Early Disease Progression Research Articles

Adherence With Oral Anticancer Therapies: Clinical Trial versus Real-World Experiences with a Focus on Prostate Cancer.

In this review, we address adherence rates in clinical settings, barriers to compliance with dosing schedules, and potential strategies to overcome challenges in maintaining high levels of adherence. Four studies reporting real-world adherence to prostate cancer medications, 52 studies describing barriers to adherence, and 16 studies on methods to minimize poor adherence were reviewed. Mean nonadherence rates of 25 to 51% have been identified in prostate cancer patients prescribed oral therapies, with higher rates in older patients. An extensive review of prostate cancer patients receiving gonadotropin hormone-releasing hormone agonist injections found an overall nonadherence rate of over 27%. Patients may encounter barriers to complying with dosing instructions related to the medication (eg, complex dosing schedules, the total burden of medication management, fasting or dietary requirements, high medication costs, adverse effects, and drug-drug interactions). Barriers may also be related to patient-specific factors (eg, suboptimal education regarding the importance of adherence, physical limitations and cognitive decline associated with advancing age, living alone without a care partner, high symptom burden, needle phobia, and comorbid mental disorders). Interventions to improve dosing adherence may include automated reminders, treatment diaries, educational materials, and the involvement of patients, family members, care partners, and healthcare teams. Many oral anticancer medications improve survival in men with prostate cancer and therefore it is vital to establish good adherence by understanding the pitfalls that patients may encounter. In situations where both oral and injectable drugs are interchangeable, injections of long-acting drugs lead to fewer opportunities for dosing nonadherence than oral therapies. In contrast, oral medicines do not require scheduling for injections and travel for injection appointments. Therefore, maximizing adherence to all treatment regimens will reduce the chance of efficacy failures and likely lead to improved clinical outcomes.

Two progression patterns in Alzheimer's disease identified from structural MRI in a memory clinic‐based cohort

AbstractBackgroundAlzheimer’s disease (AD) is known to be heterogeneous in pathobiology and clinical manifestation. Most previous studies demarcating AD subtypes rely on data‐driven clustering methods that are likely confounded by interindividual differences in disease progression within samples. Addressing this problem, we aim to identify and characterize distinct AD atrophy progression patterns in a memory clinic‐based cohort.Method N = 914 subjects (296 cognitively unimpaired, 366 with subjective cognitive impairment, 153 with mild cognitive impairment, and 99 with AD dementia) from the multicenter observational DZNE Longitudinal Cognitive Impairment and Dementia Study (DELCODE) were included. The Subtype and Stage Inference algorithm (Young et al., 2018, Nat. Commun.) was applied to ROI‐based cortical thickness and gray matter volume data obtained from T1w and T2w 3T‐MRI using FreeSurfer. Subtypes were characterized in demographics, ApoE genotype, various fluid biomarkers, and cognition.ResultTwo atrophy subtypes were identified. A limbic‐predominant subtype exhibited initial volume loss in the amygdala and hippocampus, followed by cortical thinning in the medial temporal, temporal, frontal, parietal, and occipital lobes. Contrary, in a hippocampal‐sparing subtype, cortical thinning first occured in the frontal, parietal, and occipital lobes before the temporal and medial temporal lobes, hippocampus, and amygdala were affected. Compared to the hippocampal‐sparing subtype, the limbic‐predominant subtype included subjects who were older, reported fewer years of education, and tended to have more ApoE e4 alleles, higher risk of vascular pathology, and higher plasma neurofilament light levels. The subtypes differed in their CSF biomarker profiles indicating higher β‐amyloid and tau burden in the limbic‐predominant subtype. In the limbic‐predominant subtype, cognitive impairment was accentuated in the learning and memory as well as language domains. Belonging to the hippocampal‐sparing subtype was associated with an impairment in executive functions and processing speed, visuospatial functions, and working memory.ConclusionWe provide evidence on atrophy heterogeneity that is largely in line with previous theoretical and empirical contributions while overcoming key limitations that are commonly faced in earlier studies. Heterogeneity may have substantial impact even in cohort studies designed to primarily include “typical” amnestic AD which highlights the need for optimized and subtype‐specific measures of early detection and disease progression.

HTA142 Potential Impact of Biomarker Guided-Decisions on Overtreatment in Immunotherapy for Non-Small Cell Lung Cancer Patients

With only 30% of non-small cell lung cancer (NSCLC) patients showing a durable disease control to immune-oncology drugs, biomarkers are expected to enable more personalized treatment. We have applied statistical and machine learning methods to sequential serum protein measurements to predict early disease progression in immunotherapy treated NSCLC patients. This study evaluates the potential impact of introducing such a prediction model in clinical practice on cancer management and subsequent costs.

Anti-PD-L1/PD-L2 therapeutic vaccination in untreated chronic lymphocytic leukemia patients with unmutated IgHV.

Chronic lymphocytic leukemia (CLL) patients with unmutated immunoglobulin heavy chain (IgHV) are at risk of early disease progression compared to patients with mutated IgHV. As a preventive strategy, we treated 19 previously untreated CLL patients with unmutated IgHV in a phase 1/2 trial (clinicaltrials.gov, NCT03939234) exploring the efficacy and toxicity of a therapeutic cancer vaccine containing peptides derived from programmed death ligand 1 (PD-L1) and ligand 2 (PD-L2), hoping to restore immunological control of the disease. According to the International Workshop on Chronic lymphocytic Leukemia (iwCLL) response criteria, no patients obtained a response; however, during follow-up, one patient had complete normalization of the peripheral lymphocyte count and remained in biochemical remission after a follow-up time of 15 months. At the end of treatment, one patient had progressed, and 17 patients had stable disease. During follow-up with a median time of 23.5 months since inclusion, seven patients had progressed, and eight patients had stable disease. The median time to first treatment (TTFT) from diagnosis was 90.3 months with a median follow-up time of 50.1 months. This apparent favorable outcome in TTFT needs to be investigated in a randomized setting, as our population may have been biased. More than 80% of patients obtained vaccine-specific immune responses, confirming the immunogenicity of the vaccine. The vaccine was generally well tolerated with only grade I-II adverse events. Although there were some signs of clinical effects, the vaccine seems to be insufficient as monotherapy in CLL, possibly due to a high tumor burden. The efficacy of the vaccine should preferably be tested in combination with novel targeted therapies or as a consolidating treatment.

Long-Term Outcome of Patients with Follicular Lymphoma Is Not Fundamentally Affected By KMT2D, EZH2, and Crebbp Mutational Status

