Chemotherapy-based Regimens Research Articles

Rapid Engraftment at a Cost?

Rapid Engraftment at a Cost?

Hematopoietic SCT for the treatment of multiple sclerosis

Multiple sclerosis (MS) is the leading autoimmune indication for autologous hematopoietic SCT (aHSCT). Patient selection criteria and transplant interventions have been refined through a series of cohort and registry studies. High- and low-intensity chemotherapy-based conditioning regimens have been used, creating trade-offs between toxicity and effectiveness. TBI has been associated with greater toxicity and poor outcomes. aHSCT stops MS relapses and lessens the disability in malignant MS, which otherwise rapidly incapacitates patients. Better responses occur in progressive MS earlier in the disease when it has a more inflammatory nature. aHSCT prevents further disability in many patients, but some actually recover from their infirmities. Current regimens and supportive care result in very low morbidity and mortality. MS patients experience unique complications in addition to the expected toxicities. Cytokines used alone for stem-cell mobilization may induce MS flares but are safe to be used in combination with steroids or cytotoxic agents. Urinary tract infections, herpes virus reactivation and an engraftment syndrome may occur early after aHSCT. Rarely secondary autoimmune diseases have been reported late after HSCT. Increasing experience in caring for patients with MS has reduced the frequency and severity of toxicity. Conceived as an opportunity to 'reboot' a tolerant immune system, aHSCT is successful in treating patients with MS that is refractory to conventional immunomodulatory drugs.

Salvage Therapy with Chemotherapy- or Arsenic Trioxide-Based Regimens for Acute Promyelocytic Leukemia in First Relapse.

Abstract 1062Poster Board I-84 Background:Arsenic trioxide (ATO) is currently regarded as the best treatment option in relapsed acute promyelocytic leukemia (APL). The efficacy and safety of salvage therapy using an ATO-based approach compared with chemotherapy-based regimens is not well established. We analyze the clinical outcome of 110 APL patients relapsing after front-line therapy with ATRA and anthracycline, who received second-line therapy with chemotherapy- or ATO-based regimens. Methods:From June 1997 to May 2009, 110 patients (69 M/41 F; median age: 40 years, 2-81) relapsed after front-line therapy with PETHEMA trials (LPA96, n=30, LPA99, n=60; and LPA2005, n=20). Patients presented with either molecular relapse (n=37) or hematological relapse (n=73, 14 of them involving central nervous system). Sixty-seven patients (61%) followed salvage therapy with chemotherapy-based regimens. Therapy consisted of induction with mitoxantrone plus cytarabine plus ATRA (n=46), EMA (n=7), or other chemotherapy regimens (n=14). Thirty-four patients (51%) received one consolidation cycle followed by stem-cell transplantation (SCT) (autologous, 20; allogeneic, 14). Patients not eligible for SCT received consolidation therapy with or without maintenance therapy. From October 2003, 43 patients (49%) received salvage therapy with ATO-based regimens, comprising induction with ATO (0.15 mg/kg intravenously until CR) followed by one consolidation cycle with ATO plus ATRA. Twenty-three patients (53%) received intensification therapy with SCT (autologous, 19; allogeneic, 4). Patients not eligible for SCT received maintenance therapy with ATO plus ATRA with or without Mylotarg or other chemotherapy. Results:Baseline characteristics, including age at relapse, were similar in both cohorts of patients, but patients treated with ATO-based regimens were more frequently late relapses (>18 months after initial APL diagnosis) (67% vs. 40%, P=0.005). The median follow-up in the chemotherapy-based group was 62 months (range, 6-134), and 18 months (range, 2-53) in the ATO-based group. CR rates were 84% in the chemotherapy-based group (8 deaths and 3 resistances) and 88% in the ATO-based group (3 deaths and 2 resistances) (P=0.48). Molecular remission was achieved after consolidation in 79% and 91%, respectively (P=0.13). Twenty-two patients of the chemotherapy-based group that achieved CR were not transplanted because of ineligibility for SCT (n=4), early relapse before planned SCT (n=7), mobilization failure (n=4), clinical decision/toxicity (n=6), and short follow-up (n=1). Reasons for not SCT in the ATO-based group were ineligibility for SCT (n=6), early relapse before planned SCT (n=5), and short follow-up (n=4). The 2-year overall survival (OS), disease-free (DFS), and relapse-free survival (RFS) in the chemotherapy-based group and in the ATO-based group were 44% vs. 63% (P=0.05), 34% vs. 33% (P=0.51), and 37% vs. 34% (P=0.61), respectively. For patients not receiving SCT, the 2-year OS, DFS, and RFS in the chemotherapy-based group and in the ATO-based group were 38% vs. 26% (P=0.98), 34% vs. 23% (P=0.57), and 37% vs. 23% (P=0.46), respectively. For patients receiving autologous SCT, the 2-year OS, DFS, and RFS in the chemotherapy-based group and in the ATO-based group were 60% vs. 87% (P=0.03), 40% vs. 38% (P=0.38), and 42% vs. 41% (P=0.37), respectively. For patients receiving allogeneic SCT, the 2-year OS, DFS, and RFS in the chemotherapy-based group and in the ATO-based group were 56% vs. 100% (P=0.15), 26% vs. 37% (P=0.46), and 28% vs. 37% (P=0.53), respectively. Conclusions:this study performed in a large series of APL patients relapsing after upfront therapy with ATRA and anthracycline shows high rates of CR either with ATO (88%) or chemotherapy regimens (84%). The 2-year DFS and RFS were similar in patients who received second-line therapy with chemotherapy- or ATO-based regimens. However, an apparent benefit in terms of OS was observed in the ATO-based group (P=0.05), suggesting a potential role in minimizing toxicity after administering ATO as salvage therapy. Disclosures:No relevant conflicts of interest to declare.

