5% of CD5/CD19+ cells, 1 patient had <5% of CLL cells, and 1 patient had <10% CLL cells. According to WHO toxicity criteria, over 38 evaluable patients, 4 (10,6%) experienced grade 3/4 infection; 2 patients had grade 2/3 granulocytopenia/thrombocytopenia; 1 patient had cytomegalovirus (CMV) reactivation without CMV disease; and 1 patient developed Epstein-Barr Virus with prolonged bone marrow hypoplasia.

Conclusion: Results of this second interim analysis suggest that a less intense regimen of alemtuzumab is feasible, effective, and safe for patients with refractory/relapse B-CLL after fludarabine therapy.
Pharmacokinetics of Oral Maribavir, a Novel Anti-Cytomegalovirus Agent, in Subjects with Renal Impairment.
Authors: Swan Suzanne , Smith William , Marbury Thomas , Schumacher Mary , Dougherty Carolyn , Mico Bruce , Villano Stephen
Published: October 2019

Maribavir (MBV) is an oral antiviral drug with a unique mechanism of action against cytomegalovirus (CMV). Maribavir is currently in clinical development for use in recipients of stem cell or solid organ transplants, who are vulnerable to renal impairment caused by a variety of drugs or post-transplant complications. Characterization of the pharmacokinetic (PK) profile of maribavir in patients with renal impairment was needed to determine if dose adjustment is indicated. The effect of renal function on the PK of a single 400 mg dose of maribavir was evaluated in adults with normal renal function (creatinine clearance >80 mL/min) and adults with renal impairment classified as mild, moderate, or severe, as measured by creatinine clearance 50–80, 30–<50, and <30 mL/min, respectively. Subjects requiring dialysis were not included. PK results, based on total (bound and unbound) plasma concentrations are shown in the table. Analyses of PK parameters estimated from unbound plasma concentrations of maribavir also did not show statistically significant differences between groups. Renal impairment was associated higher AUC and Cmax values as well as with reductions in the oral clearance and terminal-phase volume of distribution of VP 44469, an inactive metabolite of maribavir. Results were consistent with those of previous studies, which showed that very little maribavir was excreted unchanged in urine while about 22% of an oral dose of maribavir is recovered in urine as VP 44469. In conclusion, renal impairment does not affect the pharmacokinetics of maribavir, although plasma concentrations of the metabolite VP 44469 tended to increase with decreasing creatinine clearance. No dose adjustment of maribavir is indicated in subjects with renal impairment as classified in this study.

Mean Maribavir PK Parameters Normal Renal Function Mild/moderate Renal Impairment Severe Renal Impairment ANOVA p-value Parameter (unit) N=12 N=10 N=8 Cmax (mcg/mL) 22.6 22.0 21.5 0.869 AUC 0-∞ (mcg*h/mL) 139 145 136 0.810 T 1/2 (h) 5.51 5.61 5.28 0.780 CL/F (L/h) 3.38 3.05 3.56 0.808
Ex-Vivo Reduction of Allograft T Cell Dose Does Not Prevent Acute Graft-vs-Host Disease after Reduced-Intensity Hematopoietic Stem Cell Transplantation.
Authors: Hardy Nancy M. , Hakim Frances , Steinberg Seth , Krumlauf Michael , Babb Rebecca , Odom Jeanne , Fowler Daniel , Gress Ronald , Bishop Michael R.
Published: October 2019

Allograft T cell depletion (TCD) reduces acute graft-vs. host disease (aGVHD) after myeloablative hematopoietic stem cell transplantation (HSCT). Lower incidences of aGVHD reported after reduced-intensity stem cell transplantation (RIST) may reflect delayed donor T cell engraftment. We compared the incidence of aGVHD following RIST with TCD (19 patients (pts) vs. T cell replete (TCR) allografts (20 pts)(Table). There was no difference in the incidence aGVHD, occurring in 71% of TCD recipients (median onset Day 47) and 70% of TCR recipients (median onset Day 25). After TCD, 100% of those who engrafted prior to any DLI developed aGVHD compared with 56% of those who engrafted after DLI, including two pts who developed “late-acute” aGVHD after Day 100, upon completion of donor T cell engraftment. T cell engraftment after TCD was uneven: engraftment kinetics were associated with residual host circulating CD8+ T cell counts after immune depletion; and aGVHD did not occur in the setting of mixed T cell chimerism (Figure). These observations demonstrate that aGVHD can occur with very low doses (105/kg) of allograft T cells after RIST. Protection from aGVHD conferred by mixed T cell chimerism may be lost with full donor T cell engraftment. With limited donor T cell numbers, host T cells appear to determine kinetics of engraftment and of aGVHD after RIST. Figure:

Post-induction circulating CD8+ T cell counts in TCD recipients with delayed donor T cell engraftment. After TCD, all subjects who developed aGVHD did so at or after the establishment of T cell full donor T cell chimerism, and occasionally prior to any DLI.