BACKGROUND: Analysis of 2 large datasets from the National LymphoCare Study (NLCS) and the University of Iowa and Mayo Clinic Molecular Epidemiology Resource (MER) identified a group of patients with early progression of follicular lymphoma (FL) as having poor long-term outcome. In patients with FL who received chemoimmunotherapy as first-line treatment, progression of disease (POD) within 2 years of diagnosis was associated with increased risk of death. Understanding the genomic basis of this poor prognosis is important for improving outcome in this high-risk group. We sought to test the hypothesis that there are distinguishing features in the mutational landscape between patients with FL who experience early progression versus those without early POD. METHODS: We retrospectively identified patients with FL diagnosed at MSKCC who experienced early POD, defined as progression in less than 12 months from diagnosis (FLEP), and those who experienced late POD, defined as no progression within 36 months from diagnosis (FLLP). Genomic DNA was isolated from FFPE tissue specimens and whole exome sequencing (WES) was performed at MSKCC. Patients with FL grade IIIB, mixed histology, or de novo transformation at diagnosis were excluded. The results were analyzed to identify any mutation enrichment in the FLEP cohort versus the FLLP cohort, and whether there were any new gene mutations picked up with WES that are not covered in the HemePACT or clinical IMPACT targeted signaling platforms. Genes with significant differences or trends in the occurrence of mutations between the FLEP vs FLLP cases were analyzed in a larger cohort of patients with FL by looking at clinical IMPACT data at MSKCC, comparing progression-free survival (PFS) and overall survival (OS) by mutational status. PFS was calculated from date of diagnosis till date of progression after first-line treatment, death, or censored at date of last follow-up. OS was calculated from date of diagnosis till death or censored at date of last follow-up. To validate previous findings by Casulo et al., OS was stratified by those with POD within 2 years of diagnosis and those without POD within 2 years of diagnosis. OS and PFS analyses were performed using the Kaplan-Meier method in SAS 9.4 and log-rank tests were used to compare differences in survival. RESULTS: Exploratory analysis with WES was performed on 16 FLEP cases and 10 FLLP cases. There were no significant differences in the occurrence of gene mutations between FLEP and FLLP cases in the WES cohort. Only 1 gene, SETD1B, appeared in the WES panel that is not covered in the HemePACT and clinical IMPACT targeted signaling platforms. In the WES data, trends were observed in 3 genes: KMT2D, CREBBP, and EZH2, with a higher occurrence of mutations in FLLP cases compared to FLEP cases. To examine these trends further, a larger cohort of 295 patients with available clinical IMPACT data were analyzed. Genomic alterations in KMT2D, CREBBP, and EZH2 were identified and PFS and OS were stratified by mutational status (mutated vs unmutated) in these 3 genes. Patient characteristics are shown in Table 1. Median age of diagnosis was 57 years (range 26-92) with a slight male predominance (53%). The median follow-up was 5.1 years (95% CI, 4.5 - 5.7). Initial treatment in this series of 295 patients with FL included monoclonal antibody + chemotherapy (57%), single-agent rituximab (15%), chemotherapy (2%), radiotherapy alone (8%), and other treatments (6%). Thirty-five patients (12%) were never treated. POD within 2 years was associated with less favorable OS (Figure 1), validating previous findings that early POD identifies a high-risk FL population. Mutational status of KMT2D, CREBBP, and EZH2 were not significantly prognostic of PFS or OS. DISCUSSION: This analysis further describes the mutational landscape in FL. Our results are congruent with previous findings from the NLCS and MER datasets that early POD after initial therapy is prognostic for poor OS in patients with FL. Mutations in KMT2D, CREBBP, and EZH2 are among the most common mutations in FL, and our data suggest that long-term outcome of patients with FL is not fundamentally affected by the presence or absence of these common mutations. Further research involving targeted sequencing and gene-expression profiling is needed to understand the mechanisms behind the prognostic effect of early POD on survival and improve long-term outcome in this high-risk FL group. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Analysis of Immune Pharmacodynamic and Baseline Biomarkers in Patients with Relapsed or Refractory Follicular Lymphoma Treated with Mosunetuzumab in Combination with Lenalidomide

Background: Mosunetuzumab (M) is a bispecific monoclonal antibody targeting CD20 and CD3 that redirects T cells to eliminate B cells and has shown efficacy in patients (pts) with relapsed/refractory (R/R) follicular lymphoma (FL; Budde et al. Lancet Oncol 2022). Lenalidomide (Len) is clinically active in FL, and its immunomodulatory activity offers potential synergistic efficacy when combined with M. Here, we present preliminary data from a Phase Ib/II trial (NCT04246086), which aimed to characterize pharmacodynamic biomarkers and investigate baseline (BL) features of early progressive disease (PD), in pts with R/R FL treated with M+Len. Methods: Eligible pts had Grade 1-3a R/R FL and received ≥1 prior systemic anti-cancer therapy. Pts received ≤12 cycles of M+Len (Cycle [C] 1: 21 days; C2-12: 28 days). In C1, step-up doses of intravenous M were given on C1 Day (D) 1 (1mg) and C1D8 (2mg), with the target dose (30mg) given on C1D15 and then on D1 of C2‒12. Len (20mg) was administered orally on D2‒22 (n=10) and on D1-21 of C2-12 for the remaining 19 pts. Activation of immune cells during M+Len treatment was assessed in longitudinal collections of peripheral blood by flow cytometry, and plasma IL-6 levels were evaluated by enzyme-linked immunosorbent assay. CD20 expression was assessed by immunohistochemistry in BL and PD biopsies. CD20 loss was defined as ≤5% CD20+PAX5+ cells. Mutation profiling was performed by next-generation sequencing (NGS). A modified version of the AVENIO circulating tumor (ct)DNA analysis workflow and pipeline (Roche; for research use only) was used for NGS, based on the previously described CAPP-Seq technology (Kurtz et al. J Clin Oncol 2018). Results: A transient reduction in circulating T-cell counts (likely due to margination) and increase in percentage (%) of T cells expressing the activation marker CD69 were observed after M monotherapy in C1, and these kinetics were maintained in subsequent cycles, particularly in the CD4 T-cell population. Maturation of T cells, measured as % of T cells expressing human leukocyte antigen DR, increased after C2, following the addition of Len, and was sustained throughout M+Len treatment. The % of circulating programmed cell death protein 1 (PD-1)+ CD4 T cells increased after the first cycle of M, implying a rapid activation of T cells by M, and progressively decreased after C2. A decrease in % of PD1+ CD4 T cells suggested that sustained PD-1 expression, often a sign of T cell exhaustion, does not occur during M+Len treatment. Natural killer (NK) cells showed transient activation following M infusion (assessed as margination and % of CD69+ NK cells), and a sustained increase in functional markers, like granzyme B, during treatment with M+Len. IL-6 secretion was often enhanced after the first M infusion in C1. However, increased IL-6 levels were not observed after M+Len co-administration in subsequent cycles. As of April 25, 2022, 29 pts had been enrolled and were evaluable for efficacy. Best objective response rate was 89.7%, with complete metabolic response (CMR) observed in 21 pts (72.4%). Five cases of early PD (≤6 cycles of treatment) were observed. BL CD20 expression was heterogeneous (n=25 BL biopsies), and one CD20-negative pt experienced early PD. Two pts with early PD showed CD20 loss at progression. ctDNA analysis was performed in a subgroup of 5 pts with PD vs 5 with CMR for signal seeking. A trend towards higher median ctDNA levels at BL, measured as mutant molecules per mL, was observed in pts with early PD (400.1) vs CMR (58.6). Moreover, a higher median number of somatic variants was found in plasma (145.0) vs tissue (120.0) at BL, with a lower median concordance of plasma variants in tissue in pts with early PD (n=4; 43.8%) compared with those achieving CMR (n=5; 94.1%), suggesting higher tumor heterogeneity in early PD. Conclusions: In pts with R/R FL, our preliminary data suggest that M+Len activates the immune system. Increased % of T and NK cells expressing maturation and functional markers were observed during M+Len treatment. In contrast, addition of Len to M did not enhance IL-6 secretion, a cytokine known to be related with cytokine release syndrome, which is consistent with the manageable safety profile previously reported for this combination. Future investigations with a larger sample size are needed to further assess the prognostic value of CD20 expression in response to the M+Len combination and the prognostic value of ctDNA measurement at BL.