Comparison of Low Dose Total Body Irradiation (TBI)-Based Reduced Intensity Conditioning (RIC) Vs. Chemotherapy-Based RIC Prior to Allogeneic Stem Cell Transplantation (allo-SCT) From An HLA Identical Sibling Donor for Acute Myeloid Leukemia (AML) in First Complete Remission (CR1): a Retrospective Analysis of 1200 Patients From the Acute Leukemia Working Party of EBMT.

Abstract 1190Poster Board I-212RIC is increasingly used in allo-SCT for AML patients. RIC allo-SCT represents an attempt to harness the immune graft-versus-leukemia effect while attempting to control or overcome toxicity. Most of the RIC protocols have been shown to be highly immunosuppressive, but because of the variability in the degree of myeloablation, the toxicity and efficacy profiles might vary from one protocol to another. Low dose TBI in RIC is frequently used, however it is still unknown whether outcomes are different when comparing low dose TBI-based RIC and chemotherapy-based RIC regimens. Moreover, some transplant centres do not have radiation facilities. Therefore, the aim of this study was to compare outcomes (leukemia-free survival: LFS, Non-Relapse Mortality: NRM, and relapse incidence) between patients receiving a low dose TBI-based RIC vs. chemotherapy-based RIC prior to allo-SCT from an HLA identical sibling donor for AML in CR1.Between 2000 and 2008, 323 patients with AML in CR1 were treated with low dose TBI-based RIC (Fludarabine + TBI) and 877 received a chemotherapy-based RIC (including fludarabine in the majority of cases), and reported to the EBMT Registry. All patients received allogeneic PBSC from HLA-identical sibling donors.Patients receiving TBI-based RIC were older (median 56 y. vs. 54 y.; p<0.0001), but the median time from diagnosis to allo-SCT was shorter (143 days vs. 163 d.; p<0.0001) in the TBI group. Both groups were comparable in terms of period (median year: 2005) of allo-SCT, donor-recipient gender distribution, and CMV serostatus. In terms of AML-related risk factors, WBC (median: 9600/μL), the cytogenetics risk groups (good: 4.1%; intermediate: 81.5%; and poor: 14.4%), and the FAB subtype (M1-M2: 48.8%; M4-M5: 36.4%; M0-M6-M7: 14.4%) at diagnosis, were also comparable between both groups.The median time to engraftment (ANC>500/μL) was comparable between both groups (15 vs. 16 days, p=NS). With a median follow-up of 15 (range, 0.3-107) months, 2 years LFS were 50±3%, 53±2% in the TBI-based RIC and chemo based RIC groups respectively (p=0.16). Also, at 2 years, the relapse incidence was not significantly associated with the type of RIC regimen: 37±3%, 34±2% in the TBI-based RIC and chemo-based RIC groups respectively (p=0.17). Finally, NRM was also comparable between both groups [21±3% and 20±2% in the TBI-based RIC and chemo-based RIC groups respectively; p=0.60)Despite its retrospective nature, results from this large study suggest that RIC allo-SCT is a valid option for AML patients not eligible for standard allo-SCT. The overall outcomes (LFS, NRM and relapse) appear not to be significantly different between AML patients in CR1 receiving a low dose TBI-based RIC allo-SCT versus those receiving a chemotherapy-based RIC allo-SCT using an HLA-identical sibling donor. Disclosures:No relevant conflicts of interest to declare.

Mobilization of PBSCs with chemotherapy and recombinant human G-CSF: a randomized evaluation of early vs late administration of recombinant human G-CSF

The optimal timing for recombinant human (rh)G-CSF administration after chemotherapy for PBSC mobilization has not yet been determined. In this study, we compared two different time schedules of rhG-CSF; 4th (early) vs 7th day (late), in 48 consecutive patients with multiple myeloma and lymphoma undergoing PBSC mobilization with CE (CY 4 g/m(2) on day 1 and etoposide 200 mg/m(2) on days 1-3). The rhG-CSF dose was 10 microg/kg/day for all patients. Both groups were comparable in terms of sex, age and number of previously given different chemotherapy regimens. Duration of neutropenia, CD34(+) cell count on the first day of apheresis and numbers of aphereses were not statistically different between the two arms. However, the number of doses of rhG-CSF up to the first cycle of apheresis procedures was significantly lower in the late group than in the early group (P=0.005). The median number of total CD34(+) cells collected was 10.54 x 10(6)/kg (range 0.11-37.27) in the early group and 10.81 x 10(6)/kg (range 0.17-49.83) in the late group of rhG-CSF (P=0.781). We conclude that PBSC mobilization after late use of rhG-CSF is an effective approach and therefore, in routine clinical practice, late rhG-CSF may be used for PBSC collections after chemotherapy-based mobilization regimens in this cost-conscious era.