Shaded triangle represents the theoretical area in which values would fall if subjects developed aGVHD prior to complete donor T cell engraftment. Arrows: DLI.

Patient and Transplant Characteristics and Outcomes Protocol TCD TCR Flu/Cy: Fludarabine and cyclophosphamide; EPOCH-F: Etoposide, doxorubicin, vincristine, cyclophosphamide, prednisone and fludarabine; FDC: Full donor chimerism. Median (range) Median (range) Recipient Age 43 years (32 – 56) 44 (19 – 67) CMV Risk 14/19 16/20 Pretransplant Immune Depletion Flu/Cy EPOCH-F Conditioning Regimen Flu/Cy Flu/Cy Pre-conditioning Host Cell Counts: CD3 86 (1 – 701) 140 (21 – 441) CD4, p=0.017 44 (1 – 156) 71 (12 – 191) CD8 34 (0 – 555) 55 (2 – 309) NK 58 (0 – 376) 88 (3 – 467) Day 0 CD3 Cell Count 1 (1 – 6) 5 (0 – 42) Allograft CD34+ cells/kg 7.75 x 106 (5.1 – 12.9) 7.68 x 106 (4.6–18.4) Allograft CD3+ cells/kg 1.0 x 105 (preset) 3.63 x 108 (1.5 – 8.3) Donor T cell engraftment Day +70 (14 – 180) 14 (14 – 100)

Figure Figure
Campath 1H Versus ATG for the Prophylaxis of Graft Versus Host Disease Does Not Increase the Risk of Relapse or Infections.
Authors: Shah Ami J. , Kapoor Neena , Crooks Gay M. , Kohn Donald B. , Weinberg Kenneth I. , Killen Renna , Kuo Lily , Parkman Robertson
Published: October 2019

Graft Versus Host Disease (GVHD) is a cause of serious morbidity and mortality in > 50% of recipients of unrelated hematopoietic stem cell transplantation (HSCT). We performed a trial using Campath 1 H pre- and post-HSCT in an attempt to decrease the incidence of GVHD without increasing the risk of infection or relapse. Patients were retrospectively compared to a population of patients who received antithymocyte globulin (ATG) pre-and post-HSCT.

Materials and Methods: 27 patients were evaluated for this study. Fourteen patients received Campath 1H and 13 patients received ATG. Demographics of patients who received Campath 1H consisted of 9 males and 5 females, with a median age of 13 years (3 years–17.8 years). Thirteen patients received unrelated BM and 1 patient received unrelated PBSC. Demographics of patients receiving ATG consisted of 9 males, 4 females with a median age of 7.4 years (21 months–19 years). Twelve patients received unrelated bone marrow (BM) and 1 patient received unrelated peripheral blood stem cells (PBSC). Diagnoses were similar between the two groups. Patients who received Campath1H received a total dose of 52 mg/m2 pre-HSCT and 20 mg/m2 post-HSCT. Patients who received ATG received a total dose of 60 mg/kg pre-HSCT and 100 mg/kg post-HSCT. GVHD prophylaxis and supportive care measures were similar in both groups.

Results: There was a significant difference in the incidence of severe (grade III and grade IV) GVHD between the two arms [Campath (0/14) vs. ATG (6/13), p=0.006]. Among the patients who were transplanted for leukemia, there was no significant difference between the two arms in terms of relapse [Campath (2/14) vs. ATG (4/9), p=0.162]. The 1- year and 2-year overall survival between the two arms was not significantly different [Campath 1H (64%) vs. ATG (69%), p=0.98]. Patients receiving Campath 1H had the presence of CD3+ T cells (>30 cells/ml) in their peripheral blood later than in those who received ATG [65 days (Campath 1H) vs. 27 days (ATG), p=0.001]. The median time to the development of a response to PHA occurred later in the Campath 1H arm [240 days (Campath 1H) vs. 90 days (ATG), p= 0.0005]. The median time to an antigen specific response also occurred later in those receiving Campath 1H [365 days (Campath 1H) vs. 150 days (ATG), p= 0.008]. Patients who received ATG had a greater chance of developing a candida infection [Campath 1H (2/14) vs. ATG (8/13) p=0.02]. Among other specific viral infections, there was no significant difference between the two groups.