Treatment Sequencing and Survival in Follicular Lymphoma: A National Population-Based Study

Introduction Follicular lymphoma (FL) is characterised by a vast clinical and molecular heterogeneity. Whereas early progression of disease (POD) within 24 months has been identified as an important prognostic factor in different cohorts, potential associations with number of treatment lines, treatment sequencing and survival have not been thoroughly described in real world data. To further identify patient groups with a high need for novel therapeutic strategies in clinical routine and for inclusion in clinical trials we aimed to describe treatment patterns and survival in a national population-based setting. Methods We identified all patients diagnosed with FL in the nationwide Swedish Lymphoma register (coverage >95%) during the period 2007 to 2014, with follow-up through 2020. Information on progression, relapse, transformation and treatments was collected through review of medical records. A total of 2,079 patients were identified. Patients who did not provide informed consent (n=40), were diagnosed with transformed FL (n=144) or grade 3B (n=72), or where medical record data was missing (n=51) were excluded. The main analysis included patients receiving any first-line systemic treatment. Patients who were initially managed with radiotherapy (RT) only or a watch and wait (WaW)-approach were included in the main analysis if/when they received their first systemic treatment. Consolidation treatment including RT, maintenance with anti-CD20 antibody therapy or autologous stem cell transplantation (ASCT) was noted but did not count as separate treatment lines. Overall survival (OS) was illustrated graphically with the Kaplan-Meier method. Results In the final cohort of patients with FL (N=1,772), median age at diagnosis was 65 (18-98) years, and median follow-up time was 6.7 (0.003-13.9) years. Overall, 412 patients (23%) were managed with WaW only during the entire follow-up. Among patients with stage I or limited stage II disease treated curatively with RT at diagnosis (n=304), 60% (n=181) never needed additional therapy. In total, 1,174 patients (66%) received any first systemic treatment. The most common first-line treatment was R-CHOP (425/1,174, 36%), followed by R-single (361, 31%) and BR (184, 16%). The use of R-CHOP as first-line treatment decreased between calendar periods, whereas the use of BR and R-single in first line increased. Among patients starting any first line, 460 (39%) received systemic second-line treatment. Here, BR was most commonly administered (143/460, 31%) followed by R-CHOP (136/460, 30%) and R-single (60/460, 13%). A third-line treatment was administered to 204 patients (17%). Again, BR was most commonly chosen (67, 31%), followed by R-CHOP (41, 19%) and platinum-based chemotherapy (28, 13%). Only 81 (7%) patients required fourth-line treatment, and the maximum number of treatment lines administered were seven. The number of patients treated with the varying regimens in first and subsequent treatment lines are presented as a Sankey plot in Figure 1. Time to next treatment decreased with increasing number of treatment lines, as did OS. Time to next treatment was 2 years on average from the first to second treatment lines, 1.4 years to third line and 1 year to fourth line. The 5-year OS from first-line treatment was 75%, and the corresponding figures following second, third and fourth lines of therapy were 53%, 36% and 24%, respectively (Figure 2). During the whole study period, 173 (15%) patients received systemic treatment due to transformation, 258 (22%) received R-maintenance and 79 (7%) patients underwent ASCT. Conclusion In this national population-based cohort of FL, one in four patients never needed active oncological treatment. Among patients starting any first-line systemic therapy, 39% required a second line, and 18% a third line over a median follow-up of about 7 years. Further, time to next treatment decreased with increasing number of treatment lines and number of treatment lines was associated with dramatically worse survival. We conclude that, in addition to patients with FL experiencing POD24, patients who require multiple treatment lines (≥3) constitute a group with a large clinical unmet need, and methods to identify these patients at an early stage are warranted. The present results provide valuable real-world reference data for the design and interpretation of clinical trials of new treatments in FL. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Prediction of Early Disease Progression at 24 Months (POD24) Using Pre-Treatment Biopsies from Patients with Follicular Lymphoma (FL) Treated with Immunochemotherapy (IC)

Background: Gene expression profiling has been successfully used to interrogate FL biology related to overall survival alone or in combination with clinical parameters and mutation profiles such as the M7-FLIPI. However, none of these has ever been specifically trained against the most reproducible and pertinent predictor of excess mortality: early progression of disease by 24 months (POD24). Nor has any assay been validated on a clinical platform for testing patients in a CAP-CLIA environment. We therefore undertook a discovery analysis and also investigated published gene signatures to determine the best method for upfront prediction of POD24 with clinical progression (not transformation). Methods: For model generation, we assembled and harmonized gene expression data from frozen tissues from 377 total FL cases treated with immunochemotherapy (IC) from the Lymphoma/Leukemia Molecular Profiling Project (LLMPP; N=80, unpublished, Affymetrix), British Columbia (N=137, Silva et al, 2018, DASL Illumina), and PRIMA cohorts (N=160, S. Huet et al, 2018, Affymetrix) and performed in silico analysis to identify the most promising candidate genes to predict POD24. In addition to the identified genes, we also included all "IR1/IR2" genes (S. Dave 2004) and "PRIMA23" (Huet) genes and other published genes of interest totaling 144 genes related to tumor, microenvironment, and housekeeping functions. We used these 144 genes as the basis for an nCounter code set (NanoString, Seattle, WA), and then evaluated their expression in formalin-fixed, paraffin-embedded (FFPE) tissues from a training set of 57 matching cases from the LLMPP cohort and an independent set of 59 independent samples from the University of Iowa/Mayo Clinic SPORE Molecular Epidemiology Resource (MER). Comparing the FFPE NanoString results from the LLMPP training set to their matched fresh frozen Affymetrix results identified, 48 of the 144 candidate genes for which the two platforms showed agreement with correlation > 0.5). Multiple prediction architectures were compared using these 48 genes and optimized via cross-validation on this training set to develop a final locked down POD24 predictor ("CCP-32") based on a linear combination of the expression of 32 selected informative genes and an additional 19 housekeeping genes. Additionally, for comparison, the Huet profiling scores were calculated on the LLMPP training samples and a cut-point, optimized to select patients with POD24 as a dichotomous endpoint. These two predictors were then applied to an independent set of 174 FFPE samples from the MER population-based cohort. Samples with very low signal in the normalization genes were excluded (8/116 training and 17/174 validation). Samples from patients that were event free until they experienced transformation or were lost to follow-up in less than 24 months after IC were treated as censored and were thus excluded (2/116 training, 6/174 validation). Results: When applied to the MER FFPE validation set, the CCP-32 predictor placed 30% in a poor prognosis group with an observed POD24 rate of 56% while the remaining 70% samples had an observed 18% POD24 - an enrichment that was statistically significant (p=2.9x10-5). A training-optimized cut of the Huet profiling score performed similarly on the validation set with 44% placed in the poor prognosis group, with an observed POD24 rate of 48%, while the remaining 56% had an observed POD24 of 15% (p=1.5x10-5) Conclusions: Starting with an agnostic in silico analysis of data from frozen FL tissue to identify predictive genes, also including known gene sets pertinent to FL, we first identified genes that correlated best in FFPE tissues using digital expression profiling to develop an algorithm specifically trained to detect POD24 due to progression (not transformation) on a clinical platform using routinely processed samples. A novel predictor and the Huet profiling score were each able to detect a biological subset that was heavily enriched in the approximately 30-44% of FL patients at risk for POD24. Additional cohort analyses are underway. Integration of gene mutations and other genetic factors will also be explored to determine whether these can improve the predictive value with a long-term goal of creating a combined assay that could be suitable for use in a clinical laboratory to select high risk patients for clinical trials.

