Adult T-cell Leukemia/lymphoma Patients Research Articles

Loss of Foxp3 Is Associated With CD30 Expression in the Anaplastic Large Cell Subtype of Adult T-cell Leukemia/Lymphoma (ATLL) in US/Caribbean Patients

Adult T-cell leukemia/lymphoma (ATLL) is caused by the HTLV-1 virus, endemic to Japan and the Caribbean, and is likely derived from cells with the T-regulatory phenotype. The malignant cells express IL2 receptor α (CD25), and the majority express transcription factor Forkhead box P3 (Foxp3), in addition to T-cell markers. Occasional cases express CD30. Whereas Japanese cases are predominantly of the acute and chronic leukemic types, the less well-studied Caribbean cases are more often lymphomatous. We performed immunohistochemical analysis for CD25, Foxp3, and CD30 on samples from 42 US/Caribbean ATLL patients and correlated these markers with morphologic subtype and clinical characteristics. In the 16/42 patients who had successive biopsies, we determined the expression stability of these markers. Foxp3 was expressed in 26 of the 42 (62%) initial biopsies, and its intensity correlated with CD25 expression. It was more frequent in pleomorphic small-sized and medium-sized cell types than in large cell tumors but did not correlate with patients' clinical attributes. Foxp3 expression and morphology were unchanged in successive biopsies in 13 of 16 patients. Four initial biopsies had features of anaplastic large cell T lymphomas, all of which were Foxp3. Successive biopsies from 2 patients with pleomorphic medium cell variant showed diminishing expression of originally weak Foxp3 expression and de novo CD30 expression, whereas they showed morphologic progression to the anaplastic cell variant. A third patient's second biopsy revealed progression from pleomorphic medium to anaplastic large cell morphology with loss of Foxp3, but it remained CD30. Foxp3 expression correlates with pleomorphic small and medium cell types and may be lost with large cell transformation. The evolution of the latter type can be associated with the gain of CD30 expression; such ATLL tumors might respond to anti-CD30 monoclonal antibody therapies.

Autologous Tax-Specific CTL Therapy in a Primary Adult T Cell Leukemia/Lymphoma Cell–Bearing NOD/Shi-scid, IL-2Rγnull Mouse Model

We expanded human T-lymphotropic virus type 1 Tax-specific CTL in vitro from PBMC of three individual adult T cell leukemia/lymphoma (ATL) patients and assessed their therapeutic potential in an in vivo model using NOG mice bearing primary ATL cells from the respective three patients (ATL/NOG). In these mice established with cells from a chronic-type patient, treatment by i.p. injection of autologous Tax-CTL resulted in greater infiltration of CD8-positive T cells into each ATL lesion. This was associated with a significant decrease of ATL cell infiltration into blood, spleen, and liver. Tax-CTL treatment also significantly decreased human soluble IL-2R concentrations in the sera. In another group of ATL/NOG mice, Tax-CTL treatment led to a significant prolongation of survival time. These findings show that Tax-CTL can infiltrate the tumor site, recognize, and kill autologous ATL cells in mice in vivo. In ATL/NOG mice with cells from an acute-type patient, whose postchemotherapeutic remission continued for >18 mo, antitumor efficacy of adoptive Tax-CTL therapy was also observed. However, in ATL/NOG mice from a different acute-type patient, whose ATL relapsed after 6 mo of remission, no efficacy was observed. Thus, although the therapeutic effects were different for different ATL patients, to the best of our knowledge, this is the first report that adoptive therapy with Ag-specific CTL expanded from a cancer patient confers antitumor effects, leading to significant survival benefit for autologous primary cancer cell-bearing mice in vivo. The present study contributes to research on adoptive CTL therapy, which should be applicable to several types of cancer.

Successful treatment of a patient with adult T cell leukemia/lymphoma using anti-CC chemokine receptor 4 monoclonal antibody mogamulizumab followed by allogeneic hematopoietic stem cell transplantation

Adult T cell leukemia/lymphoma (ATLL) is an aggressive peripheral T cell neoplasm caused by human T cell lymphotropic/leukemia virus type-1 and has a poor prognosis. A new anti-CC chemokine receptor 4 monoclonal antibody (mogamulizumab) has been shown to be effective for ATLL. Although mogamulizumab is now available in Japan for patients with ATLL, the influence on allogeneic hematopoietic stem cell transplantation (HSCT) remains unclear. Here we report a woman with ATLL resistant to combination chemotherapy, who achieved complete remission following treatment with mogamulizumab and subsequently received allogeneic HSCT. The patient has remained in complete remission with controlled graft-versus-host disease. To our knowledge, this is the first report of an ATLL patient who received mogamulizumab treatment followed by allogeneic HSCT. We suggest that administration of mogamulizumab to chemotherapy-resistant patients with ATLL may improve their disease status before allogeneic HSCT and result in better survival.