Directed Engineering of a High-expression Chimeric Transgene as a Strategy for Gene Therapy of Hemophilia A

Human coagulation factor VIII (fVIII) is inefficiently biosynthesized in vitro and has proven difficult to express at therapeutic levels using available clinical gene-transfer technologies. Recently, we showed that a porcine and certain hybrid human/porcine fVIII transgenes demonstrate up to 100-fold greater expression than human fVIII. In this study, we extend these results to describe the use of a humanized, high-expression, hybrid human/porcine fVIII transgene that is 89% identical to human fVIII and was delivered by lentiviral vectors (LVs) to hematopoietic stem cells for gene therapy of hemophilia A. Recombinant human immunodeficiency virus-based vectors encoding the fVIII chimera efficiently transduced human embryonic kidney (HEK)-293T cells. Cells transduced with hybrid human/porcine fVIII encoding vectors expressed fVIII at levels 6- to 100-fold greater than cells transduced with vectors encoding human fVIII. Transplantation of transduced hematopoietic stem and progenitor cells into hemophilia A mice resulted in long-term fVIII expression at therapeutic levels despite <5% genetically modified blood mononuclear cells. Furthermore, the simian immunodeficiency virus (SIV) -derived vector effectively transduced the human hematopoietic cell lines K562, EU1, U.937, and Jurkat as well as the nonhematopoietic cell lines, HEK-293T and HeLa. All cell lines expressed hybrid human/porcine fVIII, albeit at varying levels with the K562 cells expressing the highest level of the hematopoietic cell lines. From these studies, we conclude that humanized high-expression hybrid fVIII transgenes can be utilized in gene therapy applications for hemophilia A to significantly increase fVIII expression levels compared to what has been previously achieved.

Safety and preliminary efficacy of plerixafor (Mozobil) in combination with chemotherapy and G-CSF: an open-label, multicenter, exploratory trial in patients with multiple myeloma and non-Hodgkin's lymphoma undergoing stem cell mobilization

Plerixafor, a novel CXCR4 inhibitor, is effective in mobilizing PBSCs particularly when used in conjunction with G-CSF. In four cohorts, this pilot study explored the safety of plerixafor mobilization when incorporated into a conventional stem cell mobilization regimen of chemotherapy and G-CSF. Forty (26 multiple myeloma and 14 non-Hodgkin's lymphoma) patients were treated with plerixafor. Plerixafor was well tolerated and its addition to a chemo-mobilization regimen resulted in an increase in the peripheral blood CD34+ cells. The mean rate of increase in the peripheral blood CD34+ cells was 2.8 cells/microl/h pre- and 13.3 cells/microl/h post-plerixafor administration. Engraftment parameters were acceptable after myeloblative chemotherapy, with the median day for neutrophil and plt engraftment being day 11 (range 8-20 days) and day 13 (range 7-77 days), respectively. The data obtained from the analysis of the cohorts suggest that plerixafor can safely be added to chemotherapy-based mobilization regimens and may accelerate the rate of increase in CD34+ cells on the second day of apheresis. Further studies are warranted to evaluate the effect of plerixafor in combination with chemomobilization on stem cell mobilization and collection on the first and subsequent days of apheresis, and its impact on resource utilization.

Capecitabine-based chemotherapy versus primary treatment for patients with advanced stages of undifferentiated nasopharyngeal carcinoma (UCNT): Preliminary results of a phase II study

e17049 Background: The combination of cisplatin and 5-fluorouracil (5-FU) is considered to be the standard treatment in induction chemotherapy for patients with undifferentiated nasopharyngeal carcinoma (UCNT). Capecitabine is an oral fluoropyrimidine. The aim of our study is to evaluate overall response and toxicity of this drug as a primary chemotherapy based-regimen for patients with advanced stages of UCNT. Methods: From January 2008 through December 2008, 34 chemo-naives patients with UCNT were included, mean age: 45.2 years (range 14–61 years), 12F/22M. One patient was stage IIB, nine patients stage III, 17 patients stage IVA, five patients stage IVB, and two patients stage IVC. All patients received at least 3 to 4 courses of neoadjuvant chemotherapy. The treatment plan included cisplatin at dose of 75 mg/m2 on D1 every 21 days, followed by capecitabine at a dose of 1,000 mg/m2 twice daily from D2 to D 15, with a 1-week rest period. Five patients received this scheme plus docetaxel at a dose of 75 mg/m2 on D1 with prophylactic granulocyte colony stimulating factors: lenograstim or filgrastim. All patients had a clinical evaluation of objective response and toxicity before at each cure . A CT scan was done at the end of treatment before radiotherapy. Results: After a total of 114 courses, all patients (34 pts) were evaluable for toxicity and 26 patients were evaluable for response (8 pts have not yet achieved their treatment). A clinical benefit was obtained for all patients since the first cure of chemotherapy. The overall objective response (CR+PR) was achieved in 96% of cases (25/26pts ), one patient had a stable disease. One of the two patients with stage IVC had a complete response on hepatic metastasis after 3 cures. Grade 3/4 toxicity included: diarrhea 5.2%, nausea/vomiting: 9.6%, hand-foot syndrome 3.5%, febrile neutropenia 4.3%, cardiac toxicity: 0.8%, thrombocytopenia 1.75%. Chemotherapy was interrupted for one patient after only one cure because of the cardiac toxicity. Conclusions: Capecitabine based chemotherapy is a safety and an effective regimen in patients with UCNT. However a longer follow-up is needed to confirm the benefit on disease-free survive (DFS) and overall survivor. No significant financial relationships to disclose.

