bluuebunny/crossref_metadata_2025 huggingface dataset:
Preliminary Results of Sibling Donor Immunization with Patient-Derived Id-KLH Vaccine Prior to Reduced-Intensity Allogeneic Stem Cell Transplantation for Multiple Myeloma.
Authors: Bishop Michael R. , Neelapu Sattva , Fowler Daniel H. , Krumlauf Michael , Gress Ronald , Kwak Larry W.
Published: October 2019

Reduced-intensity allogeneic stem cell transplantation (RIST) results in significant reduction in treatment-related mortality for multiple myeloma (MM) patients (pts); however, success with RIST is limited by a significant risk of relapse. To reduce the risk of relapse, HLA-matched sibling donors were vaccinated with patient-derived idiotype (Id) conjugated to keyhole limpet hemocyanin (Id-KLH) prior to stem cell donation with the goal of transferring tumor antigen-specific immunity. MM pts with HLA-matched siblings underwent plasmapheresis prior to treatment to generate Id-KLH vaccine. After vaccine generation donors received 3 SQ injections of Id-KLH + GM-CSF at 10, 8, and 4 weeks before G-CSF mobilized blood stem cell collection. During vaccine generation and donor immunizaton, MM pts received an induction regimen of EPOCH-F (etoposide, prednisone, vincristine, cyclophosphamide, adriamycin, fludarabine) to achieve a minimal disease state and deplete host T cells in preparation for RIST. MM pts then received a reduced-intensity conditioning regimen consisting of fludarabine (30 mg/m2/d x 4d) and cyclophosphamide (1200 mg/m2/d IV x 4d) followed by allogeneic stem cell infusion. MM pts were then vaccinated with the Id-KLH+GM-CSF at 3, 4, and 6 months post-RIST. Both donors and MM pts were monitored for Id-specific humoral and cellular responses. Five MM pts (ages: 50–60 years; IgG = 4, IgA = 1) and their respective donors have been enrolled onto study. Vaccine was generated from all 5 MM pts. All 5 donors completed vaccinations without significant complications; there were no grade 3 or 4 toxicities. Most common toxicities experienced by donors were erythema, pain, induration and pruritus at sites of injection and diffuse arthralgias. Four MM pts have undergone RIST. There has been one treatment-related death (GVHD) at day +67. Two patients are in CR at 15 and 9 months post-RIST; the third patient is in a PR at 4 months post-RIST. KLH-specific immunity was induced in all of the first 3 donors tested, and Id-specific T cell immunity was induced in 2 of the first 3 donors. In donor-MM pt pair #2 there was evidence that Id-specific T cell immunity was induced in the donor (Figure 1) and passively transferred to the recipient with RIST (Figure 2). Id-specific T cell responses were blocked with HLA Class I and Class II antibodies. These preliminary data confirm that Id-KLH vaccines can be safely and effectively given to normal stem cell donors. More importantly, these data suggest that tumor specific immunity can be induced and passively transferred to the recipient after RIST. Vaccination of donors with tumor-specific antigen represents a tactic to potentially reduce relapse after RIST.
Sensitization of Rituximab-Resistant Ramos RR1 and Daudi RR1 Clones to Various Chemotherapeutic Drugs by a Novel Nuclear Factor-κB Activation Inhibitor.
Authors: Jazirehi Ali R. , Umezawa Kazeo , Bonavida Benjamin
Published: October 2019

Rituximab (chimeric anti-CD20 mAb) has been recently shown to signal NHL B-cell lines (e.g., Ramos and Daudi) and inhibits the constitutively activated NF-κB signaling pathway. This results in the selective downregulation of the anti-apoptotic Bcl-xL expression and sensitization to various chemotherapeutic drug-induced apoptosis (Jazirehi et al., 2004. Submitted). The novel NF-κB factor inhibitor, dehydroxymethyl derivative of epoxyquinomicin (DHMEQ), inhibits NF-κB activity via inhibition of nuclear (translocation) accumulation of p65 (Ariga et al., JBC 277:24625, 2002). This study examined the similarities and differences observed in wild type (wt) parental and rituximab-resistant Ramos and Daudi cells following treatment with either rituximab (20 mg/ml) or DHMEQ (10 mg/ml). In the wt cells, both agents inhibited NF-κB DNA-binding activity, down-regulated Bcl-xL expression and sensitized the cells to drug-induced apoptosis. Rituximab inhibited both the NIK—IκB-α—IKK—NF-κB and the Raf-1—MEK1/2—ERK1/2—AP-1 signaling pathways, while DHMEQ specifically inhibited NF-κB activity. We have generated rituximab-resistant Ramos and Daudi clones by continuous exposure of the cells to step-wise increasing concentrations of rituximab for several weeks and clones isolated by limiting dilution. The CD20+ expressing Ramos RR1 and Daudi RR1 clones were analyzed for their response to treatment with rituximab or DHMEQ. Compared to the wt cells, the resistant clones exhibited hyper-activation of the NF-κB pathway, increased expression of Bcl-xL, and higher resistance to structurally and functionally distinct drugs; their treatment with DHMEQ (15 mg/ml), but not with rituximab, inhibited the activity of the hyper-activated NF-κB, reduced the over-expressed Bcl-xL and sensitized the highly drug-resistant Ramos RR1 and Daudi RR1 clones to various chemotherapeutic drug (CDDP, ADR, VP-16, Taxol, etc.)-induced apoptosis. These findings demonstrate that DHMEQ can reverse the acquired drug-resistance phenotype in both parental and rituximab/drug-resistant NHL B-cell lines when used in combination with subtoxic concentrations of drugs. In vivo, DHMEQ inhibits subcutaneously transplanted prostate cancer xenografts in nude mice (Kikuchi et al., Cancer Res. 63:107, 2003). Consequently, the present findings suggest the potential therapeutic application of DHMEQ in combination with drugs, in the treatment of rituximab/drug resistant B-NHL.
Vascular Endothelial Growth Factor (VEGF)-Induced Endothelial Cell Migration Requires Urokinase Receptor (uPAR) for Integrin Redistribution.
Authors: Prager Gerald W. , Breuss4 Johannes M. , Brunner4 Patrick , Binder4 Bernd R.
Published: October 2019

