Adult T-cell Leukemia/lymphoma Patients Research Articles

Clinical Impact of a Humanized CCR4 Antibody (Mogamulizumab) in 14 Patients with Aggressive Adult T-cell Leukemia-lymphoma Treated at a Single Institution During a Three-year Period (2012-2014).

Objective We elucidated the effectiveness of a humanized CCR4 antibody (mogamulizumab) on adult T-cell leukemia-lymphoma (ATL), which typically has a poor outcome. Methods We retrospectively analyzed 14 patients with aggressive ATL who had been treated at our institution with weekly cycles of mogamulizumab for eight weeks from 2012-2014. Results The patients (median age: 63 years old) were classified as having acute- (n=10) or lymphoma-type (n=4) ATL. The prior treatment regimens consisted of CHOP, VCAP-AMP-VECP, DeVIC and CHASE, with an average of two courses (range: 1-4). The prior disease responses were partial remission (n=3) and progressive disease (n=11). The treatment was administered in the primary refractory setting (n=8), for relapse (n=2), or as bridging therapy before hematopoietic stem cell transplantation (n=4). The overall response rates were 64% and 43% after four and eight cycles (or after the final cycles), respectively. The median overall survival (OS), OS rate at six months and OS rate at 12 months were 66 days, 41.7% and 20.8%, respectively. All of the patients with acute-type ATL who showed a response to treatment had an early response. Notably, six of the 14 ATL patients showed somewhat prolonged survival (>100 days). However, relapse or disease progression in the peripheral blood, central nervous system, lymph nodes, skin, and/or bone occurred within a relatively short period after treatment. The adverse effects were tolerable, and included lymphopenia, cytomegalovirus infection and skin rash. Conclusion Mogamulizumab therapy resulted in an early and high remission rate and somewhat prolonged survival in patients with refractory ATL. However, the duration of remission was short, and there was early relapse and disease progression. This study may show the current impact of mogamulizumab in clinical practice.

PRMT5 Is Upregulated in HTLV-1-Mediated T-Cell Transformation and Selective Inhibition Alters Viral Gene Expression and Infected Cell Survival.

Human T-cell leukemia virus type-1 (HTLV-1) is a tumorigenic retrovirus responsible for development of adult T-cell leukemia/lymphoma (ATLL). This disease manifests after a long clinical latency period of up to 2–3 decades. Two viral gene products, Tax and HBZ, have transforming properties and play a role in the pathogenic process. Genetic and epigenetic cellular changes also occur in HTLV-1-infected cells, which contribute to transformation and disease development. However, the role of cellular factors in transformation is not completely understood. Herein, we examined the role of protein arginine methyltransferase 5 (PRMT5) on HTLV-1-mediated cellular transformation and viral gene expression. We found PRMT5 expression was upregulated during HTLV-1-mediated T-cell transformation, as well as in established lymphocytic leukemia/lymphoma cell lines and ATLL patient PBMCs. shRNA-mediated reduction in PRMT5 protein levels or its inhibition by a small molecule inhibitor (PRMT5i) in HTLV-1-infected lymphocytes resulted in increased viral gene expression and decreased cellular proliferation. PRMT5i also had selective toxicity in HTLV-1-transformed T-cells. Finally, we demonstrated that PRMT5 and the HTLV-1 p30 protein had an additive inhibitory effect on HTLV-1 gene expression. Our study provides evidence for PRMT5 as a host cell factor important in HTLV-1-mediated T-cell transformation, and a potential target for ATLL treatment.

JAK2 V617F Mutation in Adult T Cell Leukemia-Lymphoma.

Adult T cell Leukemia/lymphoma (ATL) is a mature T-cell neoplasm that has strong association with the human T-lymphotropic virus type 1 (HTLV-I) infection. This infection is endemic in our region (north eastern Iran). It has been highlighted that Janus Kinase family proteins and specially JAK2 mutations have a pivotal role in the development of many types of hematological malignancies and in particular myeloproliferative neoplasms. So far, the underlying molecular mechanisms leading to the ATL are not well understood. Therefore, in this study it was hypothesized that JAK2 (V617F) mutation may be present in samples from patients with ATL. This case control study was performed in north-eastern Iran. Using polymerase chain reaction, JAK2 (V617F) mutation was performed in 20 DNA samples from ATL patients and 20 HTLV-1 asymptomatic carriers (control group). The results of ATL subjects and the control group were compared by using SPSS software. In the case group 13 (65%) and 7 patients (35%) were male and female respectively, with the age range between 40 and 80years. Only one patients has JAK2 mutation and this mutation was absent in 95% of ATL patients as well as the HTLV-1 asymptomatic carriers. The results of our study demonstrated that JAK2 V617F mutation is not a common phenomenon in ATL. However, further studies are required to investigate the possible dysregulation of JAK signaling in ATL.

Recent Advances in Therapeutic Approaches for Adult T-cell Leukemia/Lymphoma.

Adult T-cell leukemia/lymphoma (ATLL) is a peripheral T-cell lymphoma caused by human T-cell leukemia/lymphoma virus type 1 (HTLV-1). ATLL occurs in approximately 3%–5% of HTLV-1 carriers during their lifetime and follows a heterogeneous clinical course. The Shimoyama classification has been frequently used for treatment decisions in ATLL patients, and antiviral therapy has been reportedly promising, particularly in patients with indolent type ATLL; however, the prognosis continues to be dismal for patients with aggressive-type ATLL. Recent efforts to improve treatment outcomes have been focused on the development of prognostic stratification and improved dosage, timing, and combination of therapeutic modalities, such as antiviral therapy, chemotherapy, allogeneic hematopoietic stem cell transplantation, and molecular targeted therapy.