Advanced Risk Stratification in Multiple Myeloma Beyond Traditional FISH: The First Prospective Real-World Evidence for SKY92 Gene Expression Profiling

Background The prognosis of multiple myeloma (MM) has been significantly improved in the last decades. However, high-risk (HR) MM still suffers from early disease progression. Therefore, identifying HR MM patients may be a crucial step to improve the prognosis of this patient group. To date, fluorescence in situ hybridization (FISH) is the most commonly used method for risk stratification in MM. In recent years, gene expression profiling (GEP) approaches, e.g. SKY92, have been developed for detection of HR MM patients. Currently, real-world data of MM risk stratification applying SKY92 alone or in addition to traditional FISH are still missing. In this study, we provide the first prospective real-world evidence of the prognostic value of the combined SKY92 and FISH risk stratification in newly diagnosed (ND) and relapsed/refractory (RR) MM. Methods We prospectively collected bone marrow (BM) samples and clinical data of 147 MM patients. Cytogenetics were analyzed on purified CD138 positive MM cells by FISH, and HR cytogenetics was defined applying the Revised International Staging System (del(17p), t(4;14), and t(14;16)) (Palumbo et al, J Clin Oncol. 2015). SKY92 risk classification was determined with MMprofiler gene expression assay (Kuiper et al, Leukemia 2012). In addition, whole genome sequencing (WGS) was performed, and 150 bp paired-end sequences were generated on the NovaSeq6000 sequencing instruments (Illumina) with 100x coverage. Structural variations (SV) were called using Manta, and copy number variations (CNV) calling was performed with GATK4. Strelka2 variant caller was used for single nucleotide variations (SNV). Variants with global population frequencies >1% were excluded. Results We included 147 patients in our study (NDMM: n=51, RRMM: n=96). SKY92 classification was available for 121 (82.3%) patients. The median follow-up time was 344 days. HR SKY92 was significantly enriched in RRMM (40/76) compared with NDMM (6/45) (P<0.0001). RRMM patients with HR SKY92 showed significantly shorter progression free survival (PFS) (P<0.0001) and overall survival (OS) (P=0.0004) than standard-risk (SR). In NDMM, HR SKY92 also indicated a significantly inferior PFS (P=0.001) in comparison with SR. Of note, samples of 26 (17.7%) patients did not meet the SKY92 quality control criteria due to low BM infiltration (median BM infiltration: 25% vs 55% in other patients, P=0.038). We then combined the SKY92 classification with cytogenetic analyses by FISH, which were performed in 99 patients (NDMM: n=33; RRMM: n=66). We noticed a discrepancy between both risk stratification systems, with 44 (44.4%) and 42 (42.4%) patients being classified as HR by SKY92 and FISH, respectively. In total, 24 (36.3%) RRMM patients and 6 (18.2%) NDMM patients displayed HR in both SKY92 and FISH (double-HR) (Figure). Regarding survival outcome in RRMM, double-HR patients showed the worst PFS (P<0.0001) and OS (P<0.0001) when compared to the other patients (Figure). Noteworthy, RRMM patients with only HR SKY92 demonstrated significantly worse PFS than those with only HR FISH (P=0.007). In addition, double-HR presented a negative prognostic factor for PFS in NDMM (P=0.01). To further elucidate the discrepancy between FISH and SKY92 classifications, we performed WGS in 12 patients who exhibited either HR SKY92 only (n=9) or HR FISH only (n=3). Interestingly, 1 patient with bi-allelic TP53 inactivation (deletion + mutation) and 2 patients harbouring t(4;14) or t(14;16) were determined as SR by SKY92 but as HR by FISH; all the 3 patients were still in remission at the time point of data cut-off (July 2022). Moreover, we found abnormalities at chromosome 1 in 7 out of the 9 patients with HR on SKY92 only (gain1q21: n=6; del1p32: n=2) and, notably, gain1q21 and del1p32 were detected only by WGS in 3 and 2 patients, respectively. The remaining 2 patients did not show any known HR SV/CNV/SNVs, suggesting that HR MM may be associated with some other mechanisms, e.g. epigenetic modifications. Conclusion Altogether, risk classification using SKY92 performed well for detecting HR MM in the clinical routine. Here, we provide the first prospective real-world evidence that advanced risk stratification combining SKY92 and FISH may help to identify the "highest-risk" MM, which requires intensive anti-MM therapy and close monitoring in the course of the disease. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Autologous Stem Cell Transplantation for Treatment with Curative Intent in Adult Patients with Acute Lymphoblastic Lymphoma

Introduction Lymphoblastic lymphoma (LBL) is a rare, aggressive lymphoma that is often classified as a subtype of acute lymphoblastic leukemia (ALL). There is no consensus on the best treatment approach. It is often treated on ALL-type protocols involving prolonged courses of multiagent chemotherapy regimens; the reported long-term disease-free survival is 45-65%. In British Columbia, we take an alternative approach of consolidating initial response to induction chemotherapy with autologous stem cell transplantation (AutoSCT). We present our experience with this treatment pathway. Methods We identified 35 patients who received treatment with curative intent for LBL at our centre over the 15-year-period between January 2007 and January 2022 from our database. We excluded one patient who declined AutoSCT, one who received ALL-type chemotherapy and one who had upfront allogeneic stem cell transplantation (AlloSCT) due to complex karyotype. We collected data pertaining to demographics, disease characteristics, treatment course and outcome on the remaining 32 patients by review of clinical documents and laboratory and radiology reports. The primary outcome was event-free survival (EFS), defined as time from diagnosis to disease progression, relapse or death. Surviving patients were censored at the last follow up. We used Kaplan-Meier method to estimate survival and log-rank test and cox-hazard model for comparison of survival. Statistical analysis was performed using STATA® version 16.1 (Texas, USA). Results The median age was 35 years (range 18-64). 27/32 (84%) had T-LBL. Bone marrow, CSF and extranodal involvement was seen in 7 (22%), 3 (9%) and 24 (75%) patients respectively. The majority of patients (30/32, 94%) received induction chemotherapy on the NHL 98-01 protocol (consisting of doxorubicin, cyclophosphamide, vincristine, prednisone, and asparaginase). 16/32 (50%) achieved complete remission and 15/32 (47%) partial response post-induction. 28/32 (88%) proceeded to AutoSCT; four patients had early disease progression, preventing AutoSCT. 21/28 (75%) required bridging chemotherapy - most commonly high dose cytarabine (3000 mg/m2 on days 1-6). Nearly all patients (26/28, 93%) received conditioning with VP16-CyTBI (etoposide 1800/m2 on day -7, cyclophosphamide 50mg/kg on days -6 to -4 and TBI 200cGy BID on days -3 to -1) pre-AutoSCT. Two received BEAM (carmustine, etoposide, cytarabine, melphalan); both died from disease relapse post-AutoSCT. The stem cell source was bone marrow in 54% and peripheral blood in 46%. During treatment, all but one had febrile neutropenia and 12/21 (63%) had positive microbiology. Three patients were treated for invasive fungal infection, although only one had a confirmed diagnosis. 5/32 (16%) developed C. difficile infection. 14/32 (44%) patients had unplanned hospital admissions with an average length of stay of 21 days. 5/32 (16%) required ICU admission, two at initial presentation and two post-AlloSCT. Significant viral infections were seen only in the AlloSCT setting. After a median follow-up of 43 months (range 3-166), 16/32 (50%) patients remained alive, all but one in remission. The estimated 5-year EFS was 46% (95% CI 27-63). 13/28 (46%) patients relapsed post-AutoSCT; the median time to relapse was 10 months (range 3-57). At relapse, eight patients presented with ALL (one with concomitant CSF involvement, one with testicular involvement); three had mediastinal disease; one transformed to mixed phenotype leukemia, myeloid/lymphoid; and one had isolated CSF involvement. 3/13 (23%) who relapsed post-AutoSCT went on to receive AlloSCT following salvage chemotherapy; all died in remission from an infection at 1, 3, and 22 months post-AlloSCT respectively. All other deaths were with relapsed disease. There was no statistically significant difference in EFS by stem cell source (p=0.25). EFS was significantly longer in patients with T-LBL compared to those with B-LBL (HR 0.23, 95% CI 0.08-0.74, p=0.007; graph 2). Discussion Autologous stem cell transplantation with TBI-based conditioning for treatment of T-LBL is a viable treatment approach with acceptable tolerability and survival outcome. It also offers the advantage of a shorter treatment course compared to ALL-type chemotherapy. Further research is required to make direct comparison between these two distinct therapeutic approaches and provide guidance on the best practice. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Identification of the Proteasome Subunits PSMB4 and PSMD4 As Novel Targets in Multiple Myeloma Patients Carrying 1q21 Amplification