Conclusions: Campath 1H is effective in decreasing the incidence of GVHD without increasing the risk of relapse. Although there is a significant delay in immune reconstitution, there was no increase in infectious complications in recipients of Campath 1H.
Dendritic Cell Type 2 Counts on Day 28 in HLA-Matched Related Allogeneic PBSCT Predicts the Incidence of Acute and Chronic GVHD.
Authors: Rajasekar Reena M. , Mathews Vikram , Lakshmi Kavitha M. , Viswabandya Auro , George Biju , Chandy Mammen , Srivastava Alok
Published: October 2019

Dendritic cells (DC) are antigen-presenting cells involved in induction and regulation of immune responses. We investigated the impact of the number of infused and engrafted (day 28) dendritic cells, DC1 (lin−HLA-DR+CD11c+) and DC2 (lin−HLA-DR+CD123+) on the development of acute and chronic graft-versus-host disease (GVHD). Thirty three consecutive patients with hematological malignancies who underwent HLA-matched related G-CSF mobilized allogeneic PBSCT were included in the analysis. The mean follow up was 293 days (range: 36–417). There were 20 males and 13 females (median age: 29 years, range: 15–55). Conditioning regimen was myeloablative in 25 (Bu/Cy=13; Cy/TBI = 12) and non myeloablative in 8 patients (Flu/Mel = 7; Flu/Cy = 1). All patients received cyclosporine and short course methotrexate as GVHD prophylaxis. Three of them received steroids before day 28 for treatment of GVHD. Ten patients developed acute GVHD (grade II–IV) and 11 patients had chronic GVHD. The median DC2 count in the peripheral blood on day 28 was significantly lower among patients who developed acute GVHD as compared to those who did not and there was a trend to a lower count among patients with chronic GVHD [Table 1]. Based on the day 28 DC2 count patients were divided into a low DC2 quartile (<2.3cell/ul, n=8) and the rest were grouped as high DC2 (>2.3cell/ul, n=25). The two groups were comparable with regard to patient and graft characteristics (CD34, CD133, CD3, CD4, CD4CD45RO, CD4CD45RA, CD8, CD8CD45RO, CD8CD45RA, CD19, NK, DC1and DC2 cell dose). Patients in the low DC2 quartile group had higher probability of developing acute (P=0.000) and chronic GVHD (P= 0.022). Cox regression analysis revealed that low day 28 DC2 counts is associated with higher incidence of acute GVHD (HR=11.4; 95%CI=2.9–44.9; P=0.001) and chronic GVHD (HR=7.07; 95%CI=1.9–26.6; P=0.004). In a multivariate analysis which included other standard risk factors such as female to male transplants, conditioning regimen, CD34 and CD3 cell dose, low day 28 DC2 was found to be a risk factor for acute GVHD (HR=21.1; 95%CI=3–149.9; P=0.002) together with patient age (HR=1.1; 95%CI=1–1.3; P=0.039). DC1, DC2 counts in the graft and day 28 DC1 count did not correlate with the development of acute or chronic GVHD. Excluding patients who had developed acute GVHD before day 28 (n=3), a low day 28 DC2 count (<2.3/ul) had a positive predictive value of 80% for acute GVHD and 75% for chronic GVHD. These results suggest that the DC2 count in the peripheral blood on day 28 is a strong predictor for development of GVHD in recipients of PBSC in matched related allogeneic HSCT.