Development of an Anti-HTLV-1 Vaccine for the Treatment of Adult T-Cell Leukemia/Lymphoma

Human T-cell Lymphotrophic Virus 1 (HTLV-1) is the etiologic agent of Adult-T cell Leukemia/Lymphoma (ATL). Therapeutic options for ATL patients are very limited and in aggressive forms of the disease survival rate is only 10% to 30% with conventional chemotherapies and bone marrow transplantation. Although some clinical trials gave encouraging results regarding the efficacy of new treatments, most of them are lifelong, aggressive and failed to achieve a significant impact on long-term survival. Consequently, new treatments for ATL patients are needed to limit relapses and side effects.Specific HTLV-1 cellular immune response is dramatically impaired in ATL patients, which could favor the initiation and the progression of the disease. Hence, stimulating immune responses against HTLV-1 can be an appropriate therapeutic option to treat ATL. THERAVECTYS has developed an anti-HTLV-1 vaccine, based on its lentiviral vector technology inducing a broad, intense and long-lasting cellular immune response after intra-muscular injection. THERAVECTYS was the first company to have launched a clinical trial based on lentiviral vectors technology with the THV01 vaccine for the treatment of HIV (NCT02054286). Results obtained demonstrated both safety and immunogenicity of THV01 in human, with polyfunctional and multi-specific CD4 and CD8 T-cells responses.The anti-HTLV-1 lentiviral vector, THV02 vaccine, encodes for a unique polypeptide derived from Tax, HBZ, p12I and p30II proteins, involved in HTLV-1 pathogenicity and known to be recognized by the immune system of HTLV-1 infected patients. Our preclinical results have demonstrated that THV02 can induce a cellular immune response in C57Bl/6j and BalbC mice and in Sprague Dawley rats, as demonstrated by IFN-γ Elispot. Safety of the THV02 vaccine has been demonstrated during carcinogenicity and regulatory GLP preclinical toxicity studies. Biodistribution and shedding studies demonstrated the very limited diffusion of THV02 after injection, its fast clearance and a non-dissemination in body fluids.As no relevant ATL immunocompetent animal model is available to assess the anti-tumor effect of THV02, THERAVECYTS is developing an ex-vivo efficacy model using blood samples of ATL patients. Briefly, monocyte-derived dendritic cells (MDDC) from blood of ATL patients are purified by isolation of CD14 positive cells from PBMC and differentiation in the presence of IL4 and GM-CSF. MDDC are then transduced with lentiviral vectors encoding for the anti-HTLV-1 antigen and maturation is induced upon TNFa and PGE2 exposure before the co-culture with autologous CD8+ T-cells for stimulation of the cellular immune response. Then, stimulated CD8+ are co-cultured with autologous CD4+ CD25+ ATL cells and the cytotoxic activity is monitored by flow cytometry. Preliminary results demonstrated that MDDC from a chronic ATL patient can be efficiently transduced and matured as attested by the CD40, CD86, HLA-DR, -A, -B and C markers on their surface. In addition, we have observed a specific stimulation of the CD8+, ie an increase of IFNg, TNFa, IL2 and perforin in the media of the co-culture of CD8+ with MDDC expressing anti-HTLV-1 antigen. These data are very encouraging and demonstrate for the first time the feasibility to develop an ex vivo model to assess vaccine efficacy using ATL blood sample. The development of this model is ongoing using several ATL donors representing the different subtypes of the disease and will be presented at the meeting.Regarding the indication and the safety profile of THV02, THERAVECTYS plans to begin a clinical trial in Q4 2015. This assay will be an open-label, dose escalation phase I/II study to assess the safety and the immunogenicity (cellular immune response) of the THV02 vaccination as a treatment of ATL patients. All ATL subtypes will be considered since THV02 vaccine can be combined with conventional ATL treatments. In addition, as the THV02 antigen contains peptides derived from Tax but also HBZ, p12I and p30II viral proteins, all ATL patients can be treated whatever the status of Tax expression. As secondary objectives, both humoral immune response and clinical effect will be assessed. HTLV-1 RNA expression and clonality of HTLV-1 infected cells will be studied as exploratory objectives. Finally, up to 16 patients will be enrolled in France, UK, French Guiana, Martinique and Guadeloupe before doing a phase of extension cohort in US. DisclosuresNo relevant conflicts of interest to declare.

Current Clinico-Epidemiological Characteristics of Adult T-Cell Leukemia-Lymphoma (ATL) Based on the 11th Nationwide Survey in Japan