Gain and/or amplification of the 1q21 (1q21+) region is one of the most frequent secondary cytogenetic abnormalities present in multiple myeloma (MM) patients. Interestingly, it has been reported that the incidence of the amplification of chromosome 1q (Amp1q) in patients with pre-malignant smoldering myeloma (SMM) is about 40%. Several data indicate that the presence of Amp1q is associated with a worse clinical outcome and a poor response to therapies including proteasome inhibitors (PIs). Recently, a study showed that newly diagnosed MM (NDMM) carrying Amp1q receiving carfilzomib-based treatment have an early disease progression and shorter overall survival, compared to those with 1q21 gain. The genes driving amplification of the 1q21 region have not been fully elucidated. This study aims to identify novel targets in the 1q21 region possibly correlated to PIs treatment. We purified CD138+ plasma cells (PCs) by immunomagnetic beads from bone marrow (BM) aspirates. We used a total cohort of 29 MM patients: 11 SMM and 18 NDMM. Fluorescent in situ hybridization analysis was performed on all the patients. 48% (14/29) patients carried 1q21+. A score indicating the number of 1q21 copies was calculated based on the FISH hybridization pattern of each patient. The expression profile of all 29 samples was generated using GeneChip ClariomD Arrays (Affymetrix Inc., Santa Clara, CA, USA). The smar package was used to identify differentially expressed genes between 1q21+ and control samples. The expression profile of our cohort showed that the expression of both proteasome subunits, PSMB4 and PSMD4 was significantly upregulated in MM patients Amp1q compared to control patients (PSMB4 p=0.0006; PSMD4p=<0.0001 respectively). Additionally, we found a strong positive correlation between gene expression levels and 1q21 copy number for the proteasome subunits PSMB4 (p=<0.0001, r=0.5631) and PSMD4 (p=<0.0001, r=0.6391). Interestingly, the PSMB4 and PSMD4 expression levels were independent of the disease stage (SMM vs MM) and the expression was driven exclusively by the 1q21 copy number. We evaluated PSMB4 and PSMD4 mRNA and protein expression levels in a 1q21 wild-type MM cell line (OCI-MY5) and a panel of MM cell lines carrying 1q21+. Our results showed that PSMB4 and PSMD4 expression levels were higher in cell lines with Amp1q, following a 1q21 copy number fashion. Subsequently, we assessed the role of PSMB4 and PSMD4 to the sensibility of PI bortezomib in two myeloma cell lines carrying 1q21+. Our results showed that bortezomib treatment downregulates the protein expression of PSMD4 while PSMB4 was unaffected. Moreover, the MTT viability test correlated with the anti-myeloma effect of bortezomib. Furthermore, we generated a JJN3 PSMB4 and PSMD4-knockdown MM cell line using short hairpin RNA (shRNA) lentivectors. An empty vector was used as a control plasmid. Cell viability and apoptosis assays were performed using MTT assay and Apo 2.7 staining. Our functional studies showed that shPSMB4 and shPSMD4 decreased MM cell viability when treated with PI. Moreover, both shPSMB4 and shPSMD4 knockdown cells showed elevated levels of polyubiquitylated proteins, indicating blockade of proteasome-mediated protein degradation. In conclusion, our study identified proteasome subunits PSMB4 and PSMD4 to be significantly upregulated in MM patients carrying 1q21+, correlated with 1q21 copy number but not with disease stage. Therefore, targeting PSMB4 and PSMD4 could be a strategy to treat MM patients with 1q21+.

Successful Engraftment of Murine JAK2V617F MPN-like Disease into Unconditioned Mice

Background: JAK2V617F (JAK2VF) is the leading driver mutation present in hematopoietic cells of classical myeloproliferative neoplasms (MPN). The contribution of the non-hematopoietic compartment to MPN pathology remains obscure, although alterations and mutations in non-hematopoietic bone marrow (BM) cells (nonHC) can induce MPN-like diseases (reviewed in PMID32780848). Strikingly, the MPN-inducing JAK2VF mutation may be detected decades before MPN diagnosis, suggesting that the nonHC may act to support the expansion of the MPN clone. To examine this role of the nonHC within the BM during MPN disease, a model relying on low-level engraftment into an unaltered BM microenvironment is needed. Current transplantation models require myeloablative conditioning (irradiation) to ensure cell engraftment, which permanently alters the BM microenvironment (PMID24607941). We have developed a novel murine system that mimics JAK2VF+ MPN without the use of myeloablative conditioning, allowing the role of the BM microenvironment in the natural progression of MPN pathology to be studied. Methods: Floxed-JAK2VF (JAX#031658) were crossed with Mx1-Cre (JAX#003556) mice to produce a poly I:C-inducible MPN-like disease model (CD45.2). Five-week-old donor animals, designated JAK2MUT (Mx1-Cre(+);JAK2VF(+/-)) or JAK2CTRL (Mx1-Cre(-);JAK2VF(+/-)), were injected with poly I:C to activate the JAK2VF mutation. Five weeks later, BM was isolated and transplanted via single tail vein injection into age- and sex-matched C57BL/6 Ptprca (JAX#002014, CD45.1) recipient animals, at a concentration of 1.5x107 per animal. 10 mice (5 female, 5 male) were used as BM transplant (BMT) recipients of either JAK2MUT or JAK2CTRL BM. In addition, 10 total non-injected sex- and age-matched hosts were kept as a naïve (non-injected) group. Body weight (BW) of all 20 BMT recipients was monitored as an indicator of overall health. Blood from the submandibular vein was collected from all recipients every 4-6 weeks for complete blood cell counts (CBC) and flow cytometry analysis to determine alterations within the hematopoietic system and percentage of donor (CD45.2) chimerism within CD45.1 hosts. Results: At transplantation, JAK2MUT donors displayed advanced MPN-like disease (hematocrit (HCT) >70%, red blood cells (RBC) >1.9x107/µl, platelets (PLT) >1.1x106/µl). Over the course of the study, only male recipients receiving JAK2MUT donor cells showed a significantly different trend in weight change at 6 weeks post-transplantation with an average of 0.18% less BW gained. Hosts receiving JAK2CTRL cells displayed low engraftment efficiency <1% after 6 weeks post BMT, whereas hosts receiving JAK2MUT cells displayed ~4% observable engraftment within peripheral blood (Fig. A). Additionally, hosts receiving JAKMUT cells displayed reddening of extremities indictive of erythromelalgia, characteristic of JAK2VF+ MPN (Fig. A). When compared to donors, JAKMUT transplanted hosts displayed CBC abnormalities, characteristic of polycythemia (HCT >49%, RBC >25% naïve, unaltered levels of PLT) (PMID27956542). 2 of 10 recipients of JAK2MUT BMT died as the result of highly penetrant MPN 4-6 weeks after the transplant. Conclusion: While many ways to transplant hematopoietic cells within unconditioned animals have been described, we have successfully transplanted JAK2VF BM into the non-conditioned recipients and showed presence of diagnosable disease in animals displaying ~5% donor chimerism. Our model will offer advantages over existing methods for studying early MPN disease progression within an unconditioned murine BM. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract A061: Utility of patient-derived organoids for precision pharmacotyping, phenotypic screens, and modeling of pancreatic disease