Use of diagnostic and therapeutic biomarkers in personalized oncology based on adult T-cell leukemia/lymphoma research

Abstract Human T-lymphotropic virus type 1 (HTLV-1) infection is linked to a spectrum of diverse diseases, including adult T-cell leukemia/lymphoma (ATLL) and the chronic neuromyelopathy tropical spastic paraparesis or HTLV-1 associated myelopathy (TSP/HAM). ATLL is a neoplasm of mature CD4 + T-cell origin known to be resistant to standard anti-cancer therapies. Based on ATLL research performed in our laboratory as well as other reports, we discuss diagnostic, predictive, and pharmacological biomarkers for companion diagnostics, which are vital factors for personalized oncology. From the viewpoint of resistance to apoptosis, the FAS ligand/FAS system, TRAIL/TRAIL receptor system, and survivin are promising targets for cancer therapy. The tumor suppressor genes p16 INK4a , p14 ARF , and p53 are well known predictive and pharmacological biomarkers for various cancers as well as for ATLL. We have found that the plasma miRNAs miR-155 and miR-126 have importance as novel biomarkers to evaluate disease progression and prognosis in ATLL patients. Furthermore, ATLL is considered an appropriate target disease for epigenetic therapy. Although several molecular diagnostic methods for cancer have been approved over the past decade, only a small number of predictive biomarkers have been shown to have clinical value. In a review of our ATLL research findings, we have noticed the same trend in our search for an improved biomarker, and thus the discovery of a highly precise biomarker is one of the keys for the development of superior companion diagnostics.

Interferon-α (IFN-α) suppresses HTLV-1 gene expression and cell cycling, while IFN-α combined with zidovudin induces p53 signaling and apoptosis in HTLV-1-infected cells

BackgroundHuman T-cell leukemia virus type-1 (HTLV-1) is the causative retrovirus of adult T-cell leukemia/lymphoma (ATL) and HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). HTLV-1 gene expression is maintained at low levels in vivo by unknown mechanisms. A combination therapy of interferon-α (IFN-α) and zidovudin (AZT) shows therapeutic effects in ATL patients, although its mechanism is also obscure. We previously found that viral gene expression in IL-2-dependent HTLV-1-infected T-cells (ILTs) derived from ATL patients was markedly suppressed by stromal cells through a type I IFN response. Here, we investigated the effects of IFN-α with or without AZT on viral gene expression and cell growth in ILTs.ResultsILTs expressed variable but lower amounts of HTLV-1 Tax protein than HTLV-1-transformed HUT102 cells. Following the addition of IFN-α, the amounts of HTLV-1 p19 in the supernatants of these cells decreased in three days, while HTLV-1 gene expression decreased only in ILTs but not HUT102 cells. IFN-α also suppressed the spontaneous HTLV-1 induction in primary ATL cells cultured for 24 h. A time course study using ILTs revealed that the levels of intracellular Tax proteins decreased in the first 24 h after addition of IFN-α, before the reduction in HTLV-1 mRNA levels. The initial decreases of Tax protein following IFN-α treatment were observed in 6 of 7 ILT lines tested, although the reduction rates varied among ILT lines. An RNA-dependent protein kinase (PKR)-inhibitor reversed IFN-mediated suppression of Tax in ILTs. IFN-α also induced cell cycle arrest at the G0/G1 phase and suppressed NF-κB activities in these cells. AZT alone did not affect HTLV-1 gene expression, cell viability or NF-κB activities. AZT combined with IFN-α markedly induced cell apoptosis associated with phosphorylation of p53 and induction of p53-responsive genes in ILTs.ConclusionsIFN-α suppressed HTLV-1 gene expression at least through a PKR-mediated mechanism, and also induced cell cycle arrest in ILTs. In combination with AZT, IFN-α further induced p53 signaling and cell apoptosis in these cells. These findings suggest that HTLV-1-infected cells at an IL-2-dependent stage retain susceptibility to type I IFN-mediated regulation of viral expression, and partly explain how AZT/IFN-α produces therapeutic effects in ATL.

Reactivation of hepatitis B virus in a patient with adult T‐cell leukemia–lymphoma receiving the anti‐CC chemokine receptor 4 antibody mogamulizumab

The introduction of molecularly targeted drugs has increased the risk of reactivation of hepatitis B virus (HBV), which is a potentially fatal complication following anticancer chemotherapy even in patients who have previously resolved their HBV infection. CC chemokine receptor 4 (CCR4) has been identified as a novel molecular target in antibody therapy for patients with adult T-cell leukemia-lymphoma (ATL) and peripheral T-cell lymphoma, and the humanized anti-CCR4 monoclonal antibody mogamulizumab has been developed. We reported HBV reactivation of an ATL patient with previously resolved HBV infection after mogamulizumab treatment in a dose-finding study for this antibody. Our retrospective analysis using preserved samples also revealed the detailed kinetics of HBV DNA levels before and just after HBV reactivation.