Therapy-related acute promyelocytic leukemia: further insights into the molecular basis of the disease and showing the way forward in therapy

Acute myeloid leukemia (AML) occurring as a second cancer in patients, who were successfully treated for a prior neoplasm, has been reported with increased frequency partly due to the success of antineoplastic radiation and chemotherapy. Many of such therapy-related leukemias have been associated with recurring chromosomal abnormalities; this is suggestive of a specific interaction between certain chemotherapeutic agents and the genome with different drugs predisposing patients to specific translocations [1]. Although acute promyelocytic leukemia (APL) occurring after prior chemotherapy for other tumors has been infrequent, several recent reports have better characterized this entity and have suggested an increase in its incidence possibly due to an increased used of topoisomerase II inhibitors, particularly in the treatment of breast cancer [2,3]. In general, the clinical features, response to therapy and long-term outcome of patients with therapy-related APL appears not to be different from de novo cases of APL [2,3]. A recent report suggested that translocation breakpoints in APL occurring after exposure to topoisomerase II inhibitors such as mitoxanterone, etoposide and doxorubicin were clustered in ‘hot spots’ within PML and RARA and were common sites of mitoxantrone-induced cleavage by topoisomerase II [4]. The presence of preferential sites of DNA damage induced by mitoxantrone in PML and RARA genes was further corroborated by another study of 12 patients with multiple sclerosis (MS), who developed APL after therapy with mitoxantrone [5]. This was further suggestive of the specific interaction of the topoisomerase II poison with preferential sites on the genes involved which was independent of a predisposing genetic instability (as would be suspected in a patient with multiple cancers). In this issue of the journal, Aversa et al. report on a case of APL developing 4 years after receiving a combination of the Stanford V chemotherapy regimen with radiation in a patient with advanced Hodgkin lymphoma [6]. The topoisomerase inhibitors, doxorubicin and etoposide are amongst the agents used in the Stanford V regimen and as such, would be expected to predispose to the development of AML with associated translocation involving the specific cleavage sites. However, and perhaps somewhat surprisingly, according to the authors, this is the first reported case of APL in patients treated with the Stanford V regimen with the only other previous reported case of AML being associated with a translocation involving the chromosome band11q23. Of interest, Aversa et al. treated their patient successfully with the combination of all-trans retinoic acid (ATRA) and idarubicin and used a consolidation regimen including cytarabine, idarubicin, mitoxantrone and etoposide. This raises another question of what is the best regimen to treat a patient with secondary APL suspected to be the consequence of topoisomerase II inhibitor therapy? In addition to the intuitive concern for using the same agent to treat the disease as the one suspected to induce it, the issue of cumulative doses of anthracyclines and the attendant risk of cardiotoxicity has to be considered. The introduction of arsenic trioxide (ATO) as an effective treatment for relapsed APL and recent studies suggestive of a role for ATO in frontline therapy of patients have provided us with an alternative to anthracycline and ATRA based regimens used to treat patients with APL [7–9]. We have recently reported that the combination of ATRA, ATO, possibly with the addition of gemtuzumab ozogamicin but without chemotherapy is effective in producing molecular remissions that are durable [10]. In this issue of the journal, Ammatuna et al. report on the use of ATRA and ATO for consolidating the remission in a patient with secondary APL after mitoxantrone therapy for MS [11]. Their main incentive for using ATRA and ATO for consolidation was to avoid further cardiotoxicity in light of the patient's prior extensive mitoxantrone exposure. In light of our experience, as well as that of others, one can argue for the use of this combination for induction and consolidation in all patients who have a significant risk of anthracycline induced cardiotoxicity. There are other reasons that a ‘chemotherapy-free’ regimen may be particularly desirable. Patients with advanced age, poor organ function and poor performance status may not be good candidates for traditional cytotoxic chemotherapy and may benefit significantly from this approach. Furthermore, although the incidence of secondary myelodysplastic syndrome following treatment of APL with chemotherapy-based regimens is extremely low, there are several reported cases in the literature [12,13]. Therefore, if the ATRA plus ATO regimen is proven to be at least as effective as the standard chemotherapy plus ATRA regimens, it can be argued that it should be the preferred regimen in all patients, irrespective of their age, organ function or performance status. Ongoing clinical trials will attempt to address this question. In conclusion, despite significant strides in treating patients with APL, the story remains un-ended with future chapters hopefully introducing regimens with limited or no toxicity and universal success.

A Phase II Trial of Combination Bortezomib (Velcade®) and Rituximab for Untreated “High Tumor Burden” Indolent Non-Hodgkin Lymphoma (NHL).