VEGF activates endothelial cells to migrate and invade surrounding tissues, an initial event in the angiogenic process. For invasion, the coordinated localized formation of a proteolytic repertoir is necessary. Focusing the urokinase receptor towards the leading edge of migrating cells provides such armor and inhibition of uPA binding to its receptor inhibits invasion of endothelial cells. In addition integrins continuously have to form focal contacts at the leading edge. Thus the spatial proximity between the localized proteases and the matrix seems to be essential for matrix degradation. In order to allow cell locomotion integrins have to release their ligands when they reach the trailing end and are subsequently endocytosed and redistributed to newly formed focal adhesions in a repetitive process.

We here describe a new role of uPAR in regulating integrin redistribution. We have previously reported that stimulation of human endothelial cells by VEGF (50ng/ml) via its receptor flk-1 induces pro-uPA activation, when bound to uPAR. Subsequently a uPA/PAI-1/uPAR-complex is formed, which thereafter is endocytosed via a LDL-R family member. We now show that by this process beta-1 integrins are co-internalized in clathrin coated vesicles via a uPAR dependent mechanism. Subsequently, endocytosed uPAR recycles to focal adhesions where it co-localizes with integrin alpha-v/beta-3. Disrupting this chain of events, either by (1) RAP - a specific inhibitor of the LDL-R family - or by (2) uPAR depletion (using uPAR−/− cells or cleaving the GPI-anchor of uPAR by PI-PLC), beta-1 integrins are no longer internalized after VEGF stimulation. Under the same circumstances the migratory response of endothelial cells toward VEGF is impaired in vitro as shown by video-based migration assays and in vivo as demonstrated by matrigel angiogenesis assays. Next, we generated synthetic peptides interfering with uPAR/integrin interaction, which inhibit not only VEGF-induced integrin redistribution, but also diminish VEGF-induced endothelial cell migration, significantly.

These data suggest that in VEGF-induced cell migration uPAR plays a central role not only in focusing proteolytic activity, but also in initial integrin redistribution. Interference with this process could be a therapeutic target for diseases depending on VEGF-induced angiogenesis.
Improved Clinical Outcome and ADAMTS13 Activity Following Cyclosporine Therapy in Patients with TTP.
Authors: Cataland Spero R. , George James N. , Kraut Eric H. , Bourgeois Tran T. , Ferketich Amy K. , Kennedy Melanie S. , Caligiuri Michael A. , Wu Haifeng M.
Published: October 2019

Patients with a clinical diagnosis of TTP presenting to The Ohio State University were enrolled and treated on a prospective trial of concurrent plasma exchange (PE) and adjuvant immunosuppression.

Patients: Between April 2003 and August 2004, 15 patients were entered and followed on this study. The median age was 46 years (range, 19–59), 11/15 were female, 7/15 were African American, and 9/15 were obese (body mass index >30 kg/m2). Nine patients had been previously treated for TTP.

Method : All patients with TTP were treated initially with concurrent PE and corticosteroids. Daily exchanges of one plasma volume using cryosupernatant plasma were performed with concurrent prednisone at a dose of 1 mg/kg/day. PE was continued until a clinical remission was achieved as defined by: 1) normal platelet count 2) normalization of LDH for 2 consecutive determinations, and 3) improvement or stabilization of renal or neurologic abnormalities. After criteria for remission were achieved patients had 2 additional procedures performed every other day and the prednisone tapered over the next 4 weeks. Patients with exacerbations (defined as the need to reinstate PE within 30 days discontinuation) of TTP had prednisone discontinued and began oral cyclosporine (CSA) at a dose of 2–3 mg/kg/day orally concurrent with the resumption of PE. After achieving a second remission, PE was tapered as described previously and CSA was continued for a total of 6 months of therapy. Serial measurements of ADAMTS13 activity and inhibitor assays were obtained prior to the initiation of PE and at regular intervals during follow-up.

Results : ADAMTS13 data is available for the first 6 patients treated with PE + prednisone. A summary of clinical outcomes and ADAMTS13 activity may be found in Table 1. Of the patients suffering exacerbations after initial therapy with PE + prednisone, ADAMTS13 data is available from the first 2 of 5 patients treated with PE + CSA and is shown in Figure 1.

Clinical Responses and ADAMTS13 Activity

Inhibitor Remission Exac. Relapse Med. ADAMTS13-Pre Med. ADAMTS13-Remission Med. Remission (mo) * samples tested to date **median ADAMS13 PE+Pred. 5/6* 14/15 7/15 2/15 5% (range, 2-7%)** 5% (range, 2-7%)** 1(range, 1-9 ) PE+CSA 2/2* 5/5 0/5 0/5 Figure 1 Figure 1 6 (range, 3-10)

Conclusions : In this prospective study, no patients had significant improvement in ADAMTS13 activity despite achieving remission with PE and corticosteroids. These data showing persistently low ADAMTS13 activity at the time of remission may have contributed to the high rate of exacerbations in this group of patients. In the analysis of the first 2 patients treated with concurrent PE and CSA, there was clear and sustained improvement in ADAMTS13 activity that began after the discontinuation of PE and correlated with the clinical remission of TTP.