Introduction: Adult T-cell leukemia-lymphoma (ATL) is a distinct peripheral T-cell lymphomacaused by human T-lymphotropic virus type I (HTLV-1), which is endemic in Japan. Only a small percentage of HTLV-1 carriers infected through breast-feeding develop the disease. Previous nationwide surveys during 1980s-2000s in Japan provided a comprehensive view on the clinio-epidemiological profiles of ATL, including the establishment of the subtype-classification (i.e., the Shimoyama criteria: acute, lymphoma, chronic, and smoldering type) based on the diversity of the clinical features and prognosis. Treatment strategies have been developed by the subtype-classification; watchful waiting for indolent ATL, intensive chemotherapy followed by allogeneic hematopoietic stem cell transplantation (allo-HSCT) for aggressive ATL. The aim of this 11th survey is to characterize the current clinio-epidemiological features of ATL in Japan in the light of previous surveys.Methods: In 2013-14, we conducted an anonymous, cross-sectional, hospital-based survey of patients with ATL who were newly diagnosed during 2010-2011 across Japan. First, we asked 2500 hospitals with departments of hematology and dermatology to participate in this survey, and then we sent questionnaires to 128 participating hospitals to accumulate data of ATL. Skilled five hematologists reviewed the data of each questionnaire sheet, and the agreements of ATL diagnosis including the subtypes between the central review and participating hospitals were evaluated using Kappa statistics. Most of the collected data were analyzed by descriptive statistics.Results: A total of 996 ATL patients were registered; of these, 41 were eliminated because of the insufficient information for the diagnosis of ATL. Overall diagnostic agreement on subtype of ATL was substantial, with a kappa value 0.71 (standard error, 0.021); most of the disagreement was within aggressive/indolent category, acute vs. lymphoma types or acute vs. unfavorable chronic types. Among the 955 evaluable patients (M/F ratio, 1.12), 70% were diagnosed in the southwest region of Japan (Kyusyu/Okinawa) where HTLV-1 is endemic, which was consistent with the past surveys. The mean age at diagnosis was 68.3 years (median 68.8, range 24.7-100.3), which was significantly higher than 60.3 years in 1994-1995 and 57.7 years in 1986-1987. The proportion of ATL patients aged over 65 years was 79 % in this survey (whereas, 48% in the 1990-1991 survey), which indicates that the allo-HSCT is not applicable to the majority of current ATL patients in Japan. The proportion of acute, lymphoma, chronic, and smoldering types was 48, 28, 10 and 13%, respectively. The proportion of smoldering and chronic types tended to be greater than previous surveys (7% and 10% in the 1988-1997 surveys combined). The proportion of subtype by age group in this survey showed that the older in age at diagnosis are, the higher proportion of lymphoma subtype (10% in those aged younger than 40 years, 20% in those 50-59, and 31% in those 70 years or older.Discussion: This 11th survey revealed several clinio-epidemiological features of current ATL in Japan different from those in past two decades. First, a considerably increasing proportion of elderly ATL patients were diagnosed, which may be expected from a recent distribution of nationwide HTLV-1 carriers in Japan (Satake, et al, 2011). Second, there is an increasing tendency in the proportion of indolent types of ATL. This may be partly influenced by participation of the dermatology departments for the first time, because early phase of ATL localized in skin were frequently diagnosed in the dermatology department. Third, the proportion of lymphoma subtype was increased with age, which suggests that aging-related unknown mechanisms may affect the subtype distribution. More detailed analysis and subsequent surveys are planned to further evaluate clinical features and the efficacy of modern therapies on prognosis of ATL. DisclosuresIshizawa:Kyowa Kirin: Speakers Bureau; GSK: Research Funding; Takeda: Research Funding; Celgin: Speakers Bureau; Kyowa Kirin: Research Funding; Celgin: Research Funding; Janssen: Research Funding; Takeda: Speakers Bureau; Pfizer: Speakers Bureau. Ishida:Bristol-Myers Squibb: Honoraria. Ishida:Kyowa Hakko Kirin Co., LTD: Honoraria, Other: Research Funding to my institution; Bayer Pharma AG: Other: Research Funding to my institution; Celgene K.K.: Other: Research Funding to my institution. Tobinai:Gilead Sciences: Research Funding. Watanabe:Daiichi Sankyo Co., Ltd.: Research Funding.

Prior Use of Mogamulizumab to Allogenic Hematopoietic Stem Cell Transplantation Induces Severe Acute Graft-Versus-Host Disease

[Introduction] Adult T-cell leukemia/lymphoma (ATL) is an aggressive peripheral T-cell lymphoma (PTCL) with a dismal prognosis. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the only curative treatment in ATL patients. Mogamulizumab, a humanized anti-CC chemokine receptor 4 (CCR4) monoclonal antibody, is a novel immunotherapeutic agent, effective in treating patients with PTCL such as ATL, PTCL-not specified, and cutaneous T-cell lymphoma. However, in allo-HSCT setting, we should be careful to use mogamulizumab because CCR4 is expressed in regulatory T cells: The mogamulizumab treatment may accelerate GVHD by eradicating regulatory T cells in allo-HSCT patients. Here, we retrospectively analyzed the effect of mogamulizumab on GVHD development in ATL patients treated with mogamulizumab prior to allo-HSCT.[Patients and Methods] Data from the Fukuoka Bone Marrow Transplantation Group were retrospectively analyzed after the approval of mogamulizumab use in Japan.[Results] A total of 24 patients with ATL received mogamulizumab prior to allo-HSCT between April 2012 and April 2015 in our group. The median age at allo-HSCT was 58.5 years (range, 32-72). The median intervals from the last administration of mogamulizumab to allo-HSCT were 25 days (range, 9-126). The median total dose of mogamulizumab was 3 mg/kg (range, 1-8 mg/kg). After treatment with mogamulizumab, 18 patients (75%) had achieved in remission (CR in 4 patients and PR in 14) at allo-HSCT. Ten patients received unrelated bone marrow, 5 received related peripheral blood, and 9 received cord blood as stem cell sources. Eleven patients were treated with full-intensity conditioning and 13 received reduced-intensity conditioning. Graft-versus-host disease (GVHD) prophylaxis consisted of calcineurin inhibitors (cyclosporine or tacrolimus) with short-term methotrexate in 14 patients and mycophenolate mofetil in 9. The cumulative incidence (CI) of acute GVHD at 100 days was 66.6% in grade 2-4 and 33.3% in grade 3-4. The involved organs of acute GVHD were skin in 14 patients, gut in 10, and liver in 4. Among 14 patients who developed grade 2-4 acute GVHD, 5 had severe fluid retention such as pleural effusion or ascites associated with GVHD. Chronic GVHD was observed in 6 patients, and 5 of them were extensive disease. The CI of transplant-related mortality (TRM) and relapse at 1-year were 53.2% (95%CI, 29.3-72.3%) and 29.6% (95%CI, 12.6-48.9%), respectively. The leading cause of death was GVHD (n = 7). The 1-year overall survival and progression-free survival were 19.2% (95%CI, 5.7-38.8%) and 17.2% (95%CI, 4.9-35.7%), respectively.[Discussion] Use of mogamulizumab prior to transplantation in allo-HSCT patients has a merit to decrease the burden of ATL cells. However, it was associated with an increase of TRM due to severe GVHD. Although most of ATL patients achieved better disease status at allo-HSCT through mogamulizumab and the survival rate was expected to be 50% based on the previous data, the survival in the present study was ~20%. These data suggest that mogamulizumab administered before transplantation may have retained until an early phase of post-transplantation, and the donor or host-derived regulatory T cells might be eliminated, allowing the GVHD T-cell clone to expand. Since mogalizumab is a potent anti-ATL agent, we need to develop new treatment protocols integrating mogalizumab at a suitable dose or administration timing, to minimize the unwanted GVHD development in future studies. DisclosuresAkashi:Asahi Kasei: Research Funding, Speakers Bureau; Shionogi: Research Funding, Speakers Bureau; Astellas: Research Funding, Speakers Bureau; Celgene: Research Funding, Speakers Bureau; Chugai: Research Funding, Speakers Bureau; Bristol-Myers Squibb: Research Funding, Speakers Bureau; Novartis Pharma K.K.: Consultancy, Research Funding, Speakers Bureau; Kyowa Hakko Kirin Co., Ltd.: Consultancy, Research Funding, Speakers Bureau.