Traditional therapy for patients with symptomatic and/or high-risk indolent NHL most commonly includes rituximab combined with multiagent cytotoxic chemotherapy. However some patients are not able to tolerate chemotherapy due to advanced age and/ or co-morbidities. Further, combination of novel, targeted agents (non-chemotherapeutic) have been infrequently tested in newly diagnosed indolent NHL patient populations. Overall response rate (ORR) with single-agent rituximab in prior data for untreated indolent NHL was 73% with a complete remission (CR) rate of 37% following maintenance therapy (JCO 2002; 20: 4261), although a good portion of patients in that series had low tumor burden at study entry. We hypothesized that frontline bortezomib and rituximab therapy would be effective and well tolerated for untreated “high tumor burden” indolent NHL. We have conducted a Simon 2-stage phase II trial for untreated indolent NHL. All patients were required to have “high tumor burden” as defined by Groupe D'Etude des Lymphomes Folliculaires (GELF) criteria. Induction therapy consisted of 3 cycles: bortezomib given at 1.6 mg/m2 days 1, 8, 15, and 22 q35 days for all 3 cycles and rituximab at 375 mg/m2 x 4 weekly doses for cycle 1, then day 1 only for cycles 2 and 3. Abbreviated consolidation therapy was subsequently given with 1 dose of each drug q2 months x 8 months. Responses were assessed by computerized tomography (CT) according to Cheson criteria (JCO 1999). We report here the results of the first stage of this 2-stage trial. Twenty-two patients have enrolled, of whom 17 were in the 1st stage. There were 9 women and 8 men; median age was 63 years (range 46–78 years). 14 patients had follicular lymphoma (FL), 2 marginal zone lymphoma, and 1 small lymphocytic lymphoma. 13 of 17 patients had stage IV disease and 4 had stage III. The median Follicular Lymphoma International Prognostic Index (FLIPI) was 3 (range 1–4) and the median follow-up was 13 months (range 1–24 months). Responses according to cycle number are shown in Table 1. After only 1 cycle, the ORR was 29% (all partial remissions (PRs)) with 71% stable disease (SD). Following cycle 3, ORR was 59% (24% CR). From cycle 1 to 3, 4/5 PRs converted to CR, 6 SDs converted to PR, while 1 PR and 4 SDs progressed or were removed from the study at physician discretion. 8 of 12 eligible patients have completed consolidation therapy. Following consolidation, 1 PR converted to CR and 2 SDs converted to PR for an ORR of 71%. According to histology, the ORR among FL patients after consolidation therapy was 86% (CR 36%, PR 50%). Therapy was very well tolerated. Grade 3 toxicities seen were lymphopenia, partial small bowel obstruction, and fatigue (all in 1 patient); no grade 4 toxicities occurred. Furthermore, no cytopenias or neurotoxicity was seen. Accrual to the 2nd stage is being completed. In summary, we found in the 1st stage of this phase II trial that bortezomib/rituximab combination therapy for untreated high tumor burden indolent NHL is well tolerated and active. Response rates improved throughout therapy (i.e., from cycle 1 through consolidation), although the CR rate achieved was low compared with chemotherapy-based regimens. Chemotherapy-based therapy should be considered standard therapy for frontline “high tumor burden” indolent NHL, although non-chemotherapy options may be considered for patients not anticipated to tolerate intensive therapy. Furthermore, responses seen here with bortezomib/rituximab, in a uniform high tumor burden patient population, were similar to rituximab alone in lower tumor burden populations. Analysis of clinical trials/reports in indolent NHL should include critical assessment of patient selection and future trials in high tumor burden should incorporate novel therapies into rituximab-chemotherapy based regimens.Table 1. Response according to cycle/treatment.After Cycle 1After Cycle 3*Following consolidation therapy**ORR29% (5/17)59% (10/17)71% (12/17)CR0%24% (4/17)30% (5/17)PR29% (5/17)35% (6/17)41% (7/17)SD71% (12/17)12% (2/17)0%PD/off trial0%29% (5/17)29% (5/17)*Three patients had PD, while 2 patients were taken off study (without PD) at physician discretion.**Eight of 12 eligible patients have completed post-induction therapy.

Reduced Intensity Versus Conventional Myeloablative Conditioning (RIC vs. MAC) Allogeneic Stem Cell Transplantation (allo-SCT) for Patients with Acute Lymphoblastic Leukemia (ALL): A Survey from the Acute Leukemia Working Party of EBMT

The exact role of RIC allo-SCT for adult patients with ALL is still under considerable debate. While the use of such so-called nonmyeloablative or RIC regimens has emerged as an attractive modality to decrease transplant-related mortality, toxicity might represent only one aspect of the problem, since ALL encompasses a group of chemosensitive diseases, raising concerns that significant reduction of the intensity of the preparative regimen may have a negative impact on long-term leukemic control. In this multicenter retrospective study, the outcomes of 601 adult (age at transplantation >45 y.) patients with ALL who underwent transplantation in complete remission (CR) with an HLA–identical sibling donor, were analyzed according to 2 types of conditioning: RIC in 97 patients, and standard MAC (or high-dose) in 504 patients. Both groups were comparable in terms of gender, CR status (CR1 and CR2), interval from diagnosis to allo-SCT, and recipient/donor CMV serostatus. Patients in the RIC groups were older (median 56 y. vs. 50y in the MAC group; P<0.0001), Most of the patients in the MAC group received high dose TBI (80%), while the majority of the RIC regimens included either low-dose TBI or were ATG+chemotherapy-based regimens. The majority of patients (88%) from the RIC group received a PBSC graft. In the MAC group, the stem cell source consisted of bone marrow in 42% of patients. With a median follow-up of 13 months (range, 1–127), the incidences of grade II-IV and grade III-IV acute GVHD were: 35%, 14%, and 28%, 10% in the MAC and RIC groups respectively (P=NS). The cumulative incidence of non-relapse mortality at 2 years (NRM) was 32% (MAC) vs. 22% (RIC) (P=0.04). The cumulative incidence of relapse at 2 years was 30% (MAC) vs. 42% (RIC) (P=0.0007). However, the latter differences did not translate into any significant difference in term of leukemia-free survival (LFS) at 2 years: 38% (MAC) vs. 37% (RIC) (P=0.42). In multivariate analysis for LFS, the status at transplant was the only factor associated with an improved LFS (p<0.0001, RR=0.55, 95%CI, 0.42–0.72). The results of this retrospective registry based study suggest that RIC regimens may reduce NRM rate after allo-SCT for adult ALL when compared to standard MAC regimens, but with a higher risk of disease relapse and no impact on LFS. The latter represent promising findings, since patients who received RIC are likely to have serious comorbidities, which led the transplantation center to choose RIC, and surely most of these patients would not have received a standard allo-SCT in most institutions. Therefore, RIC allo-SCT for adult ALL (>45 y.) may represent a valid therapeutic option when a conventional standard conditioning is not possible, warranting further prospective investigations.