Figure Figure
Patterns of Care in a Random Population-Based Sample of Patients Diagnosed with CLL.
Authors: Davis Thomas A. , Clegg Limin X. , Stevens Jennifer L. , Harlan Linda C.
Published: October 2019

Over the past decade new drugs have significantly altered the treatment paradigm for patients with Chronic Lymphocytic Leukemia (CLL). Fludarabine, rituximab and alemtuzumab have established efficacy in CLL, but the patterns of disease presentation and course, and clinical intervention in general practice has not been captured. The Division of Cancer Control and Population Sciences (DCCPS) of NCI has conducted a population-based study of a stratified random sample of patients diagnosed with CLL in 1998 (n=470) who resided in the geographic areas covered by the Surveillance Epidemiology and End-Results program. Patients were followed through Dec, 2001. Logistic regression analyses were performed to study the potential factors that associated with the likelihood of receiving chemotherapy, therapeutic antibodies and/or splenectomy. Cox Proportional Hazards regression models were used to study the risk factors associated with survival time. Stages at diagnosis were 33%, 17%, 16%, and 33% for RAI 0, I/II, III/IV, and unstaged respectively. Early RAI stage was associated with younger age, private insurance, and non-Hispanic white race. Bone Marrow biopsy was performed at diagnosis in approximately 60% of patients, more frequent in patients with advanced stage. Therapy was given to 46% of patients during the follow up period, ranging from 12% for stage 0 to 80% for stage III/IV. 15%, 21% and 5% of patients received fludarabine, alkylating agents, and antibodies, respectively. Splenectomy was performed in 2.8% of stage I/II and 5.4% of stage III/IV cases. The multivariate analysis of receipt of therapy found stage, race/ethnicity, Charlson Comorbidity Score, and education were significantly associated with treatment. The average time from diagnosis to treatment was 3.1 months. Only 1.1% of patients participated in clinical trials. The most frequent reasons for therapy were symptoms, lymphadenopathy and elevated lymphocyte count (in 10–19% of patients stage 0 and III/IV respectively). Men were slightly more likely to be treated, more often with systemic therapy. Women were more likely to receive splenectomy. Blacks received therapy more often than whites or Hispanics even after adjusting for stage at diagnosis, comorbidity score, age, gender, marital status and education. In an analysis of survival, increasing age, advanced stage, minority race, being unmarried and treatment all were significantly associated with death. These data reflect an expected distribution of presentation and treatment for CLL in 1998. Notable, however, are the frequency of treatment based purely on lymphocyte count or lymphodenopathy, the frequency of antibody therapy when none were approved for this indication, the frequency of splenectomy and the impact of race on treatment and outcome.
Identification of Molecular Predictors of Response to ZARNESTRA™ (Tipifarnib, R115777) in Relapsed and Refractory Acute Myeloid Leukemia.
Authors: Raponi Mitch , Lowenberg Bob , Lancet Jeffrey E. , Harousseau Jean-Luc , Stone Richard , Rackoff Wayne , Thibault Alain , Zhang Yi , Atkins David , Wang Yixin
Published: October 2019

The orally available farnesyltransferase inhibitor (FTI) tipifarnib has demonstrated clinical efficacy in hematological disease. In an effort to identify patients with a higher likelihood of response, we have employed microarray technology to identify gene expression markers that predict response to tipifarnib. In an open label, single arm, Phase II study of patients with relapsed or refractory acute myeloid leukemia, tipifarnib was administered at a dose of 600 mg twice daily for the first 21 days of each 28-day cycle. Gene expression profiles from 80 bone marrow samples, collected before drug treatment, were analyzed on the Affymetrix U133A gene chip that contains approximately 22,000 genes. Statistical analyses were performed to identify genes that predict patient outcome following treatment with tipifarnib. Nineteen genes were selected because they showed significant differences in gene expression between the responder group and the non-responder group of patients. Several of these genes are associated with oncogenesis, cell proliferation, and FTI biology. One of the candidate genes, lymphoid blast crisis oncogene (oncoLBC or AKAP13), was over-expressed in patients who were resistant to tipifarnib. A leave-one-out cross validation (LOOCV) showed that the predictive value of this gene provided a sensitivity of 93% in identifying responders and a specificity of 61%, providing an overall diagnostic accuracy of 69%. In addition, supervised analysis identified a combination of 3 gene expression markers that together can potentially be used to predict patient response to the drug with the best overall accuracy of 74%. This 3-gene expression signature provided a sensitivity of 86% and a specificity of 70% in the LOOCV. In both instances, classification of patients using the gene expression signatures demonstrated significantly enhanced overall survival in those predicted to be responders. These data indicate that diagnostic gene expression signatures can potentially double the response rate to tipifarnib from 24% to 48%. The identification of these gene expression markers is an important step towards defining diagnostic signatures that could be used to identify AML patients who are likely to respond to tipifarnib and for understanding pathways that are affected by farnesyltransferase inhibition in AML.
Increasing the Number of Apheresis Collections Increases Lymphocyte Collection and Affects Survival after Autologous Stem Cell Transplantation for Non-Hodgkin Lymphoma.
Authors: Porrata Luis F. , Gastineau Dennis A. , Pineda Alvaro , Winters Jeffrey L. , Moore S. Breanndan , Padley Douglas J. , Bundy Kevin L. , Litzow Mark R. , Micallef Ivana N.M. , Inwards David J. , Ansell Stephen M. , Gertz Morie A. , Lacy Martha Q. , Dispenzieri Angela , Tefferi Ayalew , Elliott Michelle , Hogan William J. , Hayman Suzanne R. , Markovic Svetomir N.
Published: October 2019