Adult T-Cell Leukemia/Lymphoma: A Clinical and Epidemiological Analysis at the Medicine School of Sao Paulo University

Background: Adult T-cell leukemia/lymphoma (ATLL) is a rare disease described in Japan in 1977 and associated with human T-cell leukemia virus 1 (HTLV-1) infection. It is classified into four subgroups [1]: smoldering and chronic forms which are considered indolent and acute and lymphoma subtypes that present an aggressive behavior and short overall survival (OS) despite the treatment. Here, we describe an ATLL experience at a reference cancer treatment institution in Sao Paulo, Brazil.Methods: We retrospectively analyzed 29 ATLL patients who were attended from June/2006 to June/2015 at the Medicine School of Sao Paulo University, Brazil. ATLL was classified according to Shimoyama criteria [1] and Levine score [2] was used to estimate the probability of ATLL diagnosis. All patients were HTLV-1+. In the leukemic subtypes of ATLL, the neoplastic cells were CD3+/CD4+/CD8- or CD3+/CD4-/CD8- along with CD25+ and lack of CD7 expression. In the lymphoma type all patients showed a peripheral T cell lymphoma on their tissue biopsy. Statistical analysis was performed using GraphPad Prism Version 5.0 software.Results: Table 1 shows the clinical characteristics of patients on diagnosis. Acute ATLL was associated with higher Levine's score. The average age on diagnosis was 48.82 years old (18.69-74.26). Our data is in accordance with previous Brazilian studies that showed lower average age on diagnosis. This could be related to earlier infection, intrinsic characteristics of virus strains circulating in Americas or host immune particularities. There was confection with B hepatitis, C hepatitis and HIV in three, two and one case, respectively. Forty-five per cent of the patients had skin lesions and eight patients presented central nervous system disease (4 of acute ATLL). No patient had concomitant HTLV-I-Associated Myelopathy/Tropical Spastic Paraparesis.In our practice, smoldering ATLL was usually held in a watchfull-waiting approach. All six chronic ATLL patients were treated with interferon alpha and zidovudine (IFN+AZT) first-line. Progression-free survival (PFS) was 36.06 months and 12.4 months for smoldering and chronic subtypes, respectively. Acute and lymphoma subtypes had been treated with polichemotherapy, usually with CHOEP regimen (vincristine 1,4 mg/m2 i.v D1, doxorubicin 50mg/m2 i.v D1, cyclophosphamide 750mg/m2 i.v D1, etoposide 750 mg/m2 i.v D1, dexamethasone 20 mg i.v on day 1, prednisone 100 mg days 2 to 5) first-line. Overall average survival for lymphoma ATLL was 11.57 months, shorter than previous reports (average of 16 months, 86% treated with CHOP regimen [3]; survival of 19.7 months LSG15 protocol [4]). Eleven in 15 patients with acute ATLL had died after an average of 8.5 months (2.3 - 15.5) after the diagnosis. Overall survival for all subtypes was 15.17months (fig 1A), and 59.03; 44.47; 11.75 and 5.8 months (p= 0.0634) for smoldering, chronic, lymphoma and acute subtypes, respectively (fig 1B).Conclusion: We found an OS of 5.8 months for acute ATLL treated with chemotherapy as first-line, which is comparable to literature (average survival of 6 months [3]) but shorter than those patients treated with first-line IFN+AZT (average survival of 9 months [3]). In our setting it is still scarcely available trioxide arsenic and clinical trials for ATLL, and allogenic transplant related to mortality is still high. We are therefore changing our practice according to recent recommendations and aiming to treat leukemic ATLL first-line with higher tolerated doses of IFN+AZT to improve our survival curve.

Mogamulizumab Therapy for Adult T-Cell Leukemia-Lymphoma: A Retrospective Multicenter Study

Introduction: Adult T-cell leukemia-lymphoma (ATL) is a peripheral T-cell malignancy, which is caused by human T-cell leukemia virus type I (HTLV-1) and is considered to be derived from regulatory T cells (Treg). ATL is usually resistant to conventional chemotherapies and the patients with ATL have very poor prognosis. Mogamulizumab (Moga) is a humanized monoclonal antibody against CC chemokine receptor 4 (CCR4) which is expressed on T-helper type 2, Treg and tumor cells from most patients with ATL. It was reported that Moga used to treat ATL with 50% efficacy in a phase II study and frequently developed cutaneous adverse reactions (CAR). In that study, development of CAR was reported to be closely associated with the response to Moga therapy. To confirm efficacy and safety of Moga therapy for ATL, we retrospectively analyzed relapsed or refractory ATL patients who were treated by Moga at 4 institutes in Kagoshima, one of the endemic areas of HTLV-1 infection, Southwestern Japan.Patients and methods: There were 77 patients, who were received Moga therapy between March, 2007 (phase I study) and December, 2014. We studied about backgrounds (age, sex, subtypes of ATL, ECOG performance status (PS) at diagnosis and clinical stage) of the patients, contents of prior therapy and the response, prognostic index for acute and lymphoma type ATL (ATL-PI), PS and disease status at Moga therapy, response and adverse events (AE) of Moga therapy, and the survival.Results: Enrolled patients were 44 men and 33 women, and median age at Moga therapy was 65.6 years (range: 44-83 years). They consisted 54 acute, 18 lymphoma, and 5 chronic type ATL, and ATL-PI was low in 18, intermediate in 43 and high in 16 patients. Initial induction chemotherapies were mainly VCAP-AMP-VECP regimen in 41, CHOP like regimen in 19 patients. Median duration between diagnosis and Moga therapy was 8.1 months (range: 0.5-94.9 months). They were administered Moga median 5 cycles (range: 1-10 cycles). Disease status at Moga therapy were 23 relapsed and 54 refractory [partial response (PR): 8, stable disease (SD): 15, progressive disease (PD): 31] disease. Myelosuppression associated with Moga, development of cytomegalovirus antigenemia (19.5%) and other AE were tolerable. Best objective response rate was 42.9% including 18 complete remission (CR) and 15 PR. Fifty-four patients died after Moga therapy (50 from ATL, 4 from infection and so on). Median overall survival (OS) time from Moga therapy was 7.7 months (95%CI: 5.1-11.2 months) and 3-year OS rate was 18.2%. The cohort included 27 patients over 70 years, but their survival was no worse than younger. Twelve patients received allogeneic hematopoietic stem cell transplantation after Moga therapy, but had no survival advantage. Twenty-four patients suffered from CAR, which were developed median 7 cycles (range: 2-8 cycles). The severity of CAR according to CTCAE v3.0 was grade 1 in three, 2 in eight, 3 in eleven and 4 in two patients, respectively. In patients (n = 51) received Moga more than 4 cycles, 22 patients suffered from CAR and their OS (3-year OS: 43.6%) was significantly better than patients without CAR (median OS: 23.4 vs 7.9 months, p = 0.0003).Discussion: Moga therapy is effective and safe for ATL patients and the onset of moderate CAR is a favorable sign of the efficacy. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Prognostic Relevance of Integrated Genetic Profiling in Adult T-Cell Leukemia/Lymphoma