GVHD after chemotherapy conditioning in allogeneic transplanted mice

GVHD is a major complication in allogeneic SCT. Available GVHD models are mainly based on radiotherapy-conditioning and/or immune deficient mice. GVHD models based on chemotherapy-based regimens remain poorly studied, despite 50% of all transplantations being chemotherapy based. Our aim was to develop a GVHD model using chemotherapy as conditioning. Female BALB/c (H-2Kd) were conditioned with BU-CY and transplanted with 2 x 10(7) BM and 3 x 10(7) spleen cells from either C57BL/6 (H-2 Kb) mice (allogeneic setting) or from male BALB/c to serve as a control group for regimen-related toxicity and engraftment. GVHD manifestations and histopathological changes were evaluated. Chimerism and donor T cells presence in skin, intestine and liver were studied using FACS-, FISH analysis and immunohistochemistry. Allogeneic transplanted mice developed lethal GVHD starting from day+7 with both histological and clinical signs. Donor T cells accumulated in recipient skin and intestine with GVHD progression. BM-failure, apoptosis and T-lymphocyte infiltration into target organs were significantly higher in allogeneic when compared with the syngeneic group. No toxicity or GVHD signs were observed in the syngeneic setting. We report a mouse model of GVHD using BU-CY conditioning that represents the most common myeloablative-conditioning regimen in clinical SCT. This model can be utilized to study the role of conditioning on mechanisms underlying GVHD.

Clinical outcome and prognostic factors for patients treated within the context of a phase I study: the Royal Marsden Hospital experience

The main aim of phase I trials is to evaluate the tolerability and pharmacology of a new compound. However, investigating the potential for clinical benefit is also a key objective. Our phase I trial portfolio incorporates a range of new drugs, including molecular targeted agents, sometimes given together with cytotoxic agents. We performed this analysis of response rate, progression-free (PFS) and overall survival (OS) to assess the extent of clinical benefit rate (CBR: partial response (PR)+stable disease (SD)) derived from current trials. We analysed 212 consecutive patients who were treated in 29 phase I studies, from January 2005 to June 2006. All patients had progression of disease prior to study entry. The median age was 58 years (range: 18-86) with a male/female ratio of 2 : 1. A total of 148 patients (70%) were treated in 'first in human trials' involving biological agents (132 patients) or new cytotoxic compounds (16 patients) alone, and 64 patients (30%) received chemotherapy-based regimens with or without biological agents. After a median follow-up time of 34 weeks, the median PFS and OS were 11 and 43 weeks, respectively. The CBR was 53% (9% PR and 44% SD) after the first tumour evaluation after two cycles (between weeks 6 and 8) and has been maintained at 36 and 26% at 3 and 6 months, respectively. Treatment related deaths occurred in 0.47% of our patients and treatment had to be withdrawn in 11.8% of patients due to toxicity. A multivariate analysis (MVA) of 13 factors indicated that low albumin ( upper normal limit and >2 sites of metastasis were independent negative prognostic factors for OS. A risk score based on the MVA revealed that patients with a score of 2-3 had a significantly shorter OS compared to patients with a score of 0-1 (24.9 weeks, 95% CI 19.5-30.2 vs 74.1 weeks, 95% CI 53.2-96.2). This analysis shows that a significant number of patients who develop disease progression while receiving standard therapy derived benefit from participation in phase I trials. Risk scoring based on objective clinical parameters indicated that patients with a high score had a significantly shorter OS, and this may help in the process of patient selection for phase I trial entry.

Advanced non-small cell lung cancer therapy: historical and future perspectives

Before the 1980s, radiotherapy was the principal treatment for advanced non-small cell lung cancer (NSCLC). Radiotherapy is primarily effective for local disease control and in early stage disease, or as palliative therapy in inoperable disease. Prior to 1990, only a few cytotoxic drugs had confirmed activity against NSCLC, but a series of trials had established platinum-based chemotherapy as the most effective treatment regimen. Since then, newer chemotherapeutic agents have been found to be effective, and superior to traditional platinum combinations. Recently, chemotherapy-based regimens appear to have reached a therapeutic plateau, and effective, better-tolerated treatments are needed. Improved understanding of the molecular biology and genetics of the tumor has led to the development of more selective, less toxic, targeted therapies. Vascular endothelial growth factor (VEGF) and the epidermal growth factor receptor both play a key role in tumor growth and proliferation, and are logical targets for therapy. Bevacizumab, a monoclonal antibody against VEGF, has demonstrated significant improvements in survival and response rates when combined with chemotherapy (versus chemotherapy alone) as first-line therapy. In the second-line setting, the tyrosine kinase inhibitor erlotinib has demonstrated improved survival compared with placebo. This paper reviews the principal treatments used for NSCLC in the past two decades, provides an overview of current treatment options and considers future challenges. Prolongation of survival, reduced toxicity and improved quality of life are the main objectives. Key challenges for the future are patient-specific tailored therapy and expansion of the eligible patient population for novel therapies.

Clinical outcome and prognostic factors for patients treated within the context of a phase I study: the Royal Marsden Hospital experience

The main aim of phase I trials is to evaluate the tolerability and pharmacology of a new compound. However, investigating the potential for clinical benefit is also a key objective. Our phase I trial portfolio incorporates a range of new drugs, including molecular targeted agents, sometimes given together with cytotoxic agents. We performed this analysis of response rate, progression-free (PFS) and overall survival (OS) to assess the extent of clinical benefit rate (CBR: partial response (PR)+stable disease (SD)) derived from current trials. We analysed 212 consecutive patients who were treated in 29 phase I studies, from January 2005 to June 2006. All patients had progression of disease prior to study entry. The median age was 58 years (range: 18–86) with a male/female ratio of 2 : 1. A total of 148 patients (70%) were treated in ‘first in human trials’ involving biological agents (132 patients) or new cytotoxic compounds (16 patients) alone, and 64 patients (30%) received chemotherapy-based regimens with or without biological agents. After a median follow-up time of 34 weeks, the median PFS and OS were 11 and 43 weeks, respectively. The CBR was 53% (9% PR and 44% SD) after the first tumour evaluation after two cycles (between weeks 6 and 8) and has been maintained at 36 and 26% at 3 and 6 months, respectively. Treatment related deaths occurred in 0.47% of our patients and treatment had to be withdrawn in 11.8% of patients due to toxicity. A multivariate analysis (MVA) of 13 factors indicated that low albumin (<35 g l−1), lactate dehydrogenase>upper normal limit and >2 sites of metastasis were independent negative prognostic factors for OS. A risk score based on the MVA revealed that patients with a score of 2–3 had a significantly shorter OS compared to patients with a score of 0–1 (24.9 weeks, 95% CI 19.5–30.2 vs 74.1 weeks, 95% CI 53.2–96.2). This analysis shows that a significant number of patients who develop disease progression while receiving standard therapy derived benefit from participation in phase I trials. Risk scoring based on objective clinical parameters indicated that patients with a high score had a significantly shorter OS, and this may help in the process of patient selection for phase I trial entry.