Peripheral blood infused total autograft absolute lymphocyte count (A-ALC) correlates with day 15 absolute lymphocyte count and is an independent prognostic factor for survival after autologous stem cell transplantation (ASCT) for non-Hodgkin lymphoma (NHL). Factors to enhance A-ALC collections are not well defined. We hypothesize that the number of peripheral blood apheresis collections (PBAC) directly correlates with A-ALC. 190 consecutive NHL patients who underwent ASCT at the Mayo Clinic between 1993 and 2001 were analyzed. The primary end point of the study was to assess the correlation between the number of PBAC and A-ALC. The secondary end point was to determine if the number of PBAC affected survival post-ASCT. Of the 190 patients, 18 patients underwent 1 PBAC, 23 patients 2 PBAC, 50 patients 3 PBAC, 37 patients 4 PBAC, 50 patients 5 PBAC, and 12 patients had ≥ 6 PBAC. There was no association between the number of PBAC and the number of CD34+ stem cells collected (p= 0.25). A strong association between number of PBAC and A-ALC (Kruskall Wallis test, p <0.0001)(Figure 1) was identified. Using a cut-off of 4 PBAC, superior overall survival (OS) and progression-free survival (PFS) were observed for patients that underwent 4 PBAC or more compared to patients that underwent less than 4 PBAC (86 months vs 18 months, p <0.0001; 76 months vs 10 months, p <0.0001, respectively). Multivariate analysis demonstrated PBAC ≥ 4 is an independent prognostic factor for OS (RR = 0.654, 95%CI: 0.529–0.804, p< 0.0001) and for PFS (RR = 0.682, 95%CI: 0.561–0.826, p< 0.0001) when compared with other significant factors including performance status, lactate dehydrogenase and extra nodal disease. These data suggest that increasing the number of PBAC beyond the minimum number required to meet CD34+ collection targets may result in improved overall and progression-free survival mediated by an increase in autograft absolute lymphocyte count.
Safety and Efficacy of CBV Followed by Autologous PBSC Transplant in Children with Lymphoma after Failed Induction or First Relapse - a Children’s Oncology Group Study.
Authors: Harris Richard E. , Morris Erin , Warkentin Phyllis , Vlachos Adrianna , Chang Myron , Cairo Mitchell S.
Published: October 2019

Purpose: To determine the safety and efficacy of high dose cyclophosphamide, BCNU and etoposide (CBV) chemotherapy followed by autologous non-purged PBSCT in children with Hodgkin’s (HD) and non-Hodgkin’s lymphoma (NHL) who have either failed primary induction therapy or have experienced a first relapse.

Methods: At study entry, patients received 2–4 courses of reinduction therapy as determined by the local institution. When a CR or PR was achieved, G-CSF mobilized PBSCs were harvested and patients underwent autologous PBSCT after a preparative therapy of cyclophosphamide 6000 mg/m2, BCNU 450–300 mg/m2, and etoposide 2400 mg/m2. Patients were to receive a set dose of 5x106 CD34 cells/kg. Patients were followed for disease status and toxicities. 69 patients (38 HD, 31 NHL) were entered onto study between April 1998 and June 2002. Survival statistics were calculated as Kaplan Meier estimates.

Results: 41/69 (27/38 HD, 14/31 NHL) achieved a CR/PR at the conclusion of reinduction; 14 failed due to PD; 7 had SD; 7 were inevaluable. 38 patients (27 HD, 11 NHL) proceeded to autologous PBSCT. Overall 28/38 (20 HD, 8 NHL) of the transplanted patients survive and 21/28 (15 HD, 6 NHL) are progression free. The survival rates at 12 months and 24 months were 88%(±6) (HD 92%(±6), NHL 78%(±14)) and 73%(±10) (HD 76%(±11), NHL 65%(±22)), respectively. The rates of PFS at 12 months and 24 months were 65%(±8)(HD 72%(±9); NHL 46%(±17)) and 53%(±11) (HD 56%(±12); NHL 46%(±19)), respectively. 10 patients died after PBSCT. The causes of death were PD (N=5), infection (N=4), and toxicity (N=1). The first 17 patients received BCNU 450 mg/m2 and 8 of these experienced grade 3 or 4 pulmonary or renal toxicity. The dose was thus dropped to 300 mg/m2 and an additional 21 patients underwent PBSCT and 3 of these patients developed grade 3 or 4 pulmonary or renal toxicity. The incidence of grade 3 or 4 pulmonary of renal toxicity at 300mg/m2 was significantly lower than that at 450 mg/m2 (p=0.04, Fisher’s exact test).

Conclusions: For children with primary resistant or first relapsed lymphoma who achieve a CR or PR after reinduction, CBV preparative therapy followed by PBSCT for children with primarily resistant or relapsed lymphoma results in an acceptable survival but a lower PFS due to a high relapse rate following transplant. A BCNU dose of 300 mg/m2, but not a dose of 450 mg/m2 is well tolerated by these heavily treated patients.
Outcomes of Autologous and Allogeneic BMT for Mantle Cell Lymphoma.
Authors: Kasamon Yvette L. , Jones Richard J. , Diehl Louis F. , Nayer Hassan , Borowitz Michael J. , Garrett-Mayer Elizabeth , Ambinder Richard F. , Abrams Ross A. , Zhang Zhe , Flinn Ian W.
Published: October 2019

To evaluate BMT outcomes in patients (pts) with newly diagnosed or relapsed mantle cell lymphoma, 58 consecutive pts were selected through the BMT registry at Johns Hopkins. Flow cytometric and immunohistochemical features were confirmed. Fifty-four pts (88%) had stage III or IV disease and 39 (67%) had documented bone marrow involvement at diagnosis. First-line therapy was CHOP +/− rituximab in 71% and was fludarabine-based in 17%. Thirty-seven pts (64%) were transplanted after first partial or complete remission, 14 pts (24%) after one or more relapses, and 12% after primary induction failure (PIF). Median age at BMT was 55 years. Thirty-eight pts (66%) received autologous (auto) BMT, 19 pts (33%) allogeneic (allo) BMT, and 1 pt syngeneic BMT. Preparative regimens in all but 1 case consisted of cyclophosphamide plus busulfan or total body irradiation. The estimated 3-year event-free survival (EFS) following BMT was 51% (95% CI, 35–65%), probability of relapse 31% (17–51%), and overall survival 59% (42–73%). Median follow-up is 16 months (range < 1 month to 79 months) for all pts and 23 months for surviving pts. Twelve relapses were documented, 8 after auto BMT. Four auto pts and 1 allo pt are alive with relapsed disease, and 3 auto pts developed MDS or AML. Actuarial EFS at 3 years was 57% (CI 35–74%) after auto BMT and 37% (17–57%) after allo BMT. Actuarial relapse rate at 3 years was 34% following auto BMT and 19% following allo BMT. On multiple regression analysis, BMT after one or more relapses (HR 3.0, CI 1.2–7.4, P = 0.02), PIF (HR 5.4, CI 1.9–15.4, P = 0.002), and allo BMT (HR 3.0, CI 1.3–6.8, P = 0.007) predicted an inferior EFS;