Adult T-cell leukemia/lymphoma (ATL) is a distinct subtype of peripheral T-cell neoplasms associated with human T-cell leukemia virus type-1 retrovirus. ATL includes a heterogeneous group of patients in terms of pathological and clinical features as well as prognosis, suggesting the presence of underlying molecular pathogenesis that could explain such heterogeneity among patients. Recently, we performed an integrated molecular analysis of a large number of ATL cases and delineated a comprehensive registry of gene mutations and other genetic/epigenetic lesions in ATL. In this study, we investigated possible correlations between these genetic/epigenetic lesions and clinical/pathological phenotypes in a large set of ATL patients, with a special focus on the impact of mutations and copy number alterations (CNAs) on clinical outcome.We analyzed a total of 361 ATL samples, including acute (n = 192), lymphoma (n = 66), chronic (n = 89), and smoldering (n = 14) subtypes, for recurrent mutations and CNAs. Each subtype had characteristic genetic/epigenetic features, suggesting a distinct molecular pathogenesis therein. Aggressive (acute and lymphoma) subtypes were characterized by a higher number of mutations and CNAs including focal amplifications/deletions, hyperploid status, and CIMP phenotype, compared with indolent (chronic and smoldering) tumors. Two mutations (TP53 and IRF4) and eight focal deletions involving 1p13 (CD58), 6p21 (HLA-B), 9p21 (CDKN2A), 10p11 (CCDC7), 13q32 (GPR183), 16q23 (WWOX), 17p13 (TP53), and 19q13 (CEBPA), were more common in aggressive ATL than in indolent ATL. In contrast, showing a similar mutational distribution to those found in large granular lymphocytic leukemia, STAT3 mutations were characteristic of the indolent diseases. Gene set enrichment analysis of RNA-seq data showed a significant enrichment of MYC pathway and genes regulating cell cycle and DNA repair in upregulated genes in aggressive ATL.Next, we assessed the impact of mutations and CNVs on prognosis among 215 ATL cases, for which survival data were available. In the entire cohort, mutation in CCR4 and IRF4, focal amplification in 9p24 (CD274) and 14q32 (BCL11B), and focal deletion in 9p21 (CDKN2A) were found to be significant predictors of poor overall survival, after adjustment for disease subtype and age. Multivariate analysis revealed that disease subtype (aggressive vs. indolent) was the most significant predictor of clinical outcome in ATL. Subsequent multivariate analysis according to disease subtype showed that within the patients with aggressive ATL, older age (≥ 70 years), CCR4 mutations, and 9p24 amplification were independently associated with an adverse outcome. Based on the number of the risk factors they owned, patients with aggressive ATL were classified into three categories showing marked difference in 3-year overall survival (OS) (P < 0.001): those with no risk factors (OS, 32%), with one risk factor (18%), and with two or more (0%). Among the patients with indolent ATL, we found IRF4 and TP53 mutations, 9p24 amplification, and deletions in 9p21 and 10p11 were independently associated with reduced survival. Interestingly, these alterations, except for 9p24 amplification, were also identified as genes more frequent in aggressive ATL. More importantly, based on these risk factors, the patients with indolent ATL can be classified into two categories showing very different prognostic profiles: patients with no risk factors (OS, 89%) and those with one or more risk factors (21%) (P < 0.001, HR = 16.8, 95% CI:5.4-52.5), suggesting that patients with indolent ATL having a genetic feature of the aggressive subtypes might genetically and biologically represent a distinct subset, which should be better managed as having an aggressive disease. Among these poor prognostic factors, 9p24 amplification and CCR4 mutation are especially interesting, because these lesions might be plausible targets of available agents, including anti-PD1/PD-L1 and anti-CCR4 antibodies.In conclusion, based on the comprehensive genetic profiling, we demonstrated that the known subtypes of ATL can be further classified into genetically and biologically distinct subsets of tumors characterized by discrete sets of genetic lesions and substantially different prognosis. Our results suggest that molecular profiling can improve the prediction of prognosis in ATL patients and better guide therapy. DisclosuresTobinai:Gilead Sciences: Research Funding. Miyazaki:Shin-bio: Honoraria; Chugai: Honoraria, Research Funding; Sumitomo Dainippon: Honoraria; Celgene Japan: Honoraria; Kyowa-Kirin: Honoraria, Research Funding. Watanabe:Daiichi Sankyo Co., Ltd.: Research Funding.