Potential Contribution of a Novel Tax Epitope–Specific CD4+ T Cells to Graft-versus-Tax Effect in Adult T Cell Leukemia Patients after Allogeneic Hematopoietic Stem Cell Transplantation

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective treatment for adult T cell leukemia/lymphoma (ATL) caused by human T cell leukemia virus type 1 (HTLV-1). We previously reported that Tax-specific CD8(+) cytotoxic T lymphocyte (CTL) contributed to graft-versus-ATL effects in ATL patients after allo-HSCT. However, the role of HTLV-1-specific CD4(+) T cells in the effects remains unclear. In this study, we showed that Tax-specific CD4(+) as well as CD8(+) T cell responses were induced in some ATL patients following allo-HSCT. To further analyze HTLV-1-specific CD4(+) T cell responses, we identified a novel HLA-DRB1*0101-restricted epitope, Tax155-167, recognized by HTLV-1-specific CD4(+) Th1-like cells, a major population of HTLV-1-specific CD4(+) T cell line, which was established from an ATL patient at 180 d after allo-HSCT from an unrelated seronegative donor by in vitro stimulation with HTLV-1-infected cells from the same patient. Costimulation of PBMCs with both the identified epitope (Tax155-167) and known CTL epitope peptides markedly enhanced the expansion of Tax-specific CD8(+) T cells in PBMCs compared with stimulation with CTL epitope peptide alone in all three HLA-DRB1*0101(+) patients post-allo-HSCT tested. In addition, direct detection using newly generated HLA-DRB1*0101/Tax155-167 tetramers revealed that Tax155-167-specific CD4(+) T cells were present in all HTLV-1-infected individuals tested, regardless of HSCT. These results suggest that Tax155-167 may be the dominant epitope recognized by HTLV-1-specific CD4(+) T cells in HLA-DRB1*0101(+)-infected individuals and that Tax-specific CD4(+) T cells may augment the graft-versus-Tax effects via efficient induction of Tax-specific CD8(+) T cell responses.

Humoral immune response to HTLV-1 basic leucine zipper factor (HBZ) in HTLV-1-infected individuals

BackgroundHuman T cell lymphotropic virus type 1 (HTLV-1) infection can lead to development of adult T cell leukemia/lymphoma (ATL) or HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) in a subset of infected subjects. HTLV-1 basic leucine zipper factor (HBZ) gene has a critical role in HTLV-1 infectivity and the development of ATL and HAM/TSP. However, little is known about the immune response against HBZ in HTLV-1-infected individuals. In this study, we examined antibody responses against HBZ in serum/plasma samples from 436 subjects including HTLV-1 seronegative donors, asymptomatic carriers (AC), ATL, and HAM/TSP patients using the luciferase immunoprecipitation system.ResultsImmunoreactivity against HBZ was detected in subsets of all HTLV-1-infected individuals but the test did not discriminate between AC, ATL and HAM/TSP. However, the frequency of detection of HBZ-specific antibodies in the serum of ATL patients with the chronic subtype was higher than in ATL patients with the lymphomatous subtype. Antibody responses against HBZ were also detected in cerebrospinal fluid of HAM/TSP patients with anti-HBZ in serum. Antibody responses against HBZ did not correlate with proviral load and HBZ mRNA expression in HAM/TSP patients, but the presence of an HBZ-specific response was associated with reduced CD4+ T cell activation in HAM/TSP patients. Moreover, HBZ-specific antibody inhibited lymphoproliferation in the PBMC of HAM/TSP patients.ConclusionsThis is the first report demonstrating humoral immune response against HBZ associated with HTLV-I infection. Thus, a humoral immune response against HBZ might play a role in HTLV-1 infection.

The combination of IκB kinase β inhibitor and everolimus modulates expression of interleukin‐10 in human T‐cell lymphotropic virus type‐1‐infected T cells

Adult T-cell leukaemia-lymphoma (ATLL) is an aggressive malignancy of CD4(+) CD25(+) T lymphocytes, characterized by a severely compromised immunosystem, in which the human T-cell lymphotropic virus type 1 (HTLV-1) has been recognized as the aetiological agent. This study found that an IκB kinase β (IKKβ) inhibitor Bay11-7082 inactivated mammalian target of rapamycin (mTOR), signal transducer and activator of transcription 3 and transcription factor nuclear factor-κB in HTLV-1-infected T cells; this was significantly enhanced in the presence of the mTOR inhibitor everolimus. In addition, Bay11-7082 decreased production of the immunosuppressive cytokine interleukin-10 (IL-10), which was further down-regulated when Bay11-7082 was combined with evelolimus in HTLV-1-infected T and ATLL cells isolated from patients. Interleukin-10 is known to inhibit maturation and the antigen-presenting function of dendritic cells (DCs). The culture media of HTLV-1-infected MT-1 cells, which contained a large amout of IL-10, hampered tumour necrosis factor-α-induced maturation of DCs isolated from healthy volunteers. Culture supernatant of MT-1 cells treated with a combination of Bay11-7082 and everolimus augmented maturation of DCs in association with a decrease in production of IL-10 and enhanced the allostimulatory function of DCs. Similarly, when DCs isolated from patients with ATLL were treated with the combination of Bay11-7082 and everolimus, they were fully matured and their capability to stimulate proliferation of lymphocytes was augmented. Taken together, the combination of Bay11-7082 and everolimus might exhibit immunostimulatory properties in HTLV-1-infected T and ATLL cells isolated from patients, and this combination may be potentially therapeutic to regain the compromised immunosystem in ATLL patients.