Figure Figure

whereas PIF and residual bone marrow involvement independently predicted relapse. Notably, however, EFS curves were not statistically different for auto and allo BMT performed in first remission, with the 3 year EFS approaching or equaling 70%.

Figure Figure

The benefit of BMT for mantle cell lymphoma is thus most apparent when performed in first remission. While the comparative efficacy of auto and allo BMT remains to be determined, allo BMT warrants continued study especially early in the disease course.
KIT Exon 8 Mutations Associated with Core Binding Factor (CBF) - Acute Myeloid Leukemia (AML) Cause Hypersensitivity of KIT to Its Natural Ligand Stem Cell Factor.
Authors: Kohl Tobias M. , Schnittger Susanne , Hiddemann Wolfgang , Spiekermann Karsten
Published: October 2019

Mutations in the extracellular portion of the KIT receptor tyrosine kinase (exon 8 mutations) are strongly associated with core binding factor (CBF) - acute myeloid leukemia (AML), but the functional role of these mutations has not been elucidated. In 93% of cases, codon Asp419 is deleted and exon 8 mutations were reported to confer an impaired prognosis to patients with CBF-AML. In this study, we are the first to report pro-proliferative and antiapoptotic potential of representative KIT exon 8 mutations in a cell culture model and to show a significant difference to KIT wildtype (KIT-WT). Three representative exon 8 mutants including a single deletion of codon 419 were created by in vitro site-directed mutagenesis. The integrity of all constructs was assessed by complete nucleotide sequencing. After stable expression in IL-3 dependent Ba/F3 cells (confirmed by FACS analysis and immunoblotting), exon 8 KIT mutants were characterized by a hypersensitivity to stem cell factor (SCF) stimulation in terms of proliferation and resistance to apoptotic cell death. The differences to KIT-WT occurred in the physiological range of SCF from 1 to 10ng/ml. The proliferative response caused by stimulation with SCF was reversed in KIT-WT and exon 8 mutants in the presence of Imatinib® (Novartis) in contrast to the activation loop mutant D816V which could not be inhibited. These biological effects were confirmed by demonstrating increased phosphorylation of the KIT downstream targets mitogen-activated protein kinase (MAPK) and AKT after SCF stimulation compared to the KIT-WT receptor. Furthermore, the MEK inhibitor PD98059 and the PI3 kinase inhibitor LY294002 resulted in a dose dependent inhibition of SCF induced proliferation in exon 8 mutants. Our data show that KIT exon 8 mutations represent gain-of-function mutations by inducing receptor hypersensitivity to its ligand SCF by activation of MAPK and PI3K and might represent a new molecular target for treatment of CBF leukemias.
High-Dose Chemotherapy with Autologous Stem Cell Support Is Not Superior to Conventional-Dose Chemotherapy in the First-Line Treatment of Aggressive Non-Hodgkin Lymphoma - Results of a Comprehensive Meta-Analysis.
Authors: Greb Alexander , Schiefer Daniel H. , Bohlius Julia , Schwarzer Guido , Engert Andreas
Published: October 2019

Background: High-dose chemotherapy with autologous stem cell support (HDT) has been proven effective in relapsed aggressive Non-Hodgkin lymphoma (NHL). However, conflicting results of HDT as part of first-line treatment have been reported in randomized controlled trials (RCTs). Here, we report our updated meta-analysis to better define the role of HDT in these patients.

Methods: RCTs were identified by computerized search and handsearching of conference proceedings. Data extraction and quality assessment was performed independently by two reviewers. First authors were contacted to request individual patient data. Eight investigators provided us with individual patient data, for five trials data were extracted from survival curves. The hazard ratio (HR) was used as a measure of treatment effect; the inverse variance method (fixed effect model) was used for pooling. The relative risk was determined for binary data.

Results: 15 RCTs including 3079 patients were eligible for this meta-analysis. Overall treatment-related mortality was 6.0% in the HDT group and not significantly different compared to conventional chemotherapy (RR 1.33, p=0.59). Analysis of 13 studies including 2018 patients showed significantly higher CR rates in the group receiving HDT (RR 1.10, p=0.004). However, HDT did not have an effect on OS, when compared to conventional chemotherapy. The pooled HR was 1.04 (p=0.58). There was no statistical heterogeneity among the trials and sensitivity analyses underscored the robustness of these results. Subgroup analysis of prognostic groups according to IPI did not show any survival difference between HDT and controls in 12 trials (low and low-intermediate risk IPI: HR 1.41, high-intermediate and high risk IPI: HR 0.97). Event-free survival (EFS) also showed no significant difference between HDT and CT (HR 0.93, p=0.31). We incorporated several additional variables to possibly identify other risk factors such as the proportions of diffuse large cell lymphoma, protocol adherence, the HDT strategy used, response status of patients before HDT, the conditioning regimen used, and methodological issues. However, our analyses demonstrate that the results described here are not related on either of these factors.