Telmisartan, Angiotensin II Receptor Blocker, Induces Apoptosis and Autophagy in Adult T-Cell Leukemia Cells from Patients and Leukemia Cell Lines

Introduction: Adult T-cell leukemia/lymphoma (ATL) is an aggressive T-cell malignancy that develops after long-term infection with human T-cell leukemia virus (HTLV-1). Despite the recent advances in chemotherapy, allogeneic hematopoietic stem cell transplantation, and supportive care, the prognosis for patients with acute, lymphoma, or unfavorable chronic subtypes (aggressive ATL) is one of the poorest among hematological malignancies; overall survival at 3 years is only 24 % in the more aggressive subtypes of ATL. In case of favourable chronic or smoldering ATL (indolent ATL), watchful waiting until disease progression has been recommended. Some patients with indolent ATL develop infections during this period. Therefore, urgent need for therapy and prophylaxis of ATL are still required. Recently, drug repositioning offers the possibility of reduced time and risk as several stages common to novel drug discovery and development can be bypassed because repositioning candidates have frequently been through several phases of development for their original indication. With the successful clinical introduction of a number of non-cancer drugs for cancer treatment, drug repositioning now became a potent alternative strategy to discover and develop novel anticancer drug candidates from the existing drug space. On the other hand, the transcription factor PPARγ plays various roles in lipid metabolism, immune response, cellular differentiation and apoptosis. Among clinically available angiotensin II receptor blockers, telmisartan is well known for its unique ability to activate PPARγ. Here, we assessed how telmisartan affects ATL cells from patients and leukemia cell lines.Methods and Results: Methods used in this study were carried out in accordance with the approved guidelines by the Committees for Ethical Review of Research involving Human Subjects at Kagoshima University. The subjects were examined by standard serological testing for the presence of HTLV-1 and by haematological/Southern blotting analysis for diagnosis of ATL. The classification of ATL was performed according to the criteria of Shimoyama. Telmisartan reduced cell viability and enhanced apoptotic cells in ex vivo peripheral blood monocytes of acute-type ATL, which has a poor prognosis. Telmisartan-induced apoptosis in cells from ATL patients (acute and chronic-type) and asymptomatic HTLV-1 carriers was significantly increased compared with those from healthy donors. Telmisartan also induced significant growth inhibition and apoptosis (Annexin V+ cells and TUNEL) in leukemia cell lines (HTLV-1-related cell lines: S1T, MT-2; Jurkat and HL60), while other angiotensin II receptor blockers, irbesartan and valsartan, did not induce cell death. In apoptosis, several key events occur in mitochondria, including the release of caspase activators, such as apoptosis-induced factor, and loss of mitochondrial transmembrane potential. Telmisartan induced loss of mitochondrial transmembrane potential and generation of reactive oxygen species, although apoptosis-inducing factor level was stable. Telmisartan also inhibited cell growth via caspase activation (caspase-3, 8 and 9) in the leukemia cells. However, treatment with a caspase inhibitor did not inhibit telmisartan-induced cell death. Interestingly, telmisartan increased the LC3-II-enriched protein fraction, indicating autophagosome accumulation as well as autophagy. Thus, Telmisartan simultaneously caused caspase activation and autophagy.Conclusion: A hypertension medication that has an anti-proliferation effect on leukemia cells is intriguing. These results suggest that telmisartan is highly effective against HTLV-1-infected cells and ATL cells in a caspase-dependent and -independent manner, and its clinical use may suppress the progression from indolent ATL or carrier status to aggressive ATL, and thus improve the prognosis of patients with this fatal disease. DisclosuresNo relevant conflicts of interest to declare.

Treatment Outcomes in Relapsed/Refractory Adult T-Cell Lymphoma/Leukemia and Role of CNS Prophylaxis: A New York City Hospital Experience

Background:Adult T-cell leukemia/lymphoma (ATLL) is a rare and aggressive peripheral T-cell neoplasm characterized by clonal human T-cell lymphotropic virus type-1 (HTLV-1) proviral DNA integration with host T lymphocytes.It presents as aggressive (acute/lymphomatous) or indolent (chronic/smouldering) subtypes. The aggressive subtypes have median survival of 6-13 months despite aggressive chemotherapy regimens. Presently, there is no established therapy for patients with relapsed/refractory disease. The data on efficacy of traditional chemotherapy agents in this setting is scant. In the last 6 years, 4 new drugs have been approved by US Food and Drug Administration for patients with relapsed/refractory peripheral T cell lymphoma (PTCL): pralatrexate and 3 histone deacetylase (HDAC) inhibitors (romidepsin, belinostat, vorinostat). Treatment approaches for PTCL are often applied to ATLL, as there is little data available for this subtype. However, none of the HDAC inhibitor trials included ATLL patients and there was only one patient in the pivotal PROPEL study for pralatrexate. The prevalence of CNS disease in the aggressive subtypes varies from 3 to 50 % and the efficacy of intrathecal chemotherapy is not known.Methods:To investigate the therapeutic benefit of second-line therapy and prophylactic intrathecal therapy, we reviewed all patients with ATLL at King's County Hospital between 2006 and 2014. Individual chart review was performed to report clinicopathologic features and treatment outcomes. SPSS was used for statistical analysis.Results:Fifty five patients were identified between January 2006 and December 2013 including 33 (60%) females and 22 (40.0%) males with a median age of 54 years (range, 31-78 years). All patients had immigrated to the United States from the Caribbean or South America. Median follow-up period was 6.6 months (0.4-124). Forty four patients were dead, 5 were alive and 6 were lost to follow-up at the time of analysis. Stage distribution was 26%, 51%, 16%, 6% for stage I, II, III and IV respectively. Forty three patients (78.2%) received etoposide/prednisone/vincristine/cisplatin/adriamycin (EPOCH) for first-line therapy. Twenty nine patients received second-line chemotherapy: gemcitabine/oxaliplatin, iphosphamide/cisplatin/etoposide (ICE), romidepsin, pralatrexate and high dose methotrexate. Median progression free survival was 6.8 weeks (range 1.6-72). No complete responses were seen. Partial response was seen in 9 (n=29) patients (31%). Median duration of response was 20.8 weeks (range 9.1-40). Three (5%) patients had CNS involvement at presentation. Prophylactic intrathecal therapy with methotrexate (IT MTx) 12 mg Q14 days was given to 21 patients (40.3%). CNS relapse was seen in 3 (14.2%) patients who received IT MTx and 6 (19.4%) patients who did not receive intrathecal chemotherapy. All patients with CNS relapse also had peripheral relapse.Conclusion:ATLL is a rare and difficult disease to manage. In our experience of relapsed/refractory ATLL, patients appear to have modest response rate to a second-line chemotherapy and these responses are not long lasting. In our patient population, risk of CNS disease at presentation was low (5%) but the incidence approaches 17.3% at the time of relapse. Administration of prophylactic intrathecal methotrexate showed a trend towards reducing the incidence of CNS disease although the results were not statistically significant. DisclosuresNo relevant conflicts of interest to declare.