Table 1: Median day 28 DC2 count and GVHD n, median DC2 x 103/ml (range) Yes No P-value Acute GVHD (II=IV) 10, 2.06(0.6–24.8) 23, 11.5(1.1–46.6) 0.004 Chronic GVHD 11, 2.4(1.1–46.6) 17, 8.19(1.6–44.9) 0.070
Functional Comparison and Longitudinal Assessment of Tri-Functional T-Cells Recognizing CMV pp65 and IE-1 Polypeptides in Hematopoietic Stem Cell and Solid Organ Transplant Recipients.
Authors: Diamond Don J. , Lacey Simon F. , La Rosa Corinna , Zhou Wendy , Gallez-Hawkins Ghislaine , Thao Lia , Longmate Jeff , Limaye Ajit , Spielberger Ricardo , Forman Stephen J. , Zaia John A.
Published: October 2019

Reconstitution of adaptive T-cell responses to human cytomegalovirus (CMV) is critical to protection from CMV disease following hematopoietic stem cell (HSCT) or solid organ transplantation (SOT). However, there is an incomplete understanding of which CMV antigens and epitopes are most crucial to providing protective responses. The functional status of cytotoxic T-lymphocyte (CTL) populations recognizing cytomegalovirus IE-1 and pp65 polypeptides was investigated in PBMC from either HSCT or SOT recipients. Our previous finding of differing levels of degranulation between CMV IE1 and pp65/pp50 specific T-cells was complicated by the possibility that differences were epitope and/or HLA-specific. We generalized the approach using a combined flow-based CD107a/b degranulation/mobilization and intracellular cytokine (ICC) assays using peptide libraries as antigens. These assays indicated that a significantly higher proportion of pp65-specific CTLs were in a more mature functional state compared to IE-1-specific CTLs. Degranulation/multicytokine ICC assays also indicated that a significantly higher proportion of the pp65-specific versus IE-1-specific CTLs secreted both IFN-γ and TNF-α, in addition to possessing greater cytotoxic potential. These results support our earlier findings of functional differences between CTLs recognizing individual epitopes within the IE-1 and pp65 antigens in HSCT recipients, and extend them to a broader array of HLA-restricted responses to those antigens. A report that a subset of HIV-1 specific CTLs capable of producing both IFN-γ and TNF-α was associated with improved cytotoxic activity prompted us to investigate whether degranulation, a functional correlate of cytotoxicity, was positively associated with dual cytokine production and predicted differences between IE1 and pp65-specific CD8+ T-cells. A higher proportion of pp65-specific compared to IE1-specific T-cells were present in the trifunctional IFN-γ+,TNF-α+, CD107+ population (p=0.008) in HSCT recipients. We have extended these findings to investigate the role of donor CMV status in terms of functional maturity of CMV-specific T cell response in transplant recipients. T cell maturation/function may act as a mechanistic correlate to the survival advantage of recipients receiving a stem-cell graft from CMV sero-positive donors. These principles have also been applied to investigations of a high risk population of sero-negative recipients of a sero-positive liver allograft. Data from this study will also be reviewed in the context of the model of trifunctional T cells being indicative of enhanced protective capacity against CMV disease and associated with survival.
Prophylactic Use of Intravenous Immune Globulin in the Management of Patients Undergoing Hematopoietic Stem Cell Transplantation: A Systematic Review of Literature.
Authors: Tay Jason , Fergusson Dean , Hutton Brian , Hebert Paul , Huebsch Lothar , Tinmouth Alan
Published: October 2019

Background: Intravenous immunoglobulin (IVIG) is a scarce resource derived from pooled plasma of whole blood through industrial fractionation. IVIG for the prevention of infections and Graft versus host disease (GVHD) after Hematopoietic Stem cell transplantation (HSCT) is one of only 5 licensed indications; however, its use in HSCT is contentious with multiple conflicting reports. Given this uncertainty, we sought to summarize and quantify the clinical effects of prophylactic IVIG in the context of HSCT.

Methods: We conducted a systematic review to summarize evidence from prospective randomized controlled trials (RCTs) addressing prophylactic IVIG use in patients undergoing HSCT. In particular, we included studies which addressed clinical outcomes and excluded studies that addressed only biochemical surrogates. The search strategy included MEDLINE (1966 to 4th week of July 2006), EMBASE (1980 to 4th week of July 2006) and all EBM Reviews (2ndquarter of 2006). A random effects model was used to summarize the outcome data.