Conclusion: Despite higher CR rates, there is no benefit for HDT in patients with aggressive NHL when incorporated in first-line treatment.
Successful Treatment of AL Amyloidosis Patients over Age 65 with High-Dose Melphalan and Autologous Stem Cell Transplantation (HDM/SCT).
Authors: Seldin David Cary , Anderson Jennifer J. , Skinner Martha , Malek Karim , Wright Daniel G. , Quillen Karen , Sanchorawala Vaishali
Published: October 2019

Over the past 10 years, HDM/SCT has been employed for treatment of patients with AL amyloidosis. Although peri-transplant mortality is greater than for other hematologic diseases, HDM/SCT leads to durable hematologic complete responses (CR), improvements in organ function, and extended survival in a substantial proportion of patients (Skinner et al., Ann. Int. Med. 2004). In that study, the proportion of patients eligible for HDM/SCT was lower for patients >65 years of age than for younger patients (34.3% vs. 68.4%), but the hematologic complete response (CR) rate and survival appeared to be no different. Here, we update these results and present a detailed analysis of outcomes in patients >65 vs. those <65. Data were collected with IRB approval. Through 07/01/04, 349 patients began G-CSF mobilization, of which 66 (19%) were >65. The median age of the 66 patients was 68, range 65–80; 73% male; 18% ? and 82% ?, while for the 283 patients <65, the median age was 55, range 29–64; 57% male; 16% ? and 84% ?. The median number of involved organs was no different in the two groups, nor was the type of organ involvement or performance status. There was also no difference in the rate of serious complications during stem cell collection, as a similar fraction of patients in both groups did not proceed to transplant, 12.1% of patients >65 versus 10.3% of patients <65 (p=.659). Based on treatment protocol, only 19% of patients >65 received an IV dose of melphalan of 200 mg/m2 (the remainder being treated with 140 mg/m2 or less), vs. 64% of those <65 (p <.001). There was no difference in early transplant-related mortality (10.3% in patients >65 vs. 13.4% in patients <65, p=.665). There was also no difference in one year mortality (22.4% for those >65 vs. 20.9% for those <65, p=.859). There was a non-significant trend towards a lower rate of hematologic CR in the older patients (32% vs. 44%, p=0.155). However, the median survival after HDM/SCT was no different (see fig; 4.9 years for patients >65 vs. 4.6 years for those <65, p=0.42 by log-rank test). Thus, while fewer patients >65 meet eligibility requirements for HDM/SCT, for those who do, treatment-related mortality, hematologic CR rate, and survival are no different than for younger patients. These data strongly support the use of HDM/SCT for suitable patients with AL amyloidosis who are >65 years old.

Figure. Figure.
Follow up Analysis for MRC Myeloma VII Trial.
Authors: Morgan Gareth J. , Davies Faith E. , Hawkins Kim , Bell Susan E. , Brown Julia M. , Owen Roger G. , Drayson Mark T. , Selby Peter J. , Child Anthony J. ,   for the Medical Research Council Adult Leukaemia Working Party
Published: October 2019

The results of the MRC Myeloma VII trial and overview analysis of comparable trials have suggested that VAD-like induction chemotherapy followed by high dose therapy (HDT) with autologous transplantation may be regarded as a new standard treatment for multiple myeloma. However, there is a need for data from the extended follow up of patients in such trials to provide confirmatory evidence of the benefit of treatment incorporating HDT compared with conventional dose treatment, in particular to determine the long term difference in survival and the impact of attaining a complete response (CR) following intensive treatment. We present an updated analysis of Myeloma VII with median follow up of 5.5 years. Myeloma VII is the largest trial of its type in which patients with previously untreated multiple myeloma, age <65 years, were randomized to receive either standard conventional-dose combination chemotherapy (ABCM) or a sequence of treatment, C-VAMP followed by high dose therapy (HDT), typically melphalan 200g/m2 with autologous stem cell transplant. The planned maintenance in both arms was interferon α-2a. The trial, initiated in 1993 and closed to entry in 2000 and was conducted to MRC guidelines for good clinical practice in clinical trials. In the 401 evaluable patients the CR rate was 44% in the intensive therapy group, 8% in the standard therapy group (p<0.001). Intention to treat analysis showed a survival benefit of 14.1 months in the intensive arm (Figure 1); median 56.3 months (95% CI 46.0–74.6) vs. 42.2 months (95% CI 33.1–48.9), p=0.004 (log rank test). Progression free survival was also improved in the intensive group, median 31.2 months (95% CI 27.1–37.5) compared with 19.5 months (95% CI 16.2–21.6) in the standard group (p=<0.001). This analysis provides confirmatory evidence that treatment including high dose therapy is superior to conventional dose chemotherapy. Long term follow up of this study shows that the benefits of intensive treatment are maintained long term and that an important therapeutic aim is the achievement of CR. For the patients receiving the full protocol, the differences are accentuated, implying that maximising numbers of patients getting to transplant is an important therapeutic aim. These results would also support the continuing development of peri-HDT strategies to further improve outcomes.

Figure Figure
Hsp90 Inhibitors Induce Apoptosis in Human Leukemia Cells.
Authors: Campos Lydia , Flandrin Pascale , Olaru Daniela , Guyotat Denis
Published: October 2019