Multicenter Phase II Study of Lenalidomide in Patients with Relapsed Adult T-Cell Leukemia-Lymphoma

Multicenter Phase II Study of Lenalidomide in Patients with Relapsed Adult T-Cell Leukemia-Lymphoma

Prognostic significance of tryptophan catabolism in adult T-cell leukemia/lymphoma

Indoleamine 2,3-dioxygenase 1 (IDO1: IDO) is an enzyme catabolizing tryptophan (Trp) into the kynurenine (Kyn) pathway, and is an important micro-environmental factor suppressing antitumor immune responses. We investigated the prognostic significance of Trp catabolism in adult T-cell leukemia/lymphoma (ATL). We quantified serum Trp and Kyn in 96 ATL patients, 38 human T-cell lymphotropic virus type-1 asymptomatic carriers (HTLV-1 ACs), and 40 healthy adult volunteers. The relationships between various clinical parameters were analyzed. IDO expression was evaluated in the affected lymph nodes of ATL patients. Serum Kyn concentrations and Kyn/Trp ratios were significantly higher in HTLV-1 ACs than in healthy controls. Both increased significantly with progression from HTLV-1 AC to ATL. There were no significant differences in serum Trp concentrations between ATL patients, HTLV-1 ACs and controls. IDO was possibly produced by ATL and/or cells in the microenvironment. Multivariate analyses demonstrated a high serum Kyn/Trp ratio and high Kyn level, but not a high Trp level, to be significant independent detrimental prognostic factors in ATL and aggressive variant ATL. Quantification of serum Kyn and Trp is prognostically useful for individual ATL patients. Furthermore, ATL is an appropriate disease for testing novel cancer immunotherapies targeting IDO.

Molecular Pathology of Adult T-Cell Leukemia/Lymphoma

Adult T-cell leukemia/lymphoma (ATLL) is a peripheral T-cell neoplasm of highly pleomorphic lymphoid cells. ATLL is usually widely disseminated, and it is caused by human T-cell leukemia virus type 1 (HTLV-1). It is a disease with a long latency, and affected individuals are usually exposed to the virus very early in life. The cumulative incidence of ATLL is estimated to be 2.5% among HTLV-1 carriers. ATLL cells express CD2, CD3, CD5, CD4, and CD25, as well as CCR4 and FoxP3 of the regulatory T-cell marker. HTLV-1 is causally linked to ATLL, but infection alone is not sufficient to result in neoplastic transformation. A significant finding in this connection is that the Tax viral protein leads to transcriptional activation of many genes, while the HTLV-1 basic leucine zipper factor is thought to be important for T-cell proliferation and oncogenesis. Half of ATLL cases retain the ability to express HTLV-1 Tax, which is a target of HTLV-1-specific cytotoxic T lymphocytes (CTL). An increase in HTLV-1-specific CTL responses is observed in some asymptomatic HTLV-1 carriers. Although HTLV-1-specific CTL are also present in the peripheral blood of ATLL patients, they do not expand sufficiently. We investigated the clinicopathological features and analyzed the staining of Tax-specific CTL and FoxP3. Tax-specific CTL correlated inversely with FoxP3, an increase in the ratio of CD163+ tumor-associated macrophages was associated with worse clinical prognosis, and ATLL cell lines proliferated significantly following direct co-culture with M2 macrophages. Several clinical variants of ATLL have been identified: acute, lymphomatous, chronic, and smoldering. Oligo-array comparative genomic hybridization revealed that genomic loss of 9p21.3 was a significant characteristic of acute-type, but not of chronic-type ATLL. Furthermore, we found that genomic alteration of CD58, which is implicated in immune escape, is more frequently observed in acute than in chronic ATLL. Interestingly, the chronic cases with cell cycle deregulation and disruption of immunosurveillance mechanism were associated with faster progression to acute ATLL. Immune evasion, microenvironment, and genetic alteration are therefore important in the multi-step progression of ATLL lymphomagenesis.

Small PARP inhibitor PJ-34 induces cell cycle arrest and apoptosis of adult T-cell leukemia cells

BackgroundHTLV-I is associated with the development of an aggressive form of lymphocytic leukemia known as adult T-cell leukemia/lymphoma (ATLL). A major obstacle for effective treatment of ATLL resides in the genetic diversity of tumor cells and their ability to acquire resistance to chemotherapy regimens. As a result, most patients relapse and current therapeutic approaches still have limited long-term survival benefits. Hence, the development of novel approaches is greatly needed.MethodsIn this study, we found that a small molecule inhibitor of poly (ADP-ribose) polymerase (PARP), PJ-34, is very effective in activating S/G2M cell cycle checkpoints, resulting in permanent cell cycle arrest and reactivation of p53 transcription functions and caspase-3-dependent apoptosis of HTLV-I-transformed and patient-derived ATLL tumor cells. We also found that HTLV-I-transformed MT-2 cells are resistant to PJ-34 therapy associated with reduced cleaved caspase-3 activation and increased expression of RelA/p65.ConclusionSince PJ-34 has been tested in clinical trials for the treatment of solid tumors, our results suggest that some ATLL patients may be good candidates to benefit from PJ-34 therapy.