Results: Twenty two RCTs representing 3346 patients were included in the review; 16 RCTs addressing patients undergoing allogeneic HSCT, 4 RCTs addressing patients undergoing either allogeneic or autologous HSCT and 1 trial in patients undergoing autologous HSCT. Nine RCTs (n=1462) compared conventional IVIG to no treatment, 8 RCTs (n=538) compared CMV specific IVIG to no treatment, 2 RCTs (n=950) compared 2 different doses of conventional IVIG while 3 RCTs (n=212) compared conventional IVIG to CMV specific IVIG/plasma. Eleven RCTs comparing IVIG to no treatment did not demonstrate an overall survival advantage (RR 1.01; 95% 0.92–1.12). IVIG did not attenuate transplant related mortality (RR 1.24; 95% 0.83–1.85), acute GVHD (RR 0.95; 95% 0.80–1.14), chronic GVHD (RR 1.19; 95% 0.85–1.67), interstitial fibrosis (RR 1.00; 95% 0.50–2.00) or relapse (RR 0.76; 95% 0.38–1.52). Although CMV infections were reduced (RR 0.80; 95% 0.66–0.96), this did not result in a reduction in CMV disease (RR 0.90; 95% 0.52–1.56). Of concern, the risk of hepatic sinusoidal obstruction syndrome (HSOS) was increased (RR 3.09; 95% 1.11–8.58). Several a priori defined sensitivity analyses were performed including comparisons of the type of IVIG, dose of IVIG, type of HSCT and the quality of studies.

Conclusions: There is no evidence to support the routine use of prophylactic IVIG in improving clinical outcomes in patients undergoing HSCT. Furthermore, no subgroups appear to benefit from IVIG use. The increased risk of HSOS merits further study. Given the lack of benefit of IVIG in patients undergoing HSCT, the labeled indications for IVIG should be reassessed.
Effect of Repeated Apotransferrin Administrations on Serum Iron Parameters in Patients Undergoing Myeloablative Conditioning and Allogeneic Stem Cell Transplantation.
Authors: Ebeling Freja , Parkkinen Jaakko , Sahlstedt Leila , von Bonsdorff Leni , Salo Hanna , Ruutu Tapani
Published: October 2019

The myeloablative preconditioning for hematopoietic stem cell transplantation (SCT) disrupts the main route of body iron turnover by temporarily halting erythropoiesis. This is followed by rapid increase in transferrin saturation and appearance of non-transferrin-bound iron (NTBI) in plasma (Sahlstedt et al, Br J Haematol 2001). We have previously shown that considerable amounts of iron can in this situation be bound by a single intravenous dose of human plasma-derived ironless transferrin, apotransferrin (Sahlstedt al, Br J Haematol 2002). NTBI is cleared from circulation by the liver, to which iron-catalyzed generation of reactive oxygen species are considered to be potentially toxic as also possibly contributing to mucositis and idiopathic pneumonia syndrome. We studied the ability of three repeated apotransferrin dosing regimens to maintain the accumulating iron in a transferrin-bound form in 20 patients receiving cyclophosphamide 120mg/kg and total body irradiation 12 Gy before SCT. The low-dose group received a total dose (including loading and maintenance doses) of 340 mg/kg, the medium-dose group 610 mg/kg and the high-dose group 1040 mg/kg starting on day −6 before SCT. Serum transferrin, total iron, NTBI and transferrin saturation were analyzed from daily samples until day +14. A significantly higher increase in serum transferrin and in serum total iron was detected in the high-dose group compared with the other dose groups and controls. On the second day after start of preconditioning, the mean increase in serum iron was 48 μmol. At the same time, the 24-hour increment in serum transferrin after the apotransferrin doses decreased by 45% pointing to uptake of transferrin-bound iron by tissues. Serum iron levels remained significantly more elevated in the high-dose group compared with controls for about 10 days, after which their decrease coincided with appearance of reticulocytes in peripheral blood. In 5/8 patients in the high-dose group, no detectable NTBI was found during the study period, whereas in the controls 75% of the samples were NBTI positive. In conclusion, even with repeated administration of relatively large doses of apotransferrin, full transferrin saturation and appearance of NTBI can be prevented in only part of the patients. Achieving complete iron binding with apotransferrin in all SCT patients would apparently require very high apotransferrin doses. The remarkable rise in transferrin saturation indicates that about 180 μmol or iron per day is initially released into circulation after start of preconditioning therapy.