Abstract Pancreatic ductal adenocarcinoma (PDA) is projected to soon become the second leading cause of cancer death. Aberrant glycosylation is a hallmark of PDA, but the impact of glycosylation remains vastly understudied in PDA. Additionally, a lack of disease models that recapitulate glycosylation differences observed in human disease has hampered efforts to leverage glycan changes as therapeutic strategies. To address these needs, human patient-derived organoids (PDOs) were employed to address three major questions. First, the use of PDOs in drug screening experiments to characterize therapeutic sensitivity and resistance (i.e. “pharmacotyping”) is a promising precision medicine approach to inform clinical decisions. However, the extent to which different sources of basement membrane extracts (BMEs) in which PDOs are cultured contribute to organoid chemosensitivity profiles is unknown. Mouse and human PDA organoids representing a range of PDA disease stages (early, late, and metastasis) were subjected to a chemotherapy and targeted therapy pharmacotyping panel in different commercial BMEs. Differences in growth kinetics and drug response were analyzed. RNA-seq was performed to determine the impact of BME source on gene expression programs. Results from this work will provide key insights regarding optimal growth of pancreatic PDOs as well as the impact of exogenous factors on pharmacotyping results. Second, elevated serum levels of the glycan CA19-9 are observed in more than 75% of PDA patients. Recent evidence demonstrated that CA19-9 promotes pancreatitis and accelerates pancreatic tumorigenesis in mice, phenotypes that are reversible with the use of CA19-9-targeting antibodies. However, how CA19-9 synthesis is regulated is unknown. We developed organoid high-throughput screens to identify compounds that impact CA19-9 production. Continuing this screen across a library of hPDOs will lay the foundation for the identification of new therapeutic candidates and the understanding of regulators of glycosylation in PDA. Lastly, the pancreatitis is a major risk factor for the development of PDA, with hereditary pancreatitis patients having a 40-55% cumulative risk of developing PDA. However, reliable organoid models of human pancreatitis are lacking. To address this need, we optimized methods to derive PDOs from chronic pancreatitis specimens of genetic and non-genetic etiology. Human chronic pancreatitis organoids underwent multi-omic characterization and credentialing in order to provide the field with more representative models of pancreatitis in humans and a platform to explore early detection strategies and study pancreatic disease progression. Overall, we demonstrate the broad utility of PDOs to identify early detection biomarkers and targetable vulnerabilities in PDA. These models are a renewable resource for the field, enabling elucidation of the molecular underpinnings of the increased susceptibility of chronic pancreatitis to PDA and other fundamental aspects of PDA biology. Citation Format: Jan Lumibao, Shira Okhovat, Kristina Peck, Dannielle Engle. Utility of patient-derived organoids for precision pharmacotyping, phenotypic screens, and modeling of pancreatic disease [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr A061.

A Multi-Center Phase Ib Trial of the Histone Deactylase Inhibitor (HDACi) Entinostat in Combination with Anti-PD1 Antibody Pembrolizumab in Patients with Refractory/Relapsed Myelodysplastic Syndromes (RR-MDS) or Oligoblastic Acute Myeloid Leukemia (RR-AML) after Hypomethylating Agent (HMA) Failure

Introduction: Pts with MDS and HMA failure have a poor prognosis and need novel therapies. Success with anti-PD1 therapy in myeloid malignancies has been limited and resistance mechanisms are poorly understood. Preclinical data suggest that myeloid-derived suppressor cells (MDSCs) contribute to MDS progression (Chen et al. JCI 2013). and may mediate resistance to anti-PD1 therapy (Kim et al. PNAS 2014). As HDACi decrease MDSCs, synergistic anti-tumor efficacy with anti-PD-1 has been hypothesized leading to this phase Ib study (NCT02936752) of the HDACi entinostat and anti-PD1 antibody pembrolizumab in pts with MDS or oligoblastic AML and HMA failure. Methods: We conducted an investigator-initiated, NCI-Cancer Therapy Evaluation Program (NCI-CTEP)-sponsored, multicenter, dose escalation and expansion phase Ib trial. Adult (≥18 years) pts with MDS or oligoblastic AML (bone marrow [BM] blasts 20-30%) and HMA failure were enrolled. Pts had to have adequate end organ function and ECOG performance status ≤2. The dose-escalation part used 2 dose levels (DL1: entinostat 8mg PO on days 1 and 8 of each 21-day cycle; DL2: entinostat 8mg PO on days 1, 8, and 15 of each 21-day cycle) with pembrolizumab 200mg IV on day 1 of each 21-day cycle starting with cycle 2. In cycle 1, pts received only entinostat to determine its impact on MDSCs separately from pembrolizumab. Toxicities were tabulated and graded according to CTCAE-5. Dose-limiting toxicities (DLT) were defined as any of the following if deemed possibly related to trial therapy: Grade (G) 3/4 non-hematologic toxicity, any ≥G3 immune related adverse events (IrAEs) or any IrAE resulting in pembrolizumab interruption or discontinuation during the first 2 cycles of combined therapy. Hematologic AEs were considered a DLT only if they were unrelated to MDS and lasted for >42 days. The primary endpoint was safety and determination of the maximum tolerated dose. The secondary endpoint was the overall response rate defined as a composite of complete remission, partial remission, and hematologic improvement (HI) per the 2006 IWG response criteria in MDS and change in MDSCs and PD1/PDL-1 in BM. Results: Between 06/26/2017 and 02/03/2021, we enrolled 28 pts (25 MDS and 3 AML). Median age was 74 years (range [R], 57-86), all pts had received prior HMA with 5 pts (18%) having had ≥3 prior lines of therapy. Median IPSS-R at screening for MDS pts was 5.5 (R: 2-10). Baseline demographic and clinical characteristics are shown in Table 1. During dose escalation, 7 pts were enrolled in DL1 (1 pt not evaluable due to early disease progression during DLT period), and 6 pts were treated on DL2. There was 1 DLT on DL1 (G5 pneumonia/bronchoalveolar hemorrhage (BAH), while 2 pts experienced DLTs at DL2 (G3 pharyngeal mucositis and G3 anorexia). There were no hematologic DLTs during dose escalation. Thus, DL1 was expanded, and another 15 pts were enrolled at DL1. Across the entire study, pts received a median of 3 cycles of therapy (R: 1-12 cycles). The most frequent cause of treatment discontinuation was disease progression in 9 pts. Four pts died during the study, 2 due to therapy-related complications (1 from pneumonia/BAH, 1 from multi-organ failure which occurred after the DLT period in DL2). A summary of the AEs is presented in Table 2. Hematologic AEs were common. The most common non-hematologic ≥G3 AEs independent of treatment attribution were infection (32.1%), hypoxia/respiratory failure (10.7%) and dyspnea (10.7%). Potential IrAEs of any grade were reported in 5 pts including G3 pneumonitis in 2 pts. Serious AEs were reported in 14 pts; 8 of which were potentially attributed to treatment. Among the 19 pts with the first BM efficacy assessment after 3 months, no pt achieved a protocol-defined response. However, 2 pts had mCR (BM blasts decreased from a baseline of 7% and 10% to 2% and 4%, respectively) without HI. Twelve pts had stable disease, while 5 had progressive disease. With a median follow-up of 5.9 months (R: 0.5 - 59.1 months), median OS was 6.9 months (95% CI: 4.8 - 13.6 months). Correlative studies are being conducted. Conclusion: In this multi-center phase 1b investigator-initiated trial in MDS and oligoblastic AML pts after HMA failure, entinostat + pembrolizumab at DL1 was reasonably tolerated but had limited therapeutic efficacy. Ongoing correlative work will explore the disconnect between the preclinical and clinical data regarding potential synergy of entinostat + pembrolizumab. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Hypercalcemia: A Risk Factor for Early Disease Progression and Poor Survival in Cytogenetically Standard-Risk Multiple Myeloma