Distinct Clinical Features of Infectious Complications in Adult T Cell Leukemia/Lymphoma Patients after Allogeneic Hematopoietic Stem Cell Transplantation: A Retrospective Analysis in the Nagasaki Transplant Group

Although allogeneic hematopoietic stem cell transplantation (allo-SCT) is performed as a curative option in adult T cell leukemia-lymphoma (ATL) patients, its high transplantation-related mortality raises a serious issue. The clinical features of infectious complications after transplantation are not well known. To analyze the impact of infections after allo-SCT for ATL, we retrospectively compared infectious complications in 210 patients at 3 institutions in Nagasaki prefecture between 1997 and 2009. There were 91 patients with acute myeloid leukemia (AML), 51 with acute lymphoblastic leukemia/lymphoblastic lymphoma (ALL/LBL), and 68 with ATL. No patient received ganciclovir or foscarvir as prophylaxis, and most patients received antifungal prophylaxis with fluconazole or itraconazole. The cumulative incidence of cytomegalovirus (CMV) infection at 3 years was 69.2% in ATL patients versus 54.4% in AML patients (P = .0255). Cumulative infection-related mortality was significantly higher in ATL patients than in the 2 other groups (ATL versus AML, P = .0496; ATL versus ALL/LBL, P = .0075), and most death-causing pathogens were bacteria and fungus. The appearance of CMV infection was negatively associated with infectious mortality in ATL patients, but the P value for this association was near the borderline of significance (P = .0569). In multivariate analysis, transplantation using unrelated bone marrow and episodes of CMV infection were associated with worse overall survival in ATL patients, but were not in either AML or ALL/LBL patients. Collectively, the impact of infectious complications after transplantation in ATL patients was different from that in AML and ALL/LBL patients, suggesting that a more intensive strategy for infection control in ATL patients is required to reduce infectious mortality.

Extremely Higher Incidence of CMV-pp65 Antigenemia After Allogeneic Hematopoietic Stem Cell Transplantation in Adult T-Cell Leukemia/Lymphoma (ATL) Compared with Other Hematological Diseases

Abstract 4477Cytomegalovirus (CMV) infection is one of significant factors contribute to morbidity and mortality in recipients of allogeneic hematopoietic stem cell transplantation (SCT). Prevention and treatment of active CMV infection based on monitoring CMV-pp65 antigenemia test or CMV-DNA PCR assay have been done in this field. As the limitation of insurance, only CMV-pp65 antigenemia test can be clinically carried out in Japan. Adult T-cell leukemia/lymphoma (ATL), HTLV-1 related hematological malignancy, is known as poor prognostic disease and only allogeneic SCT had been prolonged survival outcomes. ATL cells are morphologically characterized as having complicated nuclei and their surface markers are usually shown as CD3+CD4+CD25+. Some reports suggested that ATL patients have tendency to be in immune compromised status. However, in our knowledge, there was no report about incidence of CMV-replication in ATL patients following allgeneic SCT so far. Here we analyze the incidence of CMV-pp65 antigenemia and related clinical issues in 85 allogeneic SCT recipients of single center located in HTLV-1 endemic area. There were consecutively 97 patients (106 times) undergone allogeneic SCT from November 2006 to May 2012 in Imamura Bun-in Hospital, Kagoshima, Japan. Totally, 12 patients (21 times), 9 times of deaths earlier than 30 days after SCT, 3 times of deaths earlier than engraftment, 9 times of second or more chances of SCTs, were excluded from this study. Rest of 85 (male: 52, female: 33) patients (85 times) were analyzed. We have first picked up patients’ clinical data from medical charts including result of CMV-pp65 antigenemia tests and related data. Statistical analysis had carried out using SPSS 11.0J (SPSS Japan Inc., Japan). Cumulative incidences of CMV-pp65 antigenemia were analyzed by Kaplan-Meir method in total 85 patients. Statistical significance defined P<=0.05 in Log-Rank test. Cox regression analysis about incidence of CMV-pp65 antigenemia were also done in 68 patients who had available data including positivity of CMV-IgG before SCT. Median age was 52 (range 19–69) yrs. Thirty-seven ATL patients and 48 non-ATL (AML 21, MDS 14, NHL 7, ALL 3, AA 2, MM 1) patients were included. In disease status, 49 patients were categorized as high risk and 36 standard risk. Donor sources were 19 of related donors (BM 7, PB 12), 66 unrelated (UBM 56, UCB 10) respectively. Sixty four patients carried out SCT with myeloablative conditioning regimens (MAC) and 21 reduced intensive conditioning regimens (RIC). Sixty-eight recipients (ATL: 27, non-ATL: 41) had available data of their CMV-IgG antibody before SCT and 79.4% (ATL/non-ATL: 96.3%/70.7%, P<0.001) of them were shown antibody positive. Although there were no significant differences about positivity of CMV-IgG antibody before SCT between age >=50 and <50 in ATL patients, there was significant difference between age >=50 and <50 in non-ATL patients. There were no significant differences about positivity of donors’ CMV-IgG antibody before SCT between ATL and non-ATL. Among patients shown CMV-pp65 antigenemia, 45/68 patients had administrated iv steroids before or after CMV-pp65 antigenemia. Twenty-four out of 45 were administrated iv steroids as treatment of GVHD or engraftment syndrome, on the other hand, 21 as premedication of blood transfusion. Absolute WBC counts, lymphocyte counts and CMV-pp65 antigen positive WBCs counts at the incidence of CMV antigenemia, duration from SCT to CMV-pp65 antigenemia and duration of treatments with anti-viral agents didn’t have statistically significant differences between ATL and non-ATL respectively. CMV disease occurred in 7 (ATL 4, non-ATL 3) patients, however, there was also no significant difference between ATL and non-ATL. The cumulative incidence of CMV-pp65 antigenemia in ATL and non-ATL patients were 91.9% and 60.4% respectively (P<0.001). Interestingly, recipients whose ages were >=50 showed significantly high incidence of incidence of CMV-pp65 antigenemia compared with <50 (P=0.002). However, there were no difference between age >=50 and <50 (92% vs 91.7%) in ATL recipients. In multivariate analysis, ATL (HR: 2.625, P=0.008) and MAC (HR: 2.532, P=0.014) were positively contributed to incidence of CMV antigenemia by Cox regression analyses. Our study suggests that ATL could be one of independent risk factors of CMV replication after allogeneic hematopoietic stem cell transplantation. Disclosures:No relevant conflicts of interest to declare.