Figure Figure
Comparable Results of HLA Identical Sibling Donor Peripheral Blood Hematopoietic Stem Cell Transplantation after Reduced-Intensity and High-Dose TBI-Based CD34+-Positive Cell Selection Myeloablative Preparative Regimens for High-Risk Myelodysplasia or Acute Myeloid Leukemia in First Remission: Results from a Prospective Study.
Authors: Martino Rodrigo , Valcarcel David , Pinana Jose L. , Sureda Anna , Brunet Salut , Briones Javier , Sanchez Blanca , Delgado Julio , Sierra Jorge
Published: October 2019

We prospectively compared the efficacy of allogeneic PBSCT from an HLA-identical sibling in adults with poor-risk AML or MDS in an early disease status (AML or RAEB type 2 in first CR after chemotherapy or RAEB type 1 with poor prognosis). Poor-risk AML/MDS was defined as the presence at diagnosis of one or more of the following: poor-risk karyoype, normal karyotype with flt-3 duplications or MLL mutations, high level of MRD after consolidation (>0.1%), and, in RAEB type 1, an IPSS3Int-2. Based only on the patients’ age, the transplant protocol consisted in conditioning with cyclophosphamide-TBI and use of CD34+-selected PBSCT (CyTBI-CD34+ group, if £ 50 y.o.) or a reduced-intensity conditioning (RIC) with fludarabine and oral busulphan (FluBu-RIC, If > 50 y.o.). Between 1998 and 2005, 74 consecutive patients entered the study (35 in the CyTBI-CD34+ and 39 in the FluBu-RIC group). Both groups differed in some baseline characteristics, mainly younger age in the CyTBI-CD34+ group (median 42 vs. 59 years, p<0.01), a higher transplant comorbidity index in the FluBu-RIC group (median 0 vs. 3 points, respectively, P<0.01), a higher proportion of AML (with respect to RAEB) in CyTBI-CD34+ group (82% vs 54%, respectively, P=0.02), and a higher proportion of poor-risk karyorypes in the FluBu-RIC group (32% vs 72%, respectively, P<0.01). The median follow-up exceeds 4 years in both groups. All patients had sustained donor-engraftment by day +60, except for one lethal graft failure in the CyTBI-CD34+ group. The 4-year probability of OS was and LFS were similar in both groups (52% and 53% in the CyTBI-CD34+ group vs. 53% and 53% in the FluBu-RIC group, respectively, P>0.8 for OS and LFS). In addition, the 4-year cumulative incidence of non-relapse mortality (NRM) was 25% (95% CI 11–38%) and 22% (95% CI 5–39%), respectively (P>0.8), while the incidence of relapse was 22% (95% CI 5–39%) and 25% (95% CI 6–44%), respectively (P>0.8). In univariate analysis, the only variable that decreased OS and LFS by increasing NRM was the patient male/donor female sex combination (n=18 cases). The OS and NRM in these 18 cases were 37% and 40%, respectively, while the 56 cases with other sex combinations had much better outcomes (66% OS and 8% NRM, P=0.004 and P==0.001 for the comparison of OS and NRM, respectively). Trends were seen for improved OS and lower NRM in the CyTBI-CD34+ group in patients less than 40 years of age (P=0.1) and in patients receiving higher doses of CD34+ cells/kg in the FluBu-RIC group (P=0.1). Our single-center results suggest comparable outcomes for RIC alloPBSCT in high-risk adults with poor-risk AML and MDS in an early disease phase.
Allogeneic Stem Cell Transplantation in Idiopathic Myelofibrosis: The Italian Experience.
Authors: Patriarca Francesca F. , Sperotto Alessandra A. , Bruno Barbara B. , Bacigalupo Andrea A. , Bosi Alberto A. , Fanin Renato R.
Published: October 2019