The 90-Kda heat shock protein (Hsp90), together with a number of other chaperones are involved in normal cellular differentiation and cancerogenesis. Hsp90 is implicated in the conformational maturation of a large variety of protein kinases. We have shown its overexpression in a series of 116 acute myeloid leukemias (AML). Geldanamycin and its analogue 17-AAG selectively block the activities of Hsp90, but do not interact with other members of the Hsp family. The objective of the study was to test the effect of 17-AAG on cell lines (Jurkat, U-937, HL60, HL60R : resistant to daunorubicin (DNR), and KG1a) and on 24 AML samples tested positive for Hsp90 (14 strongly positive and 10 moderately positive). CD34+ cells from bone marrow donors were used as controls. Cells were maintained in liquid culture in the presence or absence of 17-AAG. Moreover hematopoietic and leukemic progenitor assays were performed in semi-solid media containing or not 17-AAG. CD34+ cells were non affected by 17-AAG. Jurkat, U937, HL60 were partially sensitive to 17-AAG. Addition of low dose DNR to 17-AAG induced an apoptotic death in 48 hours in all samples, including HL60R. KG1a (exhibiting high HSP90 levels) was more sensitive to 17-AAG alone with a death rate of 100% at higher doses. A similar effect was observed in AML samples : 17-AAG induced cell death in all 14 cases highly positive for HSP90, but a partial death in 5 cases, and no death in 5 cases mildly positive for HSP90. DNR increased apoptosis in only 5/10 of these cases. The other 5 patients were also positive for bcl-2. When they were first incubated with 17-AAG and then treated with bcl-2 antisens oligodeoxynucleotides (bcl-2AS), a complete apoptosis was obtained. So, in the 10 samples with moderate HSP90 expression a synergystic effect was found when a combination of 17-AAG with either chemotherapy or bcl -2AS was used. While normal progenitors were not affected by 17-AAG, leukemic progenitors were completed inhibited in the 14 patients who responded to 17-AAG in liquid culture. This apoptosis was caspase -3 dependant. Finally, we investigated the implication of the ERK signal pathway in Jurkat line and in 14/24 17-AAG responder samples using an ERK inhibitor (PD98059). When this inhibitor was added prior to 17-AAD and DNR, the apoptotic effect was completely inhibited. So, ERK signal pathway may interfere with the Hsp90 function. In conclusion, these results raise the possibility that Hsp90 antagonists represent a novel antileukemic strategy in sequential addition to conventional chemotherapy
Safety of Total Therapy III for Newly Diagnosed Multiple Myeloma: Preliminary Analysis of 62 Consecutive Patients.
Authors: Anaissie Elias J. , Miceli Marisa H. , Dong Li , Saghafifar Fariba , Talamo Giampaolo , Hollmig Klaus A. , Tricot Guido , Barlogie Bart
Published: October 2019

Background: Total therapy III (TT-III) is designed to improve the outcome of newly diagnosed myeloma (MM) patients (pts), especially those presenting with unfavorable cytogenetics. Induction employs 2 cycles of V-DTPACE (Velade™, dexamethasone, thalidomide, cisplatin, adryamycin®, cytoxan®, etoposide) followed by tandem melphalan 200 mg/m2 autologous stem cell transplants (ASCT).

Objective: to evaluate the safety outcome of TT-III pts. Materials and

Methods: Prospective evaluation of the toxicities occurring throughout treatment in 62 TT-III pts enrolled between February and July 2004.

Results: Median age was 59 years (range: 23–74) and 41 pts (66 %) were males. The 1st and 2nd induction cycles were completed in 42 (68%) and 22 (35%) pts respectively, whereas 19 pts (31%) underwent their 1st ASCT. Infections and/or Grades III–IV gastrointestinal tract (GIT) toxicities (NCI Common Toxicity Criteria) were observed throughout treatment in 32 (76%) patients (table). One treatment-related death occurred in an 80 y.o. male with significant pre-existing comorbidities.

Conclusion: Gastrointestinal tract toxicities and pneumonia were the most frequent complications following TT-III. Studies are ongoing to identify the risk factors for and interventions to decrease their incidence and severity.

Infections and Grade III -IV GIT toxicities throughout TT-III

Toxicity Cycle 1 (n=42) Cycle 2 (n=22) 1st ASCT (n=19) Pneumonia 7 (17%) 1 (5%) 2 (11%) Bacteremia 2 (5%) 4 (18%) 2 (11%) Septic Shock 1 (2%) - - C. difficile colitis 2 (5%) - - Febrile neutropenia 2 (5%) 2 (10%) 5 (26%) Sinusitis 2 (5%) - - Cellulitis 1 (2%) - - Mucositis 5 (12%) - 7 (37%) Nausea/vomiting 15 (36%) 4 (18%) 12 (63%) Diarrhea 3 (7%) - 4 (21%)
Rapid Response to Treatment of Multiple Myeloma Detected with FDG PET Scanning in Multiple Myeloma - Early Results from Total Therapy III.
Authors: Walker Ronald , Jones-Jackson L. , Rasmussen Eric , Miceli M. , Anaissie Elias , Epstein Joshua , Tricot Guido , Shaughnessy John , Barlogie Bart
Published: October 2019

Fluorodeoxyglucose Positron Emission Tomography (PET) scanning can rapidly detect and quantify changes in tumor metabolism. We present early results from the first 47 patients enrolled in Total Therapy III for multiple myeloma using PET scanning and correlating with serum M protein. Since we have previously demonstrated that diffuse uptake patterns do not have prognostic significance, we have limited our assessment of these 47 patients to those with one or more PET-defined focal lesions (FL) at baseline who have had at least one follow-up PET scan (25 patients). Of this group of 25, 10 have had a second follow-up scan. These whole body PET scans were performed at baseline and at time points corresponding to immediately after two cycles of VDT-PACE, landmarks LMK1 and LMK2. Patients with complete resolution of FL on PET are considered to be in PET-CR. We find that 17/25 (68%) had a decrease in number of FL from baseline to LMK1 and 8/10 (80%) had a decrease in number of FL from baseline to LMK2. In addition, 6/25 (24%) were in PET-CR by LMK1 and 3/10 (30%) in PET-CR by LMK2. Similarly, a decrease in serum M-protein was seen in 16/25 (64%) from baseline to LMK1 and in 8/10 (80%) from baseline to LMK2.