KIR genes and adult T-cell leukemia/lymphoma in patients infected with HTLV-1

Adult T-cell leukemia/lymphoma (ATLL) is an aggressive neoplastic disease whose etiologic agent is HTLV-1. ATLL patients have a pronounced immunosuppression of innate and adaptive immune system, compared to asymptomatic carriers. Killer-cell immunoglobulin-like receptors (KIR) play an important role in the signaling of natural killer cells and also are involved in the activity of CD8+ T cells, therefore these have a great repercussion in the innate and adaptive immune response. According to their intracytoplasmic motif they have an activating or inhibiting function on the cells that express these receptor. KIRs are expressed by a family of 15 genes highly polymorphic in the number of both alleles and genes present in the genome, with respect to the latter have been described haplotypes A and B. To assess the association of KIR genes with the presence of ATLL, 14 genes KIR were genotyped using PCR-SSP. For this purpose, genomic DNA was isolated from PBMCs from 147 unrelated individuals with HTLV-1 (20 ATLL and 127 asymptomatic carriers). Odds ratios (OR) were obtained by cross products and their statistical significance using Fisher's exact Test, with 95% confidence level. To determine whether this association is independent of the proviral load (PVL), known risk factor for ATLL, logistic regression was performed with and without PVL. Association of individual KIR genes with the presence of ATLL wasn't found, but an association between AA dyplotype and the presence of ATLL (odds ratio = 3.48, confidence interval 95% = 1.15-11.69, P = 0.02) was found. A loss of statistical significance was observed when the PVL is incorporated into the logistic model (odds ratio = 2.15, confidence interval 95% = 0.65-7.12, P = 0.21), which indicates that the association between genotype AA and ATLL is not independent of proviral load. We conclude that there is not statistically significant evidence to associate KIR genes with ATLL.

Treatment of an aggressive STLV-1 associated lymphoma in a naturally infected baboon

Human T Lymphotropic Virus type 1 infection is associated with a malignant lymphoproliferation named Adult T cell Leukemia/Lymphoma (ATLL). STLV-1, the simian counterpart of HTLV-1 also causes an ATLL-like disease. During the surveillance of our STLV-1 naturally infected Papio anubis cohort (n=45), we identified a 9 years-old female baboon exhibiting dyspnea, marked emaciation, and a lymphocyte count over 1010/L, pulmonary metastases and skin lesions similar to that observed in human ATLL patients. These symptoms suggested a hematologic malignancy induced by STLV1. This diagnosis was confirmed by the evidence of massive lymphoproliferation in an inguinal lymph node biopsy and the presence of lymphocytes with characteristic abnormal nuclei (i.e. flower cells) in blood smears. As is the case for humans, the animal received a combination of AZT (Combivir) and alpha interferon (viraferon, 50 μg/week) for 4 months. During this period, blood proviral load (PVL) was measured every week. Due to the absence of health improvement and only a slight decrease in the PVL, the animal was euthanased. Histological analysis of the secondary lymphoid organs was performed, and PVL was measured in 25 different organs. All lymphoid organs contained CD3+, CD25+ lymphocytic infiltrates. Furthermore, lymphoma cells were found in lungs and liver. Tax-positive cells were detected by immunohistochemistry in spleen, lung, mesenteric, axillary, inguinal, tracheo-bronchial, lymph nodes. While all organs were PCR positive, the highest PVL was found in lymph nodes, spleen and lungs. Finally, the oligoclonality and the clonal diversity was analyzed in PBMCs throughout the treatment but also in the different organs. In conclusion, non-human primates naturally infected with STLV-1 represent a useful model to study viral pathogenesis and to evaluate new treatments.

Cutaneous manifestations of human T-cell lymphotrophic virus type-1-associated adult T-cell leukemia/lymphoma: retrospective study in Martinique

Background Adult T cell leukemia/lymphoma (ATLL) is an aggressive lymphoma that occurs in 2–5% of HTLV-1 infected persons after several decades. Cutaneous manifestations often reveal or accompany the diagnosis of ATLL patients. No data exist regarding cutaneous involvement of adult T-cell leukemia/lymphoma (ATLL) in Martinique. We sought to describe skin involvement characteristics at onset of ATLL in Martinique.

The HTLV-1 latency-maintenance factor p30II activates p53-dependent metabolic effectors to promote oncogene-activation and aberrant lymphoproliferation

The human T-cell leukemia retrovirus type-1 (HTLV-1) transforms CD4+ T-lymphocytes and causes adult T-cell leukemia/lymphoma (ATLL), an aggressive hematological malignancy that is refractive to most anticancer treatments. The highly-conserved pX sequence of HTLV-1 encodes three latency-maintenance factors: p30II, p13II and Hbz, which suppress proviral gene expression and help HTLV-1-infected cells evade detection by host immune responses as a prelude to neoplastic disease. We have previously demonstrated that p30II enhances the transcriptional and oncogenic functions of the c-Myc oncoprotein and induces aberrant lymphoproliferation through molecular interactions with the TIP60 acetyltransferase. Our recent studies have demonstrated the cooperation between p30II and c-Myc is dependent upon the induction of p53-dependent pro-survival signals. The p30II protein activates p53 and induces expression of p53-dependent metabolic effectors, including the Tp53-induced glycolysis and apoptosis regulator (TIGAR). Acute and lymphoma-stage ATLL clinical isolates frequently over express c-Myc and contain wildtype p53. We therefore hypothesize the induction of p53-dependent pro-survival signals by p30II could promote c-myc oncogene-activation during retroviral carcinogenesis by preventing c-Myc-induced cytotoxicity and apoptosis. Indeed, we have found that lentiviral-p30II induces mitochondrial expression of TIGAR and prevents the intracellular accumulation of c-Myc-induced reactive oxygen species (ROS) and inhibits oncogene-induced cellular senescence. Knockdown of TIGAR expression, using a small-interfering RNA (siRNA-tigar), inhibited the ability of p30II to suppress c-Myc-induced cytotoxicity. A panel of primary ATLL patient tumor lymphocytes exhibited over expression of TIGAR which correlated with c-Myc deregulation, compared to donor hu-PBMCs. Furthermore, we have shown that siRNA-knockdown of TIGAR expression sensitizes HTLV-1-transformed SLB1 lymphoma cells to oncogene-induced ROS and causes cellular senescence, suggesting siRNA-inhibition of TIGAR may be a plausible approach to sensitize ATLL tumor lymphocytes to anticancer chemotherapy drugs that induce oxidative damage. Our studies reveal a paradoxical role for p53-dependent metabolic effectors in promoting oncogene-activation by HTLV-1 p30II, which could promote proviral replication and leukemic disease progression.