CD30 Is a Potential Therapeutic Target in Patients with HTLV-1 Associated Adult T-Cell Leukemia/Lymphoma Presenting Outside of Japan.

AbstractAbstract 2706 Objective:Adult T-cell leukemia/lymphoma (ATLL) is a mature T-cell malignancy associated with human T-cell lymphotropic virus -1 (HTLV-1) infection. Four clinical subtypes are recognized including acute/lymphomatous (aggressive) or chronic/smouldering (indolent). For the aggressive subtypes the median overall survival is 6 months despite aggressive combination chemotherapy. Novel therapeutic targets against CD25, CD52, and NF μB have shown preliminary activity in ATLL. Recently, the chemokine receptor 4 (CCR4) antibody (KW-0761) was approved in Japan based on a phase II overall response rate of 50% and median overall survival of 13.7 months in 28 patients with relapsed/refractory ATLL. CD30 (Ki-1) is a marker of immune activation expressed on lymphocytes, and is an emerging target in lymphoma. The novel antibody-drug conjugate brentuximab vedotin targets CD30 and has shown efficacy in Hodgkin lymphoma and anaplastic large cell lymphoma (ALCL). While CD30 positive ATLL is infrequent in Japanese ATLL patients, ranging from 12.1% to 19.4%, the prevalence of CD30 positive ATLL outside of Japan has not been extensively studied. Patients and Methods:To investigate the prevalence of CD30 expression and its importance in ATLL outside of Japan we conducted a retrospective review of all patients who underwent treatment or consultation for ATLL at our institution between 1998 and 2012. Individual chart review was performed to report the clinical presentation, pathological features, and outcomes. Pathology review of CD30 expression status was conducted if specimens were available. The CD30 (Ber-H2) antibody from Ventana was used on automated platforms per manufacturer’s instructions. Specimens were determined to be positive if the CD30 expression was >20% by an expert hematopathologist (AC). Results:We identified 50 patients with ATLL. Patient characteristics were: median age 54 (range 30–82); male:female 19:31; Caribbean-39, American-6, Western African-2, Peruvian-2, and Greek-1. Subtype of disease at diagnosis was: Acute/Lymphomatous—41 and Chronic/Smouldering—9. Thirty-six of 50 (72%) patients’ samples had been tested at least once for CD30. Eighteen patients (50%) were reported positive. Of all cases reviewed (N=50), eight had pathology available for confirmatory review. Of those, five patients remained positive, 1 patient was reclassified as positive after initially being reported as negative, and two remained negative. The median overall survival of all patients was 13 months. In the subset who had CD30 status assessed the median overall survival for CD30 negative and positive ATLL was 18 and 45 months respectively (p=0.116). Conclusions:CD30 expression on normal lymphocytes is rare. Our retrospective data suggests that ATLL patients presenting outside of Japan may demonstrate CD30 positivity at a higher prevalence compared to Japanese reports. In pre-clinical studies of CD30 positive ATLL, SGN-35 has been shown in vitro and in vivo to demonstrate similar cytotoxicity compared to ALCL (Maeda et al. Cancer Sci 2010). Novel strategies are clearly needed to improve the outcome of ATLL despite recent advances. Therefore, CD30 testing may be considered in ATLL as a novel target for future research strategies. [Display omitted] Disclosures:Matasar:GSK: Research Funding; Genentech: Consultancy. Straus:Seattle Genetics: Consultancy. Zelenetz:GSK: Consultancy, Research Funding; Genentech/Roche: Consultancy, Research Funding; Gilead: Consultancy; Sanofi Aventis: Consultancy; Cephalon: Consultancy; Celgene: Consultancy; Seattle Genetics: Consultancy; Amgen: Research Funding. Horwitz:Seattle Genetics: Consultancy, Research Funding; Allos: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Bristol-Myers Squibb: Consultancy; Genzyme: Consultancy; Kyowa Hakko Kirin Pharma: Consultancy; Johnson & Johnson: Consultancy; Infinity Pharmaceuticals, Inc.: Research Funding.