Allogeneic haematopoietic stem cell transplantation (HSCT) is the only curative treatment for idiopathic myelofibrosis (IM), but it is associated with a high transplantation-related (TRM) mortality rate, especially in advanced and elderly patients. Recently, reduced-intensity conditioning (RIC) regimens were reported to be feasible in these subgroups of patients. Herein, we reported a preliminary analysis of the data of the Gruppo Italiano Trapianto Midollo Osseo (G.I.T.M.O.) Registry regarding a total of 92 patients with IM, who underwent allogeneic HSCT in 25 different Italian Transplant Centres between 1986 and 2005. One Centre performed 26 transplants, 4 Institutions performed between 6 and 10 transplants and the other 20 Centres realized five or less procedures. Ten transplants (11 %) were performed before 1995, 26 (28%) between 1996 and 2000 and 56 (61%) between 2001 and 2005. Sixty patients (65%) were male and median age was 49 years ( range 21–68). Thirty-nine patients (42%) were older than 50 and 8 older than 60 years. Forty-four (48%) received myeloablative conditioning and 48 (52%) a RIC regimen. Myeloablative conditioning was based on cyclophosphamide plus thiotepa ( 42% of the patients) or busulfan (37%) or total body irradiation at the dose of 10–12 Gy (21%). RIC transplants consisted of a combination of fludarabine and 2 Gy TBI (44%) or cyclophosphamide (4%) or busulphan (4%) or an association of thiotepa and cyclophospamide (48%). GVHD prophylaxis included cyclosporin-A and short-course methotrexate, with the association of ATG in 11 patients. Stem cells came from matched sibling donors for 70 patients (76%), missmatched sibling donors for 10 patients (11%) and from matched unrelated donors for the remaining 12 patients (13%). Forty-nine patients (53%) received BM cells and the other 53 cases (47%) PBSC. Seventy-eight out 92 (85%) achieved full engrafment. One-year TRM was 35%. Causes of TRM were as following: GVHD (33% of the patients), infections (36%), bleeding (12%), veno-occlusive disease (3%), thrombotic thrombocytopenic purpura (6%). We observed a trend of higher TRM rate in patients transplanted before 2000 in comparison with those transplanted later (48% vs 33%). However, other potential risk factors for TRM, such as patient age > 50 years, conventional conditioning and unrelated or mismatched donors did not significantly increase TRM rate. There are 43 patients (47%) alive 12 to 156 months after transplantation ( median, 35 months).

We conclude that, albeit TRM rate has been lowered in transplants performed in the last 5 years, it still involves one-third of the patients and remains a matter of concern. The ongoing analysis will focus on the impact of the clinical and biological factors at transplant on the outcome of the patient population.
Alemtuzumab (CAMPATH®, MABCAMPATH®) Has Superior Progression Free Survival (PFS) vs Chlorambucil as Front-Line Therapy for Patients with Progressive B-Cell Chronic Lymphocytic Leukemia (BCLL).
Authors: Hillmen Peter , Skotnicki Aleksander , Robak Tadeusz , Jaksic Branimir , Sirard Cynthia , Mayer Jiri
Published: October 2019

CAM307 is a phase III, open-label, multinational, randomized controlled trial comparing alemtuzumab (CAM) with chlorambucil (CHLO) for previously untreated BCLL requiring therapy. Eligible patients with Rai Stages I–IV were randomized 1:1 to either CAM 30 mg IV tiw for up to 12 weeks or CHLO 40 mg/m2 po q 28 days up to 12 cycles. CAM patients received prophylactic trimethoprim/sulfamethoxazole DS and famciclovir treatment during therapy and until CD4+ counts were ≥200 cells/μL. The primary endpoint was PFS; secondary endpoints were response rate, overall survival, and safety. A total of 297 patients were enrolled (CAM n=149 and CHLO n=148); median age: 60 years; performance status 0–1: 96%; maximum lymph node size ≥5 cm: 22%; and Rai Stage I–II: 63%, Rai Stage III–IV: 33%. Diagnosis, Rai Stage, response and disease progression were confirmed by an independent response review panel (IRRP). CAM has a significantly prolonged PFS compared to CHLO (p=0.0001; see KM survival curve).PFS in CAM vs CHLO patients with adverse cytogenetic findings of del 17p (n=21) was 10.7 mo vs 2.2 mo and for trisomy 12 (n=39) was 18.3 mo vs 12.9 mo. Results were similar for patients with del 11q (n=54, 8.5 mo vs 8.6 mo). Common (≥15%) CAM reported adverse events (AEs) (n=147), likely infusion-related, included pyrexia (70%), chills (53%), nausea (18%), hypotension (16%) and urticaria (16%). Common AEs (≥15%) in the CHLO arm (n=147) were nausea (37%) and vomiting (18%). Frequency of asymptomatic CMV viremia on the CAM arm was 52%; CMV infection occurred in only 16%, none grade 4. CAM treatment was interrupted in 56% of CMV viremic patients, and resumed in 92% with ORR 92% (31% CR). Ganciclovir was administered to 41% of CAM patients with CMV viremia. Infections, including CMV, were reported in 76% of CAM and 50% of CHLO patients while on study. Relevant grade 3/4 treatment-emergent events included (CAM vs CHLO): lymphopenia (97% vs 3%), pyrexia (8% vs 0%), CMV events (8% vs 0%) and chills (3% vs 0%). Treatment emergent grade 3/4 thrombocytopenia (16% vs 13%) and anemia (14% vs 19%) were similar, and although grade 3/4 neutropenia was more common with CAM, (45% vs. 26%), AEs of CAM vs CHLO bacteremia/sepsis (3% vs 2%) and febrile neutropenia (5% vs 3%) were comparable. Serious AEs were reported for 44% of CAM (20% for IV Ganciclovir only in CMV viremic patients) and 20% of CHLO patients while on study treatment. CONCLUSIONS: CAM307 demonstrates that therapy-naïve BCLL patients treated with CAM have significantly longer PFS and higher ORR than those treated with CHLO, with manageable toxicities. Although CMV reactivation was reported in the CAM arm, prompt intervention maintained efficacy. The activity seen here supports ongoing investigations of CAM in first line combination therapy, high risk patients and consolidation.