Introduction The advent of novel therapies over the last decade, including proteasome inhibitors, immunomodulators, and monoclonal antibodies, has drastically improved the outcomes in patients with Multiple Myeloma (MM). It is common in both clinical practice and design of clinical trials to risk stratify patients to determine poor-prognosis based on known high-risk cytogenetics and baseline health status. Despite efforts to unify and refine the definition of high-risk disease, significant heterogeneity exists within risk strata and the majority of MM patients do not harbor high-risk cytogenetics. Many patients with ostensibly standard-risk disease progress rapidly, exhibiting a clinical presentation that aligns more closely with high-risk disease biology. We retrospectively evaluated outcomes within an institutional database to determine whether variation in prognosis among patients with standard risk MM may be predicted by clinical and biochemical features that are measurable at the point of care. Methods This retrospective cohort study included patients diagnosed with MM at the Cleveland Clinic in Cleveland, OH between 1/1/2008 - 12/31/2015 who had relapsed or died prior to initiation of the study. Patients with conventional high-risk cytogenetic features including: del(17p), t(4;14), t(14,20) or t(14;16) by fluorescence in situ hybridization (FISH) were excluded. Multiple variables at diagnosis were included in the analysis: race, gender, age, serum calcium (Ca), B-2-microglobulin, albumin, kidney function, hemoglobin, involved: uninvolved serum free light chain ratio, lactate dehydrogenase (LDH), serum monoclonal (M) protein, International Staging System (ISS) stage, Eastern Cooperative Oncology Group (ECOG) score, and the presence of extramedullary disease. Hypercalcemia (HCa) was defined using 3 groups - Group 1: Ca <10.0, Group 2: 10.1 - 12.5, and Group 3: > 12.5 mg/dL. Time to event analysis was conducted using the Kaplan Meier method. The impact of clinical and biochemical features at presentation on PFS and OS was quantified using a Cox Proportional Hazard on a univariate and multivariate basis in order to determine risk factors for early relapse among this cohort of patients with standard-risk cytogenetics. Results A total of 264 NDMM patients were screened for high-risk cytogenetics and the 18 patients excluded. An additional 99 patients were excluded from our analysis due unavailable FISH data at diagnosis. Twenty-one patients did not have serum calcium levels available at the time of diagnosis and were excluded, resulting in a study population of 126. Among these patients, the median age was 61.5 years old, 77.6% (n=97) of patients were Caucasian, and 47.6% (n=60) were male. The median time to follow up was 5.2 (2.9-7.0) years. A total of 13.6% had extramedullary disease (n=17) and 25.4% had a frontline autologous stem cell transplant (ASCT) (n=32). Stratification was conducted utilizing ISS stage: 34.4% Stage 1 (n=42), 31.1% (n-38) Stage II, and 34.4% (n=42) and ECOG score: 34.4% (n=42) Score 1, 38% (n=38) Score 2, and 42% (n=34.4) Score 3. The three hypercalcemia groups were similar with regard to demographics, ECOG, and laboratory data; however, ISS stage (23%, 47%, and 73%, p=0.002) and serum creatinine (median 0.96, 1.4, and 2.3 mg/dL, p=0.001) were positively correlated with calcium level at time of diagnosis. There was a statistically significant difference in 2-year PFS among the HCa groups (54.4%, 36.1%, and 9.1%, p = 0.002 and p <0.001, respectively) (Figure 1). There was also a statistically significant difference in OS among the HCa groups (Median OS years/5-year OS: 6.1/65.3%, 4.5/46.9%, 2.4/9.1%, p=0.032 and p <0.001, respectively) as well (Figure 2). Differences in PFS and OS remained significant after adjusting for age, race, ISS stage, extramedullary disease, ECOG. and frontline ASCT. Conclusion Our results showed that serum calcium level predicted disease progression and survival in a large cohort of patients without high-risk cytogenetic features. Variation in outcomes among MM patients who do not harbor high risk cytogenetics has not been fully explained. These results may help to inform clinical decision making, refine current risk stratification models, and identify a subpopulation with the strata of standard risk for correlative studies to evaluate disease genomics and biology. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Obinutuzumab-Based Immunochemotherapy Mitigates Early Progression Risk with a Substantial 2-Year Progression-Free Survival (PFS) in Patients with Previously Untreated Advanced Follicular Lymphoma and a FLIPI Score ≥2: An Interim Analysis of the Ambispective Urban Study

Introduction. The randomized GALLIUM trial showed that Obinutuzumab-based immunochemotherapy and maintenance achieves a longer progression-free survival (PFS) and a lower rate of early disease progression at 24 months (POD24) than rituximab-based therapy. These therapeutic benefits were not yet established in a real-life setting. We present early results of the first study worldwide designed to assess the effectiveness and safety of obinutuzumab plus chemotherapy in patients with previously untreated advanced follicular lymphoma (FL) and a FLIPI score ≥2. Methods. URBAN [NCT04034056] is a non-interventional, retrospective/prospective study involving 46 sites in Italy. The treatment plan included an obinutuzumab-chemotherapy (CHOP, CVP or Bendamustine) induction phase (6 months), followed by bimonthly obinutuzumab maintenance (24 months), and 1-year follow-up period after the last obinutuzumab administration. Participants should have received at least 2 cycles of obinutuzumab-chemotherapy induction before the enrolment (retrospective part). Treatment was delivered according to existing regulatory labels and local reimbursement requirements. The primary study endpoint was POD24 rate, i.e. progression of disease or death due to progression within 24 months from treatment initiation. Secondary endpoints were 2-year PFS and tumor response at end of induction (EOI). We report POD24 and 2-year PFS results for patients who started treatment 24 months before the clinical cut-off date (CCOD) of 31-Jan-2022 and the response at EOI for those who completed induction at CCOD. Patients with/without POD and PFS at 24 months were compared by gender, age, time from diagnosis to treatment start, FLIPI, ECOG performance status, and chemotherapy backbone. Results. At CCOD, 299 patients have been enrolled, 294 were at the EOI, and 178 and 189 patients were evaluable at 24 months for POD24 and PFS, respectively. Enrolled patients (n=299) had a median age of 62 years, with 158 (52.8%) females and 182 patients (59.9%) with a high (≥3) FLIPI score. The median time from diagnosis to treatment was 1.6 (0-71.5) months. Among the 294 patients who completed the induction, 263 were assessed for response at EOI. Response was assessed by PET-CT in 207 patients, by CT scan only in 40 and by other techniques in 16. In patients assessed with PET-CT, the overall response rate (ORR) was 97.6%, with complete response (CR) in 175 patients (84.5%), partial response (PR) in 27 (13.0%), stable disease (SD) in 2 (1.0%) and progressive disease (PD) in 2 (1.0%) (1 patient was not evaluable, N.E.); in patients assessed by CT scan only, ORR was 90%, with CR in 24 patients (60.0%), PR in 12 (30.0%), and PD in 3 (7.5%) (1 patient N.E.). The figure shows the Kaplan-Meier estimates for POD24. The results of POD24 by patients' characteristics, including the comparisons between patients with and without POD at 24 months, are summarized in the Table. It is important to note that due to the COVID-19 pandemic, 16.4% and 16.8% of patients respectively evaluable for POD24 and 2-year PFS had not received the planned obinutuzumab maintenance. At the time of CCOD, 21 (11.8%) patients had a POD24 event and 157 (88.2%) did not. The rate of patients with POD24 was significantly higher in males than in females (p=0.044), but no statistically significant differences were observed for other variables. Due to study timeline, all POD24 events occurred during the pandemic. Among the 189 patients evaluable for PFS, we observed a 2-year PFS of 83.1%. No statistically significant correlations have been identified between PFS events and clinical characteristics. No new or unexpected safety signals were reported. Most common any grade adverse events were neutropenia (22.1% of patients retrospectively and 26.1% of patients prospectively), thrombocytopenia (9.7% and 5.1%, respectively) and infections, including COVID-19 (8.4% and 27.1%, respectively). Conclusions. The results of this interim analysis showed that treatment of previously untreated FL patients with obinutuzumab and chemotherapy was associated with low POD24 rates, high rates of complete response and a substantial 2-year PFS. Despite the different patient populations and the likely impact of COVID-19 pandemic on the overall management of accrued patients, these real-life results are in line with those from the pivotal GALLIUM trial. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