1062O - A Nationwide Survey of Adult T-Cell Leukemia/Lymphoma (ATL) Newly Diagnosed Over the Last Decade in Japan

ABSTRACT Introduction ATL is a malignancy of mature T-lymphocytes caused by human T-lymphotropic virus type I (HTLV-1), and it is classified into 4 clinical subtypes,i.e. acute, lymphoma, chronic, and smoldering type according to the analysis of the former nationwide survey performed in late 80's. During the 2 decades after this analsysis, treatment for ATL has improved, e.g. intensive sequential combination chemotherapy and allogeneic hematopoietic stem cell transplantation (HSCT). We therefore performed a nationwide survey to know the outcome of ATL patients newly diagnosed during the last decade. Patients and methods The clinical data was collected retrospectively from the medical record of patients who were diagnosed as ATL between 2000 and 2009 in participating institutions. Approval of this study was obtained from the Ethics Committee and Institutional Review Board of Fukuoka University where the central office is located and at each participating center based on their institutional policies. Results A total of 1552 patients' survey form was submitted from 81 institutions across Japan. Fifty-four patients were excluded due to missing data, and the remaining 1498 were analyzed. The median survival time (MST) of 897 for acute type and that of 355 for lymphoma type were 8.3 and 10.6 months, and overall survival (OS) rates at 5 years were 9% and 13%, respectively. Fifty % of patients had received CHOP/CHOP-like regimen, 31 % had VCAP-AMP-VECP regimen, and single agent was used in 6% of the patients. The number of patients with allogeneic HSCT was 227 (46% from a sibling donor and 51% from an unrelated donor), a half of them were transplanted at first remission. The MST and OS at 5 years from transplantation were 5 months and 25%, respectively. The MST of 172 for chronic and that of 74 for smoldering type were 30.3 and 36.7 months, respectively. Conclusion The prognosis of acute and lymphoma type was still poor despite the recent progress in treatment modalities, and it is of disappointment that their therapeutic outcome was not remarkably improved as compared to former survey. It is also a surprise that the prognosis of smoldering type is not good as expected from the previous survey. To note, 25% of patients who underwent transplantation experienced a long survival, but it should be validated by the prospective study. Disclosure All authors have declared no conflicts of interest.

P065 Acute crisis of adult T-cell leukaemia following soluble CD30 elevation: Shedding of CD30 and CD25 from cell surface associated with the aggressiveness

Introduction Adult T-cell leukaemia/lymphoma (ATL) caused by human retrovirus, HTLV-1, is a neoplasm of mature T-cell. In Japan, more than a thousand patients with ATL die every year because this disease still remains incurable. Acute crisis is a common phenomenon of chronic leukaemia and indolent haematological malignancy, in which proliferation of leukaemic cells is accelerated following a certain term of chronic phase. Although some genetic changes are thought to be responsible for this sudden change of characteristics in leukaemic cells, it has been unclear if they are the cause or the result of crisis. Methods We assessed the therapy and outcome of 79 newly diagnosed or referred ATL patients from 2005 to 2010. Serum sample of patient was preserved in freezer to measure the level of soluble proteins, sCD30 and sIL-2R, using ELISA. The sIL-2R concentration in serum was measureed by Cell freeN IL-2R (Kyowa Medex, Japan) and Determiner CL IL-2R (Kyowa Medex, Japan). The sCD30 concentration in serum was measured by Human sCD30 Platinum ELISA (eBioscience). In the present study, patients with ATL chronic type were investigated by monitoring changes in the serum levels of sIL-2R and sCD30. Results Six patients showed acute crisis from chronic phase (the observed periods of chronic phase are 31–866 days) and increasing sCD30 level as well as sIL-2R elevation was found as an earlier event of the acute crisis (average levels of sCD30 and sIL-2R were 2029 U/ml and 14035 U/ml in acute crisis; 341 U/ml and 5008 U/ml in chronic phase). In contrast, average of sCD30 and sIL-2R in 25 HTLV-1 carriers are 37 U/ml and 428 U/ml, respectively. Although the patterns and levels of soluble proteins elevation were unique to each case, serum sCD30 level predominantly elevated at the crisis. Interestingly, CD30 is not always detected on the surface of ATL cells. Chronic inflammation caused by constituvive activation of STATs may be associated with Matrix Metalloproteinase activation which sheds CD30 from the surface of ATL cells. Conclusion Our findings suggest that soluble protein levels in sera of patients are useful biological markers for diagnosis and therapy of ATL. Furthermore, since spontaneous remission was observed during the insufficinet level of serum sCD30 by comparison to the sIL-2R level, it is conceivable that the sCD30 protects CD30+ leukaemic stem cells from CD30 ligand-mediated cell death.