At baseline, 10 patients had serum M protein levels of 0.01 g/dl or less. Of these, 8 (80%) had PET-defined focal lesions, demonstrating PET’s ability to monitor tumor metabolism in the face of hypo- or non-secretory disease. Of these, 7 have been enrolled sufficient time to have a second PET scan, with 6/7 (86%) demonstrating a continuing decrease in number of FL in response to treatment. At baseline, PET detected 5 of 47 patients with extramedullary disease (EMD), a finding of severe adverse prognostic significance at baseline. Of these patients, all had FL at baseline PET and all had decreasing number of FL on first follow-up PET scan (two have had a second follow-up scan, one improving and one PET-CR). One of these patients with EMD is nonsecretory.

From these data, we conclude that functional imaging with PET scanning offers important and unique information about early tumor response that improves patient management by demonstrating rapid change in response to treatment that not only parallels serum M-protein response but which also is reliable in hypo- or non-secretory disease as well as in detection and monitoring of extramedullary tumor, an ominous condition that is particularly difficult to detect in the hypo- or non-secretory patient.
Outcome after Second Autologous Stem Cell Transplantation as Salvage Therapy in Patients with Relapsed Multiple Myeloma.
Authors: Mikhael Joseph R. , Samiee Sara , Stewart A. Keith , Chen Christine , Trudel Suzanne , Franke Norman , Winter Andrew , Chang Hong , Reece Donna E.
Published: October 2019

Background: Single autologous stem cell transplant (ASCT) is considered the standard of care for younger multiple myeloma (MM) patients (pts). However, it is not curative and virtually all patients will ultimately relapse. The role of a second ASCT as salvage therapy is unclear.

Method: Retrospective review of all MM pts who received a 2nd ASCT as salvage therapy at Princess Margaret Hospital.

Results: Between March 1992 and August 2004, 28 MM pts received a second ASCT for relapsed MM at our institution. Median age was 57 years (range 39–69) at second transplant. 17 pts were male.

Immunoglobulin subtype included IgG (16), IgA (8), light chain (1), nonsecretory (2) and IgM(1). Median initial albumin was 42g/l (27–48). In 15 patients in whom cytogenetic studies were available, 2 were positive for the 13q deletion.

Transplant conditioning regimen for first transplant was melphalan (MEL) + TBI +/− etoposide (E) in 6, MEL alone in 15 and other regimens in 7 pts. 2nd ASCT conditioning consisted of MEL + TBI +/− E in 2, MEL alone in 25 and BU+CY in 1. Median CD34 counts were 10.96x106/L and 4.85x106/L for 1st and 2nd ASCT respectively.

The median time from diagnosis to first transplant was 9 months (2–74). The median time to relapse after the first transplant was 29 months (6–85), with a median interval between transplants of 39 months (6–99). The median time to progression after the second transplant was 13 months (5–56).

No transplant-related deaths occurred.

At median follow-up after 2nd ASCT of 15 months (1–60), 20 (71%) pts are alive. Twelve pts (43% of all pts) are free of disease progression. The 5-year actuarial progression-free survival (PFS) and overall survival (OS) was 47% and 32%, respectively. Long term progression-free status based on the progression-free interval after 1st transplant is summarized in the following table:

Interval Total number of pts Number of progression-free pts ≤ 12 months 1 0 (0%) 12–24 months 9 3 (33%) ≤ 24 months 18 9 (50%)

Conclusions:

2nd ASCT is a feasible and safe salvage therapy in relapsed MM patients; 2nd ASCT is effective in providing prolonged remission over one year; 2nd ASCT is most effective in patients whose time to progression after 1st ASCT exceeds 24 months.
Sufficient Mobilization of Peripheral Blood Stem Cells by Single Dose Application of Pegylated G-CSF in Patients with Multiple Myeloma, Interim Analysis of a Phase II Study.
Authors: Fruehauf Stefan , Timon Seeger , Buss Eike C. , Topaly Julian , Ho Anthony D. , Goldschmidt Hartmut
Published: October 2019

Autologous peripheral blood stem cell (PBSC) transplantation leads to significant prolongation of survival in patients with multiple myeloma. For PBSC mobilization a combination of myelosuppressive chemotherapy and granulocyte colony stimulating factor (G-CSF) are administered. The optimal application of G-CSF is twice daily. New G-CSF formulations with prolonged half-life carry the promise of reduced patient strain, increased compliance and via continuously high G-CSF serum levels possibly improved PBSC mobilization. We initiated a study with pegfilgrastim-supported mobilization chemotherapy in stage II and III myeloma patients. Patients received up-front treatment with three cycles of vincristin, doxorubicin, dexamethason (VAD) or thalidomide, doxorubicin, dexamethason (TAD).

The mobilization regime consisted of four days chemotherapy with cyclophosphamide 1g/m2 day1, doxorubicin 15mg/m2 day 1-4, dexamethason 40 mg d 1-4 p.o. (CAD) and a single administration of 12 mg pegfilgrastim subcutaneously on day five. To date 17 patients (median age 56, 10 female, 7 male) have received pegfilgrastim and maximum CD34+ cell counts were observed 10-18 days (mean 13 days) after treatment with a range between 24 and 827 (mean: 161) CD34+ cells per μl. 15 patients underwent leukapheresis. In total, 6.6 * 10e6 to 40.5 * 10e6 (mean 15.3 *10e6) CD34+ cells per kilogram body weight were collected. 9 patients achieved the target number of 7.5 * 10e6 CD34+ cells per kilogram body weight during a single apheresis, while 4 patients needed two and 2 patients needed three apheresies on consecutive days. Two patients required additional administration of filgrastim. Two patients received 6 mg pegfilgrastim off study. Both achieved sufficient numbers of CD34+ cells (12.7 and 20.8 * 10e6 CD34+ per kg BW). There were only minimal adverse effects. Four patients reported of bone pain or nausea. Mobilization failures did not occur in this patient population.

On the basis of these first results we conclude that a single dose application of 12 mg pegfilgrastim after CAD treatment leads to sufficient mobilization of CD34+ cells in stage II and III myeloma patients comparable to historical data with filgrastim-supported mobilization chemotherapy.