CTNI-59. MATRIX REGIMEN FOR NEWLY DIAGNOSED PRIMARY CNS DIFFUSE B-CELL LYMPHOMA

Abstract We report our experience treating 22 patients with newly diagnosed primary CNS diffuse B-cell lymphoma with the MATRix regimen as reported by Ferreri, et al in 2016. The median age was 64 y (range 45-85); 10 patients were men and 12 were women. Twenty had cerebral mass lesions, 1 had a paraspinal mass, and 1 leptomeningeal disease. Treatment consisted of 4 cycles of rituximab 375 mg/sq m (Days 1, 6); methotrexate 3.5 g/sq m (Day 2); cytarabine 2 g/sq m every 12 h (Days 3, 4); and thiotepa 30 mg/sq m (Day 5). Patients without disease progression received carmustine 400 mg/sq m and thiotepa 5 mg/kg followed by autologous bone marrow transplantation. Four patients were switched to MATRix after 6 cycles of methotrexate and rituximab and received only 2 initial cycles including cytarabine and thiotepa. Overall, 16 patients completed initial chemotherapy. Fourteen of these 16 went on to transplantation; one patient had had early disease progression, and in one no stem cells could be collected. Five patients (median 73 y; range 64-85 y) died early after 1-2 cycles. The causes of early death were neutropenic fever, septic thrombophlebitis, and cardiac arrest. One patient who completed the entire regimen including transplantation died of fungal pneumonia and the other 13 experienced no serious acute toxicity. One patient had late disease progression and one developed symptomatic leukoencephalopathy. Fourteen of the 22 patients remain alive. Median OS for the cohort is 663 days. These preliminary data suggest that the MATRix regimen in safe and highly effective in the newly diagnosed setting. However, the high incidence of early death in patients over 65 y suggests that the regimen may be too toxic for older individuals.

Targeting α-synuclein post-translational modifications in Parkinson’s disease

Parkinson’s disease (PD) is a neurodegenerative disease characterized by the progressive loss of dopaminergic neurons in the nigrostriatal pathway. Although the exact mechanisms underlying PD are still not completely understood, it is well accepted that α-synuclein plays key pathophysiological roles as the main constituent of the cytoplasmic inclusions known as Lewy bodies. Several post-translational modifications (PTMs), such as the best-known phosphorylation, target α-synuclein and are thus implicated in its physiological and pathological functions. In this review, we present (1) an overview of the pathophysiological roles of α-synuclein, (2) a descriptive analysis of α-synuclein PTMs, including phosphorylation, ubiquitination, SUMOylation, acetylation, glycation, truncation, and O-GlcNAcylation, as well as (3) a brief summary on α-synuclein PTMs as potential biomarkers for PD. A better understanding of α-synuclein PTMs is of paramount importance for elucidating the mechanisms underlying PD and can thus be expected to improve early detection and monitoring disease progression, as well as identify promising new therapeutic targets.

SLC7A8 coding for LAT2 is associated with early disease progression in osteosarcoma and transports doxorubicin.

Background: Despite (neo) adjuvant chemotherapy with cisplatin, doxorubicin and methotrexate, some patients with primary osteosarcoma progress during first-line systemic treatment and have a poor prognosis. In this study, we investigated whether patients with early disease progression (EDP), are characterized by a distinctive pharmacogenetic profile. Methods and Findings: Germline DNA from 287 Dutch high-grade osteosarcoma patients was genotyped using the DMET Plus array (containing 1,936 genetic markers in 231 drug metabolism and transporter genes). Associations between genetic variants and EDP were assessed using logistic regression models and associated variants (p <0.05) were validated in independent cohorts of 146 (Spain and United Kingdom) and 28 patients (Australia). In the association analyses, EDP was significantly associated with an SLC7A8 locus and was independently validated (meta-analysis validation cohorts: OR 0.19 [0.06-0.55], p = 0.002). The functional relevance of the top hits was explored by immunohistochemistry staining and an in vitro transport models. SLC7A8 encodes for the L-type amino acid transporter 2 (LAT2). Transport assays in HEK293 cells overexpressing LAT2 showed that doxorubicin, but not cisplatin and methotrexate, is a substrate for LAT2 (p < 0.0001). Finally, SLC7A8 mRNA expression analysis and LAT2 immunohistochemistry of osteosarcoma tissue showed that the lack of LAT2 expression is a prognostic factor of poor prognosis and reduced overall survival in patients without metastases (p = 0.0099 and p = 0.14, resp.). Conclusion: This study identified a novel locus in SLC7A8 to be associated with EDP in osteosarcoma. Functional studies indicate LAT2-mediates uptake of doxorubicin, which could give new opportunities to personalize treatment of osteosarcoma patients.

Estimation of blood-based biomarkers of glial activation related to neuroinflammation

BackgroundNeuroinflammation is a well-known feature of Alzheimer’s disease (AD), and a blood-based test for estimating the levels of neuroinflammation would be expected. In this study, we examined and validated a model using blood-based biomarkers to predict the level of glial activation due to neuroinflammation, as estimated by 11C-DPA-713 positron emission tomography (PET) imaging. MethodsWe included 15 patients with AD and 10 cognitively normal (CN) subjects. Stepwise backward deletion multiple regression analysis was used to determine the predictors of the TSPO-binding potential (BPND) estimated by PET imaging. The independent variables were age, sex, diagnosis, apolipoprotein E4 positivity, body mass index and the serum concentration of blood-based biomarkers, including monocyte chemotactic protein 1 (MCP-1), fractalkine, chitinase 3-like protein-1 (CHI3L1), soluble triggering receptor expressed on myeloid cells 2 (sTREM2), and clusterin. ResultsSex, diagnosis, and serum concentrations of MCP1 and sTREM2 were determined as predictors of TSPO-BPND in the Braak1-3 area. The serum concentrations of MCP1 and sTREM2 correlated positively with TSPO-BPND. In a leave one out (LOO) cross-validation (CV) analysis, the model gave a LOO CV R2 of 0.424, which indicated that this model can account for approximately 42.4% of the variance of brain TSPO-BPND. ConclusionsWe found that the model including serum MCP-1 and sTREM2 concentration and covariates of sex and diagnosis was the best for predicting brain TSPO-BPND. The detection of neuroinflammation in AD patients by blood-based biomarkers should be a sensitive and useful tool for making an early diagnosis and monitoring disease progression and treatment effectiveness.