Tax is a potential molecular target for immunotherapy of adult T‐cell leukemia/lymphoma

We expanded CTL specific for Tax (a human T-lymphotropic virus type-1-encoded gene product) in vitro from PBMC of several adult T-cell leukemia/lymphoma (ATL) patients, and document its potential significance as a target for ATL immunotherapy. Tax-specific CTL responses against tumor cells were restricted by Tax-expression and the appropriate human leukocyte antigen (HLA) type. Tax-specific CTL recognized HLA/Tax-peptide complexes on autologous ATL cells, even when their Tax expression was so low that it could only be detected by RT-PCR but not by flow cytometry. Recognition resulted in interferon gamma (IFN-γ) production and target cell lysis. This would be the first report that Tax-specific CTL from ATL patients specifically recognized and killed autologous tumor cells that expressed Tax. The Tax-specific CTL responded to as little as 0.01 pM of the corresponding peptide, indicating that their T-cell receptor avidity was much higher than that of any other CTL recognizing viral or other tumor antigens. This is presumably the reason why the Tax-specific CTL recognized and killed autologous ATL cells despite their very low Tax expression. In addition, cell cycle analyses and experiments with primary ATL cell-bearing mice demonstrated that ATL cells present at the site of active cell proliferation, such as in the tumor masses, expressed substantial amounts of Tax, but it was minimally expressed by the tumor cells in a quiescent state, such as in the blood. The present study not only provides a strong rationale for exploiting Tax as a possible target for ATL immunotherapy but also contributes to our understanding of the immunopathogenesis of ATL.

Defective Epidermal Innate Immunity and Resultant Superficial Dermatophytosis in Adult T-cell Leukemia/Lymphoma

Superficial dermatophytosis is quite commonly seen in patients with adult T-cell leukemia/lymphoma (ATLL), as approximately 50% of the patients develop cutaneous mycotic infections. Because superficially infected fungi in the stratum corneum of the epidermis cannot directly contact with T cells infiltrating in the upper dermis, some perturbation of epidermal innate immunity has been postulated. Interleukin (IL)-17-producing helper T cells (Th17) can induce the keratinocyte production of antimicrobial peptides such as human β defensin (HBD)-2 and LL-37, which play an essential role in cutaneous innate immunity. We investigated the frequency of circulating Th17 cells, serum levels of cytokines, and epidermal expression of HBD-1, 2, 3, and LL-37 in ATLL patients with or without superficial dermatophytosis. The frequency of peripheral Th17 cells and the serum level of IL-17 was significantly decreased in ATLL patients, whereas the serum IL-10 and TGF-β1 levels were increased as compared with healthy controls. Furthermore, ATLL patients with dermatophytosis had higher IL-10 and TGF-β1 levels and lower IL-17 levels than did those without dermatophytosis. Immunohistochemical study revealed that the epidermal expression of both HBD-2 and LL-37 were significantly lower in ATLL patients with dermatophytosis than in non-ATLL patients with dermatophytosis. Taken together, these results suggest that the keratinocyte production of antimicrobial peptides promoted by Th17 cells is reduced in ATLL patients, leading to the perturbed innate immunity and the frequent occurrence of superficial dermatophytosis.

Long-Term Persistence of Limited HTLV-I Tax-specific Cytotoxic T Cell Clones in a Patient with Adult T Cell Leukemia/Lymphoma after Allogeneic Stem Cell Transplantation

Adult T cell leukemia/lymphoma (ATL) is a highly aggressive malignancy of T cells caused by human T cell lymphotropic virus type 1 (HTLV-1). Recent clinical studies have suggested that allogeneic stem cell transplantation (HSCT) improves the clinical course of ATL by harnessing a graft-versus-ATL effect, and that donor-derived HTLV-1 Tax-specific CD8(+) cytotoxic T cells (CTLs) contribute to the graft-versus-ATL effect after HSCT. However, little is known about the immunological characteristics of Tax-specific CTLs in ATL patients who underwent HSCT. We serially analyzed frequencies, differentiation, functions and clonal dynamics of Tax-specific CTLs in paired samples of peripheral blood (PB) and bone marrow (BM) from an ATL patient after HSCT at the single-cell level. We used flowcytometric and single-cell T cell receptor (TCR) repertoire analysis methods without culture steps. Donor-derived Tax-specific CTLs effectively suppressed HTLV-1 replication in both PB and BM at least during chronic graft-versus-host disease after HSCT. Furthermore, Tax-specific CTLs had comparable properties between BM and PB, except for preferential accumulation in BM rather than PB. Tax-specific CTLs persistently existed as less-differentiated CD45RA(-)CCR7(-) effector memory CTLs based on predominant phenotypes of CD27(+), CD28(+/-) and CD57(+/-). Our approach using single-cell TCR repertoire analysis method showed highly restricted oligoclonal responses of Tax-specific CTLs, and TCR BV7- or BV30- expressing two predominant CTL clones persistently existed and maintained strong cytotoxic activities against HTLV-1 in both PB and BM over three years after HSCT. These findings about Tax-specific CTLs provide insights into future directions for studies on immunotherapy against ATL.