Figure Figure
Allogeneic Stem Cell Transplantation (Allo-SCT) for Relapsed/Refractory T Cell Lymphomas in Adults: A Survey from the Société Française de Greffe de Moelle et de Thérapie Cellulaire (SFGM-TC).
Authors: Le Gouill Steven , Milpied Jean-noël , Vernant Jean-paul , Ifrah Norbert , Mechinaud Françoise , Gratecos Nicole , Chir Zina , Harousseau Jean-luc , Socié Gérard , Haioun Corinne , Blaise Didier , Michallet Mauricette
Published: October 2019

Background: Adult mature T-cell and NK-cell neoplasms include several lymphomas entities. Taken together, T- and NK- cell lymphomas represent 10–15 % of non-Hodgkin’s lymphoma in adults, presenting with aggressive behaviour and poor outcome (except for ALCL ALK positif lymphomas). Despite intensive chemotherapy including or not autologous stem cell transplantation upfront, a majority of patients experience relapse. Therefore, allo-SCT is an attractive second-line strategy. We retrospectively analyzed T-cell lymphomas patients (lymphoblastic lymphomas were systematically excluded) reported to the SFGM-TC registry and transplanted from an HLA identical sibling donor with or without myeloablative conditioning regimen.

Results: In the present intermediate report, we analysed 24 patients. Because of misdiagnosis, we excluded two cases. Among the 22 remaining patients, there were peripheral T-cell lymphoma NOS (PTCL) in 5 cases, angioimmunoblastic T-cell lymphoma (AITL) in 3 cases, anaplastic large cell lymphoma (ALCL) in 10 cases (ALK positif in 3 cases; negative in 2 cases and unknown in 5 cases; respectively), hepatosplenic g/d lymphoma (HSL) in 2 cases, T-cell granular lymphocytic leukemia (GLL) in 1 case and localized nasal NK/T cell lymphoma (NK/L) in one case. There were 15 males and 7 females. Median age was 38.5 years (15.5–54). All patients have been considered eligible for allo-SCT because of poor prognosis factors: HSL diagnosis in 2 cases, relapsed/refractory disease in 16 cases (including all ALCL cases) and/or failure to reach CR in 8 cases. Disease status at the time of transplantation was CR in 9 cases, PR in 7 cases and PD/refractory in 3 cases; respectively. All patients but 2 underwent myeloablative conditioning regimen prior to transplantation (TBI/EDX in 70%). The majority of patients (86%) received BMSC graft from related HLA-matched sibling donor. Median overall survival (OS) was 70 months for the all cohort. Median OS was not reached in the ALCL subgroup compared to 20 months for the non-ALCL subgroup. According to disease status, 7 out of 9 patients in CR at the time of transplantation are alive and in CR at the time of the analysis compared to 6 out of 13 in non-CR patients. Cause of death was AGVH in 2 cases, bacterial or fatal infections in 4 cases and relapse in 2 cases, respectively.

Conclusion: these preliminary results show that allo-SCT is a treatment of choice for refractory/relapsed T-cell lymphomas. Results are very encouraging in relapsed/refractory ALCL patients and highlight the role of graft versus T-cell lymphoma effect. Further analysis are required to identify prognosis factors and additional cases will be analyzed at the time of the meeting.