SAFETY OF HEMATOPOIETIC STEM CELL TRANSPLANTATION IN CHILDREN LESS THAN THREE YEARS OF AGE

Allogeneic hematopoietic stem cell transplantation (HSCT) is a standard treatment for a variety of hematologic conditions. However, very young children may experience different complications of HSCT compared to older patients. The authors retrospectively analyzed the results of 51 transplants performed on children less than 3 years of age between June 1987 and October 2005. Donors were matched-related (n = 21), partially mismatched related (n = 3), and unrelated (n = 27). The majority of patients had one or more grade III organ toxicities, but all nonrelapse deaths were attributable to infection. Perineal dermatitis was found in a large number (73%) of recipients of cyclophosphamide-based conditioning regimens. The 1-year transplant-related mortality (TRM) was 14%, but significantly declined in the more modern period. Grades II–IV acute graft-versus-host-disease (GvHD) was seen in 22% of patients, while chronic extensive GvHD developed in only 7% of patients. Relapse was seen in 40% of transplants performed for a malignant condition, most commonly in those patients not in remission at time of HSCT. The 5-year event-free survival (EFS) and overall survival (OS) were 53 and 64%, respectively. Recipients of fractionated total body irradiation (fTBI) were more likely to have at least one long-term sequelae than patients who received chemotherapy-based regimens (p =. 014). These data demonstrate that HSCT can be performed safely in very young children, especially as supportive-care techniques improve. Cyclophosphamide-related perineal dermatitis is a unique complication in very young children. Finally, the incidence of acute and chronic GvHD in this population is low.

Bortezomib in Combination with Pegylated Liposomal Doxorubicin for the Treatment of Multiple Myeloma

Many novel agents and new combinations (including bortezomib, thalidomide, and lenalidomide) have been developed in recent years for the treatment of multiple myeloma (MM), creating major shifts in therapeutic management. Achieving complete response (CR)/near CR (nCR) generally serves as a reliable clinical surrogate for overall treatment outcome, ie, prolonged survival. Indeed, some newer induction regimens are yielding similar median time to disease progression effects compared with transplantation. Thus, it can be a dilemma whether a patient with CR/nCR needs to be subjected to the potential morbidity associated with transplantation after induction therapy. Combining new agents with chemotherapy-based regimens appears to offer higher overall response and CR/nCR rates than similar combinations that do not include chemotherapy. We review the preclinical and clinical rationale for combining bortezomib with pegylated liposomal doxorubicin for the treatment of MM. The synergistic interaction in sensitizing each other toward myeloma cells in vitro and their complementary in vivo activities have justified clinical studies. We summarize data for completed and ongoing phase I/II trials of this combination. To date, results have been sufficiently encouraging to initiate an international, multicenter, randomized, phase III trial comparing bortezomib with or without pegylated liposomal doxorubicin in patients with relapsed/refractory MM. The results of this trial will confirm whether the rationale for combining bortezomib with pegylated liposomal doxorubicin is validated by improved clinical outcome, ie, improved time to progression, for patients with MM.

MiRNA-29b Targets MCL-1 and Is Down-Regulated in Chemotherapy-Resistant Acute Myeloid Leukemia (AML).

AML is a heterogeneous disorder that includes several differently biologic entities. Patients with intermediate and poor-risk cytogenetics represent the majority of AML and chemotherapy-based regimens fail to cure most of these patients that are either resistant to or relapse shortly after treatment. Therefore, it is crucial to understand the biology of chemotherapy resistance in AML. Here, we proposed to investigate the relation between chemoresistance and miRNA expression in AML. First, using a miRNA microarray platform, we analyzed the miRNA profiles in pretreatment samples from a group of 24 patients with newly diagnosed AML treated with idarubicin 12mg/m2/day (days 1–3) and cytarabine 1500 mg/m2/d (days 1–4). After background subtraction and normalization to a set of housekeeping genes, Significance Analysis of Microarrays (SAM) was performed. Among others miRNAs, miR-29b was found significantly down-regulated in pts with resistant disease (n=13) compared to those who achieved CR (n=11)(SAM score −2.92). To validate these results, we measured miR-29b levels by quantitative(q)RT-PCR in an independent set of 36 AML patients treated with the same chemotherapy regimen as described above and with no statistical differences in baseline pretreatment characteristics. We found that miR-29b was down-regulated in pts with resistant disease compared with pts who achieved complete remission (p=0.015, t-test). Interestingly miR-29b is predicted to target MCL1, an oncogene whose over-expression has been associated with resistance to chemotherapy. An inverse correlation was indeed observed between MCL1 protein levels measured by immunoblotting and miR-29b expression measured by miRNA microarray in AML patients (n=9). Next, we inserted the 3′ untranslated region (3′UTR) of the MCL1 gene containing the putative interaction sites of miR-29b into a luciferase reporter. When the miR-29b precursor oligonucleotide was transfected into MEG-O1 cells along with the MCL1 reporter construct, a 70% reduction of luciferase activity was observed. In contrast, no changes in the luciferase activity was observed when co-transfection was performed with controls inckluding a construct containing a mutated 3′UTR sequence of MCL1. To validate MCL1 as a target of miR-29b, a synthetic miR-29b oligonucleotide was transfected by nucleoporation into K562 cells, which overexpress MCL1 and lack endogenous miR-29b. This resulted in a marked reduction of MCL1 protein levels compared with controls. Finally, to explore the functional impact of restoring miR-29b and downregulating MCL1 in AML cells, we measure the apoptosis rates in K562 cells transfected with miR-29b or scrambled oligonucleotides by annexin V staining. A 3-fold increase in apoptosis was found in miR-29b transfected cells compared with scrambled oligonucleotides-treated controls. Consistent with these results, miR-29b-treated K562 cells exhibited increased chemosensitivity to ARA-C compared with scrambled oligonucleotides-treated cells. In conclusion, we demonstrate here that miR-29b down-regulation is associated with chemotherapy resistance, which might occur as the results of MCL1 overexpression. Restoring miR-29b expression levels down modulates MCL1, induces apoptosis and enhances chemosensitivity in AML cells, thereby suggesting miRNA-based therapy as a novel pro-apoptotic approach to increase response in high-risk AML.