Racial disparities in survival of adult T-cell leukemia/lymphoma patients in the United States: A SEER database analysis.

e16503 Background: Adult T cell Leukemia/Lymphoma (ATL) is an aggressive lymphoproliferative disorder etiologically linked to Human T cell Lymphotropic Virus -1 (HTLV-1). HTLV-1 infection is endemic in areas of Japan, the Caribbean, South America, and Africa. ATL runs a very aggressive clinical course. It is a rare malignancy in the United States (US), and epidemiologic data are limited. We undertook a Surveillance Epidemiology and End Results (SEER) based database analysis to identify survival data of ATL patients (pts) with emphasis on race and ethnicity. Methods: We used the SEER 17 Registry data (1973-2008) for pts with a confirmed diagnosis of ATL. ICD-O-3 code 9827/3 was used to identify pts with ATL. The following exclusion criteria were used: diagnosis at death certificate or autopsy, no follow-up records, diagnosis of second malignancies or lack of documentation of sex or age at diagnosis. The Kaplan Meier method was used to evaluate survival in different races. Statistical tests were done utilizing R statistical software. Results: 272 patients were included in the final analysis (126 females; 146 males). Pts were stratified by race: White (155), Black (80), Other (33), Unknown (4). Median age (yr) of diagnosis in Blacks (51.5) was lower than in Whites (65) and other races (65). Average age of diagnosis in Blacks was significantly lower compared to Whites (p=0.002) and non-Blacks (p=0.0008). Survival analysis of the study group showed a median overall survival (OS) of 13 mo (95%CI 10-16). Whites had a higher median OS (21 mo) compared to blacks (5 mo); the difference in survival was strongly significant (Log-rank p-value &lt; 0.001). Differences in survival between blacks or whites compared to other ethnic and unknown racial groups (n=37) were not statistically significant. Conclusions: ATL is a rare malignancy with poor prognosis in the US. Epidemiologic data on survival are limited. Blacks tend to have an earlier onset of disease and a poor prognosis compared to whites. The reasons for this aggressive course and earlier age of diagnosis in blacks are unknown.

Abstract 3132: Dynamic changes of epigenetic abnormalities during initiation and progression of adult T-cell leukemia/lymphoma (ATLL)

Abstract HTLV-1 causes ATLL in 3-5% of infected individuals after a long latent period of 40 to 60 years. ATLL is divided into four stages: namely, smoldering, chronic, lymphoma and acute types. The smoldering and chronic types are indolent, but the acute and lymphoma types are aggressive ATLL characterized by resistance to chemotherapy and a poor prognosis. Such a long latent period suggests that a multi-step leukemogenic/lymphomagenic mechanism is involved in the development of ATLL, although the critical events in the progression have not been characterized. To determine whether epigenetic abnormalities are playing the important role in the progression of ATLL, we analyzed the methylation profiles, showing that number of CpG island methylated genes increased with disease progression and aberrant hyper-methylation in specific genes was detected even in HTLV-1 carriers and correlated with progression to ATLL. The CpG island methylator phenotype (CIMP) was observed most frequently in lymphoma type ATLL and was also closely associated with the progression and crisis of ATLL. The high number of methylated genes and increase of CIMP incidence were shown to be unfavorable prognostic factors and correlated with a shorter overall survival with the Kaplan-Meyer analysis. Dynamic changes of aberrant DNA methylation status in the specific genes were observed during the progression of an ATLL patient. The present findings strongly suggest that the multi-step accumulation of aberrant CpG methylation in specific target genes and the presence of CIMP are deeply involved in the initiation and progression of ATLL not only epidemiologically but also in the clinical course of a specific ATLL patient. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 3132. doi:1538-7445.AM2012-3132

Adult T-cell leukemia–lymphoma

Adult T-cell leukemia�lymphoma (ATL) was first described in 1977 as a distinct clinico-pathological entity with a suspected viral etiology. Subsequently, a novel RNA retrovirus, human T-cell leukemia/lymphotropic virus type 1 (HTLV-1) was isolated from a cell line established from the leukemic cells of an ATL patient, and the finding of a clear association with ATL led to its inclusion among human carcinogenic pathogens. The three major routes of HTLV-1 transmission are mother-to-child infections via breast milk, sexual intercourse, and blood transfusions. HTLV-1 infection early in life, presumably from breast feeding, is crucial in the development of ATL. The diversity in clinical features and prognosis of patients with this disease has led to its subtype-classification into four categories, acute, lymphoma, chronic, and smoldering types defined by organ involvement, and LDH and calcium values. In cases of acute, lymphoma, or unfavorable chronic subtypes (aggressive ATL), intensive chemotherapy such as VCAP-AMP-VECP is usually recommended. In cases of favorable chronic or smoldering ATL (indolent ATL), watchful waiting until disease progression has been recommended although the long term prognosis was inferior to those of, for instance, chronic lymphoid leukemia. Retrospective analysis suggested that the combination of interferon alpha and zidovudine was apparently promising for the treatment of ATL, especially for types with leukemic manifestation. Allogeneic hematopoietic stem cell transplantation is also promising for the treatment of aggressive ATL possibly reflecting graft vs. ATL effect. Several new agent-trials for ATL are ongoing and in preparation, including a defucosylated humanized anti-CC chemokine receptor 4 monoclonal antibody. Two steps should be considered for the prevention of HTLV-1-associated ATL. The first is the prevention of HTLV-1 infections and the second is the prevention of ATL among HTLV-1 carriers. So far, no agent has been found to be effective for the latter. Further investigation on the pathogenesis of ATL is crucial for the prevention and treatment of this refractory leukemia�lymphoma.