Peripheral blood progenitor cell mobilization with intermediate‐dose cyclophosphamide, sequential granulocyte‐macrophage–colony‐stimulating factor and granulocyte–colony‐stimulating factor, and scheduled commencement of leukapheresis in 225 patients undergoing autologous transplantation

Interpatient variability in the kinetics of peripheral blood progenitor cell (PBPC) mobilization is commonly seen with conventional chemotherapy-based mobilization regimens. This necessitates the availability of leukapheresis (LP) facilities 7 days a week. The efficacy of an approach where LP was invariably commenced on Day 11 after intermediate-dose cyclophosphamide followed by sequential administration of granulocyte-macrophage-colony-stimulating factor (CSF) and granulocyte-CSF (Cy/GM/G) was retrospectively analyzed in 225 consecutive, unselected patients undergoing autologous hematopoietic stem cell transplantation for all diagnoses other than acute leukemia at our center. Cy/GM/G was scheduled to avoid weekend LP. After Cy/GM/G, a CD34+ cell yield of at least 2.0x10(6) per kg was achieved in 90.7 percent of patients. Optimal yield (OY; >or=5x10(6) or 10x10(6) CD34+ cells/kg depending on diagnosis) was achieved in 67.6 percent of patients. Only three patients (1.3%) required LP on Saturday or Sunday. Febrile neutropenia (FN) was encountered in 5.3 percent. PBPC yield was highest on Day 1 of LP (p<0.001). In multivariate analyses, platelet (PLT) count on Day 1 of LP (PLT-D1LP) was positively associated with achievement of OY (p<0.001). PLT-D1LP and diagnosis of myeloma were associated with a shorter time to achieve a CD34+ cell yield of at least 5x10(6) per kg (p<0.001 and p=0.002, respectively). Cy/GM/G with scheduled LP commencement on Day 11 enables optimal CD34+ cell yields in most patients undergoing autologous transplantation, despite a low risk of FN and avoidance of weekend LP.

CHOP-R + bortezomib as initial therapy for diffuse large B-cell lymphoma (DLBCL)

8031 Background: Bortezomib is a proteasome inhibitor with anti-tumor activity in B cell malignancies. These effects, which may relate to NF-kappaB associated pathways, could sensitize tumor cells to standard chemotherapy-based regimens and enhance efficacy. We report findings of a phase I/II trial of dose-escalated bortezomib + standard CHOP-rituximab in DLBCL patients (accrual of the MCL cohort of this study remains ongoing). Methods: Patients with previously untreated DLBCL (n=40) received CHOP-21 + rituximab (375 mg/m2 each cycle) plus bortezomib at 0.7 mg/m2 (Arm 0, n=4), 1.0 mg/m2 (Arm 1, n=8) or 1.3 mg/m2 (Arm 2, n=28 including phase I and all phase II) on days 1 and 4 of each cycle Results: Median age (n=40) was 58 years (range 21–86), thirty-five subjects (88%) had stage III/IV disease at study entry, and 29 (73%) had elevated serum lactate dehydrogenase (LDH). Patients generally had unfavorable baseline international prognostic index (IPI) scores of 2 in 16 subjects (40%) and 3–5 in 19 subjects (48%). Median follow-up is 21 months (range 9 - 35 months). Treatment was generally well tolerated. Peripheral neuropathy occurred in 22 subjects (55%), with 45% grade 1, 5% grade 2 and 5% grade 3. Grade 4 hematologic toxicity included thrombocytopenia (15%) and leukopenia (15%). Four subjects (3 over age 75 and all with high risk IPI) died prior to first response assessment. Intent to treat (ITT) overall response rate (n=40) is 90% with 68% CR/CRu. For the evaluable subset (n=36), ORR was 100% with CR/CRu 75%. Kaplan-Meier estimate (n=40) of 2-year progression-free survival is 72%. Of all 19 enrolled (ITT) patients in the high-intermediate or high-risk IPI groups, 14 (74%) were alive without progression at last assessment. Correlation of outcome with cell of origin type (activated B cell vs germinal center) is ongoing. Conclusions: Bortezomib can be administered with acceptable toxicity in conjunction with CHOP-R chemotherapy. Efficacy findings with this combination regimen in newly-diagnosed DLBCL are encouraging and warrant further study. No significant financial relationships to disclose.